'We don't do rabies'

When Alyssa McDonald was bitten by a stray dog in Romania, she was given excellent anti-rabies treat

"You want a babies injection?" asked the receptionist at my local GP surgery. "No," I explained as calmly as I could. "Not a babies injection, a rabies injection." "Oh ... I don't know about that," she said. "I'll have to check. Call back at six."

Two days earlier, at the end of a weekend trip to Bucharest, I had been walking through the city when one of the many stray dogs bit me - not badly, but hard enough to draw blood. I didn't really want the hassle of a trip to hospital, and I'd heard some horror stories about the Romanian ones. But then again, hospital was preferable to rabies. Virtually unheard of in the UK now, it still kills 55,000 people each year globally.

It is a particularly horrible way to die: within a week, sufferers become anxious and disorientated, developing an overwhelming thirst paired with an inability to swallow. Delusions, hallucinations and deranged behaviour (including thrashing, spitting and biting) follow; it usually takes another week or so before heart and lung failure lead to total paralysis, coma, and finally death. And once symptoms start to develop, rabies is nearly always fatal. So I was ready to put up with substandard treatment - I just wasn't prepared for quite how bad it turned out to be. And I didn't expect to find the NHS doling it out.

Dogs are a major nuisance in Bucharest. The rehousing programme during Nicolae Ceausescu's dictatorship forced many families to abandon their dogs, and now the city is home to about 200,000 strays. On average, strays bite 50 people a day; some of them carry tetanus and/or rabies. The city council has announced a couple of culls in recent years, but these programmes have never been extensive enough to tackle the problem. Fortunately, because the risk of being bitten is high, the city's hospitals are well set up to deal with the victims. The nurse I limped up to in Spitalil Colentina's anti-rabies unit spoke a little English, and within half an hour I'd been bandaged up, given shots for tetanus and rabies, and was out of the door with a prescription for antibiotics and directions on what to do when I got home. The days when rabies was treated with painful injections in the stomach are long gone; now you just need a series of five shots in your arm over the space of a few weeks. Easy.

The nurse gave me a leaflet containing information about the vaccine for my doctor in the UK. The entire service was free of charge.

As soon as I returned to London, I phoned NHS Direct to find out where to get my first follow-up shot. I was given the names of two NHS walk-in centres and a private Medicare centre before I was told that I could also see my GP.

"We don't do rabies," the receptionist at the first walk-in centre told me. "Tetanus we do, but not rabies." I called the second one. Then I tried again an hour later, and again an hour after that. Eventually I accepted that they weren't going to pick up, but I wasn't quite ready to accept the idea of paying for a treatment that I could get for free on the far side of the continent. So I skipped the Medicare option and phoned my doctor. Maybe I should have taken them up on that offer of a babies injection: I might actually have got somewhere if I had. When I called back at 6pm, the phone was engaged, and it stayed that way until the surgery closed at 6.30pm.

Life-threatening

Stuck for what else to do, I called the hospital closest to my office, St Thomas's in central London. Could they help me? The A&E receptionist was not keen. "Why didn't you call NHS Direct?" "I did," I explained, "and none of the options they suggested could help me. So now I am calling you, because I may have been exposed to rabies, and rabies is a life-threatening disease." "Where do you live?" I told her. "We're not your nearest hospital then, are we? You should have called the Royal London . . ." She was gracious enough to put me through to a doctor anyway.

"Yeah, we can do a rabies injection," the doctor told me. "But we shouldn't have to, really - you should be going to your doctor, because it's a community issue." I didn't ask why Romanian stray dogs are a community issue for Hackney Council.

So far, so incompetent. But the dismal service I'd received had nothing on what came next.

At A&E the next morning, I told the doctor what had happened, and about the five jabs the nurse in Bucharest had said I'd need. I didn't mention the antibiotics I'd been given for the wound itself; neither did he. Half an hour later, a student nurse appeared with a small syringe and the information leaflet from the vaccine, which she handed to me. She gave me the shot and smiled, "That's it! You're fine now." Really? What about the further three injections I'd been told I should have? "Oh, foreign hospitals are usually a bit overcautious with British patients. They're scared we'll sue." She assured me that I didn't need any further treatment, and that I was free to go. So I did. And I had got as far as the door when the doctor rang my mobile. He hadn't told the nurse to let me go, but since I already had, he just wanted to remind me that I'd need to see my GP for the remaining three shots.

I was confused - the nurse had said I didn't need any more treatment. "Did she? Oh, uh, then that's right." "Are you sure?" "Yes." I wasn't. But as I had the vaccine information leaflet, I could check: and like the Romanian one, it said I needed three more doses. (Not surprising, really, as that's the WHO's recognised regimen for rabies.) Why had the doctor needed me to tell him the dosage? When I went back to A&E and spoke to him, I discovered what had caused the confusion: he hadn't even read the information leaflet. And quite clearly, neither had the student nurse.

Rabies is hardly the UK's most pressing health issue, but the Health Protection Agency still treats about a thousand travellers each year who have been exposed to the disease abroad. Its line on treatment is unequivocal: as rabies is a fatal condition, the only available precaution - vaccination - must be used. The substandard treatment I received has serious implications for everyone who uses the National Health Service. In the end, my health was fine, but that doesn't excuse the level of service the NHS offered me. Being misheard, misinformed and passed from pillar to post is bad enough. But for two members of hospital staff to handle a less-than-everyday complaint by dishing out medication and advice without checking the facts is completely unacceptable, and potentially very dangerous. I contacted St Thomas's to ask for an explanation, but it was not prepared to comment unless I made a formal complaint.

According to research by the National Patient Safety Agency last summer, I'm not alone in receiving such poor service: almost 25,000 patients a year receive the wrong treatment in British hospitals. Whether the result is serious harm or just frustration and inefficiency, this is a pretty appalling track record. So, if you're looking for efficient, safe health care, try Romania. You might be less likely to end up foaming at the mouth.

This article first appeared in the 31 March 2008 issue of the New Statesman, Is Boris a fake?

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Inside the minds of the Isis murderers

As pressure on the terror group who claimed responsiblity for the Manchester attack intensifies, the threat to Britain will only become more acute.

The police and security services had consistently warned that a significant terrorist attack in Britain was inevitable. Yet no warning could have prepared us for the horror of the suicide attack on the Manchester Arena on Monday night. Twenty-two people were killed and at least 60 were wounded as they were leaving a concert by Ariana Grande in what was the most deadly attack in Britain since the London bombings of 7 July 2005, in which 56 people died.

Like the London bombers, the Manchester suicide attacker, Salman Ramadan Abedi, was British. He was 22, lived in Manchester and studied business management at Salford University before dropping out. He worshipped at Didsbury Mosque. The son of Libyans, Abedi is said to have returned recently from a visit to the North African country, where Islamic State has a foothold.

Ariana Grande is a former children’s TV star who made her name on channels such as Nickelodeon. Her fan base is overwhelmingly young and female, and many of those killed or wounded were children, including Saffie Rose Roussos, an eight-year-old girl from Leyland, Lancashire.

Islamic State inevitably claimed responsibility for the massacre, dismissing the victims as “crusaders”, “polytheists” and “worshippers of the cross”. This is not the first time Islamist terrorists have targeted children.

A Chechen jihadist group calling itself ­Riyad-us Saliheen (meaning “Gardens of the Righteous”) took more than 1,100 hostages, including 777 children, in a school siege in Beslan, Russia, in September 2004. In the event, more than 330 were massacred, including 186 children. Gunmen from the Pakistani Taliban also stormed a school in 2014, killing 148.

For terrorist actors, these are neither whimsical nor irrational acts. Contemporary jihadist movements have curated a broad and expansive intellectual ecosystem that rationalises and directs their actions. What they want is to create an asymmetry of fear by employing indiscriminate barbarism to intimidate and subdue their opponents into submission.

We have grown accustomed to a wave of terrorist attacks being carried out in the name of the self-styled Islamic State ever since the group’s official spokesman Abu Muhammad al-Adnani began prioritising them in 2014. (He was killed in an American air strike on Aleppo province in Syria in August last year.)

The US-led coalition against Islamic State has weakened the terror group in its former strongholds of Mosul in Iraq and Raqqa in Syria. In response, IS has been forced to concentrate more on what it calls “external operations” – by which it means inspiring its sympathisers and operatives to carry out attacks on Western countries. Indeed, al-Adnani encouraged the group’s supporters not to migrate towards IS-held territory but rather to focus their efforts on attacks in their home countries.

“The tiniest action you do in the heart of their [Western] land is dearer to us than the biggest action by us,” he said in an audio statement released last year. “There are no innocents in the heart of the lands of the crusaders.”

Islamic State refers to its strategy as “just terror”. Its framing places culpability for attacks on Western states on these nations themselves by claiming that IS actions are a response to aggression or assault. That much has been outlined in the group’s literature. “When will the crusaders end their hostilities towards Islam and the Muslims? . . . When will they recognise that the solution to their pathetic turmoil is right before their blinded eyes?” the militants ask in the IS magazine Dabiq. “Until then, the just terror will continue to strike them to the core of their deadened hearts.”

IS offered a rationale of this sort as justification for its bombing of a Russian commercial aircraft – Metrojet Flight 9268, travelling from Sharm el-Sheikh in Egypt to St Petersburg. That attack in October 2015 killed 224. Similar reasoning was offered for the attacks in Paris the following month in which 137 people were killed, in a series of co-ordinated, commando-style gun and bomb outrages across the city.

“Revenge was exacted upon those who felt safe,” IS declared in Dabiq. “Let the world know that we are living today in a new era. Whoever was heedless must now be alert. Whoever was sleeping must now awaken . . . The [caliphate] will take revenge for any aggression against its religion and people, sooner rather than later. Let the ­arrogant know that the skies and the lands are Allah’s.”

***

Through my academic research at King’s College London, I have ­interviewed scores of Westerners who became foreign fighters in Syria and Iraq to quiz them about their motives. Last year, one man from High Wycombe who had joined IS told me that it wanted to attack British targets in response to the vote in the House of Commons to extend British air strikes against IS targets to include sites in Syria (the British had only been targeting the group in Iraq until that point). “Do they [the British government] expect us to sit back and do nothing? ­Idiots,” he said.

In this respect, IS frames its attacks as acts of “revenge” and predicates its response on the Islamic principle of qisas, which is comparable to lex talionis or the doctrine of “an eye for an eye”. Qisas was always intended to be a tool of private redress for an individual or his/her family to seek justice in matters relating to bodily harm. Typically, it relates to cases of murder and manslaughter, or acts involving physical mutilation (say, leading to loss of limbs). The principle creates a framework for retributive justice.

The contemporary Salafi-jihadi movement has adopted a particularly innovative approach to the concept of qisas in two ways. First, groups such as IS have taken the idea and construed it in a way that justifies indiscriminate terrorism, such as the attack in Manchester. They argue that qisas has a political dimension and that it can be applied to international affairs in a way that holds civilians responsible for the perceived crimes of their governments.

Second, qisas is normally applied only in cases where the aggressor is known. IS, by contrast, holds every citizen-stranger of an enemy state responsible for the actions of his or her government. Thus, when it released its statement claiming responsibility for the Manchester attack, it said that it had struck against a “gathering of the crusaders . . . in response to their transgressions against the lands of the Muslims”.

It is this militaristic construction of qisas that allows IS to rationalise the bombing of a venue where large numbers of young girls had gathered to watch a pop concert, dismissing them as “crusaders”.

This is not new. In 1997, Osama Bin Laden told CBS News that “all Americans are our enemies, not just the ones who fight us directly, but also the ones who pay their ­taxes”. His rationale was that all Americans, by virtue of citizenship alone, are vicariously liable for the actions of their government.

Just a few years later, Bin Laden used the same idea to justify the 11 September 2001 attacks and also invoked it in reference to the Israeli-Palestinian conflict. “The blood pouring out of Palestine must be equally revenged,” he wrote. “You must know that the Palestinians do not cry alone; their women are not widowed alone; their sons are not orphaned alone.”

IS used the concept most dramatically in January 2015, when it burned alive a Royal Jordanian Air Force pilot, Muath al-Kasasbeh, whose plane had crashed in its territory. A video of the killing was circulated on the internet and social media. The group claimed his bombing raids had killed civilians and that it wanted to punish him with “equal retaliation”, in keeping with qisas.

What is well known about al-Kasasbeh’s murder is that he was burned alive inside a cage – but that is not the whole story. To understand how IS tethered this to the principle of qisas, it is the end of the gruesome video that is invested with most significance. After al-Kasasbeh has died, a truck emerges and dumps rubble over the cage. It was claimed this was debris from a site he had bombed, thus completing the “equal retaliation” of returning like for like. The idea was that IS had retaliated using the two principal forms in which a missile attack kills – by fire or debris.

***

The Manchester attack came on the fourth anniversary of the brutal murder of Fusilier Lee Rigby in Woolwich, south London. Rigby was killed by Michael Adebolajo and Michael Adebowale in the middle of the afternoon on a street outside a military barracks. That attack was in keeping with a pattern we have become increasingly accustomed to in Europe: an unsophisticated plot that employs ordinary, everyday items – a car, say, or a knife.

The consequences of such attacks have been seen across Europe, most notably in Nice on 14 July 2016, when 86 people were killed during Bastille Day celebrations after a jihadist drove a truck into crowds on the promenade. Similar attacks followed in Berlin, Westminster and Stockholm.

The security services find that these murderous attacks are extremely hard to disrupt because they typically involve lone actors who can mobilise quickly and with discretion. The Manchester attack was different. Explosives were used, which means the plot was inherently more sophisticated, requiring careful planning and preparation.

We know that two of the 7/7 bombers had previously trained in Pakistan’s lawless tribal regions, where they honed their skills. In other plots, such as the connected attacks in London and Glasgow Airport of 2007, the explosive devices failed mainly because the bomb-makers had found it difficult to travel abroad and develop their skills in safe environments. Whatever Abedi’s connections, the long war in Syria and Iraq has once again created a permissive environment for terrorist training and attack planning.

The devastating impact of this has already been felt across Europe. Since the Syrian uprising began in 2011, more than 800 Britons are believed to have travelled there to fight. From Europe as a whole, the figure is over 5,000, of which a significant number are believed to have joined IS. Of the British contingent, the security services estimate that about half have returned or become disengaged from the conflict. Of those who remained, a hundred are believed to be active, the rest having been killed.

It is improbable that Abedi acted alone in Manchester or that this plot had no international component. Indeed, he was already known to the authorities (and had returned recently from Libya). As pressure on IS intensifies across Syria and Iraq, the threat to Britain will only become more acute as the group’s sympathisers prepare for what they consider to be a fightback.

This speaks to the scale of the threat facing Britain, and Europe more generally. Our police and security services have been stretched and continuously tested in recent years. Just recently, in March, the Metropolitan Police assistant commissioner Mark Rowley told Radio 4’s Today programme that 13 plots had been thwarted since Lee Rigby’s murder in 2013. Put another way, the police have disrupted terrorist plots every four months for the past four years.

Naturally, Islamic State is not the only threat. On 13 May, one of Osama Bin Laden’s sons, Hamza, released a video, titled “Advice for martyrdom-seekers in the West”, on behalf of al-Qaeda. Hamza, 27, who was his father’s favoured successor to lead the group, called on its supporters to concentrate on attacks in the West rather than migrating to conflict zones in the Middle East and beyond. Scenes of previous ­terrorist attacks in Britain played throughout the video.

The central leadership of al-Qaeda is increasingly looking for opportunities to reassert itself after being eclipsed by Islamic State and losing control of its affiliates in Syria. It needs attacks and a cause in the West with which to revive itself. Hamza therefore cited the January 2015 Charlie Hebdo attack in Paris as a critical example, calling for the assassination of anyone deemed to have “insulted” Islam.

The Charlie Hebdo attack was especially important for al-Qaeda because it enabled the group to transcend the fratricidal conflicts that frequently define relations between the various jihadist groups. In Syria, for instance, al-Qaeda’s affiliates (when it had better control over them) and Islamic State have been in open war with each other.

Yet, the Charlie Hebdo attack brought warm praise from the group’s Islamist rivals because none of them wanted to appear ­unsupportive of an atrocity that had, as the terrorists proclaimed, “avenged” the Prophet Muhammad’s honour.

The British man from High Wycombe who joined IS told me the group had welcomed the attack for precisely those reasons. It was something that, in his view, had confirmed the “nobility” of the attackers, even if they had not been members of IS.

Is it too late for the West to save itself, I asked him. What if the West simply accepted all of Islamic State’s demands: would that provide respite?

The answer was as emphatic as it was stark: “We primarily fight wars due to ppl [sic] being disbelievers. Their drones against us are a secondary issue.”

He went on: “Their kufr [disbelief] against Allah is sufficient of a reason for us to invade and kill them. Only if they stop their kufr will they no longer be a target.”

In other words, we are all guilty, and we are all legitimate targets.

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at King’s College London’s International Centre for the Study of Radicalisation.

This article first appeared in the 25 May 2017 issue of the New Statesman, Why Islamic State targets Britain

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