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A right pig’s ear

The government panicked over the threat of swine flu – and got its response completely wrong

Brace yourself - swine flu is on the rise again. The second wave coincides with mounting disquiet among doctors about the way we as a nation are responding to the disease. A recent survey by Pulse, a leading GP periodical, found that 61 per cent of family doctors believe the government should review its policy of blanket provision of Tamiflu to all suspected sufferers. It also reported a growing number of cases that have resulted in death or serious harm after conditions such as meningitis have been misdiagnosed as flu, and wrongly treated.

Swine flu has wrong-footed everyone. For many years it was assumed that when the next pandemic arrived, it would create havoc: thousands would die in Britain alone; the exponential demand for services would be mirrored by the decreasing number of healthy doctors able to deliver them; societies would crumble. This projection was based in part on the 1918 global flu pandemic - which caused an estimated 50 to 100 million deaths - coupled with the high fatality rate among the few hundred cases of "bird flu" (H5N1) over the past few years.

In the UK, huge quantities of antiviral drugs were stockpiled, plans for establishing a national pandemic flu phone line were laid, and organisations both public and private were exhorted to draft detailed contingency plans for when the carnage began. Both chambers loaded, the shotgun was trained on the far horizon, the collective eye of the viral surveillance world squinting down the barrel, seeking out the first sign of an emergent threat.

Along came swine flu (H1N1). To be clear: people have died - 82 in the UK and an estimated 4,041 worldwide, at the time of writing. According to the World Health Organisation (WHO), roughly 60 per cent of the severe or fatal cases have occurred in recognised risk groups, such as people with grave underlying health problems; the remaining 40 per cent have affected fit children and adults. Each death is tragic, but the mortality figures are tiny, viewed against the millions of mild cases globally.

Writing in the British Medical Journal in September, Peter Doshi, a doctoral student at the Massachusetts Institute of Technology, proposed a framework to differentiate between disease patterns. Type 1 infections are widespread and severe - exactly the kind towards which the current pandemic flu plans are geared. But swine flu sits in Doshi's type 3 - widespread but usually mild. These different beasts present different challenges, but because pandemic planning failed to anticipate anything other than a type 1 scenario, swine flu has triggered a completely inappropriate response.

Marginal effects

Central to doctors' unease is the National Pandemic Flu Service (NPFS). Telephone-based and web-based assessments of symptoms are made using a computer algorithm. If the computer says "swine flu", patients are given antiviral medication, usually Tamiflu. The problems are twofold.

First, data from the Health Protection Agency, which conducts confirmatory laboratory tests on a sample of cases, shows that less than 10 per cent of NPFS diagnoses are correct. The other 90 per cent of supposed swine flu sufferers have other illnesses whose symptoms happen to overlap. (Doctors fare only slightly better, diagnosing at best a quarter of cases accurately.) Second, the drugs being doled out are by and large worse than useless, even in the correctly diagnosed cases. Tamiflu makes only a marginal difference to the course of uncomplicated flu and causes side effects in up to 40 per cent of people who take it. On the whole, these are just bothersome - vomiting is the most frequent - but serious, even fatally adverse reactions do occasionally occur.

In late August, WHO advised that antivirals were not necessary for fit patients suffering from uncomplicated swine flu. The Department of Health defends its continued policy of Tamiflu-for-all on "safety first" grounds. Its concern is those exceptional cases of severe disease in fit individuals, where Tamiflu might (no one knows for sure) make a difference if started early. However, the logic - that it is better to treat everyone than risk missing those who might have benefited - belongs to a strategy for dealing with a Doshi type 1 pandemic, where the chance of severe disease is high. For swine flu, damage from indiscriminate use of antivirals outweighs the supposed benefits of catching atypical cases early.

The real challenge of a Doshi type 3 pandemic is identifying the small minority who actually and urgently require help. These could be those rare individuals with severe flu, or they might be patients in the early stages of another serious disease such as meningitis. Doctors are good at doing this (though far from infallible) and many GPs believe that only medically qualified staff should be undertaking flu assessments, but this is not achievable, given our capacity for mass hysteria. During the first wave of swine flu - before the NPFS was launched - the NHS front line was overwhelmed by waves of worried callers in flu hot spots. One of the main reasons for setting up the NPFS was to prevent a meltdown in services, but it should now change its focus from diagnosing swine flu (at which it is hopeless) to identifying patients in trouble.

The trickiest problem is when patients who initially feel mildly unwell start to deteriorate. The Department of Health stresses that patients are advised to consult a doctor if they get worse, but this fails to appreciate the Tamiflu effect. Having been "diagnosed" with swine flu and put on antivirals, patients are then falsely reassured that appropriate treatment is under way. By stopping its blanket use of Tamiflu, the NPFS would greatly increase the likelihood of patients consulting a doctor if they deteriorate.

Lessons in planning

Swine flu may in time be seen as a great learning opportunity. It has exposed a rigidity in pandemic planning that needs urgent correction. WHO has a scale to denote the spread of in­fection - level six being pandemic. It needs to develop a simple, parallel system to differen­tiate between Doshi types, one that should trigger responses appropriate to the particular challenge posed.

For now, the Department of Health should stop sticking doggedly to contingencies laid against a very different threat. The public and the NHS need clear identification of the at-risk groups and a message that the danger of swine flu, for everyone else, is almost certain to be minimal. They also need information about the warning signs of a more serious problem. The vast stocks of antivirals should be left on the shelf to go quietly out of date.

Yet it may be too late. Another facet of the Tamiflu effect is that we have educated hordes of people that what they thought felt like just a bad cold (and, most of the time, was just a bad cold) needed treatment with powerful drugs involving mystical rituals with a special authorisation number and a flu friend. Doctors will be dealing with mass hysteria in the face of ­minor illness for some time to come.

Phil Whitaker is a doctor and novelist. He is currently working on his fifth novel, "Sister Sebastian's Library"


Computer says flu

What do malaria, meningitis, diabetic coma, leukaemia and appendicitis have in common? They are just a few of the conditions that were originally diagnosed as swine flu during the first wave of the pandemic. Most patients have lived to tell the tale; some have not. The case reports have been appearing in the letters pages of medical journals, and on discussion forums of networking sites for doctors. The GPs reporting them are frequently unsure who in authority should be informed.

In fact, the National Patient Safety Agency (NPSA) has been tasked by the Department of Health with investigating alleged misdiagnoses. In a statement, John Scarpello, NPSA deputy medical director, confirmed that the agency had received "a small number of reports where swine flu may have been misdiagnosed", but was unwilling to go into detail while the facts had not been established. Given that the reporting system is entirely voluntary, and few clinicians know to contact the NPSA, this "small number" of reports is likely to be the tip of an iceberg.

The National Pandemic Flu Service is a first: never before have patients been diagnosed by computer or unqualified call-centre staff. There is a real need for research to examine this approach, yet none appears to be planned. The Department of Health refers inquiries about patient safety to the NPSA, while the NPSA believes commissioning such a study would be outside its capacity and brief.

Phil Whitaker

This article first appeared in the 12 October 2009 issue of the New Statesman, Barack W Bush

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Brothers in blood: how Putin has helped Assad tear Syria apart

The Syrian catastrophe has created the worst humanitarian crisis since the end of the Second World War. And the world watches helplessly as Putin and Assad commit war crimes.

Sometimes we know the names. We know Omran Daqneesh, the five-year-old boy who, covered in mud and dust, was pictured on the back seat of an ambulance in the aftermath of an air attack. We know his name because pictures and a video of him were released on social media and travelled around the world. The outrage that followed was widespread and sincere, the image of the dazed little boy seeming to symbolise the greater plight of the beleaguered residents of Aleppo. But then the moment passed. Few will know that a few days later doctors announced that Omran’s elder brother Ali, who was injured in the same air strike, had died from his injuries. He was ten.

Sometimes we know the names of the babies pulled from the rubble of collapsed buildings – occasionally alive, but often dead; or the names of the children weeping over lost parents; or the women grieving over lost husbands and children; or the elderly simply waiting (and sometimes wanting) to die.

We know Bana Alabed, the seven-year-old girl trapped inside Aleppo whose Twitter account has gone viral in recent weeks. “Hi I’m Bana I’m 7 years old girl in Aleppo [sic],” reads the on-page description. “I & my mom want to tell about the bombing here. Thank you.”

A series of pictures depicts Alabed and her mother, Fatemah, struggling to live as normal a life as possible, one showing the little girl sitting at an MDF desk with a book. Behind her, in the corner, is a doll. “Good afternoon from #Aleppo,” says the caption in English. “I’m reading to forget the war.”

The conflict, however, is never far away. Alabed, whose mother taught her English, has repeatedly tweeted her own fears about dying, followed by stoic messages of defiance whenever the immediate threat of an impending air strike passes. On the morning of 3 October, her words were simply: “Hello world we are still alive.” On 17 October, Fatemah tweeted: “The airstrikes ended in the morning, all the last night was raining bombs.”

But in most cases we never know the names of the victims of air assaults led by Presidents Bashar al-Assad and Vladimir Putin. One of the most haunting images to emerge in recent weeks was that of a mother and child, killed while sleeping in the same bed. The scene had an eerily preserved-in-amber feel to it: a snapshot of snatched lives, frozen in the act of dying. Pictures of ruined buildings and distraught civilians have become routine now, holding our attention briefly – if at all.

As many as 500,000 people are believed to have been killed since the beginning of the Syrian uprising in early 2011. According to a report released in February this year by the Syrian Centre for Policy Research, a further 1.9 million have been wounded. Taken together, those figures alone account for 11.5 per cent of Syria’s pre-revolutionary population. Combine that with the number of Syrians who have been displaced – more than ten million (almost 50 per cent of the population) – and the sheer scale of the disaster becomes apparent.

The conflict has become the worst humanitarian crisis since the Second World War. Today it centres on Aleppo, in north-west Syria, one of the oldest continuously inhabited cities in the world, and a cradle of human civilisation. Various conquerors from the Mongols to the French have fought battles there but none, so it would seem, has been quite as ruthless or committed to the city’s annihilation as Bashar al-Assad.

Aleppo remains the most significant urban centre to have been captured by the anti-Assad rebels, most of whom will (by now) be strongly influenced by an Islamist world-view. Indeed, the most prominent fighting groups on the rebel side are overwhelmingly Islamist in their troop composition and beliefs, a sad marker of Western failures to support secular forces that led the anti-regime resistance in the incipient phases of the uprising.

Yet Aleppo remains too important to fail. Although rebel forces succeeded in capturing only half of the city – the western side remained firmly in the control of the regime – the symbolism of anti-Assad forces holding ground in Syria’s second city (which also served as the country’s economic hub) has buoyed the rebel movement.

Assad is more brazen and bullish than at any other point since eastern Aleppo fell into rebel hands in July 2012. That optimism is born of a strategy that has already worked in other parts of the country where the regime’s troops have slowly encircled rebel-held areas and then sealed them off. Nothing can leave, and nothing can enter. Once the ground forces seal off an area, an aerial campaign of barrel bombs and missile attacks from both Syrian and Russian fighter jets inevitably follows.

To get a sense of just how terrible the aerial campaign has been, consider that the United States accused the Russian air force of potential war crimes when a UN aid convoy was bombed just west of Aleppo last month. It was carrying food and medicines when it was hit. Since then, the UK and France have said that Russia’s bombardment of Aleppo amounts to a war crime.

Putin’s support has come as a boon to Assad ever since Russia formally entered the conflict in September 2015. Despite his administration already using Iranian forces and aligned groups such as the Lebanese Shia militia Hezbollah, rebels had continued to make significant gains throughout the early months of 2015. The most important of these was the capture of Idlib city, 40 miles from Aleppo, which presented Assad with two problems. The first was that it dented the official narrative of revanchist military successes by his forces. The ­second was that it handed the rebels power in a province adjoining Latakia Governorate in the west, where Syria’s Alawites are largely concentrated (Russia has an airbase in an area south-east of the city of Latakia). The Alawites are a heterodox Shia sect to which the Assad family belongs, and which forms the core of their support base.

Keen to reverse these gains – and others made elsewhere – Assad enlisted Putin, given Russia’s long-standing interests in, and ties to, Syria. The Kremlin has long regarded Syria as an important ally, and has served as the country’s main arms supplier for the past decade. There are important assets to preserve, too, such as the Russian naval base in the port city of Tartus on the Mediterranean, which was first established during the Soviet era.

For his part, Putin has felt emboldened by events. The world is changing – not just in the Middle East and North Africa, where the
contours of power continue to be recast, but also closer to home in Ukraine, where the pro-Russian president Viktor Yanukovych was overthrown in 2014.

The West is still haunted by the 2003 invasion of Iraq and has been reluctant to be drawn too deeply into the Syrian War. In 2013, the Assad regime used chemical weapons against its own people. This was a violation of President Barack Obama’s so-called red line against the use of chemical weapons, but no retaliatory action came and there was nothing to prevent the Kremlin from using force to shape events in Syria – as it had done in Ukraine.

All of this has marked a new phase of brutality in a conflict already noted for its barbarism. Civilians who avoid death from combined Russo-Syrian air assaults suffer under Assad’s strategy of “starve or submit”, in which supplies are withheld from besieged areas, slowly choking off those ­inside. It has been used to devastating effect against civilians in towns such as Madaya and in Daraya, on the outskirts of Damascus, both of which fell to government control after being sealed off from the outside world for several years. Such a strategy is not designed to deliver quick victories, however. Consider how the residents of Daraya defied Assad’s forces for four years before capitulating in August 2016.

Assad and his allies (Putin, Iran, Hezbollah) have decided to punish and brutalise, deliberately, civilian populations in rebel-held areas. To invert the famous aphorism attributed to Chairman Mao, they hope to dredge the sea in which the revolutionaries swim. And so, it is the 300,000 residents of eastern Aleppo who must suffer now.




It’s easy to lose track of precisely what is happening in the Syrian War as parcels of land swap hands between rebels and the regime. Assad’s forces first began encircling Aleppo at the start of July this year and succeeded in imposing a siege by the middle of that month, after cutting off the last of two rebel-controlled supply routes into the city. The first was the Castello Road, which leads from the town of Handarat into the north-western part of ­rebel-controlled territory. The second route, via the Ramouseh district (which led into the south-western end of the city), had already been sealed off.

The closure lasted for roughly four to five weeks before the rebels re-established access. Aleppo is too important for them, and the siege has forced various groups to work together in breaking it. The effort was led by Jaish al-Fateh (JaF, the “Army of Conquest”), an umbrella group and command structure for several of the most prominent jihadist and Islamist groups operating in northern Syria. JaF also co-ordinated the Idlib military campaigns. One of its key members is Jabhat Fateh al-Sham (JFS, “the Syrian Conquest Front”), which was previously known as Jabhat al-Nusra (JaN or “the Supporters’ Front”) and was recognised as al-Qaeda’s official chapter in Syria.

Several months before the regime began its assault on Aleppo, rebel groups in the north recognised the deteriorating situation there, stemming principally from Russian air strikes. As a result, al-Qaeda urged the various factions to merge and work together to counteract not just Assad, but also Putin. Even the global leader of al-Qaeda, Ayman al-Zawahiri, issued a speech last May titled “Go Forth to Syria”, in which he called on all fighting groups to unite in order to consolidate their control across the north. This opened the way at the end of July for Jabhat al-Nusra to declare that it was formally severing its links with al-Qaeda. It “rebranded” as Jabhat Fateh al-Sham.

There are two reasons for doing this. The first is to erode partisanship among the Islamist groups, forcing them to set aside differences and narrow their ambitions in favour of the greater goal – in this case, the breaking of the siege of Aleppo, while also deepening rebel control across the north. The second aim of rebranding is to win popular support by portraying themselves as fighting in the service of ordinary civilians.

Groups such as JFS and others are succeeding in both of these goals. Responding to the abandoned and assaulted residents of Aleppo, they have repeatedly demonstrated their commitment to alleviating the humanitarian crisis. Much of their messaging echoes this theme. The group’s English-language spokesman is Mostafa Mahamed, an Egyptian who previously lived in Australia. “[JFS] is deeply embedded in society, made up from the average Syrian people,” he explained on Twitter, after the group decoupled from al-Qaeda. “We will gladly lay down our lives before being forced into a situation that does not serve the people we are fighting for . . . jihad today is bigger than us, bigger than our differences.”

It is indisputable that this ethos of “fighting for the people” has endeared the group to civilians living in besieged areas – even when those civilians don’t necessarily agree with the full spectrum of its religious beliefs or political positions. That goodwill was only reinforced when the group helped break the siege of Aleppo (in which approximately 500 rebels were killed) in August, if only for a few days. Assad reasserted control within a week, and entrapped the residents again in the middle of that month. The rebels are now planning how to break the siege decisively, but have not yet launched a major counteroffensive.




A freelance American journalist and film-maker, Bilal Abdul Kareem, who has reported on rebel movements inside Syria more intimately than most, has found himself among those trapped inside eastern Aleppo since the siege was restored seven weeks ago. “We came here expecting a two- or three-day trip,” he told me during an interview over Skype.

Life inside is becoming insufferable for civilians, Abdul Kareem said; every building is potted and scarred by shrapnel damage. Those whose homes remain standing are the lucky ones. “Your day consists of nothing,” he said. “There’s no work, there’s no fuel, no industrial zone, no food to sell. ­People sit around and chit-chat, drink tea, and that’s all they do.”

Food supplies are already running low, with most people limiting themselves to basics of chickpeas and groats – crushed grains such as oats or wheat. Sealed off from the rest of the world, those inside preoccupy themselves with survival and wait for the next wave of attacks.

It is tempting to ask why the inhabitants of Aleppo did not flee when they had the chance. Indeed, the Assad regime routinely accuses the rebels of preventing civilians from leaving besieged areas, though there is no evidence to support this view. On 17 October Russia and the Syrian regime said they would halt their bombardment for eight hours on 20 October to allow rebels and civilians to evacuate the city.

In truth, what choice do the civilians have? Most do not trust Assad and they are therefore unwilling to move into regime-administered areas. The alternative is to become refugees, with all the uncertainties and trials associated with that. For instance, refugees have found themselves subject to sectarian violence in Lebanon, and they have few opportunities to find employment in Lebanon, Turkey or Jordan, the three countries where most of the fleeing Syrians have found shelter.

For them, merely to exist in rebel territory is an act of defiance, which is precisely why Assad’s forces make no effort to distinguish between combatants and civilians in rebel areas. To be present is a crime.

The effects of this have been devastating. A spokesman for the Syrian American Medical Society told Middle East Eye, an online news portal, that in July, Syrian and Russian jets had hit medical facilities in rebel-held territory every 17 hours.

Only a few hospitals and medical staff remain. The physical conditions are primitive and perilous. Doctors work in makeshift facilities – a former flat, a commercial garage – which makes them unable to provide anything beyond basic emergency care. In-patient facilities are non-existent, not just because of high demand from those newly injured in fresh attacks, but also from fear that the facility itself will be targeted. “People are literally shuffled out of the hospital with IV [intravenous drips] in their arms,” Abdul Kareem says.

The West’s indifference to all this – coupled with its occasional pious pronouncements and diplomatic dithering – has squandered any goodwill Washington might once have had among Syria’s beleaguered civilians. When Sergey Lavrov, Russia’s foreign minister, and John Kerry, the US secretary of state, agreed a ceasefire in September it lasted barely two days because they overlooked the fears of those trapped inside eastern Aleppo.

The deal had stated that no party would try to capture any new territory. That might seem reasonable enough but given that the ceasefire came into effect just days after Assad re-established the siege of Aleppo, those on the inside were being asked, in effect, to acquiesce to their own starvation.

Deprived of food and medication, no one trusted Assad to negotiate access in good faith, especially after he thwarted UN efforts to deliver aid. “People saw it as a conspiracy,” Abdul Kareem told me. Moreover, there were no significant groups inside eastern Aleppo that claimed to have accepted the terms of the ceasefire in the first place. Kerry had negotiated on their behalf without approval and without securing any humanitarian concessions.

“What planet are these people on?” Abdul Kareem asked. “[Do] they think people will turn on their protectors, for people who didn’t do them any good? They look to JFS and Ahrar [Ahrar al-Sham is one of the Islamist groups fighting in JAF]. Western intervention is pie in the sky.”

The rise of these reactionary rebels is a direct result of liberal elements not being strongly supported at any stage in the conflict. Left to fend for themselves, many have deserted their cause. Those who have persisted not only risk the constant threat of being killed by Russo-Syrian bombs, but are also at threat from jihadist elements operating in rebel areas. That much was clear when remnants of the secular opposition protested against the leader of JFS, Abu Mohammed al-Golani, in the southern Idlib town of Maarat al-Nouman earlier this year. Many of those who did were arrested by jihadists and intimidated into silence.

Whereas liberals are fragmented and frayed, the Islamist rebels continue to coalesce into an ever more coherent unit. The overwhelming might of Russian airpower has convinced them of the need to form a united front in order to pool their resources and co-ordinate their efforts. That is one of the reasons why a jihadist group called Jund al-Aqsa (“Soldiers of al-Aqsa”) announced early this month that it was disbanding and being absorbed into JFS.

Herein lies the real story of how Aleppo – and, indeed, Syria itself – has been delivered to the jihadists. A conspiracy of all the external parties has forged a menacing millenarian movement that is embedded in civil society and communities across the north. Whether Aleppo falls or not, the jihadists will endure.

Shiraz Maher is a contributing writer for the New Statesman and a member of the war studies department at King’s College London

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 20 October 2016 issue of the New Statesman, Brothers in blood