Is Labour abolishing illness?

The new rules on incapacity benefit stake everything on a major gamble: that a large proportion of c

Incapacity benefit has become one of this year's favourite scare stories. Hardly a day passes without a new headline deploring its soaring costs and the rising numbers of claimants who get "something for nothing", at the expense of decent, hardworking taxpayers. We are told that we are footing an outrageously escalating bill for 2.4 million people, a million of whom shouldn't be on the benefit at all, and each successive work and pensions minister vows to be more ruthless than the last.

The true picture is somewhat different. The unreported version, which can be culled from Department for Work and Pensions (DWP) data, is that only 1.4 of the 2.4 million actually receive any payment, the rest get national insurance credits only, and numbers have been falling since 2003. The basic benefit is worth barely £3,000 a year. After two small rises in the first year there is no further increase, other than index-linking. All those who get the benefit have to pass a rigorous "personal capability assessment" (PCA) with doctors appointed by the DWP; and they can be re-examined at any time. The audited estimate of fraud is under 1 per cent - the lowest of any part of the social security system.

Nonetheless, the 2007 Welfare Reform Act is now being implemented across the country. It replaces support, as of right, for illness/disability (one of the planks of our rapidly disappearing welfare state) with a new, conditional employment and support allowance. Claimants are held on a basic allowance until it is confirmed that their capability for work is limited. This is determined by a "work capability assessment" tougher than the old PCA. Those deemed capable of one day returning to work (and the arbiters are health professionals rather than doctors) must engage in a series of "work-focused" interviews and activities. These include, among other things, "condition management", which in practice is likely to consist of group sessions loosely based on cognitive behavioural therapy. All this brings an additional slice of benefit that can, however, be cut for those who do not engage in it without "good cause" - a potential loss of 40 per cent of income. Ultimately, any whose capability for work remains limited through failing to follow medical advice, or "any prescribed rules of behaviour", face a period of disqualification. (A further provision of the act, to be piloted in nine areas, is that people served with Asbos - antisocial behaviour orders - can face cuts in their housing benefit for refusing local authority offers "to help address any problem behaviour".)

A main selling point of the reform was the great savings it would bring. It would staunch the outflow of benefits and get many people into jobs where they would pay tax and provide for their old age. This government's cherished goal is an employment rate of 80 per cent of the working-age population - though it is difficult to find any reasoned argument in support of this since our present rate of 75 per cent is, with Canada's, the highest in the world. The government accepts that employers must be paid to take on people with an illness record and, for the time being, it has pledged not to cut the benefits of existing claimants. Any immediate savings, therefore, can only come from bumping as many as possible off the benefit, shaving future benefit levels (already well in hand), and making it harder for newcomers to get it in the first place. Delivery is being farmed out to private agencies paid by results - which means, of course, the setting of targets. The next few years will be a bad time to have a crippling accident or succumb to a serious disease, particularly a psychiatric or neurological one that does not have obvious outward symptoms.

Blaming the "cheats"

The reform of incapacity benefit has been over ten years in the making, leaving in its wake a dense trail of commissioned reports. A curious thing about this voluminous material is how little information it contains on the actual health conditions for which benefit is paid. This is no accident, for the reformers long ago made up their minds that claimant numbers are too high, therefore a large proportion - usually put between a third and a half, but lately upped to 70 per cent in some quarters - must be spurious. An appeal to history is repeated like a mantra that, back in 1979, only 700,000 claimed the old sickness/invalidity benefits. Since then, money has been poured into the NHS while health care, living standards and longevity have improved beyond all expectations. People must be healthier, which proves that huge numbers are exploiting a slack and obsolete system. Who is to blame, apart from outright cheats? It can only be the self-indulgent, who fancy themselves sicker than they really are, and complacent GPs who let them think they are too ill to work.

Crucially, the reformers bracketed illness with disability. The disability lobby had long argued that "disability" was a discriminatory label imposed by society, and it was bent on removing the barriers to work that excluded those so labelled and kept them in poverty. But the bracketing brought confusions - for those with disabilities may be extremely fit (consider the disabled athlete), whereas the able-bodied can be extremely ill. More confusion arises with conditions such as "stress", "anxiety" and "chronic fatigue" that sound trivial. As for "back pain", how unreasonable is it to take time off sick for something best dealt with by a stiff upper lip and the odd aspirin? It is easy for those in good health to pooh-pooh such things, agreeing with the government that "Work is the best therapy".

The government's declared mission is to "liberate" claimants, to bring them into its "reformed, coherent welfare state for the 21st century". It seeks to overturn a culture based on the "medical model" of illness that allows them to "drift" on to long-term benefits without realising that "symptoms, feeling unwell, sickness and incapacity are not the same" - hence the appeal of cognitive behavioural therapy, which it understands as a treatment that will talk the sick into believing they can lead normal lives.

Doctors - so often the refuge of desperate people trying to find out what is wrong with them - should as far as possible be excluded from the process. Even those working for the DWP have opinions that are "unfounded, of limited value and counter-productive", while GPs are "unaware of the importance of work, the absence of which leads to depression, poor health, higher rates of suicide and mortality, poverty, and social exclusion". (The quotations are from a 2005 study from the Unum Provident Centre for Psychosocial and Disability Research at Cardiff University, whose ideas and rhetoric infuse the reform. Unum Provident is an American firm, the largest disability insurance company in the world, which is currently in litigation in different countries for refusing to pay out on some of its policies.) A private agency has now taken over the running of its first GP surgery here, and doctors dealing with disability living allowance are advised not to invite patients to explain how their condition affects them.

Features of the reform are familiar from other policy areas. First, a demonisation of a needy or vulnerable group, followed by a rebranding: so claimants become not even "clients" but "customers" (as in the just published "Commissioning Strategy" document); incapacity benefit becomes employment and support allowance; sick notes are redrafted for doctors to certify, not what patients can't but what they can do. Next come "partnerships", on an unchallenged assumption that the public sector has failed. The new system is farmed out to for-profit or non-profit-making agencies paid by results. This entails targets, and where targets are set, sanctions follow, for any who "fail to recover".

There are features of the new programme that look intelligent and humane, doubtless owing much to the efforts of the disability lobby. They include a longer and more flexible bridging period (and a back-to-work grant) between benefits and work, and a broader view of "work- focused" activities. The crunch will come with those described as not able or prepared to engage "because [of] the nature and severity of their health condition, or more a matter of attitudes, perceptions and expectations which may or may not be accurate . . . It is a question of what the claimant cannot do vs what they will not do."

For the reform stakes everything on a gamble: that a large proportion of claimants, present and to come, are fit enough to work. There seems no way of proving or disproving this, other than trying it out, at the risk of much waste of public money, and much personal grief. Deliberate rejection of the "medical model" deprives us of all we might have learned (from the wealth of data available) of the impact of illness on our society.

I have scratched my head long and hard over this reform (among other things sending out lengthy submissions to all concerned during the long consultation phase in 2005-2006) because so much in its theory and rhetoric contradicts my own experience: of chronically and seriously ill family members and friends, of several years as a Mind volunteer, and further years of peripheral involvement in action groups for chronic fatigue conditions. All this has indelibly impressed me with the courage of many who live with horrible complaints, the sheer hard work involved in their day-to-day coping, their relentless search for any amelioration, let alone cure, often at costs hard to spare from limited resources.

I have witnessed, too, and at close quarters, the hurt and stress of living difficult lives as people have to do, in a perpetual culture of disbelief and threat, where some of the most valiant are blamed for their conditions and conflated with the alleged "can't work, won't work" unemployed. For the message of the reform that comes across, for all its fashionable rhetoric, is that a person is valued only as a productive unit. Compassionate cases aside, those too ill to work are outside society and money spent on them is wasted. Sickness, disablement and inability to work have no place in a modern society - they can't and shouldn't be afforded.

No one pretends that illness is not a blight, imposing personal and social costs going far beyond the financial; but - pace the government - no one as yet knows how to remove it from the human condition. Why waste valuable time and resources on an ill-founded reform, when they could instead be used to further understanding of the real impact of illness on our society?

Alison Ravetz is a professor emeritus of Leeds Metropolitan University who writes on housing policy and welfare reform

This article first appeared in the 05 May 2008 issue of the New Statesman, High-street robbery

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Fight to the death in Mosul

The street-by-street battle against Islamic State for control of Iraq’s second city.

The men of Iraq’s special forces map their victories over Islamic State (IS) by tracing the scars on their bodies. “These four bullets were from a sniper in Ramadi,” said one soldier, lifting his shirt to show a pockmarked torso. A gap-toothed gunner called Ahmad turned a wrist and revealed his wound, a souvenir from Fallujah. Their commander’s close-cropped hair has deep furrows, the result of a rocket-propelled grenade (RPG) attack in the same city.

Both Ramadi and Fallujah were retaken from IS this year, which restored the confidence of the Iraqi military after its humiliating retreat from the terror group. Two years ago, the Iraqi army ran from Mosul and a caliphate was declared. Now, the soldiers’ task is to build on their recent gains and liberate the country’s second-largest city.

At the tip of the spear in Mosul is the Iraqi Special Operations Forces’ 1st Brigade, also known as the Golden Division. It is commanded by Major Salam al-Abeidi, the man who survived the RPG attack in Fallujah and led the offensive against IS in Ramadi. He is a compact figure, a black streak of ­motion in his special forces uniform, never at rest. (“He would exhaust 20 soldiers,” said one of his men.) He prefers to be on the offensive. “It’s when we are in defensive positions that we take the most casualties,” he told me.

Al-Abeidi does not smile much, but he enjoys a joke. In his hands is always one of three things: a walkie-talkie, a can of Red Bull, or a cigarette. His seven-month-old German shepherd, named Caesar, has recently joined him at the special forces headquarters. Most of his men, fearless when fighting IS, are terrified of the puppy.

The major leads from the front. In the morning, he is on patrol; in the afternoon, he is on the roof guiding air strikes. One evening, I found him climbing into a tank, heading out to defend a road. “Do you ever sleep?” I asked.

“Sleep? I drink 20 cans of this a day,” he joked, holding up the energy drink.

The Golden Division is making slow but steady progress through the eastern residential neighbourhoods of Mosul. This city is different from the ones in his previous campaigns, the major told me.

“Most of the areas we fought in while in Ramadi were nearly empty of residents,” he said. “Here, it’s heavily populated, making the security forces very cautious while advancing, so as to avoid civilian casualties. The enemy uses a lot of car bombs.”

The Zahra (formerly known as Saddam) and Qadisiya 1 districts of eastern Mosul are the battlegrounds of the moment. IS has blocked the streets with concrete barriers to impede the Iraqi military advance, and the Iraqi army has constructed earthen berms with the aim of slowing down the IS car bombers. The gunfire is constant; so, too, are the boom and thud of suicide attacks and coalition air strikes.

“Here come the French,” said al-Abeidi, as fighter aircraft roared overhead while another explosion shook the eucalyptus and citrus trees of the neighbourhood’s gardens.

On the front line, a four-lane road separates the Golden Division’s Bravo Company from IS. On the lookout in an abandoned house, a young sniper named Abbas pointed out a dead IS fighter lying a few hundred metres away. “Over the last four days, I killed three Da’esh [the Arabic acronym for IS]. But my buddy, he killed four or five,” he said.

A car bomb detonated nearby, the shock wave blowing out what was left of the room’s windows. A French photographer accompanying us, who had refused to wear a helmet, almost dropped his cigarette.

Abbas fired into IS territory, a precaution in case the car bomb was followed by attackers on foot. He continued: “Here, the difficult thing for us is that IS fighters carry babies in their arms, and all of them look the same – they have beards.”

Outside, it looked and smelled like a war zone. Shops had been destroyed and I saw a burnt-out suicide truck that had crashed into a storefront. The street was littered with the remnants of another car bomb.

Car bombs are the IS equivalent of cruise missiles. The militants have no aircraft, so they rig up and deploy these heavily armoured high explosives on wheels instead. The unit I was with had at least two a day aimed at it. They move fast and are often hidden, lying in wait. Only when the military think that a neighbourhood is clear do they appear, driven at speed and often with deadly precision.

None of the forces fighting IS – the Iraqi army, the Kurdish peshmerga, the Shia militias – releases casualty numbers. If any ever does, these will show that many of their men were killed by car bombs.

To avoid the militants’ RPGs and sniper fire, Bravo Company created rat runs through homes and backyards. My guide to the front line was called Sergeant Haider. Rooms and upturned domestic life flashed past us. The sergeant’s Frank Zappa moustache and wraparound shades were complemented by a grey knitted beanie. He looked like he should have been snowboarding, not touring a front line.

“There are many more Da’esh here than in Anbar,” he said, referring to the province where Fallujah and Ramadi are situated. “Because this area has been under its control for two and a half years, Da’esh has really taken control. This looks like just the beginning of [retaking] Mosul.”

Iraq’s prime minister, Haider al-Abadi, wants Mosul “liberated” by the end of the year. That is unlikely to happen. It will take a month at least, perhaps more, to make it to the banks of the Tigris, which runs through the city. And IS is concentrated in the west. Across the river, there is worse to come.

***

The scar that Rana Ibrahim Hamad carries is not visible. It is a memory of the baby she lost shortly after giving birth during IS rule. “I lost the baby because doctors were not available. The baby had a brain haemorrhage and died,” she told me, standing on the street. We could hear the sounds of a gun battle nearby but Rana didn’t blink – she had grown used to it.

It was the first time that she, her husband, Amer, and their three-year-old daughter, Azel, had left their home in five days. Until then, the fighting around them had been too fierce.

Rana was pregnant again and ready to give birth any day. After detailed questioning by the military, the family would be allowed to leave for a hospital in Erbil. An armoured Humvee would be their ambulance.

She told me that she hoped that having the new child would help her forget her loss. “Life is difficult,” she said. “We all live in fear. Pain is coming from fear. I pray it gets better.”

In October, I flew over Mosul with the Iraqi air force. It was not on a combat run, but on a propaganda mission. Under a bomber’s moon – full and bright – the planes dropped leaflets by the million, sometimes still in their cardboard boxes, from the side doors of a C-130 cargo plane. Below, the land was lit up, roads and buildings illuminated and stretching for miles in the dark. From 17,000 feet, Mosul didn’t look like a city under occupation. It looked alive.

Later, in its industrial suburbs, I found a few of the leaflets in the dirt. Some, at least, had found their target.

“Nineveh, we are coming,” they proclaimed, a promise to Mosul and the surrounding province. They encouraged people to stay away from IS buildings. And the Iraqi government told people not to flee. It feared that there would be a humanitarian crisis if the city, which has more than a million residents, were to empty.

As Mosul’s fight enters its second month, however, services are still largely absent. “The army brought us food and lentils but there’s no government,” said Bushra, a woman from the city of Tikrit who is now trapped in Mosul. “We are living, but [we have] no water or electricity. We sleep at eight. We don’t have any services. I didn’t get my husband’s salary this month. We live off his pension.”

As the men of the Golden Division move through houses and parts of the city, they find more than just IS dead, weapons and supplies. They also discover records of rule. Although the group is cruel and murderous, it keeps tidy books and distributes welfare. We found dozens of the militants’ ledgers, recording payments made to widows, the poor and the sick.

***

Across Iraq, senior military and police commanders complain that Baghdad is not moving fast enough to fill the gaps left by the fighting, and that although they distribute water, food and medicine to local people, their men must come first.

In the war against IS, no city has been bombed more than Mosul. The coalition air strikes come day and night. The only let-up is during bad weather, which also results in ground operations being paused.

According to some monitoring groups, as many as 1,300 civilians have been killed in coalition air strikes so far. Yet it is Islamic State that is doing most of the killing, through executions and sniper and mortar attacks. The militants have murdered and continue to murder hundreds of people inside the city each week.

During one patrol, an IS sniper pinned down the unit I was with inside a house. One by one, the soldiers ran to their armoured vehicles – me among them – and to safety. The bangs sounded especially loud. We soon discovered why. The marksman was firing armour-piercing bullets. One managed to penetrate the turret of a Humvee and the gunner inside it was wounded.

Mosul, the beautiful, once-cosmopolitan centre of northern Iraq, became a mystery under IS. The fighters cut off its contact with the outside world. At the edge of the city, I walked through a former IS workshop. There, between 20 and 30 men had cast and milled mortar shells every day. Thousands of the steel casts remained in piles, waiting to be finished. The roof of the foundry had been peppered with shrapnel. IS had tried to conceal the factory from passing aircraft by burning oil fires through the roof.

It struck me then that the militants had spent their two years in Mosul with one priority in mind: preparing for this battle. Who knew how many mortar shells, filled with explosives, were now inside the city, ready to be fired? This was weapons production on an industrial scale.

“Isis was scared shitless of the Iraqi soldiers. Believe me, we saw. They pissed their pants,” said Alaa, an English teacher who lives near the front line. White flags were hanging from homes along the street. He described to me the past few days of fighting and how the Iraqi special forces had ­arrived in his neighbourhood.

“Now I feel safe, because they are here,” he said. “And if they need any support, all these people will be with them. Even the people who were influenced by the Isis talk, now they are not, because they endured two years of suffering, two years of depravation, two years of killing, mass killing.”

At the mosque across the street from Alaa’s house, males over the age of 13 were being lined up for security screening, to see if they were IS supporters. The soldiers kept their distance, fearful of suicide bombers. The local people carried their identification papers. Some had shaved off their beards but others had not. They did not share Alaa’s optimism, and said they were afraid that IS could return.

***

Safar Khalil’s wound had no time to heal and become a scar. The bright red hole in his chest came from an IS sniper round, his brothers said. A medic tried to plug it with his finger and stabilise him but the damage inside was too great. Safar’s lungs were gone.

He spewed out dark, thick blood. His face was covered in it. And there, in front of me, he died.

Two of his brothers – one a small boy, the other a young man – stood screaming nearby. They had left their home only a few moments earlier to sell eggs. An army sleeping bag was brought to cover Safar’s face. At first, I thought he was a teenager, because the blood and gore made it difficult to tell how old he was. On his right hand, he wore a heavy ring with an amber stone. Afterwards, I learned that he was 26.

They took his body on a cart back to his home. From inside the house, grief exploded. The women, his relatives, tried to run out, fear and rage written on their faces. But it seemed that the sniper was still nearby, so they were pushed back inside and a family member pulled hard on the metal door to keep them contained.

The women’s voices filled the neigh­bourhood. In the middle of the street, looking horribly alone, Safar’s body lay on the cart. It was not yet safe enough to take him to the cemetery.

There are other fronts in the war to retake Mosul: the federal police and army are moving in from the south and may soon retake what is left of the city’s airport. To the west, the Shia militias of Iraq’s Popular Mobilisation Forces have cut off escape routes to Raqqa in Syria and are on top of the IS stronghold of Tal Afar. In the north, several towns and villages have been taken by the Iraqi army’s 16th Division and the Kurdish peshmerga.

But it is in the east that Mosul proper is being cleared of IS militants. Major al-Abeidi’s convoy was hit again the other day. He sent me pictures of his badly damaged Humvee and complained that he had lost the car and spilled his energy drink.

“We’ll be at the river in weeks,” he said confidently. Until then, eastern Mosul and its people will remain in the maelstrom – surviving not in a city, but on a battlefield.

Quentin Sommerville is the BBC’s Middle East correspondent

This article first appeared in the 24 November 2016 issue of the New Statesman, Blair: out of exile