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War can be seen as a crucible in which global geopolitical forces act on a population in a transformative manner. The psychological impact of war can be described in many ways, from the diagnostic to the narrative, from the intrapersonal to the relational. This paper explores whether the forces driving the conflict relate to the consequent psychological processes of those caught up in it. Geopolitical drivers, underlying global issues and the consequences on mental well-being are described. The models we use to define the consequences of war determine the degree to which the causes are seen as relevant to restorative, transformational or therapeutic processes; however a simple model reducing the consequences to traumatic events and symptoms, whilst having some validity, is not a sufficient description of the human experience. Understanding the causes and consequences of war is a multidisciplinary venture.

Mass violence carries with it an enormous impact on health; the psychological impact is well recognized but poorly understood. There is a need for health professionals around the world to learn basic issues about the psychological impact of violence and to have available more specialized training to equip them with skills necessary to work directly with victims of mass violence. Organizing mental health services in conflict and in post-conflict situations requires many skills and complex work across sectors. Understanding mass violence from a public mental health perspective provides a framework for a curriculum that covers treatment for individuals and interventions for populations as well as exploring the mental states and social relationships which promote peace. Training implications are broad and should take account of individual and population needs, but also of a deeper human need to understand and contain that violent side of our nature that threatens us with extinction.

All people with learning disabilities should be able to choose from a variety of residential placements as a way of achieving greater community integration. However, many are still placed away from their borough of origin, resulting in complex consequences for them, and their families and for clinicians. This article explores the nature of the problem, defining the current issues, and examining the role of the stakeholders and the implications for psychiatrists working in this field.

The education of doctors shapes their professional identity: who they are and how they practise. Where does the issue of learning disability fit in? What is it and of what factors should doctors in training be aware? The training of medical students has been defined by the General Medical Council (

This survey describes the socio‐demographic, clinical and forensic variables of all patients referred to a medium secure unit in the psychiatry of learning disability. Of the sample, 67.5% were referred following an index offence and 76.6% had at least one previous conviction. Just over half (50.6%) came from either prisons, special hospitals or medium secure units and the remainder from mental health/learning disability hospitals or community resources. The majority (91.7%) had prior contact with a mental health or learning disability team. Most (81.5%) had a mild or ‘borderline’ learning disability, 46.8% had either a psychosis or major mood disorder, 58.4% had personality disorders and 56.6% had a history of illicit substance abuse. Of the 79 referrals 29.1% were accepted for admission. Arson as an index offence and a previous conviction for arson were significantly associated with being accepted for admission.

This article describes a project run by MEDACT in conjunction with UNICEF, supporting local mental health professionals who were providing treatment to children in the Federal Republic of Yugoslavia following the war in Bosnia and Croatia. It explores issues of engagement, of the responses of professionals and of understanding some of the psychological processes at work. It also describes a model of working with overseas colleagues in disadvantaged circumstances which is compatible with life in the busy UK health service.

(1998). The SIrUS project towards a determination of which weapons cause ‘superfluous injury or unnecessary suffering’. Medicine, Conflict and Survival: Vol. 14, No. 3, pp. 243-249.

In this article, the experiences of persons with epilepsy were explored in terms of coping with providing a basis of discussion and training to support groups, particularly in Zimbabwe. Coping mechanisms lay stress upon the individual's control in mastering the disease. It was assumed that a systematic research effort of intra-cultural and cross-cultural sharing of experiences could enhance discussion and training in the support groups. Coping with epilepsy was explored with 37 adults (27 from Zimbabwe and 10 from the Midwest, USA) using open-ended questions in a written questionnaire. Questions aimed to elicit general feelings, experiences and strategies and skills in coping with epilepsy. The questionnaire covered such semantic domains as childhood, education, employment, friendships, relations within the family, and handling of seizures in public places. Coping mechanisms were categorized into two modes, one, adjustment to the disability (palliative), the other adjustment to the environment (problem-solving). In comparing the information between the two groups, some trends can be distinguished which need a larger scale validation. First, palliative skills during childhood in the Zimbabwean group is indicative for early development of personality characteristics and socialization as a result of the illness experiences. A great variety in palliative mechanisms in handling seizures indicates better familiarity with seizures in the Midwestern group. Similarities between the two groups are found in the friendship domain, where palliative coping skills seem to be of no importance, as well as in the domain of intimate relations, where a trend in adherence to medication is observed in both groups. Second, many problem-solving skills are developed in both groups but vary in context. In view of public education and training activities and the enhancement of problem-solving skills, the domain of education for the Zimbabwean group and the domains of friendship with the Midwestern group and the family perhaps deserve more attention. Third, coping skills in the Zimbabwean group tend to be related to the experience of 'being different', while in the Midwestern group 'not being able to doing things' is a major experience. Fourth, in linking coping mechanisms to the cultural environment, two major cultural influences in Zimbabwe stand out as being different from the Midwest, the first being the belief in external control and cause of mental and physical health, and the second, cultural conflict.

Violent conflict for political ends, including war and civil war, is a major cause of mental ill health and although there are different approaches and ways to understand this relationship some consensus is emerging on the psychological, social and cross sector responses to post conflict situations. Globalization has changed the relationships of nation states, corporations and international organizations creating different patterns of political violence and different ways to organize the responses. Victims, weapons and humanitarian aid are considered within a public mental health framework, describing the consequences of war and other forms of political violence. Secondary and primary levels of intervention in public mental health consider the monitoring, preparation for and prevention of political violence, taking the new sciences of human relationships as a basis to look at international relationships. The need to re-establish a reformed United Nations at the centre of global decision making and to increase the global expenditure on peace making are two conclusions from this analysis.

First apologies for the short issue; unfortunately we had to withdraw a paper and a book review at the last minute around issues of risk and copyright; but more of that later. The continued work of...

Medical student electives havecome a long way since theirintroduction in the 1970s. One ofthe authors of this commentaryremembers (fondly) his elective inUganda, shortly after its liberationfrom the murderous Oboteregime, and just as the HIV epi-demic took hold. Negotiating roadblocks manned by 13-year-oldsbrandishing Kalashnikovs seemedexciting and character-building,although we doubt if many med-ical schools today would supportan equivalent experience in, say,the Democratic Republic ofCongo or Somalia. Preparationand support from the medicalschool was close to non-existent,whereas now there would almostcertainly be briefings about howto minimise risks such as thosefrom HIV, malaria and road trafficaccidents. This experience con-trasts in terms of its organisation,although probably not in educa-tional impact, with the interna-tional electives at MaastrichtMedical School described in theevaluation study reported byNiemantsverdriet et al.

The recent International Committee of the Red Cross report, Civilians without Protection, makes it clear that the conflict in Iraq is inflicting immense suffering on the civilian population.1 Mental health as an aspect of suffering in war has been receiving increasing attention, with particular concerns centring on children because of their vulnerability and the growing awareness of the potential long-term harm to society through disruption of human attachments, and the development of aggressive patterns of behaviour, which have the potential to aid recruitment to terrorist networks.2,3 There is debate about models of treatment, resources for reconstruction and protection of the innocent. Iraqi children and adolescents form more than 55% of the Iraqi population (29 million people). Over the last two decades they have experienced high levels of psychological trauma, such as loss of parents due to imprisonment or death, dislocation of families, exposure to violence and conflict, and the witnessing of scenes of carnage; many have suffered religious and political persecution, detention and torture. Since 2003, rates of direct physical harm and abuse have been high. There is no hard data on child deaths, though Burnham et al. record 26 of the 300 violent deaths in their survey as being children under the age of 14;4 it is therefore likely that many tens of thousands of children have been killed and injured in this conflict. There is concern about an increase in physical violence against children within families. There are also a significant and growing number of orphans for whom no organized services are available. Many reports indicate that insurgent groups and militias are involving minors, including orphans and children of insurgents, in the fight against the Multi-National Force (MNF) and Iraqi Security Forces (IFS).5 Children have been arrested and detained by the MNF and by the IFS. There are reports that children are held in the same cells as adult detainees and subjected to the same treatment, including torture. Human Rights Watch recorded the case of a juvenile who was beaten with cables and underwent falaqa (beating on the sole of the foot) while being held in the custody of the criminal intelligence service.6 An estimated four million Iraqis—nearly 15% of the total population—have fled their homes, 50% of whom are children. Approximately 1.9 million people have sought refuge inside Iraq, and 2.2 million have crossed the border into neighbouring countries. Amongst those fleeing are doctors, nurses and teachers—a devastating brain-drain that is leaving many Iraqi children without access to quality education and basic health care.7 The impact of all this on the mental health of children and adolescents must be great. A study in Baghdad in 2006 showed that 47% of children reported exposure to a major traumatic event during the previous two years; 14% suffered post-traumatic stress disorder (PTSD). In a second study in Mosul, 30% of adolescents had symptoms of PTSD.8 Other studies have shown that up to 50% of Iraqi children have behavioural problems. The response to these problems has to take into account the high levels of threat, the different developmental stages of the affected children and the diverse and different cultural values, and requires ongoing debate and development. Key to it all is social stability, especially for the family, and continued education.9 However, an estimated 50% of children living in urban areas no longer go to school because of the security threat. In rural areas the numbers are even higher; in some areas drop-out rates for attendance in 2006-2007 were as high as 70%.10 UNICEF has called for greatly increased support for education and basic services for the two million Iraqi children now displaced and relocated in more stable areas, and has launched an appeal for US$42 million.7 The mental health services, along with other health services, have collapsed, and while security is a crucial consideration, there has been great concern expressed about the failure of promised resources to materialize and the misuse of resources once in Iraq.11 In 2003 the World Bank estimated that $56 billion was required to rebuild Iraq, of which $33 billion was pledged. So far only 56% of the money promised to Iraq in 2003 by the international community has been made available.12 Over the four years since 2003, the UK Department for International Development has donated £107 million for health care in Iraq12 (about 93 pence per capita per annum). Last year Medact reported that despite $1 billion being given to the health system by the US, 25% of this had gone on security and the Iraqi Ministry of Health was estimating that $8 billion was required over the next four years, in addition to operating costs.11 Prevention is an essential medical approach. The protection of the innocents in war has been a key theme of the Geneva Conventions and, along with the UN Convention on the Rights of the Child, provides a legal framework by which child protection can be addressed by state signatories. The International Criminal Court can provide the framework to prosecute parties breaching these conventions, especially the recruitment of children into military and para-military activities. A strengthening of the UN High Commission for Human Rights and the role of the Special Representative for Children in Armed Conflict is required. However, if dominant states are not brought to account for alleged wrongdoings, such as detention and torture of children, then the chance of these laws becoming firmly established is reduced and the protection of children in war is less likely. The situation in Iraq is an example of the dreadful human cost of war. If wars cannot be prevented then realistic resources need to be made available for post-conflict reconstruction, the laws protecting children need to be strengthened and applied, and the management of the mental health aspects of suffering need to be further developed. Whilst human resilience is an important notion, it is also important to consider the damaging impacts of war not only for the people caught up in it, but for the region and for humanity itself.2

The Iraq war, and the subsequent involvement of various stakeholders in the post con£ict reconstruction of the health sector, presented an opportunity to learn about mental health policy development, challengesand obstacleswithin apost con£ict context in 2003.This paper documents and explores mental health policy in post invasion Iraq, using qualitative methodsand a health policyframework that analyses context, content and process. Findings indicate that there are many challenges, both in repairing an already weakened health sector, and in maintaining mental health as a health priority. In addition to security issues, fragmentation of power, change of leadership and lack of funding pose signi¢cant problems. Achievements are evident, though insu⁄cient to address the overall mental health burden. The policy process is examined over a four-year period. Lessons learned are presented as best practice guidelines for post con£ict mental health reconstruction.

The term Global Health has become increasingly used over the last decade; whilst some debate remains about its meaning and how it has emerged, there is a growing consensus that it applies to the he...

Medical Action for Global Security (MEDACT) is an organisation whose members are mostly from the health professions and are committed to nuclear disarmament, prevention of organised conflict, third world development and enhancing the prospects of a safer and healthier world. In 1994, UNICEF UK approached the psychosocial group of MEDACT, which was working on refugee issues, to see if they would offer assistance to the UNICEF psychosocial pro grammes for war-traumatised children in the former Yugoslavia. The group, numbering about 15 from a variety of disciplines, held a series of meetings to discuss this possibility, to educate itself and to develop a model of practice. It was felt that by using a cautious, reflective approach, support could be offered by means of short visits on an ongoing basis to various UNICEF projects in the former Yugoslavia. A contract was established whereby UNICEF met the local costs and MEDACT met travel costs through fundraising. Four programmes of visits were established, this paper describes two.

EDITOR,—Three recent papers highlight the potential impact of global threats to health.1 2 3 Over the past two years clinical students at two medical schools in London have been given a questionnaire, before seminars in primary care or public health, seeking their views about the greatest threats to the health of humans in the next 30 years. They were asked to write five threats in order of priority, on …