• civil unrest
• GHQ-12
• firearms
• social capital
• social disadvantage
• the Troubles
• Northern Ireland

Mental ill health is the new global epidemic and its wider determinants of great social significance.¹ In this issue O’Reilly and Stevenson present findings from Northern Ireland indicating that the prolonged civil conflict there seems to have had an adverse effect on the mental health and wellbeing of citizens.² The study is of interest for several reasons. Firstly, Northern Ireland is an internationally famous example of a longstanding violent political conflict apparently resolved by a major peace initiative over the past five years.³ As there are many such political trouble spots globally, the immediate and longer term public health implications are always of interest. Secondly, the specific independent measure reported in this study, the GHQ-12, is a well validated indicator of mental health status and the interpretation of its significance is important.¹ Thirdly, internationally both the social variations and health promotion literature have focused increasingly on concepts of social capital and cohesion in interpreting how macrosocial processes might affect individual and community wellbeing.^4,5 In this context the breakdown of community relations to the point of outright conflict, particularly in circumstances of material disadvantage, is highly pertinent to our interpretation of this paper.

The data O’Reilly and Stevenson present are based on the Northern Ireland Health and Wellbeing survey of 1997. In assessing the impact at area and personal level of “the Troubles”, careful account is taken of religious affiliation, socioeconomic status, long term illness or disability, major life event stressors, and available social support. Their findings show an independent effect on GHQ-12 caseness score of personal and area based exposures to the Troubles, even when these various socioeconomic indicators are taken into account. Notwithstanding this, it is also true that those living in disadvantaged circumstances were much more likely to rate an impact of the Troubles on their lives. For confidentiality purposes, it was not possible to link individual level data directly to specific postal areas, which might have afforded a more in depth multilevel analysis on the directionality of this phenomenon, including other ecological level contextual data. We cannot therefore say with certainty how precisely the effect of the Troubles is mediated at individual level.

Many individuals and families since 1968 were directly affected by material or personal loss. More indirectly, prolonged exposure to fear of injury, death, or bereavement might well lead to anxiety and distress in vulnerable people, even if in statistical terms their absolute risk exposure is small. These are the two main pathways proposed by O’Reilly and Stevenson.² The material disadvantage and restriction of amenities associated with the conflict might have a role in specifically vulnerable communities. It is also possible that the hostility and distrust inherent in the conflict might affect individuals’ sense of wellbeing and control, an argument more in keeping with the social capital literature.^4,5 Though these data were collected in 1997 at the outset of the peace process it should be noted that paramilitary style shootings and beatings continue at community level and arguably have little if anything to do with the larger political agenda. This holds resonance for the debates in the general health inequalities literature, where prevalence of violent crime, particularly related to firearms, has been associated with increased mistrust, personal vulnerability, and increased rates of mental ill health. Hseih and Pugh conducted a metanalysis of available literature in 1993 that emphasises the role of poverty and relative disadvantage in predicting violent crime.⁶ Similarly Kennedy et al relate firearm associated crime to measures of income inequality and social mistrust in the United States.⁷ Understanding conflict they assert requires an appreciation of wider material and psychosocial determinants than the immediate availability of weapons.

Ireland provides specific context in deconstructing how and whether national and local politics might affect health. The island of Ireland has been partitioned since 1922, Northern Ireland remaining as part of the United Kingdom with England, Scotland, and Wales and Southern Ireland now an independent republic. The two jurisdictions share many common characteristics and there has historically been high migration out of Ireland, that diaspora having a poorer health profile over at least two generations, based on present evidence.^8,9 This is explained partly, but not completely by social disadvantage and adverse lifestyles. Both North and South of Ireland have relatively poor mortality patterns compared with other European neighbours, with high rates of cardiovascular disease and of some cancers.¹⁰ Findings from the PRIME study of cardiovascular disease in France and Northern Ireland indicate that the differences are not explicable by traditional risk factors.¹¹ There is some evidence that adverse Type A characteristics are more prevalent in Northern Ireland.¹² However, genetic predisposition, perhaps mediated through diet is another suggested explanation.¹¹

Where North and South diverge, interestingly, is in self rated measures, as seen in this study by O’Reilly and Stevenson.² In fact several studies of self rated health, satisfaction with life, and GHQ-2 scores show that those in the Republic of Ireland have paradoxically positive self ratings, whereas GHQ-12 scores in the North are worse than in all their neighbouring countries.^1,10 We have argued previously that the positive social capital in the South has not translated into better objective patterns of morbidity and mortality however and that patterns of material disadvantage must also be taken into account.¹⁰

Until recent times Northern Ireland was comparatively more industrialised and affluent than the South. Many large employers, often associated with one religious persuasion have scaled down or disappeared. Economic gains have been higher in the South for a variety of reasons, including its status as a member state of the European Union. At least one adverse impact of “the Troubles” has been the hampering of economic investment in the North so that it is in many respects the most disadvantaged area in the United Kingdom. Sociodemographic factors expressed partially through religious affiliation have played a continuing part. Catholics tend to be more deprived than Protestants and to have poorer health profiles but the religious difference disappears when socioeconomic circumstances are taken into account, as O’Reilly and Stevenson have shown previously.¹³

This divided society has its roots in Irish political history. In simplistic terms for the general reader, the root of the “Irish Question” over several centuries has been the wish of Nationalists, mainly but not exclusively of a Roman Catholic tradition, to become independent of the United Kingdom and the wish of Unionists, again mainly but not exclusively of Protestant tradition, (and in a majority in Northern Ireland since partition in 1922) to remain in the United Kingdom. This is not a simple sectarian issue however and indeed it is possible to legitimately hold either point of view without resorting to violence. Furthermore, early Nationalist Republicans were often non-conformists inspired by the enlightenment tradition and the revolutions in France and the USA. What matters to some analysts is the economic basis for this conflict, as Ireland traditionally has been much poorer than the rest of the United Kingdom, (with the arguable exception of Northern Scotland) and suffered a devastating famine period in the mid-19th century. Alexis De Tocqueville, for instance, who found much to praise in the emerging Republic of the USA, was scarified by the disadvantage of the Irish peasant.¹⁴ As that peasantry was overwhelmingly Catholic and the Protestant plantation immigrants into the country over the past three centuries were likely to take up land holdings, the fundamental part played by relative disadvantage in understanding the Nationalist politics of Ireland is critical.

What then is the directionality of these processes? Is material disadvantage a root cause or a result of ethnic, racial conflicts? The immediate probable explanation for the adverse mental health profile in Northern Ireland is as a consequence of the conflict in itself rather than the wider determining history, not least because North and South diverge so sharply in mental health indicators. The psychosocial hypothesis as a mediating influence in relative disadvantage is an attractive possibility but the issues are complex and more direct evidence of an independent effect is required, particularly in assessing disease specific pathways.

We do not need to understand the precise mechanisms at a social scientific level to make a general public policy point that access to weaponry leads to injury and death, particularly in vulnerable, disadvantaged communities. Exposure to that risk causes mental distress that can be clinically significant. Reducing access to weaponry requires political solutions by bringing people to the point of negotiation. Both top-down and bottom-up strategies are needed to achieve this. It seems reasonable to suggest however that getting the gun out of Irish politics was seen to be the critical first start to breaking the vicious circle of violence,³ just as getting the gun out of American ghettos might have the same cogency in the long run, in very different sociopolitical circumstances.

Finally what action may be taken at community or health service delivery level? The authors indicate that clinical significance of GHQ caseness scores at a population level are disputed. They also produce evidence that actual health service utilisation has not increased.² Whether therefore the solution lies in treating the population as potential patients or attempting to instigate community level changes is the question. In this respect several initiatives have been taken in the past few years at cross-border level and community levels to try to reduce barriers around stigma related to mental illness and also to foster more health promoting community relations. These have been reviewed recently for the Institute for Cross-Border Studies.¹ While the initiatives are admirably motivated, many are at an early stage and few are systematic enough to render measurable outcome data, which is indeed an exciting challenge for the mental health promotion literature generally.