Conflict, peace and mental health

Addressing the consequences of conflict and trauma in Northern Ireland

David Bolton

• Publisher: Manchester University Press
• Year: 2017
• ISBN:
  9781526116406
• Edition: 1
• Topic: Histoire
• Subtopic: Histoire de l'Irlande

What are the human consequences of conflict and what are the appropriate service responses? This book seeks to provide an answer to these important questions, drawing on over twenty-five years of work by the author in Northern Ireland and elsewhere. Focusing on the work undertaken following the Omagh bombing, the book describes how needs were assessed and understood, how evidence-based services were put in place, and the training and education programmes that were developed to assist first those communities affected by the bombing and later the wider population affected by the years of conflict. The author places the mental-health needs of affected communities at the heart of the political and peace processes that follow. This is a practical book and will be of particular interest to those planning for and responding to conflict-related disasters, policy makers, service commissioners and providers, politicians, civil servants and peace makers.

1

The Omagh bombing and the community’s response

On the afternoon of Saturday 15 August 1998, at around 3.10 p.m., a car with a bomb on board exploded in Market Street, one of the main shopping streets in Omagh, Co. Tyrone, Northern Ireland. The explosion killed 29 adults and children, including a woman at an advanced stage of pregnancy expecting twins. Over 400 people were injured, of whom 135 suffered serious injuries; 12 children aged 0–12 years and 39 people aged 13–20 years were hospitalised (Jenkins and McKinney, 2000). Seven hospitals in Northern Ireland received casualties on the day, with two more hospitals providing specialist services in the days that followed. The bombing was the largest single incident, in terms of dead and injured, that had occurred during the civil conflict in Northern Ireland, which had commenced in 1969 (McKittrick et al., 2007). In the words of Froggatt it was ‘the worst of many’ examples of carnage (Froggatt, 1999: 1637). The explosion and its traumatic consequences were experienced and witnessed by thousands of people who were present at the time, or in the immediate aftermath at the scene, in the hospital nearby, and in other locations in the town.

The bombing came just four months after the Northern Ireland peace agreement, known formally as the Belfast Agreement (1998) and more informally as the Good Friday Agreement. The Agreement had been signed by the British and Irish Governments, with the support and agreement of most of the political parties in Northern Ireland, and the support of the United States of America. The bombing had been carried out by two proscribed Irish republican groups, the Real IRA (Irish Republican Army) and the Continuity IRA, which were opposed to the political settlement that had been agreed earlier in the year. Apart from the human tragedy of the bombing, the atrocity immediately gave rise to significant concerns about the stability and future of the political agreement (Dingley, 2001).

As outlined in the Introduction, two days after the bombing, the British Secretary of State with responsibility for British direct rule in Northern Ireland, Dr Marjorie Mowlam M.P. visited Omagh and met with many of those who had been directly affected, including emergency services, politicians and clergy. She also met with health and social care staff who had been involved in the immediate response to the bombing and who were already putting in place arrangements to respond to the community’s needs. Dr Mowlam enquired about the immediate and longer-term implications of the bombing. She asked two important questions. The first was what the human impact would be. The second was what should be done to address the needs of people affected by the bombing. After a discussion on these fundamental questions she asked for a report and advice on how best to proceed. She was anxious that there would be no obstacles to people receiving help, and asked that strategic coordination arrangements be put in place to ensure that delays and unnecessary bureaucracy could be overcome. The report was prepared and sent to her shortly after her visit (Bolton, 1998).

Earlier in 1998, as part of the work undertaken in the development of the Belfast Agreement, Dr Mowlam had commissioned a report on the human impact of the years of civil conflict, to include recommendations on the responses required to address the identified needs. The work was undertaken by a former head of the Northern Ireland Civil Service, Sir Kenneth Bloomfield. His Report, We Will Remember Them (Bloomfield, 1998) was published in May 1998, some weeks after the Belfast Agreement, and three months prior to the Omagh bombing. The report described and evaluated the experiences of those affected by violence linked to the conflict, and made a number of recommendations for addressing the impact. The initiative was the first governmental comprehensive assessment of the human impact, since the most recent period of violence (the Troubles) had commenced in 1969. Another report from Northern Ireland’s Department of Health and Social Services (DHSS, 1998), which was published within weeks of the Belfast Agreement had made further recommendations focusing on some health and social care issues. In the wake of the Omagh bombing, these reports and their recommendations created new possibilities and expectations as to how the impact of the bombing could and would be addressed.

The initial responses to the bombing

Within minutes of the bombing, the local hospital in Omagh, The Tyrone County Hospital, which was located less than a kilometre away from the scene, began to receive casualties. The small accident and emergency facility was quickly overwhelmed and other areas of the hospital were put into service to receive and treat casualties. The ambulance service and local people brought casualties to hospital in cars, taxis and commandeered buses. Soon after, helicopters from the nearby army base began to transfer seriously ill casualties to the regional trauma centres in Derry/Londonderry and Belfast, and the overflow of less seriously injured to the sub-regional hospitals in Enniskillen and Dungannon. Local general and military medical practitioners also provided immediate treatment. Staff from the hospital who were on leave went to the hospital after a public appeal for help that was broadcast on radio and television. Medical, nursing and various health and social care practitioners from other parts of Northern Ireland and the Republic of Ireland came to Omagh to assist. Practitioners from other places who were in or close to Omagh on the day also offered their help.

Alongside the care and treatment of the casualties, a large number of people from the local community, who were concerned for relatives and friends, began to gather at the hospital seeking information. Community-based health and social care staff and staff from local not-for-profit organisations, working with the hospital staff, quickly set up arrangements to assist those who were seeking information about relatives. The demands were such that it was decided to move the missing relative enquiry service off the hospital site to the nearby Omagh District Council leisure centre, at the invitation of the Council’s chief executive. This was a very suitable facility, providing large spaces for people to gather, private areas, toilets, telephones and a restaurant, and was very accessible to the hospital and other key facilities in the town, such as the temporary mortuary at the local Army barracks. The decision also had the effect of diverting many hundreds of people from the hospital to an alternative location, providing more space at the hospital for the care and treatment of the casualties, and space and privacy for their families. Also, the focus of the media at this stage was on the hospital. This meant that the response team at the leisure centre was able, at least in the early hours, to carry out a sensitive and complex task with bereaved families without a large media presence.

Within hours, and continuing over the following thirty-six hours, the leisure centre became the focal point for coordinating details about the location and movements of people who were reported missing and those who had been transferred to the regional hospitals. Later in the evening on the day of the bombing, details of those who were missing and unaccounted for were coordinated by police and health and social care staff with information about those who had been killed. Preliminary information about the possible death of loved ones was shared with families, whilst further information was being sought. The rupture of a major telephone cable in the explosion, along with the heavy traffic on both landlines and mobile phone systems, meant that there were great difficulties in communications. Fortunately one telephone line from the leisure centre remained operational throughout and this was restricted to urgent telephone calls with, for example, the nearby hospital, the police casualty bureau in Belfast, and regional hospitals.

Towards midnight, family representatives of those who were missing and believed to be dead, police, staff from the leisure centre, local clergy and the health and social care team assembled in a more private room to be briefed on the arrangements that would follow to undertake identification of the dead. The senior manager with the Sperrin Lakeland Health and Social Care Trust (the local public health services provider) and the senior police officer, who were coordinating the efforts to locate the missing and identify those who had been killed, briefed the gathering. The proposals on how identifications would be undertaken were outlined. It was going to take a long time and families were offered assistance to go home if they wished to change clothes or to allow another family member to take their place at the leisure centre. This solemn and sad gathering concluded with a short address by the chief executive of Omagh Council, and with prayers by two Christian church leaders, the Catholic Bishop of Derry and the President of the Methodist Church in Ireland.

Throughout the night, family-by-family, relatives were brought to the temporary mortuary at the army barracks by the police, supported by each family’s choice of clergy, friends and other relatives, or health and social care staff, to undertake the identifications. The arrangements for those who had died and for their identification were very sensitively put in place by the army with advice from Omagh’s most senior police officer and the Sperrin Lakeland’s community services director. A sports pavilion was made available as an anteroom, where tea and coffee were provided, and where families could gather and be briefed by the police on what would take place. Next door was the viewing room, which had been carefully prepared in a short time with flowers and appropriate furniture to be as respectful and supportive as possible. Depending on the religious denomination of the family, religious artefacts were assembled in the room for each identification. Some families had more than one person to identify. After the formalities of identification were over and families had spent some time with their deceased relative, they withdrew to the anteroom, where they were given time to compose themselves and where any questions they had could be addressed, before returning to the leisure centre. These arrangements also overcame the added difficulty of bringing identifying relatives into a mortuary where there were deceased persons, other than their family members. Considering there were, at that point, twenty-eight deaths, this took all of Saturday night and well into Sunday. It was a very difficult period for the families, who were greatly distressed. Many of those who had died, or their families, were known personally to staff from the police, the leisure centre, the clergy and the health and social care team, which included staff from not-for-profit agencies. The loss of so many, and the evident distress of their families, was deeply felt by all. Who could have imagined that a day could end like this?

The human impact

By the following afternoon the number of deaths was confirmed at twenty-eight, including the woman carrying twins. It became and remained important for the community to remember the twins in the deadly toll of the bombing. At that point, one person was unaccounted for but was subsequently confirmed to have been elsewhere at the time of the bombing. Another man was to die from his injuries three weeks later. Two days after the bombing a man died in a collision between his car and an ambulance transferring patients between hospitals. He and his family were subsequently remembered as an indirect casualty and bereaved family of the bombing.

Of the over 400 who had been injured, 135 were very seriously injured, with severe burns, severe soft tissue injuries or traumatic amputations. It was also clear that thousands of people had been exposed in one way or another to the experience of the bomb explosion or its immediate traumatic consequences. This included those who were in Market Street, where the bomb had exploded, and those who had felt the explosion from nearby shops, car parks or other streets, many of whom went to Market Street in search of relatives or to offer assistance. The scene immediately after the explosion was profoundly traumatic. Others who were at a greater distance or in their homes and who heard the explosion also came in search of relatives whom they believed might be in the town shopping or working. Soon after, the emergency services began to arrive and they too were faced with a scene of devastation and seriously injured adults and children. Then, in the first hour or so, many who gathered at the hospital witnessed scenes of the seriously injured being brought in ambulances or in improvised and commandeered vehicles to the accident and emergency department. They witnessed great distress amongst those who were seeking relatives or who had otherwise been caught up in the tragedy. The urgency and scale of the situation meant that many civilians witnessed scenes that would normally only be seen by those directly involved, and by emergency service personnel in the most extreme situations. Later, similar scenes played themselves out in the leisure centre and the temporary mortuary, and in many homes across the town, in nearby villages and the countryside. Additonally, the impact of the bomb was felt beyond Omagh, in Buncrana in Co. Donegal, and Madrid, Spain, from where some of those killed and injured came. This was a deeply felt community tragedy for adults and children and their families and friends from the Omagh district, from both the nationalist and unionist traditions, with wider and international repercussions.

How the longer-term response took shape

It was clear within hours that the bombing posed a serious mental health risk for the bereaved, the injured, families, witnesses, rescuers, networks of friends and colleagues, school and faith communities, and those who had been involved in the care, treatment and support of casualties and the bereaved. Within hours, work began on putting together a strategy for addressing the mental health impacts. This would involve a range of interventions and responses, which are discussed in more detail below.

Whilst at one level the impact was understood, there was a need to communicate the impact and risks in a way that would stimulate and support urgent and appropriate policy and service responses. Concerns were expressed by the public, community organisations, family doctors services and mental health services about the psychological and mental health risks that would follow the bombing. However, it was not until the major studies discussed in Chapter 3 were undertaken that it was possible to provide robust estimates of the psychological impact of the bombing. In the meantime, politicians, service commissioners and civil servants wanted some assessment of the impact and a way of expressing this. There was a parallel need to provide a sense of hope and expectation of recovery for the community, as many in positions of leadership were concerned at the community, political and service implications. On sensing the scale of the human devastation caused by the bombing, one senior politician expressed deep concern as to how a community could possibly ever recover from such a blow and was at a loss to know what might be done politically to address the personal and communal consequences.

Table 1: Framework for considering the impact of community tragedies

Less negative impact		More negative impact
Expected		Unexpected
Contained		Extensive
Low horror		Intense horror
Few losses		Multiple loss
No displacement		Extensive displacement
No disruption		Extensive disruption
Control maintained		High loss of control
Minimal uncertainty		Sustained uncertainty
A shared and common view		Conflicting understanding
Accidental or natural		Inflicted/human cause

To convey where the bombing registered as a community tragedy, reference was made to a framework developed some years earlier to reflect upon the impact of the Enniskillen bombing of 1987 (Table 1). The framework provided a short series of questions that could be posed about community tragedies and their psychological and social implications, upon which decisions and actions could be based (Bolton, 1999: 203).

Using the framework to assess the impact of the bombing, a picture emerged of a significantly toxic psychological event in the life of the Omagh community, with potential risks for the psychological well-being of individuals, and associated social and economic implications. The bombing:

• was unexpected;

• was inte...