Belfast—a personal journey
We went to the cinema last week. Hardly something to write about. But this was different. It was the first time since the start of the pandemic. And it was different in another way too. Usually we go for entertainment, to be amused, informed, or thrilled. This time it was a personal journey, to see a film that took me back to the city of my birth. That film was, of course, Belfast. Written and directed by Kenneth Branagh, another Belfast boy who later moved to England, this semi-autobiographical film is shot in black and white. It conveys the grim reality he experienced as a child in 1969, growing up in poverty just as what we now know as The Troubles were beginning.
The Belfast captured in the film, and experienced by the young Branagh who is loosely represented by the nine year old Buddy, its star, was in many ways far from the one I inhabited. He lived in what was then one of the most deprived areas in Western Europe. Rows of two up two down Victorian houses had only outside toilets. Some didn’t have running water. I was brought up in the leafy suburbs, with parents, uncles, and cousins who were doctors. But I was very familiar with the scenes portrayed. My parents’ general practice straddled the sectarian divide. Their patients were divided by their religion, but united in poverty.
Often I and my brother, who would later take over their practice, would help out in their surgery or the local pharmacy. And it was at those times that we, like the young Branagh, witnessed riots like those portrayed graphically in the film. I still recall the time, when crossing a barricade, that a volley of shots smashed into the wall a few metres above my head. As my school was in the centre of Belfast, lessons were frequently interrupted by bombs. For us the greatest risk was from those that went off as we went home. We were fortunate that no-one in my year group was killed (although one, who joined the police, would later be murdered). But we did have many close escapes, more than once coming home covered in the ingrained soot released by explosions, sufficiently shocked for my teetotal great aunts to reach for the medicinal brandy.
So what has this to do with medicine? A lot. Just like his father, played by Jamie Dornan—himself the son of a professor of obstetrics who taught me as a student—Buddy’s grandfather had gone to England for work when he was younger. He had worked in the coal mines and his lungs bore the scars. We see him in Whiteabbey Hospital, a TB hospital in which my mother worked before I was born. We don’t know whether it was TB or lung cancer that killed him. But even if it wasn’t on the death certificate, we are left in no doubt of the role that poverty played, what we now call one of the “causes of the causes.”
Again, this was all too familiar to me. After graduating, I started on a journey that I hoped would lead, eventually, to a consultant post in medicine. Three years later, with my newly acquired MRCP, I began a series of medical registrar posts, soon taking up a research post in the Department of Medicine at Queen’s University. But the work I was doing in the laboratory was miles away from the problems of the patients I was seeing, patients from the same part of Belfast that the young Branagh had left over a decade earlier. TB was still common and some even had scurvy or Beri-Beri. It was then that I decided to change direction, joining the public health training programme.
The introductory course I now teach takes my students through the different determinants of health. We start with the scientific, the mechanisms I learnt in my pathology lessons, before moving on to the social determinants, so clearly conveyed in the film.
We then move on to the corporate determinants of health. They don’t feature in the film, but they were something I was also very familiar with, even if, like “social determinants” I never used those words. I learnt about the role of the flax industry in high rates of byssinosis and the toll of asbestos-related disease in shipyard workers. The first death certificate I wrote was for a man who had retired weeks earlier after a lifetime working in a tobacco factory. He had spinal secondaries from a primary in his lung. Even then, in my youthful naivety, I reflected on how the free cigarettes they handed out had saved them from paying his pension.
It is the political determinants that, for me at least, provides the backdrop for the scenes we see in the film. As a child, looking at the miserable conditions in which my parents’ patients lived, regardless of religion, I wondered why they didn’t join together to demand better conditions. Later I would learn that the prospect of a united working class was a threat to those who wielded power, whether as employers or religious leaders (of both denominations). It was only later that I discovered research, to which I would subsequently contribute, showing that divided societies are less willing to invest in collective goods, such as social infrastructure or health services.
Since leaving Northern Ireland my work has taken me to many other divided societies, including Sarajevo under siege, the Russian-Georgian border, Lebanon, and Israel. Each was different, but there were many parallels. Once when I was in Jerusalem, a young woman about to be married was killed in an explosion. She was taken to the hospital in which her father worked. Something very similar had happened to a family who lived opposite us years earlier. In all of these situations, the suffering I saw was firmly rooted in the actions of politicians. I am sure that my experience in Belfast has given me a deeper understanding than I would otherwise have had. And it shaped my response to those politicians who still encourage division, including those who have promoted a hostile environment for migrants in the United Kingdom and who, unforgivably in my view, are currently using Northern Ireland to pursue their deeply misguided Brexit policy.
One recurring scene in the film has Buddy with a drawing of a fork in a road. Kenneth Branagh and I have followed very different roads since leaving the city of our birth. But both of us were shaped indelibly by our experiences there. And for me, while his film is not primarily about public health, it reminded me why, all those years ago, I set out on the road that I have followed for four decades.
https://www.bmj.com/content/376/bmj.o278
https://eurohealthobservatory.who.int/about-us/staff/biography/martin-mckee
Remember… since leaving Northern Ireland my work has taken me to many other divided societies… In all of these situations, the suffering I saw was firmly rooted in the actions of politicians. — Professor Martin McKee
