Linking up Health and Faith: re-learning old lessons

baroque-st-teresa3
The Ecstasy of Saint Teresa by Bernini. Santa Maria della Vittoria, Rome

One of my scientific and theological interests has, for some time, been dialoguing scientific evidence on health and medicine with faith.  I believe dialogue between health and faith needs to be scientifically, theologically and epistemologically rigorous in equal measure.  A growing body of robust scientific research is remembering what people of faith seem to have not quite forgotten, than people mediate their understanding of health, and their coping and living strategies, at least in part through their belief systems. That has profound implications for our health and wellbeing.

 

 

Some practical examples

Less than a month from now, in October 2017 a new series of videos, and in November a website Positive Faith will be launched as one embodiment of this. This will be series of videos and resources by, about and for people living with and affected by HIV. This exercise has been funded by Public Health England, and led by Catholics for AIDS Prevention and Support.  The resource privileges the voices of People with HIV over professionals of any kind. People with HIV explicitly address these issues of health and belief.

The FaithAction health and faith portal remains, for me, one of the great things to come out of Public Health England’s partnerships with the community sector because it works at applying these lessons and collates practical examples.  There are many more. I have been privileged to work with  FaithAction for some time. Their report contextualising the evidence on faith and health for UK commissioners and policymakers is important reading.   Their work on mental health and dementia friendly places of worship has much to offer a prevention and community engagement agenda.  FaithAction have created a series of resources for commissioners, practitioners and faith communities to use together.

A series of Catholic mental health demonstration projects has been delivered.  A mental health access pack for Churches – written by professionals and experts by experience – has been created by a charity whose values commit them to work on disability and health. You can read my invited blog on why I endorse the pack, here.

The University of Leeds with Leeds Public Health team has explored the links and barriers between religion and public health in some really exciting work on mental health.

I don’t claim any of what I say here makes people of faith better or more special than those of no faith in the world of health and care. I merely say that we have legitimate and understandable motivations and values to be in that world, and we have a contribution to make every bit as valuable as anyone else.  And our values inform that. We can no more leave our values or identity at the door that anyone else.

Faith cannot be the one “protected characteristic” that is private when every other one is recognised to be part and parcel of the person. But that’s for another blog.

The scientific evidence behind this

Most of you who know me well know this is an area of interest. I do my job because of my value base.  Early next year my review article on some of the best recent publications in health and faith will make its appearance in Reviews in Religion and Theology

In the process of entertaining this interest I have amassed a smallish library of 200 volumes in several languages, including volumes which stand out like Ellen Idler’s (the polymath Epidemiologist and Sociologist) recent and rather excellent Public Health volume on Religion as a social determinant of public health , the brilliant theological/philosophical work Flourishing by one of my theological heroes Neil Messer  and a range of materials on psychology, psychopathology and religion.  I’m preparing this collection (well the stuff in English anyway) for donation to a library where people will get easier access to it.

Faith still relevant to our population

Some of you may think Faith – especially explicitly religious faith – is a minority interest. Well you may be right, but that minority is still between 37% and 43% of the population depending on who you speak to.  We wouldn’t now be so discriminatory as to dismiss LGBT populations because they’re 2% – 3% of the population depending on who you read, would we?   So let’s recognise that our value bases inform who we are, and most of us are part of some minority. It’s inclusion of every minority’s best offerings which makes social life vibrant.

Prof Stephen Bullivant a sociologist at St Mary’s University has undertaken analysis of ONS data (I believe as yet unpublished) which suggests that, for example, Catholics are present in the health and care field in numbers around eight times more than they would be if they were just present in the same proportion as their presence in the general population.  Incidentally, Stephen Bullivant’s recent report on the “No Religion” population is a good read for anyone in public policy.

People still understand and filter their health experiences, beliefs, behaviours and life choices (including the choice to serve) through their religious belief.  NICE guidance recognises that and has stated there is a strong evidential case for its salience in care.  It is folly not to engage with this. My invited paper to the Equality and Human Rights Commission on what this means for healthcare employers in terms of workforce strategy, service quality and equality and diversity law explores the practical and organisational implications of this further.  The growth of non-religious spiritual and pastoral care in our hospitals, recognising that humanists and others who describe themselves as non-theist and non religious, have spiritual needs too, is welcome and valuable alongside care for those who do have religious faith.

The Guild of Health and St Raphael

A short while ago, I was approached by the Guild of Health and St Raphael to become their president, a role which I shortly take on, after a bit of reflection and dithering on my part. I look forward to this immensely.  It came, to me at any rate, as something of a shock. I did the “why on earth would they want me, couldn’t they find anyone better?” And “why  on earth would they want a Catholic? ”  thing. I then thought of suggesting Archbishop Justin Welby before realising he’s a patron already.  And then I thought of Lord Rowan Williams, who’s a patron of something else they do already. Whoops!

In discussing this with a good colleague , she reminded me that she calls me “the health and faith babel fish”. By which she means I seem to be good at translating the field of health to the field of faith. She asked me “do you think the Guild does important things?” “Yes”, I answered. “Does it have a sound theology?”  “Yes”.  Have they got people who are scientifically credible?”  Again, “yes”. Just for starters, the Director, Gillian Straine is a PhD qualified Scientist and an ordained Anglican priest.  “Does it resonate with your desire to make clear the links between health and faith?” “Yes, vey much so.” “Well, then in your own words -get on with it.”   And so, with that kick up the motivations, here begins a journey.

Formed in 1904 to bring together members of the clergy and medical professions to study and promote the healing ministry of the Church, it claims to be the oldest organisation in the UK working in the field of Christian health.  Anglican in heritage it is now ecumenical in outlook. The two Anglican Archbishops of York and Canterbury are Patrons along with the Methodist Church’s President, and now the Guild has let in a – rather stumbling – Catholic President! (What were they thinking, I hear you ask?)  An academic journal is coming. And practical resources. We have plans!

Academic community of interest

The academic community interested in the crossover between health and faith in the UK is growing. From Professor Chris Cook (psychiatry and psychology) at Durham, to the Guild’s newly launched Raphael Institute collaboration with epidemiologists, scientists, medics and psychologists, through to the work of Professor Michael King at UCL and many others I could mention, a body of work is beginning to be pumped out in a UK context examining the links between health and faith.  Similar communities in German medical schools, Swiss Universities,  Italy and, of course, the United States are creating work of use and value to the public health community.

Putting effort where my mouth is

There are a number of reasons why I am delighted to take on the role of President. First, Health and Faith, and the links between it, are an enduring interest.  My paid professional role as a Director of Public Health seeks to improve and protect the health of a population, something to me which resonates deeply with the call I believe all faiths – including the humanists I am lucky to know and learn from – have to improve human life and hold in good stewardship our earth.  I have written elsewhere, in The Universe about the vocational aspect of this.   And I guess as part of that I need to play my part in dialoguing the health and faith world constructively and rigorously to help us find what mitigates for maximum human flourishing – for those of all faiths and none.  That doesn’t mean those of us of faith leave our values at the door of the office, by the way.

The second is that participation in the work of ensuring people are as healthy as possible, in all dimensions, is a direct participation in one of the ultimate purposes of what most people of faiths do – the cherishing of and service to the human. Visit a Sikh or Jewish social service centre if you haven’t ever done so. You’ll be amazed.

The third is that because of this insight, people of faith have much to offer from “all our best traditions” as the hymn goes to the world of healthcare, and to the whole issue of what health means.  In fact, we were here first. Long before the NHS, before organised health care, we were there.  And people like the Historian of Science Gary Ferngren and others are writing the history of that engagement.

Christian Social Teaching as a Health Inequalities Manifesto

A further reason is that this provides a much needed opportunity to explicitly link Catholic Social Teaching (sometimes called the Catholic Church’s best kept secret) and its seven principles embodying Justice, dignity of the person and so on to issues of health.  Read any book on inequalities in health and a book catholic social teaching side by side and they say very similar things.  People have a right to health, and the means to health including good , healthcare, education and so much else and this is part of doing justice to our world. Good quality healthcare is framed as an exercise in justice and love in such teaching. I can find that link implicitly or explicitly everywhere I look. The founder of the Science of Healthcare Quality and Healthcare Improvement, who was not a Catholic, explicitly defined Quality Improvement in Healthcare as an exercise in love.  The links are significant. For more on the seven principles of Catholic Social Teaching, read here. Recent changes over the past fifteen years in US health care policy have generated a significant body of Catholic thought on Just Health Care policy including a whole body of thought on access. I’ll be discussing my take on what Public Health and Catholic Social Teaching agree on with regard to access, equity, justice and commissioning policy at an International conference on mental health in Oxford in summer 2018.

The fourth reason is that now, explicitly in the policy frameworks of all of the four devolved administrations of the UK, there is the recognition that health has many social dimensions, and needs social actors. This is a Kairos moment – an auspicious time when we can speak into the agenda of what it means to be healthy, and what health and social care is about. We have things to say.  And that means re-energising communities about what they can do on their health.  Faith communities can be a part of this. And examples of good practice here abound, from dementia friendly places of worship to social inclusion programmes and projects for people with long term conditions.

The riches of tradition informs the progress of today

The fifth reason is that while each of us can offer things from our own tradition – I have a particular tradition which feeds my commitment to improve and protect the heath of the population.  I don’t claim it’s better, I just claim it has enduring relevance. Catholics founded religious orders dedicated to health and healing, for example. Countless people we call saints have been engaged in health.  The St Vincent de Paul Society is a Catholic charity providing help from white goods to holiday breaks to clothing to utility crisis payments and has a bigger volunteer workforce than CAB last time I looked.  Entirely funded by Catholics.  Mary Aikenhead, founded the order which created the hospice of which I am a trustee. Her values of advocacy for and inclusion of the most excluded (and said in those words) are a constant reminder to me not to become complacent in a public health system where it would be easy just not to try  to find a way through the cuts being imposed on us.

Those Catholic religious orders still run health and care services across the World and the UK (and over 150 centres from hospices to refuges for victims of human trafficking in England today).  One of those orders is the biggest non-governmental emergency aid agency in the world, among whose volunteers I am proud to count myself. My tradition is supposed to roll up its sleeves, include and serve. (and it often needs a good kick to remind it of that.) Moreover, my tradition attests to the fact that health is social as much as it is individual.  These must go together. No human being is anything other than precious.  Justice, Love and Hope are the hinges on which we embody that insight.

Institutions sometimes get decadent and fail people. That happens in the NHS and public sector as much as it happens in the churches. The point is that continual renewing of our purpose – maximum human flourishing. Every faith which has a sense of the divine is at its best committed to human flourish and justice – even if at its worst we shamefully can and do at times betray and sully that commitment – because we believe that’s what God wants for God’s world.

The whole person

The sixth reason I am keen to do this is because the scientific evidence supports these insights as much as it informs them. We are becoming increasingly aware that health includes the whole person, and especially for those who cannot be cured, health is about making a good response to the realities we face. Like the Guild’s Director, Gillian, I am a cancer survivor, lucky to be alive after a Grade IVB lymphoma. Like Gillian, that experience has shaped how I am rediscovering the riches of the Christian tradition to speak to today’s world on health. Her book Cancer: a pilgrim companion is a brilliant read.

For those with long term conditions or disabilities, those with long term mental health challenges, those who are dying, the World Health Organization’s definition of health as a complete state of psychological, physical, spiritual wellbeing is hopelessly optimistic, and unreal. It implies they are less than fully human, and with that comes the risk they become devalued.  That is not a Christian view. Suffering, limitations and disabilities are not valueless.  It is also not a view that sits with the science of health inequalities, otherwise why bother with the discourse of tertiary prevention?

The World Health Organisation’s vision is valuable, but its valuable because of where it points us. It is future rather than present, a hope for the future. That means we have to revisit what health means here and now. And I would argue that the science and our theology are mutually affirming on this, and the Guild is ideally placed to do that work from the academic work at one end of the spectrum to the work of caring, praying and doing at the other.

Called to serve

Earlier this year, The RC Diocese of Westminster led a season of events entitled Called to Serve the Sick. I hate the term “the sick” but that’s for another time.  The series was intended to be a practical continuation of Catholics being recalled by Pope Francis in 2016 to serve and welcome, when we sometimes exclude too easily.  A series of roadshows, which I was privileged to present at, discussed a Catholic Understanding of Health and Social Care, why Catholics should feel a particular importance of committing to health, social justice and social care, and what local communities can do about it. We had an audience of health and care workers, and people struggling with health issues. And people of all faiths and none. We’ve been asked to do more. There is a demand for this work.

The Bishop who led this season, Bishop Paul McAleenan said that “It is fitting that this season comes as a continuation of the Year of Mercy, giving us the opportunity to practice that most important act of Christian love, care for our neighbour. Good health, poor health, disability and ultimately our death, are integral aspects of what it means to be humans precious to God, and so they are of huge importance to us as people of faith.

On this, I hope, people of all faiths and none can make common cause.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Chemsex: Why should it be a Public Health issue?

 

I don’t know about anybody else, but I can’t help thinking that the issue of chemsex is one we are still not really getting our act together on.  I claim no specific expertise here, but what I do know is this issue is impacting on the health of our population, and an already vulnerable one at that, so we need to act. And I have several friends and colleagues from across the country -the youngest 24 and a student, the oldest 50 and a professional in the City, whose processes of getting out of the harm they’ve come to I have helped with.

We seem to have depressingly little in the way of national leadership or action on this from the Public Health community, with the work of some dedicated individual clinicians and community activist -step forward David Stuart and 56 Dean Street, Greg Owen, Matthew Hodson, GMFA , James Wharton, MenRUs, Burrell Street Clinic for their Safer Chemsex Kit and a few others being most visible. I have provided links to several pieces of this work in the footnotes, but let me also direct you to  London Friend’s work on LGBT drug use and recommendations for treatment services .  I hope anyone I have missed off will forgive me.

It is simply unacceptable for the skills and resources of the Public Health profession to be absent from this issue.

I was discussing this today at another meeting. I said to a colleague from another agency “people say we don’t have a problem locally” and before I could continue to say “and they’re wrong” he interjected, “they should just open grindr, it’s everywhere.”

The use of some kind of substance to enhance sex is known and common throughout history (drinks while dating?) And if people are fine about that and use without harm, then I don’t feel it’s my business.  But recently the phenomenon of chemsex has become a bit better known than it was. A search of MEDLINE and PSYCARTICLES when I was doing a quick review to inform this blog, after removing duplicates, found in 2014 3 papers, a search for 2017 found 48 papers so far in the health and psychological literature.

Chemsex is a term for a complex of behaviours – use of dating apps to have parties where sustained group use of drugs happens, particularly drugs like cocaine, crack, GHB (gamma hydroxybutyrate) and crystal methamphetamine. Sex is often but not always a given at some of these parties. Slamming – injection of drugs for quicker highs, sometimes happens, and with it sometimes sharing needles.

While it may be more of a scene for gay men, bisexual men and heterosexuals do it too. What will that pattern will be in two years time? We know that trends started by gay men sooner or later get picked up by the wider heterosexual world, or am I just remembering disco through rose tinted (glitter encrusted) spectacles? (Showing my age there.)

Increasingly, use of chems or drugs is reported by men using dating apps for 1-1 encounters too. Recent work has shed more light on the multiple motivations and issues at play.  From the many paper available, I have a few which I think resonate. Weatherburn et al[1] identify a range of motivations linked to “enhancing the qualities valued in sex” including enhancing attraction, heightening sensation, intensifying intimacy and connection and, for some men, overcoming lack of libido. Media attention[2] and the interest of the scientific press[3] seems to have been somewhat limited to date.

The increasing intelligence from reporting by clinicians and community groups of problems presenting from chemsex is concerning. From understandable motives – socialising, feeling good, enjoying sex and coping with life pressures are reported as factors, certainly in GHB use for some time[4] , the drug use is primarily intended as a facilitator of these. But clinicians are reporting a range of harms including addiction and other sequelae.

Dedicated professionals like David Stuart and others working on this issue[5],[6] have brought greater light on chemsex. The publication by James Wharton of his chemsex experiences[7] in Something for the Weekend and the associated meda reporting[8],[9]have gone some way to cast some light on this as an issue which needs addressing.

Parties are not the only places, however, where chemsex is becoming an issue. Increasing use of chems with sexual hook ups means some men may rarely have sex sober. It’s not just physical risk, but psychological. Intimacy may become associated with being high, and for some, dependent on it.

Prevalence

A 2014 BMJ editorial suggested a minority of men engage in chemsex[10] but community reports suggest this is growing and becoming more prevalent. There are as yet no robust epidemiological estimates. Weatherburn et al report up to 18% of men from three London Boroughs uses cocaine and 10.5% GHB compared to 4.8% and 1.6% respectively of men elsewhere in England[11].

Wharton quotes estimates that a gay man dies in London from GHB overdose every 12 days but very few have been high profile[12]. Estimates of prevalence vary in recent reports[13] but what is clear is that this is becoming an increasingly prevalent presenting problem in sexual health clinics, and few services as yet seem prepared to address it effectively.

Harm

There are also some people who seem to be able to use drugs regularly without seeming to come to harm. If people genuinely can do that safely, and we can help them successfully avoid harm, then my interest ends there. But many do come to harm, and it’s those who experience harm in any form I’m interested in here. And the harms from chemsex can be wide.

Whether or not this is a minority phenomenon in terms of the population, the harms to some users are significant and the barriers to accessing services also important disablers of helping men deal with harms arising from chemsex[14].

What we don’t know reliably is how many men engage in chemsex without coming to some form of harm. Most data from clinics and the small amount of research to date identifies some kind of harm. A spectrum of harms across physical, psychological and social health is possible. Some of the documented and reported harms are shown in Table 1 below. But this isn’t exhaustive.

Table 1: Harms from chemsex

Physical Health ·      STIs, HIV and other Blood borne viruses

·      Physical effects of comedowns

·      Risks to circulatory system from injection

·      Respiratory risk from frequent use

·      Risk of death from overdose

·      Disrupted sleep patterns, anorexia, weight loss

·      Impaired immune function

 

Psychological/Mental Health ·      Use of chemsex to facilitate social contact and overcome loneliness, isolation

·      Coping mechanism for stigma and homophobia

·      Impact on coping skills, sleep, employment, cognitive functioning

·      Impact on relationships of becoming habituated on having sex while using drugs

·      Psychological impact of financial problems from financing habit

·      Impact on identity integration and acceptance

·      Bereavement from people in social networks dying as a result of G

Social health ·      Group identification

·      Coping with stigma

·      Holding down a job and responsibilities

·      Risk of debt and homelessness

·      Criminalisation for possession of drugs and sometimes dealing

 

Public Health Issues

Chemsex is not just a drugs or an HIV or a sexual health issue. For most men it seems to be linked to a complex manifold of issues. From the physical risks to health, to the psychological risks and impact on lifecourse development, there are significant issues which impact on the populations and individuals who use it.

I have spoken, written and presented elsewhere on how the need to ensure LGBT populations are able to live happily and successfully across the lifecourse must be a public health issue[15],[16]. So I won’t repeat that here. One of my worries is that chemsex for some can hamper or impair that process.

The mental health impact of being unable to have sex or be intimate unless high presents a number of challenges. But there is another set of issues. If some gay men use chemsex to cope with stigma or feelings about being gay, that must be seen as potentially problematic. It is a commonplace in psychology of LGBT populations that a key task is identity integration and acceptance[17]. Theory and evidence assumes that identity integration and assimilation is crucial to health and wellbeing outcomes for gay men across the lifecourse[18],[19],[20]. It is assumed to be especially important to ensure inclusion for LGBT people in education and employment. If chemsex disrupts such processes, or means a population or sub-population of gay men can only feel good enough about themselves where mediated through drug use (either individual or in groups), there may be significant avoidable psychological morbidity as a result. If what Wharton says about younger gay men finding it easy to get into this scene is true, then that has worrying implications about the ability of those men to form attachments and integrate their identity as they grow, with potential maladaptation and poor coping and mental health across the lifecourse[21].

Policy frameworks and action

While chemsex is mentioned in the new UK Drugs Strategy, there has been much criticism of the lack of commitment on what to do about it[22]. There remains no coherent public health response. Community harm reduction approaches[23] including safer injecting kits[24] are most visible interventions with the best available frameworks for clinical response being those developed by David Stuart[25] There is as yet no clear national policy framework or consensus guideline on what can or should be done. Community intelligence is still crucial to developing action on this, and we need to find ways of making sure we capture and factor that into response planning, on a more agile basis than we sometimes do.

What can be done?

A range of action is needed, and this needs to be revised as we know more. I group suggested actions under domains here.

Domain 1: Establishing prevalence and incidence

  1. We need as clear a picture of prevalence, service use, harm, morbidity and mortality as can be compiled, nationally and locally
  2. Including and using community intelligence in this development will be crucial
  3. Asking about chemsex use should become a routine question in sexual health services on the electronic patient record

Domain 2 : Harm Reduction strategies

  1. We need to work with providers of dating and sex hook-up apps to target information on harm reduction to users engaging in chemsex
  2. The current good practice (chemsex care plan and harm reduction information and kits) should be rolled out to those areas who identify they have a developing issue
  3. Support harm reduction including continued information and kits to reduce harm
  4. Agencies could consider safer chemsex courses as a way of helping reduce harm including teaching people skills of what to do about GHB overdoses
  5. Agencies should combine efforts to make available a single reliable source of information on reducing harm from chemsex and where to get help
  6. Sex venues should consider placing information on chemsex and where users can get help.

Domain 3: Service response and readiness

  1. Most chemsex users don’t find drugs services resonate with them on the whole. We need to identify what drugs services and sexual health services can to do address this and roll it out
  2. Sexual health and drugs services should identify what they can to do ask gay men about, identify and respond to chemsex issues, and develop collaborative approaches to sharing skills
  3. Those services should become skilled in particular identity and lifecourse issues facing gay men
  4. Services should consider whether they can recruit people recovering from chemsex harm to work with those seeking support
  5. Drug services should consider as part of this work both the LGBT supplementary guidance of the NEPTUNE programme work on NPS ,the London Friend work on drugs services and LGBT populations and the work of David Stuart

Domain 4: Developing consensus on interventions

  1. Agencies working on this should convene with experts on drug use, sexual health and LGBT development to develop some consensus guidelines on harms and issues, and intervention strategies, and keep this under review.
  2. Learn from the work being developed by the London Chemsex Network as part of this

Domain 5: Community resilience

  1. LGBT community groups who provide social groups or counselling facilities should consider what they can do to continue to support gay men with lifecourse identity development
  2. Employers with large numbers of gay men in population centres likely to be affected should consider what resilience and support packages they can put in place for employees with performance issues arising from chemsex

 

[1] http://sti.bmj.com/content/93/3/203

[2] http://www.newstatesman.com/politics/health/2016/04/what-chemsex-and-how-worried-should-we-be

[3] https://www.newscientist.com/article/2140756-what-is-chemsex-and-why-is-the-uk-government-worried-about-it/

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3611333/

[5] https://gregowenblog.wordpress.com/2015/10/17/chemsex-the-film/

[6] http://www.davidstuart.org/

[7] Wharton, James (2017) Something for the Weekend: London : Biteback Publishing

[8] http://attitude.co.uk/exclusive-former-british-soldier-james-wharton-opens-up-about-addiction-chemsex-culture-is-now-gay-culture/

[9] http://www.telegraph.co.uk/men/the-filter/11942081/Nine-things-you-should-know-about-GHB.html

[10] http://www.bmj.com/content/351/bmj.h5790

[11] http://sigmaresearch.org.uk/files/report2014b.pdf

[12] http://www.bbc.co.uk/news/magazine-35976705

[13] https://www.lambeth.gov.uk/sites/default/files/ssh-chemsex-study-final-main-report.pdf

[14][14] http://www.bmj.com/content/351/bmj.h5790

[15] https://www.slideshare.net/jamesgmcmanus/british-psychological-society-sexuality-and-wellbeing-symposium-a-public-health-perspective-on-lgb-populations

[16] https://www.slideshare.net/jamesgmcmanus/lgbt-public-health-agenda-idahot-2016

[17] https://msu.edu/~renn/BilodeauRennNDSS.pdf

[18] https://pcilab.ucsc.edu/wp-content/uploads/sites/472/2017/06/Hammack-et-al-2017.pdf

[19] Hammack, P.L (2009) The Story of Sexual Identity: Narrative Perspectives on the Gay and Lesbian Life Course New York: Oxford University Press

[20] https://www.ncbi.nlm.nih.gov/pubmed/12666737

[21] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215279/

[22] http://www.independent.co.uk/news/uk/home-news/drugs-treatment-strategy-government-criticism-problems-campaigners-a7841986.html

[23] https://www.gmfa.org.uk/Pages/Category/safer-chems

[24] https://www.menrus.co.uk/drugs/introduction/

[25] http://www.davidstuart.org/care-plan