“In January it was like seeing a tsunami coming that no one else could really see yet”

in Features

Interview with Dr Sohail Bhatti, Director of Public Health, Gibraltar

We are grateful to Dr Bhatti for taking the time out of his busy schedule to talk to us about his work and the current pandemic and why he loves Gibraltar…

How did you get into Public Health?

I wasn’t clear exactly what I wanted to do but I was clear that I was good at public health and there had been a significant change in government policy after I graduated and  public health was expanding, so I applied to join the formal training programme in the North West of England; obtaining an MSc in Public Health in 1994 from Manchester University, having previously qualified in Medicine from Glasgow University in 1985.  Public Health is subject to political influences. When I joined, the speciality was expanding but when I finished training it was contracting because a new government had come in and introduced new policies, so I had a longer training period. 

Do you think medical science was simpler, in the sense of the number of threats in the past?

The threats have always been there. Global travel and connectivity have made more of the population subject to them. If you go back to the Spanish conquest of South and Central America, syphilis and measles were introduced and it decimated the population; some estimate ninety percent were wiped out. If you introduce infections into a new population, there can be a big impact if they’ve never been exposed. This has been within human beings throughout history. In fact most infectious diseases have a counterpart in animals, called zoonoses. These are very similar diseases, making us think that they transferred to humans some time ago. For example, canine distemper is similar to measles and bovine TB is similar to TB. The only diseases that are specific to humans are Smallpox – which is why we have eradicated it and also Polio, which we have nearly eradicated.  

The North of England made an impression on you. What was your moment of greatest satisfaction when you look back on your time in Manchester, Huddersfield and Lancashire?

I did some pioneering work whilst I was there. When I was training, my thesis was on focus groups as a method of consultation; in those days nobody had heard of them. I also did a lot on geodemographics which links geographic and health information, with deprivation; also pioneering work at the time. Our work in Huddersfield compared information in a novel way that illustrated how bad deprivation was. I wrote about how ethnic minorities were paying a disproportionate price in terms of their ill health. I had a broad set of interests and worked voluntarily supporting charities which was enjoyable because I was able to use my skills and knowledge in helping others which revitalised my batteries. I am vocationally driven and want to help our communities and leave them better off from where I found them. The nature of change is such that if you wish your change to stick you have to make others the custodians of it; they have to own the change and believe they were the authors of the change, even though you know you had introduced and implemented the concept. I would like to think that things I started carried on after I had left. That is one of the things that would make me feel warmest. For example, I helped set up a primary care resource centre in Manchester’s Moss Side, which was handed over to the community to run. Its greatest credit was the way people took it up. It was a vibrant, thriving centre when I revisited it 10 years later, which was great to see in the heart of a deprived community. 

You took up your current position as Director of Public Health (DPH) in Gibraltar in 2008, having previously held the same position in Huddersfield, East Lancashire, City of London, the London boroughs of Hackney and Hounslow, as well as the City of Bristol. What made you think of Gibraltar as your next work destination?

I spent a long time in the NHS and felt wedded to it so when latterly my speciality moved into local government, I felt this a bridge too far. I wanted to help people and see my work have impact.

I had visited Gibraltar and it intrigued me: a community that was self-contained, somewhere I might be able to leave a legacy and make a measurable difference to a community; it had all these wonderful hallmarks. I am a great believer in diversity and that is Gibraltar: a polyglot community, multigenerational, multiracial, in fact it is a model for the world. When one goes back historically and looks at Andalusia and Cordoba, they were multicultural societies that promoted learning. Gibraltar inherited that model; built on trade, people spending a lot of time and effort acquiring knowledge, a legal framework, medical infrastructure. 

This is one of the greatest medical emergencies the world has faced in recent times. What’s your take on it and how the world’s healthcare systems are coping?

Pandemics of this nature happen rarely. The last one was in 1918. In some ways my entire training has been for this moment. I am privileged that I am able to utilise all of that training whilst still professionally active.

This pandemic is unique because it challenges our healthcare systems with overwhelming demand. No healthcare system created sustainably could withstand this kind of attack. This is a war and all wars by their nature are unexpected and aren’t fought like the previous war. Gibraltar has shown a huge entrepreneurial flair to expand its healthcare system, such that our modellers suggest that if we had the worst-case scenario – and we won’t – that our healthcare is sufficient to allow us to cope. However this has come at a huge cost and relies on workers coming here and PPE brought from abroad etc., so we can’t relax too much and think we have it made; we haven’t. 

The best system promotes prevention because this virus is a bad lifestyle virus. It targets people who modern healthcare has kept alive because they have had a bad lifestyle. The best cure is not to fall ill. Bad lifestyles abuse the free good, the asset which most – though not all of us – are given; a body which functions. Over time through alcohol, smoking, eating too much, not exercising enough, our bodies pay the price of decades of abuse. The human body is designed for persistence running; our ancestors survived by hunting game. The great strength we had was the ability to store glycogen in our liver and so effectively run prey into submission. If you keep a car and never run it, it will cease up; indolence is abuse for the body. Smoking exposes the body to 3,000 chemicals including dioxin, arsenic, cadmium. Alcohol is a toxin and we can lose control with it. It is not the natural state of our body to live in an environment of plenty all of the time; these are all metabolic challenges and that is how we lose the greatest asset we have, which is our well-being. 

“this virus is a bad lifestyle virus. Alcohol, smoking,  eating too much, not exercising enough, our bodies pay the price of decades of abuse”

Is the COVID-19 situation something that could have been prevented? Or have lifestyle choices made something like this inevitable?  

Humans are first and foremost social creatures; we thrive through joint enterprise: we hunt together, squabble together, but build civilisations and societies together. Touch is important to us; it releases endorphins in our brain and affects our dopaminergic system (the reward systems in the brain). We thrive on relationships and touch. This virus targets us because of this; it spreads through close proximity, the very things that make us human beings – it is our Achilles’ heel. Other viruses came and went because we developed immunity or a strategy to cope with them. 

Gibraltar has efficiently contained the virus so far; can we continue in this vein with correct measures in place or are we delaying the inevitable given the global impact? 

Our problem is that we are part of the Iberian peninsular and we thrive on trade, human interaction is a core part of our being. We live in extended families and thrive on those relationships, living in a tightly packed community. We are always going to be subject and vulnerable to a virus that attacks our sociability. It is asking us to change who we are. We are a very adaptable species, so we will change who we are, but it takes time. The great blessing of this virus is that young people – our investment in the future – by and large are protected. 

The issue is whether there will be a vaccine and how we are going to live with it if this persists: they are big questions. The challenge for a vaccine is that, if this virus is anything like the other corona viruses, immunity may be weak and not persistent, so a vaccine may not be as successful as we hope. In fact, the vast majority of people have such a minor illness, that they don’t even know they have got it, hence it has thrived. My great hope therefore is antivirals, to give us ways to protect ourselves, minimise the harm or successful treatments for those older people who have more severe reactions. There are many trials underway. These drugs are being repurposed from drugs that have already been tested. There may be a long-term goal to develop an entire new class of antivirals to target this one. If it was easy, we would have a vaccine against the common cold. 

What is it you like the most about Gibraltar?

It is easy to fall in love with this place. It is a concentrated piece of heaven: the people are warm and lovely, and people make a place. They squabble but that is part of their charm; they feel passionately for each other. They have many languages and nationalities and they all get along fine with each other. This is an asset that is difficult to replicate anywhere else. The environment is lovely; you just need to go up the rock to feel like you are in a different place, and where else can you stand and look across at two continents. Gibraltar has invested in its young people; the level of knowledge and education is superb and that Gibraltar manages to attract its young people back is testament to this. It is a safe environment to bring up children. There is commerce and some industry, it is full of entrepreneurs that bring opportunities. It has the hallmarks of becoming a new Singapore or Hong Kong, but it would need more space for this. I am a great believer in empowering others. The quality of the politicians both in government and in opposition is another quality it should be proud of.  

If there was one medically beneficial behaviour you would encourage everyone to adopt, what would it be?

The number one issue for Gibraltar is smoking. For those that smoke, PLEASE PLEASE PLEASE give up and if you can’t give up then vape; it is 90% safer than smoking. What made our ancestors thrive was having days without feeding and doing exercise to catch their food, so we also need to exercise more. 

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