Bentham Brooks Institute Research Journal 2021-22

RESEARCH JOURNAL

University College London

2021-2022

Published by

Bentham Brooks Institute

BBI Research Journal 2021-2022

About the BBI The Bentham Brooks Institute (BBI) is a student-led think tank based at University College London. Its mission is to inspire talented students to pursue careers in academia, think tanks, and the public sector. Through a yearly research program, the BBI brings students together to produce

high

quality,

peer-reviewed

research

papers

providing

concrete

policy

recommendations and pragmatic solutions to some of the world’s most pressing issues.

The BBI proposes a yearly research agenda to encourage students to delve into an area about which they are passionate. The research agenda for the academic year 2021-2022 consisted of the following areas:

▪

Climate Crisis

▪

Terrorism and Extremism

▪

Global Health

▪

International Conflict and Cooperation

▪

Transformative Technologies

The Bentham Brooks Institute Committee would like to thank all the advisors* and peerreviewers, without whom this publication would have never been possible. The time they set aside to guide and support researcher along the way has been invaluable.

*

Dr. Stephen Jivraj, Dr. Marcos Gonzalez Hernando, Dr. Tim Hicks, Dr. Melanie Garson, Dr. Silvia Binenti, and Prof. Kentaro Toyama 1

BBI Research Journal 2021-2022

Table of Contents

Lost in Translation: the Media and People’s Attitudes toward the Climate Crisis .................... 3

How do War Traumatisms, Combined with State-Induced Political Violence, Influence Radicalisation of the Youth in War Zones? ............................................................. 46

Personal Protective Equipment Availability and Healthcare Workers Mortality Rates at the Beginning of the Covid-19 Pandemic ................................................................ 102

Instability and Violence in the Levant: Foreign Involvement and its Impact on Inter-Religious and Intra-Religious Conflict ......................................................................... 166

Exploring the Digital Divide Associated with the Increasing Use of Transformative Technologies in Southeast Asia ............................................................................................. 220

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Lost in Translation: the Media and People’s Attitudes toward the Climate Crisis

Remina Aleksieva, Seba Boerescu, Paree Desai, Camille Fayet*, Ambrine Pirbay-Katchera, Ieva Sturina, Jenny Wong

The Bentham Brooks Institute Climate Crisis Research Team thanks Dr Tim Hicks for the guidance and support in the newspaper content analysis. *

Research Team Leader 3

BBI Research Journal 2021-2022

Table of Contents Introduction ............................................................................................................................................................ 5 Power of the Media ................................................................................................................................................ 7 Measuring Intention to Act ............................................................................................................................. 9 Bridging the Intention-Action Gap ............................................................................................................... 10 Discussion..................................................................................................................................................... 11 Climate Crisis Attitudes ...................................................................................................................................... 12 Dataset .......................................................................................................................................................... 12 Relevant Variables........................................................................................................................................ 13 Selection of a Complete Case Study Sample ............................................................................................... 16 Descriptive Statistics .................................................................................................................................... 17 Multiple Regression...................................................................................................................................... 18 Discussion and Limitations .......................................................................................................................... 20 Newspaper Content Analysis .............................................................................................................................. 21 Data Extraction: NewsAPI ........................................................................................................................... 22 1. Newspaper Writing Style ............................................................................................................................ 25 Methodology................................................................................................................................................. 25 Results .......................................................................................................................................................... 27 Discussion..................................................................................................................................................... 29 2. Newspaper Political Orientation ................................................................................................................ 31 Methodology................................................................................................................................................. 31 Results .......................................................................................................................................................... 32 Discussion..................................................................................................................................................... 38 Conclusion and Policy Recommendations ......................................................................................................... 40 Bibliography ......................................................................................................................................................... 43

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Abstract: How do people form their beliefs about the climate crisis? Why are we concerned about the climate crisis and have good intentions to act and yet do close to nothing? The climate crisis is a novel and complex issue, with scientists and politicians disagreeing what action should be taken, how quickly and what the economic consequences will be. We argue that people’s perceptions of the climate crisis are influenced by the framing of the issue in the media. As the main source of information on the climate crisis, the media gives a narrative that shapes people’s level of concern and sense of urgency, the perceived effectiveness of solutions and ultimately their willingness to engage in eco-friendly activities. Using the Wave 17 of the 2014 – 2023 British Election Study Internet Panel (Fieldhouse et al., 2020), we find that attitudes about the climate crisis vary across newspapers. We also find that content and framing vary depending on the political affiliation of the newspaper and its writing style.

Introduction In 2021, following the COP26, 68% of Britons declared being worried about the climate crisis and its effects (Yougov, 2021). Climate change has long been in public discussion with activists urging people to act, striking media headlines about its devastating effects, and politicians and business leaders proposing different innovative policies in hopes of achieving net zero emissions by 2050, and hosting international forums such as the COP26. Considering recent polling results (Yougov, 2021; BEIS, 2021), it appears that people have been making some changes to their lifestyle as a response to the threat caused by climate change. However, these changes remain small and are not sufficient to achieve the net zero goal. Much wider ‘climate action’ is needed to reach this goal, resulting from a collaboration both of individual action as well as action from the government and big corporations. This paper focuses the consumer side and explores the extent to which the media’s narrative impacts people’s perception of the climate crisis by answering the question “how do different news outlets present the crisis, and could this affect public support for climate action?”.

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The issue of climate change is complex and novel with elites and scientists disagreeing on what action should be taken, what the economic consequences will be and the extent of the damage caused by the crisis on the planet. These factors all create more difficulties for individuals to fully understand the implications of the climate crisis, and the importance of individual action.

There has been a lot of research on how people feel about the climate crisis (Yougov, 2021; BEIS, 2021; ONS, 2021), but we know relatively little on how they form their specific views.

It has been shown that for similarly complex issues such as austerity, belief formation might be linked to the way the media frames the issues (Barnes and Hicks, 2018). This seems particularly relevant to the climate crisis since the media is the main source of information for scientific issues and the climate (Lopera, 2014; Boykoff and Boycoff, 2004).

We studied the UK case and ran two different analyses to provide evidence of the relationship between the framing of the climate crisis in the media and people’s attitudes about the issue.

Using the British Election Study data, we first ran a regression analysis to provide evidence of a difference of beliefs depending on which newspaper individuals read. We then ran a content analysis to provide evidence that the framing of the climate crisis is different depending on the newspapers. This second analysis allowed us to explain the variation in attitudes, given that if the content did not change, the differences in attitudes would be explained by another factor altogether.

We found evidence that personal beliefs about the climate crisis depends on the newspaper individuals obtain their news from. Variations in personal beliefs originates from the types of newspaper read - broadsheet or tabloid - and the political orientation a newspaper represents.

This paper aims to contribute to the growing literature in understanding the role of different types of media on belief formation in general, and more specifically on the climate crisis

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(Barnes and Hicks, 2018; Arlt et al., 2011; Maran and Begotti, 2021). It also aims to participate in the effort to develop an understanding of the gap that has formed between intention to act and climate action (Momsen and Stoerk, 2014; Carrington et al, 2014).

Power of the Media Does an increase in the access to information automatically correspond to a deeper understanding on the topic in question? In an age of digitalisation, while information is easily within our reach, the downside is having an overflow of information. The responsibility therefore lies on the media to deliver information to the public, thus granting the media a role to exert influence on public opinion. Contrary to popular belief, Wahlberg and Sjoberg (2000) argued that the content of media is not as biased as people think. Instead, they discovered that the media’s influence is stronger on a general perception of risk, but not on a personal level.

In particular, the impact of the movie “The Day After Tomorrow” is explored to demonstrate people’s perceptions of climate change (Lowe et al, 2006). While it did show a short-term increase in concern towards the topic, the public actually experienced difficulties in distinguishing the climate crisis from scientific fiction, interestingly leading to a reduction in their belief in climate change despite an increase in attention (Lowe et al, 2006). This is due to the lack of practical information available, but also showing how positive emotions are more effective in triggering climate action instead of negative emotions of fear and guilt (Lowe et al, 2006). Ellen (et al, 1991) further proposed how the media’s narrative should move from “sick baby” to a “well baby” appeal, reinforcing how a positive mindset of how the problem can be solved with individuals making a difference would increase effectiveness of generating climate action. This study also echoes with Weingart and Pansengrau’s article (2003) in

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examining the impact of scientific fiction films on raising the public’s interest in scientific issues such as the climate crisis, but still not being able to feel a sense of urgency. They ultimately regarded the lack of urgency in the public’s perception on climate change into the lack of knowledge as well, especially with few scientists well known among the public, while they are more familiar with fictional figures like Frankenstein (Weingart & Pansengrau, 2003).

Building on the lack of urgency, Moser and Dilling (2010) identified three factors of why the US public opinion undermines the urgency of climate change: (1) enormous time lags in climate and our social systems, (2) climate change less visible in developed countries, and (3) overshadowed by other more immediate problems. To create higher climate action, it was proposed to have an internalisation of motivations through implementing (1) empathetic understanding of the difficulties brought by change of behaviours, (2) providing maximum choice and flexibility over the course of alternative action, and (3) a persuasive rationale for the required change (Moser and Dilling, 2010). Given the high cost for individuals to make a voluntary sacrifice in their lifestyles, simpler actions should be prioritised: for instance, explicit guidelines in simplifying the processes of separation and collection are necessary for a willingness to act to be blended in people’s habits (Ellen et al, 1991). Ellen’s findings are consistent with Arias’ study (2020) which also found that less complex actions are more likely to be carried out by individuals.

It is also the inevitable reality for journalists to produce quick breaking news, in which Nelkin (1987) reasoned as one of the causes for imprecise and biased articles as journalists simply do not have the time to examine complex scientific opinions. It is important to note that journalism is ultimately a “business” to “present the news of the day in the interests of economic privilege” (Nelkin, 1987). With that in mind, Boykoff and Boykoff (2004) mentioned how journalistic

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norms are also present with the practice of balanced reporting amplifying minority voices such as a small group of global warming sceptics, which could create confusion towards the public.

Measuring Intention to Act Ellen (et al, 1991) defined perceived consumer effectiveness (‘PCE’) as the extent to which a consumer believes that an individual’s efforts can make a difference. While consumer concerns on environmental issues are not equivalent to acting in pro environmental behaviours, individuals with a higher PCE are found to be more likely to engage in environmentally conscious behaviours, showing that self-efficacy beliefs of PCE do translate into climate action (Choi & Kim, 2005). PCE could be influenced by factors including knowledge, direct and indirect experiences, and general or abstract value orientations: more collectivistic individuals are more likely to engage in climate action in hopes of expecting other members to perform the same behaviour by making a difference altogether (Choi & Kim, 2005). However, Ellen (et al,1991) also emphasised on how the PCE should not be used to predict generalised behaviours, furthered by Arias (2020) with the mentioning of an indirect effect model. For instance, PCE does not predict the recycling rate, but the use of reusable shopping bags.

In light of the low engagement of climate action, Hornsey (et al, 2006) proposed needing clearer criteria to set out the goals of collective action, and to measure effectiveness. The criteria are as follows: (1) extent to which the relevant out-group would be influenced by collective action, (2) which relevant third parties would be influenced by collective action, (3) collective action would be successful in building an oppositional movement, and (4) which collective action would be successful in expressing one’s values (Hornsey et al, 2006).

Collectivism is therefore essentially an individual-level value orientation (Choi & Kim, 2005).

They furthermore stressed how a greater perceived self-efficacy influences the likelihood for

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consumers to act in green purchase behaviours (Choi & Kim, 2005). On the governmental level, it was discovered that a public’s perceived policy effectiveness does influence an intention to act such as committing to recycling (Wan and Shen, 2013). For example, people are more inclined to recycle if they believe it is effective to do so.

Yet we should keep in mind that an increase in intention as shown by the PCE is not equivalent to an increase in climate action (Barr, 2006). In Barr’s study, it was found that the actual action depended upon factors such as age, gender, and policy knowledge (Barr, 2006). The study was, however, conducted in 2006, which may not be an entirely accurate reflection of the present situation.

Bridging the Intention-Action Gap Four factors were identified in transforming intention to action (Carrington et al, 2014). Firstly, ethical concerns should be prioritised as it is often inconvenient and difficult for people to change their behaviour, while ethical concerns could offset the additional cost required.

Secondly, forming consistent habits is the key. Thirdly, there should be a willingness to commit and sacrifice as it is inevitable for costs and inconveniences to be incurred while adapting a greener lifestyle. Fourthly, people should adopt a constant mindset of decision-making especially when shopping (Carrington et al, 2014).

Kelly (1993) also highlights how some people’s intentions stem from seeking favourable selfcategorisation in being environmentally aware, the activist identity is another way to increase chances of engagement. Additionally, perceiving that other people care about the environment is a factor that can motivate eco-friendly behviour (Bouman, Steg, 2019). On the contrary, it is

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also possible for people to start with more practical reasons such as financial incentives and family safety (Kennedy et al, 2009).

Discussion The media remains highly intertwined with the process of forming public opinions on climate change. Evidence suggests that merely talking about the problem is not enough to urge people to act (Dickinson et al., 2013). In fact, it can do quite the opposite – desensitise them from acting on it at all. Climate action is lower than the intention to act due to public misconceptions on the science behind the climate crisis and journalistic norms. To solve this urgent yet persisting issue of climate change, the media should adopt a unified narrative (Bushell et al, 2017). This not only helps journalists address the complex range of factors, but also provide a coherent explanation for government strategy (Bushell et al, 2017). This would also effectively increase the motivation behind initiating people’s behavioural change. Namely, the “well baby” appeal by Ellen (et al, 1991) should be adopted and the number of solutions offered should be maximised and these solutions simplified (Moser & Dilling, 2010). This would make it easier for individuals to accept the cost of changing their lifestyles with greener habits (Ellen et al, 1991) (thus increasing PCE alongside their climate intention and awareness) and ensure a higher level of consistency (Carrington et al, 2014). An ecolinguistic approach is endorsed in light of the public’s unfamiliarity with scientific jargon such as “enhance” and “positive trends” (Kaushal et al, 2022). Individual actions to contribute are also reinforced by emphasising green consumerism, surface transportation behaviour, a reduction in household energy use, and recycling (Kaushal et al, 2022). These measures would all support the idea of collectivism that stems from individual efforts in adopting behavioural changes. The media, therefore, is in a powerful position to influence climate action given that people’s perceptions are formed and

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derived from the information relayed and delivered by journalists (Lopera, 2014; Boykoff 2004).

Climate Crisis Attitudes Our entire analysis is contingent on the hypothesis that the kind of newspaper people read influences their opinion about the climate. In this section, we will attempt to demonstrate this hypothesis by fitting a multiple linear regression model. The null hypothesis is that the newspaper one reads has no influence on whether they prioritise the environment or not.

Dataset For our analysis, we are using Wave 17 of the 2014 – 2023 British Election Study Internet Panel (Fieldhouse et al., 2020). The dataset includes answers from 34,366 respondents about various matters, from basic characteristics such as age and gender to political views, opinions about matters of societal interest and perceptions about the performance of public institutions, such as the NHS. Even though the study we are using is longitudinal, for the purpose of our analysis, we will only need a single wave, therefore our focus will be cross-sectional.

It is important to note that the study does not use a probability sample, meaning that we must use weighting in our analysis to account for the fact that the sample of respondents is not necessarily representative of the UK population in terms of age, education, and other characteristics. This is also helpful when dealing with survey non-response. The weights we have used are the ones provided by the British Election Study in the dataset.

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Relevant Variables The outcome variable is a categorical variable registering three possible responses to the question ‘Is the environment a priority for you?’. The three possible answers are ‘no’, ‘yes’, and ‘don’t know’. In my dataset, ‘no’ is represented by 0, ‘yes’ is represented by 1, and ‘don’t know’ is ignored, since it does not provide any useful insight. The missing and unsubstantive answers were eliminated by subsetting the data into a smaller sample. Therefore, the estimate for each category in my regression will be a number between 0 and 1 which signifies the percentage of people in that category that identify the environment as a priority.

The main predictive variable is also a categorical variable indicating the newspapers people read on a daily basis. This variable has been structured in two different ways. Firstly, the newspapers have been put into categories based on writing style (tabloid/broadsheet).

Secondly, they were organised by political affiliation (left/centre/right). The political orientation labels are based on a study conducted by Matthew Smith (2017) and published on YouGov. We have also considered other relevant facts such as the parties each paper has publicly endorses in the past and the stances, they have expressed regarding relevant political issues.

Two models have been fitted for both these variables, in order to pinpoint what it is exactly about different newspapers that influences people’s opinion on the climate. The structure of each category is outlined in the table below.

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Newspaper

No. of readers in dataset

Writing style

Political Affiliation

The Express

137

tabloid

right

The Daily Mail / The Scottish Daily Mail

1114

tabloid

right

The Mirror / Daily Record

245

tabloid

left

The Daily Star / The Daily Star of Scotland

26

tabloid

centre

The Sun

518

tabloid

right

The Daily Telegraph

341

broadsheet

right

The Financial Times

37

broadsheet

centre

The Guardian

803

broadsheet

left

The Independent

154

broadsheet

centre

The Times

393

broadsheet

centre

The Scotsman

16

broadsheet

centre

The Herald (Glasgow)

23

broadsheet

centre

The Western Mail

10

broadsheet

centre

Other local daily morning newspaper

209

none/other

none/other

Other Newspaper

390

none/other

none/other

None

3888

none/other

none/other

Table 1 – Classification of newspapers in the dataset.

Two mentions must be made at this point. One is that we have classified some of the newspapers (e.g., The Scotsman, The Western Mail) as ‘broadsheet’, even though they are published in compact form. This is because we have judged that these papers have a broadsheet writing style, and therefore were included in the same category. This is why the classification is called ‘writing style’, rather than ‘format’.

The second mention to be made here is that this classification is obviously not strict. Some of these publications have a flexible or ambiguous political stance. The very classification of left/right can be put to debate and it is certain that some people would take issue with the judgment we made when constructing these categories. Nevertheless, it is useful to look at the data this way and we have tried to be as unbiased as possible when considering the political affiliations of the papers above.

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Our regression also takes into consideration several covariates that contribute to the explanatory value of the model. These include age, education and political ideology. For each of these variables, there are theoretical reasons why we believe they could have an influence over the environmental stance. We expect higher levels of education to be correlated to a higher concern for the environment since it is probable that a considerable number of people do not consider the environment to be a priority because they lack the proper knowledge on the topic.

Political ideology, also, can play a big part in whether someone considers the climate to be important since leftist discourse usually ascribes higher importance to the environment. This indicator is measured on a left-right scale from 0 to 10, with a higher value indicating a stronger leaning to the right. Age might also be a relevant factor because climate change is likely to be felt stronger by future generations, which means that the level of concern of people might be influenced by considerations about their future or their family’s future, which most likely varies with age.

The inclusion of these covariates is also based on existing literature. Neumayer (2004) found that conservatism is correlated with a lower level of concern for the climate and that left-leaning individuals are more likely to support ecological policies. This has been confirmed by McCright and Dunlap (2011), who find that white conservative males in the US are the least likely to express concern for the climate. Similar findings based on political orientation can be found in papers written by Eisler et al. (1990) and Schulz and Stone (1994). Age is also found to be relevant for environmental characteristics. Research indicates that younger people tend to be more environmentally concerned (Arcury and Christianson, 1993; Klineberg et al., 1998), while older people tend to have a more sustainable behaviour (Gilg et al., 2005; Swami et al., 2011). Education as well is considered relatively important in several countries, as respondents

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with higher education levels tend to be more concerned for the climate (Arcury & Christianson,1993; Klineberg et al., 1998).

It is important to include these variables because it could be that they are correlated with newspaper choice and, in that case, a simple model would overestimate the influence of the main predictor on the outcome variable, when in fact there might be another variable that influences both newspaper choice and opinion about the climate.

Selection of a Complete Case Study Sample One of the most important limitations of our study is the item non-response affecting the outcome variable. Out of the 34,366 participants, we have available data for our outcome variable for only 8,663 (25%), and a valid ‘yes’ or ‘no’ answer for only 8,304 (24%). Since more than three-quarters of the respondents have not answered this question, we considered it to be wiser to restrict our sample, instead of doing any imputations since an inadequate imputation for such a large proportion might skew our results even more. Another obstacle is the fact that the variable consists of categorical data and there is no guarantee of a monotone missing pattern. There are proposed solutions to this problem in the existing literature (Wilson and Lueck, 2014). However, we considered that non-standard imputation methods are too big of a risk for the simple hypothesis we are trying to demonstrate and that our restricted sample should still be relevant, especially when using the survey weights.

For other variables included in the dataset, we have used hot-deck imputation, using closely related variables as reference. For example, for the left-right scale, we used the party voted for in the 2019 general election.

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Descriptive Statistics To get an initial impression of the data, we can first look at the descriptive statistics. The table below shows the percentage of people who consider the environment to be a priority for them, ordered from lowest to highest based on the newspaper they read daily.

Newspaper

Percentage

Political Orientation

Writing Style

The Sun

37 %

right-wing

tabloid

The Express

41 %

right-wing

tabloid

The Daily Mail / The Scottish Daily Mail

42 %

right-wing

tabloid

The Daily Star / The Daily Star of Scotland

42 %

centre

tabloid

The Western Mail

50 %

centre

broadsheet

The Daily Telegraph

52 %

right-wing

broadsheet

The Mirror / Daily Record

52 %

left-wing

tabloid

Other local daily morning newspaper

55 %

none/other

none/other

None

55 %

none/other

none/other

The Scotsman

56 %

centre

broadsheet

The Herald (Glasgow)

57 %

centre

broadsheet

The Financial Times

57 %

centre

broadsheet

The Times

59 %

centre

broadsheet

Other Newspaper

65 %

none/other

none/other

The Independent

71 %

centre

broadsheet

The Guardian

80 %

left-wing

broadsheet

Table 2 – Percentage of people who identify the environment as a personal priority based on the choice of newspaper.

From looking at the descriptive statistics, we can observe that there seem to be important differences between different readers, with results ranging from 37% to 80%. The regression analysis will give us a better idea of the relevance of this predictor.

Furthermore, we can observe the way other characteristics of the respondents seem to be related to our outcome variable in the table below. These provide a basis for a better understanding of the covariates of the model and their potential relevance.

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Number in sample

Proportion in category

Most read newspaper

Percentage of people who consider the environment a priority

18-40

2212

27 %

The Guardian

61 %

41-60

3088

37 %

The Daily Mail

52 %

61

3150

38 %

The Daily Mail

54 %

0-3

4511

54 %

The Guardian

61 %

3.5-6.5

3315

40 %

The Daily Mail

50 %

7-10

478

6%

The Daily Mail

39 %

No qualification

605

7%

The Daily Mail

43 %

Below GCSE

421

5%

The Daily Mail

48 %

GCSE

1911

23 %

The Daily Mail

48 %

A-level

1684

20 %

The Daily Mail

54 %

Undergraduate

2831

34 %

The Guardian

60 %

Postgraduate

847

10 %

The Guardian

67 %

Age

Left-Right Scale

Education

Table 3 – Descriptive statistics based on covariates.

Multiple Regression The two tables below summarise the results of two multiple linear regressions. For the first one, we classified the different newspapers by writing style. For the second one, the classification is made by political affiliation. In both cases, the covariates are the same. For the ‘age’ variable, we have used a polynomial transformation since the relationship between age and the outcome variable is not linear. The confidence level we have used is 95% (α = 0.05).

Estimate

Standard Error

t-value

p-value

Intercept

0.9519

0.0459

20.757

0.0000

Left-Right Scale

-0.0375

0.0026

-14.202

0.0000

Education

0.0416

0.0042

9.796

0.0000

Age

-0.0144

0.0019

-7.692

0.0000

Age squared

0.0001

0.0000

7.691

0.0000

Writing Style of Newspaper Read - Reference Category: Broadsheet tabloid

-0.2099

0.0169

-12.443

0.0000

none/other

-0.1000

0.0142

-7.038

0.0000

Table 4 – Regression summary with writing style.

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From the table above, we can make some meaningful observations. First of all, all the p-values are far below the confidence level, so we can reject the null hypothesis. We notice that, compared to broadsheet readers, both tabloid readers and people that read other newspapers or none are less likely to identify the environment as a personal priority. We also observe that, as predicted, higher levels of education are associated with a greater concern for the climate. An increase in age initially results in a decrease in environmental concern, and then an increase.

The model predicts that an individual aged 72 will be the least likely to consider the climate to be a priority. Consistent with our initial intuition, the more an individual leans right politically, the least likely he is to prioritise the climate.

Estimate

Standard Error

t-value

p-value

Intercept

0.8913

0.0494

18.029

0.0000

Left-Right Scale

-0.0318

0.0027

-11.783

0.0000

Education

0.0459

0.0231

10.990

0.0000

Age

-0.0154

0.0041

-8.254

0.0000

Age squared

0.0001

0.0000

8.344

0.0000

Political Orientation of Newspaper Read - Reference Category: Centre left

0.0735

0.0257

2.863

0.0042

right

-0.1612

0.0231

-6.955

0.0000

none/other

-0.0521

0.0216

-2.403

0.0163

Table 5 – Regression summary with political affiliation.

Just as previously, all our p-values are below the confidence level, so I can reject the null hypothesis. In terms of findings, the models are very similar. This model, however, emphasises the political affiliation of the newspapers, rather than the writing style. More specifically, somebody who reads a right-leaning publication is less likely to identify the climate as a priority, compared to someone who reads a centrist newspaper, on average. Similarly, someone who reads other newspapers, or none, is also less concerned about the climate compared to the average reader of centrist publications, although the correlation is not as strong and the difference is smaller. Readers of left-leaning papers are more inclined to prioritise the climate.

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The other results are consistent with the previous model. At 6.8%, the explanatory power of this model is only slightly higher compared to the previous one.

Discussion and Limitations Our analysis allows us to work on the premise that the newspaper one reads has an influence on one’s opinion and attitude about the climate. In the rest of our analysis, we will try to identify what it is more specifically that tends to create these differences in terms of the framing and content of the articles. It seems so far, that the political affiliation of the publication, as well as its writing style, are important factors when it comes to influencing opinion. Having established that, we are now concerned with what are the specific textual differences that determine this statistically significant discrepancy in opinion.

There are several important limitations of our analysis so far. One has already been discussed earlier and concerns the nonresponse level in the dataset. Another one is the relatively low explanatory power of the models, indicating that even though the relationship is statistically significant, the model does not explain a lot of the factors that influence the outcome variable in reality, meaning that it would not be particularly wise to use the model to make predictions.

Further work can be developed for a better understanding of what influences someone’s stance on climate change.

Furthermore, the outcome variable we are using is not necessarily the most representative measure of people’s opinion about the environment. The framing of the question ‘is the climate a priority for you?’ might be interpreted differently by different people. It could be that someone believes that climate change is a serious issue that needs to be thoroughly addressed, but they simultaneously believe that there are other issues that take priority. The reader must

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bear in mind that these answers are given by people and they are not checked against an actual metric of how ‘green’ they behave or whether their electoral choices are based on considerations about environmental policies. As is the case very often with social science, it is wise to consider the flexible nature of survey answers, especially when the question asked could have multiple interpretations.

Newspaper Content Analysis As mentioned previously, we know that there is a wide research gap between individuals’ intention to act on climate change and them actually acting on it (Momsen and Stoerk, 2014; Carrington et al, 2014). It is also evident that the framing of messages from the media plays an important role in people’s willingness to act (Stevenson et al., 2018). Some evidence suggests that framing messages regarding the climate crisis negatively (e.g. relating to danger of one’s health or life) does not increase people’s interest in taking personal action on climate change (Dickinson et al., 2013). In some other cases, positive framing of messages can increase people’s interest in taking personal action to some extent (Badullovich et. al. 2020).

The previously conducted multivariable regression identified two statistically significant relationships, 1) between newspaper writing style and attitudes towards climate change and 2) between newspaper political affiliation and attitudes towards climate change. It has been identified that, compared to broadsheet newspapers readers, tabloids readers tend less to consider climate change as a personal priority. Similarly, readers of right-wing newspapers tend less to view climate change as personal priority compared to readers of left wing and centre news outlets. This section aims to investigate a reason for this result by answering the following research question: Is there a difference in the framing of the climate crisis between 1) broadsheet newspapers and tabloids and 2) right, centre and left-wing newspapers? We do 21

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so by conducting a content analysis of newspaper articles by writing style and an analysis by political orientation. Specifically, we hypothesise that there will be a significant difference between the framing of the climate crisis between broadsheet newspapers and tabloids. Our second hypothesis is that there is a significant difference in framing depending on the political orientation of the newspaper (and that their differences will vary related to their political orientation.)

Adopting a positivist approach, we use content analysis to analyse 223 UK Newspaper articles.

Our findings suggest that there is a significant difference in the topics and narratives the different types of newspapers focus on. We found that certain topics are more likely to be found in broadsheet newspapers or tabloids, and similarly for left, right and centre newspapers, suggesting that people’s personal beliefs about climate change might be different, depending on the types of newspapers individuals obtain their views from and the framing of the messages in them respectively.

Data extraction: NewsAPI In order to conduct our analysis, we needed to extract a sample of articles from different media sources which are listed in table 1 below. We have focused on news outlets based in the United Kingdom and the United States of America as they have closely matched levels of democracy and similar political systems in terms of having two major political parties, dual chambers of parliament and scheduled elections, thus making their news sources suitable to be grouped for analysis, allowing for more data that enhances the accuracy of our analysis. We have also used the same UK sources as those used in the previously carried out regressions to help maintain some continuity in the overall study. Furthermore, the sources used are mainstream media with

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online platforms, wide readerships, and a national focus. This helps remove any potential biases based on region or narrow factional attitudes or beliefs.

Source

Number of articles

Political Orientation

Type of media

The Guardian

45

Left

Broadsheet

Daily Mail

31

Right

Tabloid

Fox News

7

Right

Tabloid

The Independent

57

Centre

Broadsheet

Daily Mirror

7

Left

Tabloid

The New York Times

17

Centre

Broadsheet

The Telegraph

4

Right

Broadsheet

BBC News

21

Centre

Broadsheet

CNN

10

Left

Broadsheet

Bloomberg

24

Centre

Broadsheet

Table 6 - Sources, number of articles, political orientation, and type of media.

We used a total of 223 articles for the analysis, the breakup of which by source can be viewed in table 1. These articles were extracted using NewsAPI.org, a simple and easy-to-use Application Programming Interface (API) that enables computer applications to search results for current and historic news articles published by over 80,000 worldwide sources. We chose this API because it was easy to adapt the API link to suit our needs and it was compatible with R. NewsAPI also had the advantage of giving us access to a wide range of sources, which is more efficient than requesting data from individual news outlets’ APIs.

In terms of the selection of articles, we filtered the data to only include articles that had the term “climate change” in their titles or descriptions to ensure their relevancy. We sought to choose the most neutral term to get relevant results because we wanted to avoid a kind of systematic error wherein, we get inherently biased results in the extraction itself. Hence, we chose “climate change” as we believe that the other terms like climate “crisis” or “catastrophe” are part of an article’s narrative, which is the dependent variable that we are attempting to 23

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investigate. We then used API links for each news source to access their articles, imported the data into R, and converted them into datasets to be used for our analysis.

The chosen sample of articles were published between 2nd January 2022 and 2nd February 2022 since the freely available “developer version” of NewsAPI restricted our access to a onemonth period. However, we estimated that a month’s worth of data was sufficient to provide a short-term general indication of each source’s narrative on climate change. The developer version of NewsAPI also restricted the content of each article to its first 260 characters, which approximately constitutes the first paragraph of each article. This obviously hinders our analysis but given the journalistic norm of articles having a lead paragraph, we considered the available data to be adequate for our purpose of studying how each source presents the problem of climate change as the paragraph sums up all the major facts and sets the tone for the rest of the article.

We also observed some further limitations in our extraction of data. Firstly, some articles were not particularly relevant to climate change despite our filtration process. However, as we were only aiming to analyse a general trend in the narrative regarding climate change, we deemed it unnecessary to individually reject these articles as the subsequent analysis would exclude these outliers. Secondly, since the data only include each article’s lead paragraph that aims to grasp the reader’s attention, we run the risk of some of our content being sensational and not accurately representing the overall tone of the article which may result in biases in our results.

Thirdly, the number of articles from each source varies due to the time constraint leading to different weights for different news outlets in analyses where we group together sources by political orientation or media type. This introduces another potential bias in our analysis based on the relative size and focus of the news sources. And lastly, due to the fact that we have used

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news outlets belonging only to two countries with several similarities, it might be the case that our results do not hold in countries with different characteristics like perhaps a country with a dissimilar political system compared to the US and UK.

1. Newspaper Writing Style The previously conducted regression analysis sought to identify whether newspaper writing style influences individual attitudes towards climate change. We uncovered the existence of a statistically significant relationship: individuals reading predominantly tabloids tend to be less concerned about climate change than those reading broadsheet newspapers. This section aims to understand this relationship by answering the following research question: Does the framing of climate change differ between broadsheet newspapers and tabloids?

Methodology To provide an answer to our research question, a structural topic model was computed using the dataset defined in the previous section. This was achieved using the stm package in R.

Firstly, we cleaned the articles’ content to remove any character unnecessary for our analysis.

This includes discarding capital letters, punctuation, numbers, and common English stop words defined by the SMART list. We chose to remove additional terms which had a high frequency in our data but did not greatly contribute to our analysis. This includes terms related to journalism such as ‘caption’, ‘podcast’ or ‘comments’. However, it is important to note that this process was done manually and this list is non-exhaustive: it may be that other terms which would fit that description did not get removed. The full list of personalised stop words can be found in the Appendix R script. We also elected to remove the terms ‘climate’ and ‘change’ due to their evident frequency in the articles selected: these terms were the keywords for our 25

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NewsAPI query. This data cleaning was done with the aim of ensuring that our results would be both reliable and relevant to our analysis.

The next step in our analysis was to convert our data to a format compatible with the stm package and to run our structural topic model. This was done by defining several parameters:

1. The documents to analyse consisted of the articles’ content and the whole dataset was included as metadata.

2. To improve topic classification, we used the newspaper style variable as a prevalence parameter. This ensured that topics would be defined accounting for whether the source was a broadsheet newspaper or a tabloid.

3. After conducting a searchK test with identical parameters, we defined the optimal number of topics to be 7. This ensured an acceptable trade-off between semantic coherence and limiting residuals (Figure 1).

Figure 1 – searchK plot.

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Results Table 6 reports the 5 words with (a) the highest frequency and (b) the highest ranking FREX for each topic. Highest frequency words refer to the words that are the most likely to be found in the dataset whereas the highest ranking FREX words refer to words that are both frequent but also distinctive from other topics. Frequency provides information on the general trend in topics whereas FREX provides information on the differences between topics.

Topic 1

Topic 2

Topic 3

Topic 4

Topic 5

Topic 6

Topic 7

Frequency

Carbon Energy Power Dioxide Will

Report Threaten American Suggest Charles

Crisis Plan Fight Billion Minister

Govern Green Temperature State Federal

Will World Challenge Time Northern

Biden World President Economy Bill

Global Major Expert Region Continue

FREX

Dioxide Clean Company House Atmosphere

American Suggest Charles Judge Live

Crisis Billion Johnson Accuse Cost

Britain Plant Consequence Temperature State

Northern Second Annual Capital Ireland

Biden President Economy Democrat Legislation

Region Cop Disease Movement Confer Failure

Table 6 - Highest frequency and FREX words results from STM analysis.

From these results, it is apparent that our topics have different focuses. For example, Topic 1 seems to be related to the scientific aspect of climate change whereas Topic 6 appears to focus on key actors, in the United States in particular. Stemming from these results, we aimed to see if certain topics were more likely to be found in broadsheet newspapers than tabloids. This was achieved by plotting the estimated effect of newspapers’ writing style as shown in Figure 2.

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Figure 2 - Plot of the effect of newspaper writing style on topics

Figure 2 indicates whether a particular topic is more likely to be found in broadsheet newspapers or tabloids with 0 indicating that no difference exists. From this figure, it is apparent Topic 1 is significantly more likely to be present in broadsheet newspapers as opposed to tabloids. However, no other statistical significance can be established as all other confidence intervals include 0. This means that we cannot ascertain from this data that there is a difference in the likelihood of finding these topics between both writing styles. Nevertheless, we observe that, from this data, Topic 5 is the most likely to be found in tabloids and Topic 1 in broadsheet newspapers.

A further investigation consists in comparing the content of these two topics. This would allow us to see if there is a difference in framing between tabloids and broadsheet newspapers which could explain the previously established difference in climate attitudes. Such comparison can be made using Figure 3 and 4.

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Figure 3 – Topic 1 word cloud

Figure 4 – Topic 5 word cloud

These word clouds have been constructed such that bigger and more central words indicate a higher frequency in our data. It can be noticed that Topic 1 contains more scientific terms. This corroborates the observations made in Table 6. In contrast, Topic 5 appears to contain terms highlighting the danger posed by climate change such as ‘doomsday’, ‘challenge’ or ‘extreme’.

Discussion The results presented above and a reading of a random sub-sample of 50 articles enables us to discern the differences between broadsheet and tabloid news sources. We know from Figure 2 that Topics 1, 2 and 7 are more likely to appear in broadsheet newspapers while Topics 3, 4, 5 and 6 are more likely to appear in tabloids. The differences between these topics can be broadly divided into two parts: the tone and the focus.

Firstly, we observe that broadsheets have a more scientific tone while tabloids have a more emotive tone. In Table 6, Topics 1 and 7 seem to have a more scientific tone because words like “carbon”, “power”, “expert” and “region” would all usually be used to refer to facts about climate change. On the other hand, Topics 3 and 5 contain more emotive words such as “crisis” 29

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and “challenge”. This fact is further corroborated by the wordcloud for Topic 5 (Figure 4) which contains more dramatic terms such as the ‘doomsday’ ‘clock’ striking ‘midnight’. These not only tend to elicit an emotional response from readers but also make climate change seem like a bigger challenge to tackle than when it is described less sensationally and more factually.

Thus, tabloid readers might be less motivated to act to remedy climate change than broadsheet readers because they believe that the issue is too great for any individual action to solve.

Secondly, the focus in Topics 2, 3, 4, 5 and 6 is on the actions of world leaders and governments as can be seen from words relating to British Prime Minister Boris Johnson, US President Joe Biden, state and federal government, democrats, and legislation. Meanwhile, we notice that Topics 1 and 7 focus only on facts about climate change. This distinction might affect readers in the sense that those reading tabloids believe that the worsening climate crisis and the lack of adequate climate action is the government’s responsibility whereas those reading broadsheet news are exposed to this narrative less often. As a consequence, tabloid readers might be less concerned about climate change because they do not believe that it is their responsibility to influence the issues they read about while broadsheet readers might be more concerned and motivated to act as they have read more facts about climate change and less about it being the government’s job or fault.

Nevertheless, Figure 3 and 4 show that, in essence, both writing styles describe climate change in similar ways. Topic 1 contains negative terms such as ‘difficult’, ‘risk’ or ‘struggle’ and Topic 5 contains factual words like ‘net-zero’, ‘biodiverse’ and ‘research’. This suggests that differences between writing styles mainly lay in differences in newspapers’ focus which will lead them to use certain terms more frequently.

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2. Newspaper Political Orientation The regression analysis performed showed a statistically significant difference between the political orientation of a newspaper and how likely their readers are to identify climate change as a priority. Those who read right-leaning newspapers or none/other are less concerned about the environment than those reading centrist newspapers. Comparatively, those reading leftleaning newspapers prioritise the climate more than readers of centrist newspapers.

As such, the aim of this section is to explore the following research question: Does the framing of climate change differ between left-, right-leaning and centrist newspapers?

Methodology In seeking to answer the research question, a structural topic model was computed using the dataset defined above. To achieve this in R the stm package was used.

The first step was to clean the article content, the aim of which is to ensure results are robust and relevant to the analysis. It was accomplished by removing capital letters, punctuation, numbers and common English stop words defined by the SMART list. Additionally, terms which appeared frequently in the data but had no real explanatory power such as ‘published’ were also removed. The full list of additional words removed can be found in the R code published in the appendix. However, as the process used to remove these words is prone to human error, the list of additional removed terms is non-exhaustive. Similarly, the words ‘climate’ and ‘change’ were removed due to their appearance in every article as a result of these terms being chosen as the keywords for the NewsAPI query.

The second step was to convert the data such that the format is compatible with the stm package in order to run the structural topic model. To do this, several parameters were defined: 31

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•

The documents to analyse consisted of the content of our articles and the whole dataset was included as metadata.

•

To improve topic classification, we used the political orientation of newspapers as a prevalence parameter. This ensured that topics would be defined accounting for whether the source was a right-, a left-leaning or a centrist newspaper.

•

After conducting a searchK test with identical parameters, we defined the optimal number of topics to be 10. This ensured an acceptable trade-off between semantic coherence and limiting residuals (Figure 5).

Figure 5 – searchK plot

Results Table 7 displays the 7 words with (a) the highest frequency and (b) the highest ranking FREX for each topic. Highest frequency words are defined as words most likely to appear in the dataset which provides information on the general trend of topics. On the other hand, the highest frequency FREX words are those that are not only frequent but also distinctive from other topics providing information on the differences between topics. It is important to note, that these results are interpreted from their stems and may therefore not be the most accurate choice, furthermore, the table is split into two tables of 5 topics each for clarity purposes.

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Topic 1

Topic 2

Topic 3

Topic 4

Topic 5

Frequency

World Work Charles Plan Region Doomsday Government

Governement Expert Future Record Threaten Water Warn

Crisis American State Weather Day Study Break

Carbon Dioxide Global Release Stay Year Issue

Will Northern Target Energy Clean Investment Legislation

FREX

Charles Doomsday Work Clock Endorse Harry Leaders

Cause England Winter Future Threaten Expert Water

American Break Crash Trouble State Day Crisis

Dioxide View Stay Carbon Release Atmosphere Make

Ireland Net-Zero Northern Control Reserve Vote Watch

Table 7a – Highest frequency and FREX words results from STM analysis, Topics 1-5 Topic 6

Topic 7

Topic 8

Topic 9

Topic 10

Frequency

Gas Focus Concern Issue Glasgow COP26 Protest

World Government Citizen Face Capital Claim Vehicle

Warm Will Global Limit Temperature Human Year

World Global Biden Studies Coffee Threat Support

Energies Green Need Fight Particular Nation Power

FREX

Disease Judge Movement Focus Cancel Conference Depart

Capital Claim Vehicle Citizen Conservative Woman Tackle

Chain Coral Unusual Limit Human Warm Suppliers

Coffee Pass Start Biden Threat Earth Pose

Need London Nuclear Green Particular Energies Nation

Table 7b – Highest frequency and FREX words results from STM analysis, Topics 6-10 33

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From the tables above, it can be clearly seen that topics have a different focal point and thereby different ways of framing climate change. Topic 2 uses more emotive language such as ‘threaten’ and ‘warn’ whereas topic 8 focuses more on the facts using words such as ‘temperature’. Moreover, it is clear that most of the topics take on a broad outlook, mentioning the ‘world’, ‘government’, ‘American’ or ‘leaders’. The latter point is reflective of the climate change issue itself, it is a broad issue as it affects many people across the globe in varying ways; from rising sea levels to an increase in extreme weather occurrences.

Furthermore, table 8 reports the estimated effect of political orientation on each of the 10 topics.

Choosing a statistical significance level of 95%, as per political science standard, it is clear to see that the intercept (effect of centrist newspapers) for each topic is statistically significant.

This shows that the impact of centrist newspapers on the prevalence of our topics (as shown by the regression coefficients) can be generalised to a wider population. However, left leaning compared to centrist newspapers only exhibit a significant difference in the effect in Topics 3 and 6. In Topic 3 the difference is 0.929 and in Topic 6 it is -0.080. Meanwhile, right-leaning compared to centrists only has a significantly different effect in Topic 1, equal to 0.148.

Consequently, the majority of inferences cannot be generalised to the wider population.

Table 8 shows that Topic 1 has the most prevalent positive differences (highest positive coefficient) of right-leaning newspapers compared with centrist ones whilst on the other hand Topic 8 has the most prevalent negative effect when compared to centrist newspapers.

Moreover, Topic 3 exhibits the largest positive differences between left-leaning and centrist newspapers which contrasts Topic 6 which has the largest negative difference compared to centrist newspapers. Overall, the regression table suggests there does not exist a statistically significant difference in the effect of political orientation across topics.

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Category

Coefficient

SE

T-Value

Pr.

0.078

0.018

4.279

2.74E-05

-0.039 0.149

0.034 0.049

-1.151 3.069

0.251 0.002

0.107

0.022

4.919

1.36E-06

-0.007 -0.031

0.039 0.043

-0.191 -0.706

0.849 0.481

0.081

0.019

4.249

3.09E-05

0.101 -0.033

0.039 0.042

2.613 -0.785

0.010 0.433

0.079

0.019

4.133

4.98E-05

0.020 0.064

0.039 0.042

0.510 1.515

0.610 0.131

0.108

0.021

5.127

3.98E-07

-0.036 -0.046

0.038 0.042

-0.944 -1.086

0.346 0.279

Topic 1 Intercept

Orientation Centre Left Right Topic 2 Intercept

Orientation Centre Left Right Topic 3 Intercept

Orientation Centre Left Right Topic 4 Intercept

Orientation Centre Left Right Topic 5 Intercept

Orientation Centre Left Right Topic 6 35

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Intercept 0.133

0.023

5.818

1.93E-08

-0.080 -0.040

0.039 0.047

-2.056 -0.839

0.041 0.402

0.076

0.019

4.050

6.95E-05

0.053 0.069

0.03 0.043

1.337 1.600

0.302 0.138

0.133

0.022

6.017

6.74E-09

-0.043 -0.071

0.041 0.048

-1.035 -1.486

0.302 0.138

0.105

0.023

4.604

6.79E-06

0.045 0.008

0.047 0.046

1.060 0.178

0.290 0.859

0.101

0.019

5.408

1.56E-07

-0.019 -0.071

0.035 0.041

-0.532 -1.706

0.595 0.089

Orientation Centre Left Right Topic 7 Intercept

Orientation Centre Left Right

Topic 8 Intercept

Orientation Centre Left Right Topic 9 Intercept

Orientation Centre Left Right Topic 10 Intercept

Orientation Centre Left Right

Table 8 – Summary of a regression model that estimates the effect of political orientation on Topics

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Further analysis seeks to compare the content of three Topics: 1,3 and 8, one for each political orientation. For the purposes of a consistent comparison, positive estimates were chosen for all three political orientations, after that, the largest estimate was identified for each orientation and that Topic chosen. This allows for the Topic chosen to be the one that has the biggest positive effect for each political orientation. They also happen to be the Topics which have statistical significance at the 95% level indicating that the inferences made could be generalised to the wider population. This analysis aims to explore whether a difference in framing between left-leaning, right-leaning and centrist newspapers exists as this could help to explain the difference in climate attitudes established earlier. The comparison is made using Figures 6, 7 and 8.

The word clouds are constructed in such a way that bigger and more central words indicate a higher frequency. Topic 3, focusing on left leaning newspapers, contains more words pertaining to the broadness of the issue, same as Topic 1, which focuses on right leaning newspapers. This cements finding that the broadness of the issue is covered by most of the topics, as seen in Table 8 above. Both Topics also consist of emotive language using words such as ‘extreme’, ‘downhill’, ‘doomsday’ and ‘attack’. In contrast, Topic 8, which focuses on centrist newspapers, appears to contain more scientific language such as ‘scientists’, ‘high’ and ‘temperature’ whilst simultaneously focusing on the broadness of climate change.

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Figure 6 – Topic 3.

Figure 8 – Topic 1.

Figure 7 –Topic 8.

Discussion Combining the above results and the reading of a random sub-sample of 50 articles enables us to distinguish differences between left-leaning, right-leaning, and centrist newspapers. As shown above in Table 8, Topic content results in either negative or positive effects of rightand left-leaning newspapers when compared to centrist newspapers. Other than for Topic 3, the direction of the effects is the same for the opposing political orientations.

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Firstly, a positive regression coefficient arises for right-leaning newspapers. This could be due to the use of a more emotive tone which is created by words such as ‘doomsday’ whereas the negative coefficient is observed when a more scientific tone is employed through the use of words that refer to facts about climate change such as ‘limit’, ‘temperature’ and ‘warm’ to name a few. This finding is strengthened by the wordcloud for Topic 1, with a right-leaning focus, which also contains the following terms ‘clock’, ‘attack’ and ‘help’. These result in connotations of time running out and a sense of emergency. Consequently, climate change could be viewed as a more urgent issue by the readers who foster a belief that the issue needs immediate attention. However, when considering this alongside the regression analysis which concluded that right-leaning readers tend to consider the climate crisis as less of a priority and combining it with the sick baby appeal theory (Ellen et al, 1991), it can be inferred that emotive bias makes it seem like the issue of the climate crisis is too big for any individual to do anything to tackle it. Nevertheless, it is important to note, that this is one interpretation, and there could be other reasons for the observed effects.

Secondly, the focus in Topic 3, which has a left-leaning focus, is more on the size of the issue and the use of emotive words such as ‘crisis’, ‘extreme’, ‘weather’ and ‘now’ appearing.

Contrasting this is Topic 6 which uses more scientific language; ‘gas, ‘COP26’ and ‘focus. It is the scientific tone of the articles which appears to creates the most prevalent negative difference of left-leaning compared to centrist newspapers. A potential reason for this may be that scientific language helps people understand the true scale of the issue and as much makes them more likely to act. For example, if readers encounter a fact about needing to reduce the rise in global temperatures to below 1.5 degrees Celsius, whilst the current trend is closer to 3 degrees Celsius, they may be inclined to view the issue as a priority. This does not fully coincide with the results of the regression analysis that found those who read centrist

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newspapers view the climate crisis slightly less as a priority issue than those who read left leaning newspapers. This can imply that the use of scientific language in relation to climate change is a way to encourage readers to prioritise it as a concern. Furthermore, in relation to the sick baby appeal, it may imply that for readers of left-leaning newspapers other factors such as the political ideology may have a higher impact on their attitudes than direct framing from the media.

Despite this, it can be seen from the figures above that similar language is used by left- and right-leaning newspapers. This may explain why the direction of the effects for political orientation are the same for all Topics except 3. It may also go towards explaining why so few of the regression results are statistically significant. For example, an analysis of Topic 8 for right-leaning and Topic 6 for left-leaning newspapers reveals that scientific language has a negative effect (coefficient) when compared to centrist newspapers. From this, it could be inferred that scientific language has a negative effect independent of political orientation.

Therefore, it could be concluded that emotive versus scientific framing is important when discussing climate change, whereas the political orientation of the newspaper has less impact on the issue of climate change and how it is discussed.

Conclusion and Policy Recommendations The Climate crisis is described by many as the biggest threat to humankind, and yet it seems that not much is done by individuals to help prevent its potential disastrous consequences. It is not that individuals have not heard of the crisis; it appears that it is the way they are told about it that is more problematic. As previously mentioned, while there are some limitations to our findings, they still indicate a significant relationship between people’s attitudes toward the climate and the newspaper they read. Readers of right wing newspapers are less likely to 40

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consider the climate crisis as a priority than people who read centrist newspapers. Additionally, people who read left leaning newspapers are more likely to consider the climate crisis a priority.

Similarly, readers of broadsheet newspapers care more about the climate crisis than people who read tabloids.

The content analysis allowed us to explain some of this variation in people’s attitudes by revealing important differences in the way the media frames the climate crisis. Broadsheet newspapers seem to talk about the climate crisis in a more scientific way, while tabloids appeal to the readers’ emotions to make the narrative more sensational. Tabloids’ narrative appears to fit Ellen’s (et al, 1991) model of the ‘sick baby’ appeal whereby emphasising on the severity of the crisis may enhance one’s level of concern but decrease their willingness to act by reducing the perceived effectiveness of solutions. Additionally, readers of tabloids’ may be even less motivated to act despite the sense of urgency because they may believe that governments and institutions are responsible for acting. Content seems to vary less depending on the political affiliation. Contrary to our expectations, we did not identify much of a difference between left- and right-leaning newspapers. Both their narratives appeared to be emotional, while centrist newspapers were slightly more factual and scientific. Nonetheless, overall, these findings suggest that the framing of the climate crisis in the media plays a role in defining people’s attitudes.

While our findings do not explain the whole variation in people’s attitudes - bearing in mind the limitations of our data - we can still draw some useful conclusions for policymakers. As highlighted by our findings and those of other papers mentioned in the literature review, the way the climate crisis is portrayed is important in fostering individual action. The government may not have much power over the content of privately owned media, nonetheless, a few

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recommendations can be made. The government could organise a unified communication campaign about the climate crisis that would be displayed on social media platforms - before YouTube videos and in between Instagram posts - on tubes and buses, before movies in the cinema and on billboards in city centres. This campaign would have to present the issue of the climate crisis as a problem that impacts us all that can be tackled by everyone. For instance, it could present particular ways in which climate change will impact specific communities and include a range of simple actions that individuals can easily undertake. This could allow for an increase in perceived effectiveness of solutions and of the sense of urgency and thereby could turn intention to action. This campaign could also involve training journalists, spokesperson for governments and institutions as well as scientists on risk communication and more specifically on the climate crisis. This training would allow for better knowledge of what gets lost in translation and therefore how to effectively talk about the climate crisis. Finally, this communication campaign could also involve making online media platforms (including social medias) display an official banner on every post about the climate crisis. This banner would be linked to a government’s page with some official information and recommendations from the government on climate change - in the same way that is done for political campaign posts and Covid-19 related posts. §§

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Fieldhouse, E., J. Green, G. Evans, J. Mellon & C. Prosser (2020) British Election Study Internet Panel Wave 17.

Available at: Wave 17 of the 2014-2023 British Election Study Internet Panel - The British Election Study. Accessed on Feb 16, 2022.

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https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/threequartersofadultsingreatbritainworry aboutclimatechange/2021-11-05. Accessed on: Feb 20, 2022.

Schultz, W. and Stone, W. (1994) ‘Authoritarianism and attitudes toward the environment’. Environment and Behavior, 26, 25–37.https://doi.org/10.1177%2F0013916594261002 Smith, M. (2017) ‘How left or right-wing are the UK’s newspapers?’. YouGov. Originally published in The Times. https://yougov.co.uk/topics/politics/articles-reports/2017/03/07/how-left-or-right-wing-are-uks-newspapers Stevenson, K. T., King, T. L., Selm, K. R., Peterson, M. N., & Monroe, M. C. (2018) ‘Framing climate change communication to prompt individual and collective action among adolescents from agricultural communities’.

Environmental Education Research, 24(3), 365-377. https://psycnet.apa.org/doi/10.1080/13504622.2017.1318114 Swami, V., Chamorro-Premuzic, t., Snelgar, R., Furnham, A. (2011) ‘Personality, individual differences, and demographic antecedents of self-reported household waste management behaviours’. Journal of Environmental Psychology, 31, 21–26. http://dx.doi.org/10.1016/j.jenvp.2010.08.001 Wahlberg, A.A.F, and Sjoberg, L. (2000) ‘Risk perception and the media’. Journal of Risk Research, 3(1), 31-50.

DOI: 10.1080/136698700376699 Wan, C., Shen, G.Q. (2013) ‘Perceived policy effectiveness and recycling behaviour: The missing link’. Waste Management, 33(4), 783-784. https://doi.org/10.1016/j.wasman.2013.02.001 Weingart, P., & Pansegrau, P. (2003) ‘Introduction: Perception and Representation of Science in Literature and Fiction Film'. Public Understanding of Science, 12(3), 227–228. https://doi.org/10.1177/0963662503123001 Wilson, M., K. Lueck (2014) ‘Working with Missing Data: Imputation of Nonresponse Items in Categorial Survey Data with a Non-Monotone Missing Pattern’. Journal of Applied Mathematics, 2014. https://doi.org/10.1155/2014/368791 YouGov (2021) COP26 Main Release. Available at: https://doi.org/10.1016/j.matpr.2021.08.093. Accessed on: Feb 20, 2022.

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How do War Traumatisms, Combined with State-Induced Political Violence, Influence the Radicalisation of the Youth in War Zones?

Max Bryant, Ipshita Das Gupta, Camille Dusart*, Chhavi Khullar, Freya Proudman, Aryana RisLuamháin, Ziqian Wang

The Bentham Brooks Institute Terrorism and Extremism Research Team would like to particularly thank Dr Melanie Garson for her invaluable advice, support and guidance in the construction of our research, and would like to highlight the crucial efforts deployed by non-governmental organisations such as Amnesty International, the United Nations’ UNICEF, Human Rights Watch and the World Health Organisation in their constant fight for children’s rights across the globe. *

Research Team Leader 46

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Table of Contents Introduction ................................................................................................................................................................. 48 Literature Review ........................................................................................................................................................ 50 Justifying the Case Studies ......................................................................................................................................... 59 Power of the Media ...................................................................................................................................................... 64 1. Quantitative Analysis ......................................................................................................................................... 65 2. Qualitative Analysis ............................................................................................................................................ 71 Afghanistan .......................................................................................................................................................... 71 Syria ..................................................................................................................................................................... 75 Chechnya.............................................................................................................................................................. 78 Limitations ................................................................................................................................................................... 84 Policy Recommendations ............................................................................................................................................ 85 Conclusion .................................................................................................................................................................... 91 Bibliography ................................................................................................................................................................. 93

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Abstract: Terrorism can be defined as an “asymmetrical deployment of threats and violence against enemies using means that fall outside the forms of political struggle routinely operating within some current regime.” (Tilly, 2004). In current conflict zones, where indiscriminate civilian targeting is heightened, the process of radicalising amongst the youth has become a crucial and pressing issue in societies, and has presented great challenges for counterterrorist research and policymaking. The process of radicalisation encompasses the adoption of “extremist political beliefs with a particular emphasis on those ideologies that encourage violent action” (Helfstein, 2012). The research supports the existence of a relationship between the extent and the magnitude of internationalised internal armed conflicts in a country on the incidence of terrorism. The results were obtained through the use of qualitative and quantitative analysis, through the crosscheck of existing data on radicalisation and the collection of testimonies and reports from civilians and non-governmental organisations. The research demonstrated the influence of state induced violence and traumatisms of war on the radicalisation of the youth in conflict areas. Educational, psychological and security vectors in for policymaking offer recommendation to implement stronger humanitarian structures in war zones.

Introduction In 2021, the occurrences of terrorist attacks increased by 17% globally, reaching a devastating height as the Islamic State (IS) surpassed the Taliban as the deadliest terrorist organisation worldwide (GTD, 2022). The OECD defined two statistical features connected to terrorist activity: social fairness, which depends on the acknowledgment and consideration of civilians by authorities, and societal endorsement of violence, rooted in psychological and physical traumatisms of war and the perception of violence as a collective mean for social retribution against the perceived perpetrators of indiscriminate violence.

As counterterrorism remains a priority for states and international organisations, it is therefore crucial to highlight the current context surrounding the global incidence of extremism and terrorism. Alarming figures emphasise the necessity of analysing the processes of radicalisation and the impact of counter-insurgencies military operations on civilian populations; indeed, the frequency of terror attacks increased by 29% during the Taliban's campaign for governmental control of Afghanistan in 2002, and according to studies, children raised in military conflict settings 48

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are more prone to developing post-traumatic stress disorder (World Health Organization, 2001). In 2018, there were approximately 3,704 to 4,640 foreign minors involved with the Islamic State in Iraq and Syria (Cook & Vale, 2018). Consequently, transnational jihadist insurgency still poses significant threats and remains of substantial concern in international security policymaking and implementation (Clarke, 2021).

The persistent radicalisation of young people raised in war zones is overlooked in contemporary terrorist research (Souleimanov, 2015), and scholars have identified a research deficit in behaviourist approach as a component of the radicalisation process (Pokalova, 2015; Tarn-Sanz & Ter-Ferrer, 2018). Similarly, psychosocial research in terrorism aims to improve comprehension of radicalisation of action, since psychological features of individuals and communities are considered among the risk factors of violent extremism in war zones (EUCPN, 2019; McCauley & Moskalenko, 2017).

In 2021, the incidence of internationalised conflicts rose significantly, increasing from nine in 2012 to twenty-five by 2020 (Pettersson, T. et al, 2021). These crises have been characterised by crimes against civilians by local and international authorities, as interstate wars are embedded in insurgencies. Civilian targeting in counter-insurgent military operations accelerates the radicalisation process of terrorist groups, for the youth is primarily, psychologically and physically impacted by the hostilities. Therefore, this research project aims to determine the impact of war traumatisms, combined to state-induced political violence, on the ideological radicalisation of the youth in war zones.

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This paper will first detail the local context of the research, as well as the influence of multiple subfactors of non-combatant attacks on the psychological development of children; secondly, a quantitative study will demonstrate the effects of internationalised domestic armed conflicts and the degree of political terror on the prevalence of terrorism in a country; subsequently, a qualitative case-study of Afghanistan, Syria and Chechnya will be undertaken in order to analyse pre-existing field research data. Finally, this research paper will provide applicable and realistic policy recommendations, aiming to prevent the prevalence of terrorism and radicalisation in war zones, and to efficiently protect the youth living in conflict areas.

Literature Review In the context of this research, the term ‘radicalisation’, including what it designates and the behavioural consequences it conveys must be defined. Radicalisation can be defined as the psychological process in which an individual engages in prior to participating or joining a terrorist organisation. This process is characterised by the adoption of radical and violent views, based on a root ideology opposed to the dominant socio-political structure (Dalgaard-Nielsen, 2010; Pisoiu, 2014; Wilner & Dubouloz, 2011). Academic disagreements exist regarding the mechanisms involved in the radicalisation of an individual, but a general scholarly consensus prevails regarding the three different levels of radicalisation: the individual-level, which includes personal grievances and experiences; the group-level, characterised by the perceived and/or existing polarisation, oppression, deprivation and humiliation of a defined group by the ‘perpetrators of injustice’ (Moghaddam, 2005); and finally, the mass-level mechanism of radicalisation, defined by widespread acceptance of the ideology and goals, through the endorsement of violent actions and

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the mobilisation of additional resources, whether human or material (Crenshaw, 1981; McCauley & Moskalenko, 2011).

It is crucial to delineate that while radicalisation of opinion represents a significant factor in the survival and growth of terrorist organisations, this research focuses solely on radicalisation of action, or impelled support (Boylan, 2015; McCauley & Moskalenko, 2017). In the context of Islamist terrorism, radicalisation of action inherently succeeds a primo radicalisation of opinion and is distinctively ascertained by the mechanism of jihadisation (Silber & Bhatt, 2007).

Jihadisation represents the subsequent stage of indoctrination, defined in this regard as the adoption of Islamist ideology, and the active involvement in Islamist terrorist organisations, by participating in the armed struggle for the holy war, or jihad (EUCPN, 2019; Sageman, 2004; Silber & Bhatt, 2007).

Scholars have suggested a multitude of socio-psychological “push” and “pull” factors in the radicalisation process of an individual including subjection to an extremist ideology, marginalisation of a group, rejection of a distrusted authority, and personal traumatisms (Brown, 2013; Costalli & Ruggeri, 2015; Nanes & Lau, 2018). In a war zone, the influence of these factors can be enhanced by the experience of post-traumatic disorders amongst the civilian population which are directly induced by the conflict (Bar-Tal & Cehajic-Clancy, 2014; Jensen, Seate, & James, 2018; Ramasamy, 2021).

Political violence and insurgent fighting perpetuate violence against civilians and can lead to human rights violations. These experiences can create war traumatism which may enhance individuals' vulnerability to extremist radicalisation. War traumatism refers to a physical and 51

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emotional response to a highly stressful scenario brought about through war and conflict. It is often associated with a continuous or long-term exposure to a traumatic situation (Khamis, 2018). The World Health Organization (WHO) estimates that between one-third and one-half of the people exposed to political violence will endure some kind of mental distress, including PTSD, depression, or anxiety (World Health Organization, 2001). Existing literature reveals how exposure to human rights infringements and political violence may negatively affect youth. For example, such experiences can cause extreme psychological distress, directly linked to scale of the negative event and can increase a young persons’ vulnerability to terrorist recruitment (Slone & Hallis, 1999; Darden, 2019). While acknowledging that exposure to political violence is multifaceted, Barber (2013) claims that all experiences affect the fundamental resource that the youth possess, which is their identity, both in individual and collective frameworks. He notes that political conflict is “often a fight to achieve, preserve, or survive a threat to collective identity”. Using Sousa’s (2014) three domains of collective functioning: individual, community, and governmental, political violence can be seen to affect community and governmental functioning which may weaken an individual’s willingness to engage in extreme socio-political groups, including terrorist organisations.

In war zones, an established jihadist presence can act as a “push” factor for radicalisation among the youth. The psychological and physical vulnerabilities of individuals, along with shared perceived grievances against a distrusted authority and a sense of collective deprivation establish a foundation for the emergence of cognitive frame alignment (Benford & Snow, 2000; Borum, 2014; Jansen, Seate & James, 2018). Cognitive frame is a cognitive bias defined as a “mental template that individuals impose on an information environment. to give it form and meaning” (Walsh, 1995); individuals frame their behaviour based on their positive or negative perception of events surrounding them.

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In war zones, cognitive frame alignment intrinsically appears as a result of psychological traumatism emerging from a socio-political crisis indiscriminately targeting citizens, marginalised or not, thus justifying a perceived necessary violent response (Chin, 2015; O’Connell & Benard, 2006).

The existing literature suggests that the experience of political violence accompanied by human rights infringements and war traumatism encourages the radicalisation of youth. Political violence, as defined by the World Health Organisation, is the deliberate use of power and force to achieve political goals (WHO, 2002). It has frequently implicated civilians as a target of both government and insurgent group action. Supported by the theory of cognitive frame alignment and the subsequent analysis of social movement, the principal reason scholars believe civilians are targeted is the willingness of those engaged in conflict to disregard the laws of war including the protection of civilians, to follow commands from superiors regarding violence against civilians, and most importantly to fulfil a “desire to win at any cost” (Jose & Medie, 2016).

In warzones, the delimitation between peril and safe place becomes obscured. Disruptions to everyday life can impact a child’s ability to function in daily life and access education. (Shonkoff et al., 2012). This can serve as a catalyst for radicalisation (Catani, 2018), for the immediate aftermath of a conflict can greatly impact the population’s recovery. This is primarily based on reconstruction and socio-economic resilience. For children, the re-establishment of the schooling system is especially important (Dupuy & Peters, 2010). Additionally, long-term childhood subjection to trauma can be an impetus for mental illnesses including PTSD, depression and emotional dysregulation, learning disabilities, conduct disorders and aggression. These issues can persist into adulthood even long after the traumatic event has passed (Shonkoff et al., 2012).

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Existing literature also suggests links between exposure to violence and propensity to turn to aggression including the use of terrorism as an outlet. Gvirsman et al. (2013) found a positive correlation between exposure to political violence and higher levels of post-traumatic stress symptoms and aggression; by using of structural equation analysis (SEM), Gvirsman et al. (2013) further highlighted a strong correlation between aggression and exposure to violence. Furthermore, research has revealed developmental impacts on children born into and raised in war zones, as children may develop PTSD, which impacts their cognitive and emotional capabilities, as well as behavioural issues including increased irritability and outbursts of anger (MSF, 2014). All of these will deeply compromise children’s abilities to perform well in school and properly engage in social relationships with others (Catani, 2018).

While the main focus of our research is the impact of political violence and war traumatism on radicalisation, it is important to also review the wider literature regarding several other factors that appear to influence the radicalisation of youth including the methods of recruitment into Islamic extremist organisations as well as the broader socio-economic situation.

The recruitment strategies of different Islamic extremist organisations appear critical to encouraging the radicalisation of the youth in terrorist organisations; Islamist insurgent groups are united by a similar modus operandi: suitable candidates are identified, indoctrinated, and subsequently recruited (Yayla, 2021). This is demonstrated through an exploration of Al-Qaeda’s and the Islamic States’ (ISIS) recruitment processes; Al-Qaeda’s internal guidebook, published online in 2009, details the most effective practices when recruiting new members into the

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organisation, complete with a self-evaluation scoring system. In this guidebook, recruitment is divided into five stages (al-Qa’idi, 2009).

The first stage, “Getting Acquainted and Choosing”, details the filtration of the candidacy pool and reveals an explicit preference for young men, particularly those who are enrolled in higher education, as the target candidate (al-Qa’idi, 2009). This is consistent with wider literature in which several scholars have found that men, especially those between the ages of 15 and 35 from patriarchal societies, are most vulnerable to radicalisation (Gartenstein-Ross & Grossman, 2009; Pauwels & De Waele, 2014; Sageman, 2004; Silber & Bhatt, 2007). ISIS also publicises the inclusion of youth in its activities. This is not only because young people are believed to be more easily malleable and receptive to indoctrination, but because they also offer physical abilities that adults do not possess. This includes transporting weapons on the premises, as it is less likely that a child will be searched at checkpoints, and they are also a “low cost” resource that can act as human shields in protecting more experienced and invaluable fighters (Vale, 2018). Both Al-Qaeda and ISIS display a preference towards candidates demonstrating religious zeal, anti-government sentiment, desire for revenge, and a need for group belonging, recognition, and identity creation (al-Qa’idi, 2009; Venhaus, 2010). Among all recruits, one thing was common, they were all “looking for something” (Venhaus, 2010).

The second part of Al-Qaeda’s modus operandi is the “Getting Close” stage which encourages a recruiter to bond with a candidate in order to establish trust while also surveying them and their personal life. Bonding is accomplished through consciously seeding interactions between the recruiter and the candidate. As an example, these planned interactions can include accompanying a candidate in their place of work, assisting them in their needs, or giving them gifts (al-Qa’idi, 55

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2009). Young individuals, particularly those who may have lost family members or a parent during war, are especially vulnerable to the invitation of forming a bond with an older figure. Studying ISIS, Darden (2019) notes that many young people are recruited through their family members and friends in the belief that membership will help defend their families and communities. Other children are duped, trafficked, kidnapped, or forcibly recruited.

After a bond is formed between the candidate and recruiter, the “Awakening of Emaan [Faith]” stage details the tactics of seeding extremist faith through traditional religious sentiment. The guidebook includes several references to materials, both printed and audio/visual, which can be used to encourage and influence the candidate. The dichotomy of heaven and hell is noted by Abu Amr as a strong motivator for religious observance and a subsequent key to jihadi sentiment. As well as this dichotomy, other Islamic principles are introduced, such as the importance of truthfulness and sincerity and the observance of obligatory prayers (al-Qa’idi, 2009; Warius & Fishman, 2009).

Scholars suggest that ISIS may begin this systematic indoctrination process from an even earlier stage by targeting school children with learning resources such as books and apps that feature graphics of weapons and contain written content that profess jihad teachings (Gramer, 2017). Vale (2018) claims this enhances children’s progression towards their own conduct of violence as a natural way of life.

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In Al-Qaeda, the leap from traditional Islam to jihadi interpretation is then made in the fourth stage, “Planting Concepts”, where Abu Amr does not shy from stating the subsequent materials will be used to “indoctrinate” the candidate. In this stage, there are five concepts central to indoctrination into jihadi sentiment: Strictly adhering to religious principles and disassociating with Mujahedeen who make mistakes in their context, the obligation of jihad and the duty of preparing for it, disbelief of a ruler who governs by means other than Islamic principles, the rejection of parliament or democracy in bringing about the resurrection of the Islamic Caliphate, and the concept of Al Wala Wal’ Bara – loving or hating for the sake of Allah. The recruiter is also encouraged to introduce the candidate to jihadi ideology through establish texts and audio/visual propaganda. The candidate should also be encouraged by the recruiter to interact with jihadi communities online.

When a candidate is fully indoctrinated, the final stage, “Establishment of the Brigade'', is reached.

This stage implies that the candidate has progressed through recruitment and radicalisation to the point of accepting jihadi ideology, and it is from this stage that they are directed by the recruiter to wage jihad (al-Qa’idi, 2009). This brief overview of the general modus operandi for Islamic radicalisation demonstrates that the recruitment process is designed to encourage young people towards radicalisation. This element is crucial in understanding the many factors that can influence youth towards radicalisation.

To offer a thorough overview of factors that influence youth radicalisation, it is important to briefly discuss some of the extensive literature conducted on the role of socio-economic factors. While socio-economic factors are often associated with radicalisation (Lum, Shirley & Kennedy, 2006), the literature suggests a complex and nuanced relationship. Many studies offer contradictory findings when discussing the effects of socio-economic factors such as income and education.

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Studies by Krueger & Malečková (2003) and Sageman (2004) suggest that those most susceptible to Islamist radicalisation are educated individuals from middle-class backgrounds. Similar findings were established by Altunbas and Thornton (2010) who, in a comparative study of Islamist extremists and the general Muslim British population, found that extremists were often middleclass, better educated, and had higher incomes. However, research conducted in the United States concluded the opposite; extremist often had little education and occupational success (GartensteinRoss & Grossman, 2009). As a result, Copeland and Marsden (2020) suggest an “inverted Umodel” for understanding the role of socio-economic factors on radicalisation. They claim that those involved in terrorist activities are usually from the middle of the socio-economic curve because unlike those at the bottom, they are not struggling to “meet basic needs”, but unlike those at the top, they do not have as much “to lose” from terrorist behaviour.

While studies suggest there is little relationship between radicalisation and poverty (Bjørgo, 2005), some scholars found that unemployment increased the possibility of radicalisation (Pauwels & De Waele, 2014). Further research showed that comprehensive social spending on unemployment benefits, job seeking programmes, and healthcare reduced terrorism (Copeland & Marsden, 2020).

These findings are consistent with data suggesting that countries with social welfare systems are less likely to experience homegrown terrorism (Copeland & Marsden, 2020).

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Justifying the Case Studies Having reviewed the literature on radicalisation and the several factors that can “pull” and “push” youth towards radicalisation, this study has selected three case studies to support the investigation on the effects of war traumatism and state-induced political violence on the radicalisation of youth in war zones. An instrumental case study approach provides an in-depth exploration of complex and nuanced issues while affording attention to their context and real-world settings (Merriam, 2009; Simons, 2009; Stake, 2006; Yin, 2014). This approach provides insights which advance the understanding of and refinement of youth radicalisation and its associated theories. Case studies have an explanatory goal and are particularly useful in addressing research questions focused on understanding “how” a phenomenon occurs (Yin, 2014), and typically permit a range of secondary data collection tools and sources for consultation.

For this study, the three case studies are Afghanistan, Syria, and The Russian Federation. Part of the research question seeks to examine the effects of state-induced political violence on radicalisation and uses a Westphalian understanding of the state as a territorially defined sovereign unit. As a result, the case studies selected involve political violence which is carried out by the state actor or a foreign state actor onto the domestic population within the state’s territorially defined limits.

As our research question focuses on the impact of war traumatism and state-induced violence on radicalisation it is important that each of the case studies experience those trends. Each of the case studies: Afghanistan, Syria, and The Russian Federation focuses on a particular war conflict or series of conflicts beginning in the 1990s or early 2000s. There is evidence that in each of these

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conflicts there has been state-induced political violence, from the local state itself or a foreign state, and the presence of war traumatism due a high number of civilian fatalities. The Afghanistan case study primarily focuses on the Afghan War beginning in 2001. The Syrian case study centres around experiences during the Syrian Civil War which began in 2011. Thirdly, The Russian Federation focuses on Chechnya and the two Chechen Wars which occurred between 1994-1996 and 1999-2009 and which continue to impact Chechen society. Additionally, these case studies are well suited for exploring the question of radicalisation amongst the youth, for all these states have experienced an increase in Islamic radicalisation, which has been observed through a rising number of terrorist attacks from Islamic terrorist groups operating within each state since the start of the states’ conflict.

Afghanistan exemplifies the struggle of state-induced violence on civilians, as the Afghan War involved state-induced political violence particularly from the United States, inflicted onto the domestic Afghan population. These experiences suggest that the population may be vulnerable to radicalisation. Historically, Afghan people have frequently been a target of extremist ideology.

During the Cold War, the United States provided large financial sums for the development of learning resources that would promote an Islamic jihad against the Soviet Union (Porges, 2012).

The trend of radicalisation continues to the present day through extremist religious figures who seek to extend their influence “beyond the mosques and madrassas” (Fazil et al, 2015). The dominant ideology in Afghanistan is Islam and religious leaders and institutions have significant value. The U.S. Department of State suggests that there are a “small, yet influential number of madrassas teaching extremist doctrine in support of terrorism” (Fazil et al, 2015). Mosques play a central role in daily Afghan life and with an estimated 60,000 unregistered mosques in Afghanistan, radicalisation might be occurring within some of these institutions (Fazil et al, 2015). Afghanistan 60

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is a strong case study for examining the impact of radicalisation of youth because the youth are particularly targeted by the methods of radicalisation that are used in terrorist groups in Afghanistan. Terrorist recruitment methods in Afghanistan include “night letters, inspirational songs… CD’s and DVDs’” (Fazil et al, 2015). These are increasingly popular contemporary methods that are enhanced through mobile and social media technology. The primary target audience for these methods is the youth. This is aided by increasing intervention of terrorist organisations in Afghanistan’s educational system which is enhanced radicalisation through education (Ibid). Furthermore, Anecdotal stories of young Afghans joining terrorist insurgency groups include unaddressed frustrations including anger towards the violation of their rights during the conflict, the failure of the Afghan government to protect civilians, and a desire for revenge (Fazil et al, 2015). The youth are “especially susceptible to grievance-oriented rhetorical exploiting societal unease and unhappiness with the government” (Fazil et al, 2015).

Syria was chosen as a case study because since the start of the Syrian Civil War in 2011, the Syrian domestic population has experienced political violence which has been induced by the current Syrian regime led by Bashar al-Assad along with support from the Russian Federation. The conflict has featured many civilian victims including over 350,000 civilian fatalities (Sanadiki, 2021).

Additionally, there have been several allegations of human rights violations during this conflict including the use of chemical warfare attacks on civilians, with the international chemical weapons watchdog concluding that Syria has likely or definitely employed chemical weapons 17 times since 2012 (Aljazeera, 2021). These experiences have likely contributed to war traumatism and radicalisation among the domestic population. The dominant religion in Syria is Islam and several Islamic terrorist groups are present within the state including ISIS. As the literature review suggests, the presence of these groups could contribute to increased radicalisation and recruitment.

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Syria represents a particularly useful case study for examining youth because the conflict has had a large impact on young people. On average, over the last 10 years in Syria, one child was injured or killed every 8 hours and a total of 12,000 children were killed in Syria between 2011 and 2021 (UN, 2021). Additionally, nearly 5 million children have been born into the war-torn Syria, growing up dealing with the consequences and reality of the brutal war (UNICEF, 2020). Research suggests that neurologically, young children and youth experience a more gradual development of their prefrontal cortex (used for reasoning and self-control) as compared to their amygdala (the centre of human emotions). Therefore, they are more likely to react to situations impulsively and emotionally, rather than rationally. This amygdala-driven emotional turbulence leads to more psychological instability (Ramakrishna, 2016), that when coupled with an upbringing in the wartorn Syria, worsens and results in the desperate search for an external form of validation, typically for a sense of personal identity and self-esteem. This is precisely what terrorist groups, unwavering in their extremist rhetoric, provide for youths in such contexts. As a result, there is an alarming level of statistics for the recruitment of children and youth, with children as young as 14 years being recruited into the groups. Although the total tally of children involved in such armed groups is unknown, between 2011 September and 2014 June, there were 194 recorded deaths of “noncivilian” male children fighting as recruits in Syria (Violations Documentation Centre, 2014). The annual United Nations report found that there were 961 verified instances of child recruitment in Syria in just 2017, with 90% of them serving in combat roles. This recruitment number is a 13% increase from the previous year, emphasising the importance of Syria as a case study when trying to understand and explain the recruitment of youth and children into these extremist groups.

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The Russian Federation, with a focus on The Republic of Chechnya, was chosen as a case study because there appears to be evidence of all three trends this paper seeks to explore: political violence, war traumatism, and youth radicalisation. Following the collapse of the USSR, Chechnya sought to mobilise in support of national self-determination and become its own separatist state independent of the Russian Federation. This led to the First Chechen War which began in 1994 and was temporarily ended in 1996 with a Peace Accord. However, a rise in terrorist attacks on the Russian Federation from Chechen insurgent groups led to the start of the Second Chechen War in 1999. These war experiences have been influential in the increased radicalisation of the Chechen population. There is evidence that Russian forces used indiscriminate violence during the conflicts and several organisations such as the Human Rights Watch and the European Court of Human Rights have accused Russia of committing human rights violations. (Human Rights Watch 2002a, 2002b, 2006). It is said that the Russian forces did not just want to “win the war but break the entire Chechen population through terror” (Hertog, 2007). There are anecdotal stories including Russian artillery and air strikes on civilian residential areas, village-sweeps, forced disappearances, torture, rape, random executions, and arson attacks (Vishnevetsky, 2009). As a result, the Chechen population endured mass civilian casualties which caused many children to grow up without one or both parents (regnum.ru, 2007). Chechnya is a useful case study for studying the youth because an entire generation of children grew up witnessing immense violence. The wars have led to a lack of access to schooling and education as well as issues including high unemployment, starvation, and poverty (Vishnevetsky, 2009). The living conditions for children were poor and psychological traumatisation from the conflict was high (Speckhard & Akhmedova, 2006). This wartime experience combined with the readily available nature of firearms may have normalised and legitimised violence as a common feature of everyday life in the eyes of children (Vishnevetsky, 2009). The literature review suggests this may make the youth susceptible to radicalisation.

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Additionally, although Islam has been present in Chechnya since the late 16th century, scholars suggest that it was the experience of the Chechen Wars which “sowed the seeds of religious extremism in Chechnya” (Hertog, 2007). They believe the political violence and injustice faced by the Chechen people contributed to extremism and the radicalisation of Islam (Hertog, 2007).

Therefore, this research evaluates and analyses the radicalisation process of each case-study following the local conflicts’ timeframes; from 2001 until 2021 for Afghanistan, from 2011 until now for Syria, and from 1999 to 2009 for Chechnya.

Methodology The study is predominantly a qualitative study using the case study approach, coupled to the review and analysis of existing data. Three case-studies (Afghanistan, Syria, and Chechnya) will demonstrate qualitatively and quantitatively the impact of indiscriminate civilian targeting by states on the radicalisation of youth in a war zone. This research thus implements a qualitative study, but quantitative data is used for triangulation purposes, in order to demonstrate a rich in-depth understanding of the topic.

Quantitative data analysis was obtained from the Quality of Government Standard Dataset 2022 Cross-Section, from the University of Gothenburg (Teorell et al., 2022) using the statistical software Stata, while qualitative data was prevailingly collected and combined from multiple official and neutral sources, such as Human Rights Watch, UNICEF, Memorial and extensive field research conducted by proficient scholars and independent journalists. As a result, we

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predominantly use a triangulation method in which quantitative and qualitative data are used to add increasing information and knowledge to understanding the overall research question.

1. Quantitative Analysis Fig. 1 seeks to explore whether there is a relationship between a country’s political violence scale, coupled with occurrences of internationalised internal armed conflicts, and the prevalence of terrorism on its soil. We predict that in a comparison of countries with ongoing conflicts, those with a higher Political Terror scale, coupled with occurrences of internationalised internal armed conflicts, will be more likely to have a higher prevalence of terrorism than countries with lower Political Terror scale, lower conflict rates, and fewer internationalised internal armed conflicts.

Figure 1 – Prevalence of terrorism as a result of political violence and occurrences of internationalised internal armed conflicts, in a comparison of countries.

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Countries, including the Syrian Arab Republic, Afghanistan, and the Russian Federation (Chechnya), represent the unit of analysis. This analysis seeks to highlight the combined impact of political terror and internationalised internal armed conflict on the prevalence of terrorism in countries. As highlighted previously in the literature review, socio-political factors greatly affect the frequency of radicalisation amongst the civilian population (Chin, 2015; O’Connell & Benard, 2006). Existing research has demonstrated that dynamics such as indiscriminate civilian targeting by governmental forces, as well as conflict-induced psychological and physical traumatisms (Darden, 2019), act as push factors in radicalisation processes occurring in war zones. Thus, it is necessary to evaluate the correlation between the appropriate available statistics, and the results of this analysis, to conclude on a possible relationship between the number of internationalised internal armed conflicts and the political violence scale of a country, impacting the prevalence of terrorism on the territory.

This analysis utilises four variables available from the Quality of Government Standard Dataset 2022 - Cross-Section, from the University of Gothenburg (Teorell et al., 2022).

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Dependent Variable

Global Terrorism Index

Independent Variable 1

Internationalised internal armed conflict

Independent Variable 2

Political Terror Scale - Amnesty International

Independent Variable 3 (Control)

Conflict Intensity

“The Global Terrorism Index (GTI) is a comprehensive study which accounts for the direct and indirect impact of terrorism in 162 countries in terms of its effect on lives lost, injuries, [voh_gti] property damage and the psychological after-effects of terrorism, and covers 99.6 per cent of the world’s population.”

(Institute for Economics and Peace, 2020) “Number of internationalised internal armed conflicts per country in a given year. An internationalised internal armed conflict occurs between the government of a state and one or [ucdp_type4] more internal opposition group(s) with intervention from other states (secondary parties) on one or both sides.”

(Pettersson, T., Davis, S., Deniz, A., Engström, G., Hawach, N., Högbladh, S., Sollenberg, M., & Öberg, M., 2021) “Political Terror Scale Levels from the yearly country reports of Amnesty International, ranging from 1 to 5, in ascending order. Political terror is defined as violations of basic human rights to the physical integrity of the person by agents of the [gd_ptsa] state within the territorial boundaries of the state in question. This index is not synonymous with terrorism or the use of violence and intimidation in pursuit of political aims.”

(Gibney, M., Cornett, L., Wood, R., Haschke, P., Arnon, D., Pisanò, A., Barrett, G., & Park, B., 2020) “Measure of social, ethnic and religious conflicts, with values ascendingly ranging from 1 to 10.” (Donner, S., Hartmann, H. & Schwarz, R., 2020) [bti_cibis] (Donner, S., Hartmann, H., & Schwarz, R. (2020).

Transformation index of the Bertelsmann stiftung 2020.

Bertelsmann Stiftung.)

Table 1 – Chosen variables.

Figure 1. demonstrated a correlation between the number of internationalised internal armed conflicts and the scale of political terror, and their combined impact on the prevalence of terrorism in a country. Afghanistan represents the extremity of cases, with three internationalised internal armed conflicts (3) and the highest score on the Global Terrorism Index (9.60). The lines of best fit for the relationships between (1) the number of internationalised internal armed conflicts and

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the Global Terrorism Index and (2) the Political Terror scale and the Global Terrorism Index, show that general tendencies in a comparison of countries correlate for both variables.

The Syrian Arab Republic’s values for both variables, is above the lines of best fit in Figure 1.

With two internationalised internal armed conflicts and a Political Terror scale of 5, the Syrian Arab Republic attains an extremely critical score of 7.8 on the Global Terrorism Index. Indeed, after running a multilinear regression with these three variables, controlling for a fourth variable “Conflict Intensity”, we obtain the following results over a range of observations of 51 countries:

The beta coefficient relates to the estimated change in the dependent variable (here, the Global Terrorism Index) with a 1-unit increase in the independent variables. The three coefficients are positive, explaining the positive slopes for the impacts of Political Terror and the occurrences of internationalised internal armed conflicts, observed in Figure 1.

There is a positive relationship between the number of internationalised internal armed conflicts and the Global Terrorism Index, with a 1-unit change in [ucdp_type4] leads to an increase of 0.51 in [voh_gti]. On average, there is 10.2%1 increase in the prevalence of terrorism in countries where there are increasing internationalised internal armed conflicts. A 1-unit change in the Political Terror Scale [gd_ptsa] leads to an surge of 0,87 on the Global Terrorism Index, meaning a 17.4%2 increase in the prevalence of terrorism in countries where Political Terror increases. Finally, a 1unit change in the Conflict Intensity Scale [bti_cibis] leads to an increase of 0.63 on the Global

1 2

By multiplying the original scale (1-5) by 20 to produce percentages.

Idem.

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Terrorism Index. Thus, there is a 6.3%3 rise in the prevalence of terrorism in countries where ongoing conflicts escalate, compared to countries with a lower rating on the Ongoing Conflict Scale.

The constant coefficient indicates the average Global Terrorism Index of a country when all three independent variables [ucdp_type4], [gd_ptsa] and [bti_cibis] equal zero. In the context of this research, the average GTI is -3.30, on a recoded scale of 1 to 104. This result is purely mathematical and should not be interpreted in a substantive manner as it is realistically impossible for all the independent variables to be null. This is an occurrence in real data, and therefore the interpretation of that coefficient is not meaningful in this specific research design (Grace-Martin, 2013).

The p-values for the overall regression, the three variables and the constant meet the conventional standards of statistical significance in which p is equal or less than 0.05. This indicates that the null hypothesis of no difference can be rejected because there is less than 5% probability the results are due to random sampling error.

The correlation coefficient allows analysis of the model fit for the relationship between the variables. For substantive analysis, the adjusted R2 is a more precise indicator of the impact of independent variables, including additional ones on the dependent variable. The regression highlighted that 72.17% (adjusted R2 = 0.7217) of the variation in the Global Terrorism Index is

3

By multiplying the original scale (0 - 10) by 10 to produce percentages.

Original scale from 0 to 10 but recoded to exclude outliers that did not support our model fit (the prevalence of terrorism was too low to be relevant to this research, and the observations of these countries did not appear in the recoded variable [bti_cibis], which assumed the presence of an ongoing conflict). See appendix.

4

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explained by variations in the number of internationalised internal armed conflicts, coupled to the Political Terror and the Conflict Intensity scales. Therefore, this hypothetical research model corresponds to real-world data for 72.17%.

The original hypothesis can be accepted, and highlights the influence of internationalised internal armed conflicts, political terror and the conflict intensity on the prevalence of terrorism, in a comparison of 51 countries. These results are corroborated by Figure 2, which illustrates the evolution of the Global Terrorism Index, from 2000 to 2021.

Figure 2 – The Evolution of the Global Terrorism Index from 2000 to 2021, across 163 countries. Highlights of the evolutions of the Global Terrorism Index of Afghanistan, the Russian Federation and the Syrian Arab Republic.

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2. Qualitative Analysis Afghanistan State-induced violence is widespread in Afghanistan, as children’s upbringings in Afghanistan were characterised by an incessant number of airstrikes from governmental and international forces (Action on Armed Violence, 2021). Between 2016 and 2020, 50% of overall civilian casualties (including deaths and injuries) were perpetrated by international forces. An amalgamation of factors has obscured the distinction between warzone and safety for children and adults. Indeed, between 2017 and 2019, US forces dropped bombs in Afghanistan at a rate of more than 20 explosive devices a day, and casualties tripled from 247 civilian deaths in 2017 to 757 deaths in 2019 (Action on Armed Violence, 2021). Such substantial bombardment led to the deadliest year of airstrikes for children in Afghanistan on record. This ultimately led to a culmination of 236 minors killed by airstrikes in 2018 (AOAV, 2021). Save The Children (2021), a welfare organisation serving children in Afghanistan since 1976, reports that suggests that almost 33,000 have been killed in the country over the past two decades.

Massacres and Human Rights violations from international forces are desolately frequent in Afghanistan, enacting civilians as the primary targets of these inhumane treatments. On the 27th of March 2007, in the Shinwar District of the Nangarhar Province, US Marines fired on individuals and cars surrounding them as they fled the site of a car bomb explosion and ambush by Afghan insurgents, killing 19 civilians and wounding over 50 more (Walsh, 2010).

On the 6th of July 2008, in the Haska Meyna District of the Nangarhar Province, a US-led airstrike killed at least 47 civilians at a wedding, including 39 women and children. The remains of the

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victims were unidentifiable. The United States Government negated that non-combatants were murdered during the military operation (AFP, 2008; HRW, 2008).

The Granai massacre, which occurred on May 4, 2009, was the consequence of an airstrike led by a US Air Force B-1 Bomber in the village of Granai in the Farah Province. Between 86 and 147 Afghan citizens were reportedly killed. 93 of them were children (Amnesty International, 2014; Schmitt & Schanker, 2009). The list of slaughters and Human Rights violations in Afghanistan, as a result of indiscriminate civilian targeting, is long, and almost no reparations nor acknowledgment of these actions were initiated by American forces and authorities.

The youth are especially vulnerable in this conflict. Furthermore, young people are often implicated in attacks. Between 2016 and 2020, 44% of those wounded by airstrikes from the U.S. and Afghan government were children. Between the start of 2020 and mid-2021, there were 4,301 child casualties, including 806 children who were killed from this conflict in the violence. The Youth Policy Indexes on Afghanistan highlight a critical and worrying factor on the upbringing of Afghan children; the Youth Development Index is 0.27, while the Human Development Index is 0.37. Both indicators are extremely low, emphasising a precarious situation (Youth Policy, 2021). These low numbers can be explained by the poor infrastructures aiming at protecting, educating and supporting the youth in the country.

Additionally, 12.9 million children need humanitarian help. Access to healthcare also represents a crucial component in the deprivation of Afghan civilians. Without sustained access to basic primary health care services for life-saving care, an estimated 212 children will die every day. In 2004, three years after the beginning of the war and the invasion by the United States and the international 72

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coalition, medical centres were terribly lacking in the country, as only one health facility would be shared by 27,000 to 300,000 civilians (Bose, 2020). Currently, with 76% of the Afghan population living in precarious regions, nearly one-quarter of the civilians cannot access healthcare services and facilities (Bose, 2020; OCHA, 2022). This crisis particularly affects children, as an estimated 9.7 million to 12.9 million children suffer from extreme precarity (OCHA, 2022; UNICEF, 2022).

According to official reports from non-governmental organisations and international agencies, one in two Afghan nationals is psychologically distressed, and approximately 11.5% of the children are affected by mental illnesses and paedo-psychological complications on a daily basis (HealthNet International and Transcultural Psychosocial Organisation, 2021). Despite the fact that the psychological impact of war is incredibly difficult to assess over such a lengthy period of time, the conditions surrounding psychological relief and support represent a crucial vector in the humanitarian crisis in Afghanistan.

Furthermore, this humanitarian disaster severely originates from the concentration of the international humanitarian aid resources by a wealthy and minor elite, leading to over two-thirds of the aid bypassing the Afghan authorities and to 40% of the funds returning to donor nations in company profits and remunerations for project consultants (Cordesman, 2009). As a result, lifesaving healthcare is unavailable due to a lack of essential medical resources; it is estimated that child mortality will rise to 212 daily infant deaths every day (UNICEF, 2022). This high figure is increasingly due to severe malnutrition, causing 45% of infant mortality in Afghanistan (UNICEF, 2022).

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Such desolate conditions may foster pessimism, negativity, and anti-government resentment which may lead young people especially susceptible to turn towards tenets of extremists, viewing them as a sign of hope.

The deprived state of the education sector in the country has also greatly contributed to diverting children towards violence. The sector faces persistent problems from both the demand as well as the supply side factors. Frequent attacks on schools through air strikes, shelling and explosives(Human rights watch, 2021) has led to loss of life and has also contributed to fear in the minds of people, discouraging them to send their kids to school. Many kids receive education at madrasas, some of which are considered to be hotspots of radicalisation involving teachings of extremism. Girls have been denied education in some ways or another, and the absence of male teachers and distance from school continue to be the biggest barriers for them. Female teachers accounted for only 30% of all teachers in primary schools from 2007 to 2011 (EPDC). A large young population not being occupied at school, can be a very easy target for extremism. In 2020, 196 boys (172 by the Talibans) were recruited as soldiers. Organisations such as the Impact of the Armed Conflict on Children Recruitment, Training and Use of Children by Parties to the Conflict (UNAMA) is deeply concerned about recruitment of under 18-year-olds into armed forces and armed groups.

In the last half of 2011, UNAMA interviewed 67 boys, in 13 provinces, who were detained in Juvenile Rehabilitation Centres on accusation of association with armed groups. These children ranged in age from 9 to 17, of which approximately a quarter had been recruited by AntiGovernment Elements to conduct military activities, plant IEDs, or plan suicide attacks. It is coherent that one crucial and influential factor is the destitution that these children’s government 74

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leaves them in, inducing resentment and an ideal environment for anti-government radicalisation.

In 2011, Afghan security forces arrested 204 boys under the age of 18 on charges relating to endangerment of national security (UNAMA, 2021).

Syria Since the 2011 Arab Spring, Syria has been caught in an ongoing civil war, experiencing constant armed conflict and attacks. Caught between the pro- and anti-government groups, the past decade has witnessed a descent into terror and violence, with the United Nations Security Council effectively absent due to the usage of the veto (Nadin, 2017). In this case study, we examine the effect of these attacks and the violence on the lives of the Syrians, particularly the children and youth.

The youth are among the ones most affected by the decade-long crisis and extensive harm has been done to children living in Syria. With the advent of the Civil War there was a clear consequent increase in the number of child soldiers being recruited into the war, with some children being as young as 14 (Human Rights Watch, 2014). A UN report found that there were 961 verified cases of child recruitment into the war in 2017 alone, with 90% of them working in active combat roles (Syria Justice and Accountability Centre, 2018). However, with this increase in child recruitment, the number of fatalities has also increased with confirmed reports of 194 children combatants losing their lives between 2011 and 2014. Additionally, it has been found that an average of 1 child has been injured or killed every 8 hours over the past 10 years of the Syrian War, and an overall 12000 children have died throughout the duration of the war (Akacha, 2021). However, this only represents one aspect of the widespread damage caused by the war, with 12,000 deaths of children being just a fraction of the 360,200 deaths caused by the civil war between 2014 and 2021 75

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(Sanadiki, 2021). Additionally, around 5 million children have been born since the Syrian Civil war began and have lived their entire lives in a warzone. Another 1 million Syrian children were born as refugees in neighbouring countries who have never seen their war-torn homeland.

Furthermore, access to food and trade has impacted daily life in Afghanistan. Agriculture, which was previously a mainstay of the Syrian rural economy, has been severely impacted by the lack of vital resources and security. Simultaneously, neighbouring countries’ tightening of border controls and restriction of the movement of goods has made trade increasingly difficult. As a result of decreasing supply of agriculture and falling trading, prices have been on the rise, with this price inflation resulting in a decreased purchasing power of most average low to middle income households in Syria. In fact, the situation has become so dire that findings reveal households “have coped by using up their savings, selling off goods or assets, or taking on new and sometimes, highrisk and socially degrading forms of employment” (ICRC, 2021). As financial difficulties impact households, individuals turn to other areas to find solutions. One common solution is then extremist organisations. This is most clearly evidenced by the several recorded instances where individuals have switched membership and allegiance to the groups based on the salaries and resources offered as well as the regularity of payment, showing that economic survival was placed as the highest priority, over personal investment in the group’s ideology. This then explains a high recruitment level, with the unemployment rate as high as 90% in certain areas in Syria (ICRC, 2021), therefore making these individuals susceptible to join extremist organisations as a solution.

Another key reason that Syrian youths choose to join extremist groups as fighters is often to seek revenge for the deaths of their families. Research shows that nearly half of young Syrians have had a member of their immediate family or a close friend killed. Over 90% of Syrian youth are therefore 76

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motivated to avenge the deaths of their family members by joining in on the violence (Aubrey, Aubrey, Brodrick, & Brooks, 2016). Often, this revenge channels into the direction of overthrowing the incumbent Assad regime, therefore meaning that the most militarily well-equipped, efficient, well-resourced groups will prove to be the most popular. Thus, economic survival and the desire to seek revenge are more significant considerations than belief in any of the groups’ ideologies.

Beyond the key motivations behind the youths’ decision to join these groups, we need to examine how these extremist ideologies then mould the children. Often, these ideologies are part of the first formations of consciousnesses for some of these children brought up in the war. Save the Children’s Syria Response Director Sonia Khush called these children ``ISIS's first victims' ', stating that “[a] 4-year-old boy does not really have an ideology. He has protection and learning needs.” (VOA News, 2021) Such a view reveals how extremist groups, such as ISIS, have not just presented concrete reasons (economic need, lust for revenge) to join them, but have furthermore exposed children to extreme ideology. During its nearly 5-year-rule over much of Syria, ISIS made a priority of indoctrinating children in its brutal interpretation of Islamic law, training them to be child fighters, teaching them how to carry out beheadings using dolls and having them carry out killings of captives in propaganda videos (VOA News, 2021). The extent of involvement of these children shows ISIS’s exploitation of the vulnerable, easily impressionable age and how children raised in this environment are easily susceptible to propaganda and violent action, before having developed a full understanding or consciousness of the actions they are carrying out. Given the extent of usage of child fighters in ISIS’s radicalisation plan, it is of paramount significance to implement policies targeting this particular age group.

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Chechnya In December 1994, the First Chechen War began, as an insurgence led by the secessionist Chechen Republic of Ichkeria against the Russian Federation. After two brutal years of war, the conflict ended with a ceasefire, initiated by the Russian authorities. In August 1996, Russian General Alexander Lebed and Chechen President Aslan Maskhadov signed a formal ceasefire agreement, the Khasavyurt Accord, which ultimately led to the signature of the Treaty on Peace and Principles of Relations between the Russian Federation and the Chechen Republic of Ichkeria (CRI) on the 12th of May 1997. Researchers and humanitarian organisations generally estimate the casualties of the First Chechen War to range from 30,000 to 50,000 civilian deaths (Dunlop, 2000; MSF, 2004).

The Second Chechen War, which began in August 1999, and officially ended in April 2009, increased indiscriminate civilian targeting and resulted in the deaths of between 25,000 to 80,000 civilians and non-combatants (Amnesty International, 2014; Coene, 2009). However, academics agree on the difficulty of assessing the accurate number of civilian deaths, as thousands are reportedly buried in unmarked graves (Amnesty International, 2014). In October 1999, following the assault of Russian troops in Chechnya, both the Kremlin and the Chechen Republic of Ichkeria claimed the other side was preparing biochemical and toxic agents to be used as weapons during the conflict. None of these claims has been independently verified (Kristensen, Godsberg & Garbose, 2006). Between August 1999 and September 19999, Russian sources stated that over 1,250 bombing raids were perpetrated in Chechnya and Dagestan, in the span of two months (Wilhelmsen, 2017). The daily average of 34 bombing raids on Chechen territory particularly affected the towns of Grozny and Gudermes and resulted in over a dozen of fifty-year old unexploded soviet bombs, scattered on the streets of Novolaksoe (Politkovskaya, 2001; Wilhelmsen, 2017). Between October 1999 and February 2000, airpower was expended to over 78

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4,000 conflict incursions; illegal rockets, such as TOS-1 and cluster bombs, were deployed; Chechen and Dagestani women were unfairly targeted as “possible enemy sniper”; and zachistki, or cleansing operations, were committed in villages across the North Caucasus (De Haas, 2003; Politkovskaya, 2001; Wilhelmsen, 2017).

On 5th February 2000, a sweep operation was conducted by the special police force of OMON (Otryad Mobil'nyy Osobogo Naznacheniya) in Grozny’s south-western district of Novye Aldi.

Over 60 people, including a one-year-old baby and a pregnant woman, were arbitrarily slaughtered during the ethnic cleansing massacre, and at least three women were raped by OMON forces (HRW, 2000; Rights in Russia, 2016).

As the Russian forces penetrated further in Chechnya, ethnic cleansing operations, or massacres of non-combatants, increased. Russian troops assassinated between 57 and 70 civilians in the northwestern district of Staropromyslovsky, in the Chechen capital, after the army suffered consequential losses during battles in December 1999 (Le Huérou & Regamey, 2015).

Inconceivably, General Viktor Kazantsev, who occupied the function of Commander for the North Caucasus Group of Forces at the time, seemingly attributed the Russian Army’s "mistakes" on their " soft-heartedness", thus blatantly refusing to acknowledge the crimes, and refusing to take appropriate responsibility (HRW, 2000). As a result, in 2003, the United Nations called Grozny “the most destroyed city on Earth'' (Wingfield, 2013), representing a violation of the International Humanitarian Law (IHL), despite the Russian Federation ratifying the treaty in 1996 (Korostelina & Kononenko, 2012). The World Organisation Against Torture reported an average of 20% to 80% of the rural villages destroyed, depending on the areas; not a single Chechen district was able to

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retain more than 50% of their housing buildings, as about 80% of accommodations in Chechnya has been destroyed (OMCT, 2004; Secours Catholique Francais, 2003).

Subsequently, between 200,000 and 368,000 refugees were reported to have fled from the North Caucasus between 1999 and 2004 (Global IDP Database & Holland, 2004; Politkovskaya, 2001; USCR, 2004). Such important displacements and violence led to at least 40% of Chechen families to survive in extreme precarity, with the UN World Food Programme providing 70% of the emergency alimentary aid to Grozny in 2001 (UN, 2001).

In 2007, the Chechen Ministry of Labour recorded 55,000 children as directly injured by the military operations, corresponding to 18,5% of the Chechen youth (Vishnevetsky, 2009; Chechenstat, 2007). At least 25,000 children in Chechnya were reported to have “lost one or both parents” in the conflicts, from 1994 to 2008 (UNICEF, 2008; Seierstad, 2008). The violence of the war directly and indiscriminately targeted children, as the official statistics from the Chechen Ministry of Labour assessed 24,157 handicapped and mutilated children, and 77% of the respondents of a Médecins Sans Frontières survey reported suffering from “discernible symptoms of psychological distress” (Chechenstat, 2007; MSF, 2014; Vishnevetsky, 2009). In 2006, UNICEF reported that 73% of the children surveyed in Chechnya had “experienced traumatic events”. These high and concerning figures stem from the intensity of the conflict and its direct impact and targeting of civilian structures: 505 schools were either destroyed or damaged in 2001, and not a single one, but School N°2 in Gudermes, was still welcoming pupils (Institute for War and Peace Reporting, 2001; Politkovskaya, 2001). Not only was there no educational facility left to protect and educate, but an ideological trend began to legitimately surface amongst the youth: children were reported to reject Russia and Russian scholastic principles (IWPR, 2001). With a two-to80

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three-year disruption in their education, Chechen children suffered from a setback in their class, with consequences a few years later; in 2010, only 11,5% of Chechens completed higher education, and 2,6% never attended school, which was 4,33 times higher than the Russian average at the time (Federal State Statistics Service, 2010; Institute for Democracy in Eastern Europe, 2000).

The Chechen population was also increasingly suffering from discrimination. From January 2000, ‘only children under the age of 10, men over the age of 65 and women’ would be accepted as refugees. Men ‘between the ages of 10 to 60 years old’ were banned from entering or leaving Chechen territory (HRW, 2000; MSF, 2014). A survey undertaken after the 1999 Moscow bombings alleged that 64% of Russians “wanted all Chechens expelled from the country”, and an equivalent quotient expressed a favourable attitude towards bombing Chechen villages and cities (Russell, 2005).

Access to healthcare and medical assistance was also alarmingly absent; internally displaced Chechens in Chechnya and Ingushetia suffered from a rise of critical health issues, such as an increase in tuberculosis cases and measles (Global IDP Database, 2005). Doctors Without Borders (“Médecins Sans Frontières”) estimated that children were the primary victims of this lack of medical support, and that Russian authorities had not developed and deployed any aid for the educational and medical reconstruction of Chechnya (MSF, 2014). Accounts of Russian troops stopping the influx of international humanitarian organisations coordinate with Akhmad Kadyrov’s announcement in February 2001, forbidding NGOs to operate freely on Chechen soil (UNICEF, 2005).

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As of September 2005, UNICEF kept on developing rolling programmes and structures intended to tackle the spread of HIV and AIDS and taught healthier life habits to the Chechen and Ingush youths. A total of three Youth Information Centres and three Youth Friendly Clinics were created

by UNICEF in cities such as Grozny and Malgobek, in order to support the youth’s post-war rehabilitation and supply appropriate and complex psychological and medical help (UNICEF, 2005). Psychological, especially pedo-psychological, assistance was crucial to the recovery of the Chechen youth, as 62% of the refugees surveyed in an Austrian mental health facility suffered from clinically significant psychological traumatisms (Ottomeyer, Renner & Salem, 2006). Following a comprehensive study funded by the World Health Organisation, Chechen psychiatrist Dr Kyuri Idrisov assessed that 86% of the Chechen population was affected by “physical or emotional distress”; among them, 31% were diagnosed with post-traumatic stress disorder (Vazayeva, 2003).

Another study of 320,000 Chechen children diagnosed by the chief of the Maternity and Child Health Department, Mr Hasan Gadayev, estimated that over 80% of Chechen children had developed health complications. Most of the diseases were of ‘neurological’ and ‘psychological’ nature, and he estimated that 70% of the children were affected by tuberculosis (European Parliament & Dupuis, 2004).

Psychological and physical abuse against Chechen and Dagestani children was heightened by the irreversible consequences of the prevalence of child recruitment amongst terrorist organisation of the Chechen Republic of Ichkeria. Figures such as Aslan Maskhadov and Shamil Basayev recruited children as young as twelve years old and would subsequently train them on battlefields; a special unit of 1,500 teenage suicide bombers was reportedly trained in Grozny (Allenova & Udmantsev, 2000; Ivanov, 2007; Pryganov, 2001). Children were thus also considered combatants by both the Chechen and the Russian forces and governments; according to Korostelina and Kononenko 82

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(2012), the Russian legal system was not able to support and offer adequate protection to children of Chechnya, leading to large-scale cruelty from both armed sides.

The ongoing radicalisation of the Chechen youth is overlooked in prevailing terrorist study, and a disparity on the academic understanding of Chechen terrorism has been underlined by experts (Pokalova, 2015; Shaffer, 2016; Souleimanov, 2015; Tarín-Sanz and Ter-Ferrer, 2018). As of 2018, Russian Jihadist Foreign Fighters (JFFs) were estimated to constitute 13,97% of JFFs, the highest frequency from a country after Syria; an assessment of over 5,000 Russian-born jihadists was reported in 2018 (Cook and Vale, 2018). Reports of indiscriminate use of force by Russian troops, internment camps, and attacks on civilians were published by Human Rights groups. Scholars have even used the term "state terrorism" to describe Russia's counterinsurgency operation (Cornell, 2003; Galeotti, 2014; Hughes, 2007; Lyall, 2009; Sagramoso, 2012).

Conditions, such as (1) low socio-economic structures (Dannreuther, 2014); (2) a pervasive and shared perception of oppression and resentment (Russel, 2007; Sagramoso, 2012); (3) survivor guilt (Akhmedova & Speckhard, 2006); and (4) the experience of war-induced psychological traumatisms (MSF, 2004) instigated Chechen teenagers to legitimise the concept of violence (Rezvani, 2014). Additionally, jihadist movements in the province supplied a conducive environment promoting the proliferation of Islamist terrorism. Indeed, experts believe that the JFFs introduced a "heritage" following the Chechen Wars, in which the insurgent movement's ideology transitioned from ethnic nationalism to extremist Islamic fundamentalism (Albert, Freitag & Forde, 2020; Hughes, 2007; Pokalova, 2015). Assessments of Chechen JFFs highlight a high level of engagement in terrorist conflicts abroad; these conflicts exclude traditional Chechen jamaats (Shaffer, 2016; Vishnevetsky, 2009). An academic consensus suggests that the radicalisation 83

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process currently undergone by young Chechens strongly operates in the mechanisms of global jihadism (Tarín-Sanz & Ter-Ferrer, 2018).

Limitations Research process can be complex in terrorism and extremism studies, due to many complicating factors such as the difficulties of conducting field research and retrieving data, the extreme experiences of conflict endured by the communities and hostile environments where freedom of research is neither endorsed nor accepted by local authorities. The difficulty to assess crisis and conflict situations is heightened by the current isolationist tendencies of the countries on which the case-studies analysis was based on. A potential bias and misreporting likely exist and need to be underlined when considering the figures announced by local authorities. The impossibility to physically survey or assess the situation also represents a limit in data collection and consideration.

The sheer nature of accessing and analysing research undertaken in the midst of a humanitarian disaster imposes limitations on the findings, resulting in insufficient documentation on the psychological health of the Chechen, Syrian, and Afghan youths. Further studies and research on the impact of state-induced violence on the mental wellbeing and collective traumatism endured by civilian communities should be conducted. Certainly, other factors such as the social environment, collective trust and familial settings need to be considered and explored (Betancourt, 2004).

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Policy Recommendations Education holds the key to restructuring the mindset of the youth which has been deeply traumatised and negatively influenced by the wars, political instability and insurgency. By creating a space where the voices of the children are being heard, a ‘pedagogy of remembrance’ is developed through training for teachers and parents, and the appropritae reconfiguration of education allows a collective healing process for the youth (Porobić & Jeftić, 2020). Indeed, opportunities to participate in education reduce the likelihood of young people’s involvement in armed conflicts (Barakat and Urdal, 2009; Thyne, 2006). A safe and inclusion platform for education opens doors to better economic prospects in the future, consequently leading to upliftment of the individual. A study by The Asia Foundation (2015) found out that 54.5% of afghans do not have any formal education or home schooling (Sadat et al, 2015). The statistics revealed a significant difference between education among men and women, with 37.8% men having no formal schooling, while it was 69.3% for women (Sadat et al, 2015). Children are believed to spend an average of two to four hours only in school or madrasas. Parents prefer to send their children to religious madrasas due to financial limitations, where children receive free education. Madrasas are widely believed to be sources of radicalisation; however, parents continue to send their children there even though they are aware of the very high possibility of them becoming radicalised there. The madrasas usually would prepare their own syllabus, and some of which preach extremist ideologies. Universities are also considered another possible source of radicalisation. Study by Zaman and Mohammadi (2014) observed a strong presence of islamist groups in the campuses even though their direct role could not be deduced. “Nangarhar University in particular was identified as a point of radicalisation for violent extremist groups such as the Taliban and, more recently, ISIS.” The need of the hour is significant investment in the education sector. However, keeping in mind the economic crisis the

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country is currently facing, restructuring and compiling a new syllabus for madrasas and other educational institutions can be much more effective. Proper monitoring of such institutions is required on a periodic basis. Higher authorities must carry out monthly inspections of the teachers and student’s performance to ensure understanding of the correct prescribed syllabus.

This responsibility of monitoring the type of education received falls on the community. Parents and other leaders must get regularly involved in their school’s or madrasas’ teachings through regular meetings with the teachers in order to understand what their kids are learning at school.

The large young population of the country needs to be diverted towards activities where their talent and energy can be productively utilised. Skill development centres and vocational schools could be highly effective in generating soft and hard skills among the youth which would not only keep them engaged in the short term but also increase their prospects of getting high paying jobs in the future. The civil society in Afghanistan has not been able to play a strong role as moderate groups have the opinion that “they were being outmanoeuvred by both violent extremist groups and nonviolent Islamist groups and charismatic mullahs with better organisational skills and better grassroots contacts and networks, particularly among youth.” A strong civil society can be extremely effective in community building. Community information programmes organised by former reformed victims/members of extremist groups can be helpful in making youth understand the perils of joining such groups. Getting to know about first-hand experience of former participants can help in reaching out to youth in ways that others might not be able to and act as a counter incentive.

In his writing on Afghanistan’s insurgency, Seth Jones made some valuable key points regarding policy (Jones, 2008). Firstly, efficacious law and order must be founded, and the security 86

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framework of the government must be strengthened. In 2007, security forces in Afghanistan accounted for just 0.5% of the population. Jones notes that there is no set number of security personnel required for prosperous counterinsurgency operations, but historical efforts indicate that the figure should be doubled at least (Dobbins, 2007). Ideally, this aperture in personnel should be filed with police, military and NATO forces. Ameliorating essential services including healthcare and access to education could have a ‘stabilising effect’ in the long term, providing the ‘light at the end of the tunnel’ that the youth need in order to evade the radicalisation tactics of extremist recruiters. This is especially pertinent to those in rural areas who suffer particularly from a lack of resources – dams and other such projects are their lifelines (Abu Amr, Dowd, et al., 2013; Amnesty International, 2014; Synovitz, 2017). Diplomatic channels between Afghanistan and its neighbours should be opened to strengthen the country as a political figure and marshal the humanitarian relief needed (University of Nottingham, 2021). Partnerships with development assistance organisations to provide further support are vital and any humanitarian aid should not be conditional on the activities of the Taliban. International engagement should be on-going: isolationism would be detrimental both geopolitically and to Afghans (Ponzio and Barakat, 2021).

The “National Directorate of Security'' (NDS), the agency responsible for the collection of strategic & tactical intelligence in Afghanistan, has been found to be “failing to collect high-value information that could be beneficial to Afghan’s domestic security” according to Mishra (2018).

Due to lack of equipment and funds allocated to the NDS, a reliance on human intelligence from sources such as farmers and teachers has produced arguably low quality and unauthentic intelligence (Wardak, 2016). Low quality intelligence can lead to misleading analysis which subsequently causes suboptimal decisions to be made on behalf of government or military officials (Ibid.).

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Effective intelligence produces effective early warnings (Duncan, 2021). When guided by effective intelligence, security organizations can pre-emptively allocate appropriate resources to counter the efforts of terrorist organizations (Ibid.). Bolstered regional intelligence efforts in key provinces is paramount for informed decision making and pre-emptive countermeasures in the context of terrorism recruitment. Adequate funding should be allocated to appropriate military and law enforcement intelligence agencies in order to improve the quality of analysis which is required to supplement key decision making.

Countering radicalisation on different scales (i.e., local, familial or governmental) implicates a policy that encourages the reconnaissance and acknowledgment of psychological distress and deprivation amongst the youth, a factor that increases in the context of war zones. Victoroff (2005) insists on the cruciality for counter-terrorist and humanitarian policies to encompass extra-social and intra-individual factors, as well as the dynamics of the war. As psychology represents a fundamental influence in the process of radicalisation, with para-elements increasing the likelihood of joining a terrorist organisation; grievances and perception of discrimination harboured by the population, coupled to the experience of traumatic events can lead to a sense of dissociation, that culminates to one's individual obsession with vengeance, retribution and collective defence (Burgess & Ferguson, 2009; Speckhard, 2006). The psychological consequences of the youth’s exposure to violence, perpetrated by the authorities, presents a high risk of leading young individuals to perceive violence as legitimate and securing. Thus, as encouraged by multiple humanitarian organisations, local governments and international authorities need to understand and prioritise the issue of violence-based psychological behaviour through the funding and implementation of psycho-medical support.

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Between November 2014 and February 2015, a study was conducted on the efficiency of the mental health programme implemented by Médecins Sans Frontières in Grozny, Chechnya. The programme included individual counselling, which was implemented by Médecins Sans Frontières as part of a larger humanitarian initiative operating in five hospitals in Chechnya. The report demonstrated that psychological assistance provided by humanitarian organisations strongly improved the lives and mental health of the Chechen community, reduced symptoms of psychological trauma and distress, such as anxiety and depression, while also reducing the incidence of post-traumatic stress disorder (PTSD) amongst individuals. Therefore, it is fundamental that policies include a socio-psychological vector in their implementation in war and post-war zones, as negative and extreme psychological conditions create an opportunity for greater negative emotions (Bar-Tal, De Rivera & Halperin, 2007; Jarymowicz, 2001), generating a psychological vulnerability susceptible to radicalisation. It is primordial to enforce psychological approaches and support to communities affected by war, conflict and subsequent psychological disorders.

With regards to Syria, one of the most outstanding and pressing factors appears to be that of economic despair. A quick look into the Syrian economic structure reveals that its economy is reliant on services, and includes other sectors like trade and agriculture, albeit to a much smaller degree. With an unfavourable balance of trade and falling international revenue due to the Syrian Civil War, the country has suffered in its income, affecting the income and employment numbers.

Syria is then left with an alarmingly high rate of unemployment, as stated in the analysis above, often driving Syrian youth and children to turn to the income from extremist organisations as a last

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resort. Therefore, policy should revolve around two main points: economic growth and economic stability.

Firstly, economic growth can be achieved through the creation of stable economic infrastructure.

This applies to essentials such as schools, hospitals and roads, and (in relative terms) non-essentials such as the building of shopping centres and targeted tourist attractions. Sound economic infrastructure is a foundational step to economic rebuilding and recovery as they allow for more efficient work in everyday life, therefore increased productivity, which we can then link to increased profits. At the same time, this makes Syria more attractive to tourists. Syria currently ranks 105th in the world for number of tourists per resident (adjusted based on population numbers) – an uptick in these numbers will not only boost the economy as it is, but also create more jobs such that those unemployed can step into these roles. In the long-term, sound economic infrastructure also attracts more foreign investors, which will improve the number and quality of jobs available to Syrian youth and children, among other benefits. Therefore, the need to turn to extremist organisations for income support will be heavily lessened. In fact, sound economic infrastructure is also helpful for long-term economic stability as it functions as a building block for future economic growth which will precipitate upon basic infrastructure.

Another long-term investment for economic growth and stability would be to invest heavily in education, introducing policies like compulsory primary school education and ensuring that every district has at least one school. The benefit of proper religious education is already clearly evinced above, but this section adds that education not just has personal and social, but also long-term economic benefits that are worth looking at.

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Lastly, we have been looking at long-term economic policies, but these policies should be implemented alongside a shorter-term policy simultaneously for a more cohesive approach. The recommendation we offer for a short-term policy would be to increase government spending (in this case, it makes sense to increase spending on either short-term relief or long-term infrastructural investment), which will then increase the aggregate demand of the country, ultimately raising the Gross Domestic Product (GDP) of Syria and lowering unemployment levels, which as previously explained, will lead to less instances of youth and children needing to turn to radical groups for support.

Conclusion The study was undertaken with an aim to understand the impact of state induced political violence and war traumatism on radicalisation of youth in war torn countries. To analyse this, we focused the research on three countries, Afghanistan, Syria and The Russian Federation. The three case studies were chosen due to the outset of violence as a result of war related conflicts since 1990s or early 2000s and also because all three have witnessed violence at the hands of either the home state or a foreign state. The proposed hypothesis seeks to substantiate the presence of a relationship between a country’s political violence scale and magnitude of internationalised internal armed conflicts on the prevalence of terrorism within the borders. The analysis involved one dependent variable, the Global Terrorism Index and three independent variables, Internationalised internal armed conflict, Political Terror Scale - Amnesty International and Conflict Intensity. Multilinear regression on the aforementioned variables conducted over the observations of 51 countries resulted in 72.17% of the variation in the Global Terrorism Index being explained by variations in

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the three independent variables. The proposed hypothesis can thus be accepted, evidenced by a high level of influence of the independent variables on the prevalence of terrorism.

The objective of this paper was to draw links between the prevalence of state-induced violence and radicalization of youths in warzones, utilising historical internal strife in Syria, Chechnya, and Afghanistan as case studies. The study employed the method of data triangulation, using data analysis, in order to synergize quantitative and qualitative findings. Qualitative and quantitative data cited by this paper demonstrated evidence of these links; quantitative data reported the prevalence of terrorism to political violence and internationalised internal armed conflicts returned promising trends, and qualitative data for each case study highlighted documented instances of stated-induced violence and relative contextual information for each case study, to draw specific conclusions. In reflection of cited evidence, this paper recommended renewed economic investment in countermeasures such as education, security, and intelligence.

Despite promising evidence citing a link between state-induced violence and youth radicalization, there is a notable absence of research into the radicalization process relating to residents of a state engaged in internal conflict. To aid efforts to curb the rate of radicalization by gaining further insights into recruitment practices, this absence must be resolved. §§

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Personal Protective Equipment Availability and Healthcare Workers Mortality Rates at the Beginning of the Covid-19 Pandemic

Caroline Portia Greenig*, Juliane Greenig*, Sorana Bucseneau, Marie Barberon, Karolina Maria Kwiatkowska, Nancy Yang, Rose Bourges, Imrana Pirpay, Ingrid Wittendorff Humblen, Alexandra Farsari *

Research Team Leaders 102

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Table of Contents Introduction ............................................................................................................................................................... 104 Literature Review ...................................................................................................................................................... 108 PPE Evidence from Previous Coronaviruses ..................................................................................................... 108 Experimental PPE Evidence for COVID-19 ...................................................................................................... 110 Qualitative Studies of HCW Experiences during COVID-19 ........................................................................... 112 Methodology ............................................................................................................................................................... 114 Collecting Total Healthcare Worker Data ......................................................................................................... 114 Collecting Healthcare Worker Deaths Data ....................................................................................................... 118 Standardising Healthcare Worker Deaths Data ................................................................................................. 119 Compiling Standardised COVID-19 Case and Death Counts ........................................................................... 119 Compiling and Coding PPE Policies ................................................................................................................. 119 Results ......................................................................................................................................................................... 120 Discussion ................................................................................................................................................................... 126 Legal Requirements for PPE .............................................................................................................................. 127 Respirator Fit-Testing ........................................................................................................................................ 129 PPE Provision: United Kingdom ....................................................................................................................... 132 PPE Provision: United States ............................................................................................................................. 135 PPE Provision: Germany ................................................................................................................................... 138 PPE Provision: New Zealand ............................................................................................................................. 140 PPE Provision Strengths and Limitations .......................................................................................................... 144 Other Factors Impacting Healthcare Worker Infection and Mortality During COVID-19 .............................. 144 Testing................................................................................................................................................................ 145 Other Infection Prevention Considerations ........................................................................................................ 145 Occupational Mental Health .............................................................................................................................. 146 Strengths and Limitations......................................................................................................................................... 146 Scope of the Research ........................................................................................................................................ 149 Conclusion .................................................................................................................................................................. 150 Recommendations .............................................................................................................................................. 151 Further Research ................................................................................................................................................ 152 Bibliography ............................................................................................................................................................... 153 Appendix..................................................................................................................................................................... 163

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Abstract: During the COVID-19 pandemic, healthcare workers around the world have been lauded as a key occupational group at the “frontline” of the fight against disease transmission. However, their roles put them in danger of infection, psychological strain, and even mortality as they navigate increasingly burdened health infrastructures to provide the highest standards of patient care. Motivated by significant numbers of COVID-19-related deaths in this population during the “first wave” of the pandemic in Europe and the Americas, our study investigates the relationship between personal protective equipment (PPE) guidance and healthcare worker mortality in the United Kingdom, United States, Germany, and New Zealand from the beginning of each country’s outbreak until July 1st. We find that more stringent guidelines (i.e. those advising staff to use equipment affording them a greater standard of protection) may be linked with lower mortality rates in this small sample, with this association possibly strengthened when taking into account countries’ overall responses to the pandemic. Our conclusions demonstrate the importance of supplying sufficient and high-grade PPE to healthcare workers in need to protect them and the general population from adverse outcomes and ensure a more rapid recovery from the pandemic.

Further research is needed to improve data quality for both healthcare worker deaths reporting and PPE guidelines, as well as to innovate alternative PPE solutions such as reusable masks to lessen cost and environmental burden.

Introduction Ever since the reported cases of pneumonia in Wuhan, China in late 2019, the COVID-19 outbreak has rapidly progressed, being declared a pandemic by the World Health Organisation (WHO) roughly 4 months after on the 11th March 2020 (World Health Organisation, 2021). From the first confirmed case outside China on the 13th January in Thailand (World Health Organisation, 2021), to initial cases in the US, Germany, UK and New Zealand on the 21st January, 27th January, 31st January and the 28th February respectively, this novel virus managed to spread fast, and cause many deaths, with approximately 100,000 worldwide by the 8th April 2020, and 508,055 by the 1st July 2020 (Think Global Health, 2021; World Health Organization, 2020a).

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The virus implicated in the pandemic, SARS-CoV-2, is very similar to, but more infectious than, previous coronaviruses such as SARS-CoV-1 (Harrison et al., 2020). COVID-19’s enhanced transmission may be explained by the differences that exist between the spike glycoproteins of SARS-CoV-1 and SARS-CoV-2, which mediate entry into host cells. For instance, both viruses bind to angiotensin-converting enzyme (ACE2) receptors on host cells in order to invade them (Cevik et al., 2020b), however, SARS-CoV-2’s spike glycoprotein has up to a 20 times greater affinity for ACE2 receptors (Wrapp et al., 2020), and thus forms a stronger bond.

Nonetheless, the route of transmission for SARS-CoV-2 is like any other coronavirus. Its primary mechanism is through direct (e.g., inhalation) or indirect (e.g. via contaminated surfaces) contact with infected respiratory droplets (>5-10μm in diameter), which are released when a person coughs or sneezes, and can enter the body through our nasal, oral, and conjunctival mucosa (World Health Organisation, 2020b, Cevik et al., 2020b).

One of the major challenges with COVID-19 is that the incubation period, the number of days from infection to symptom onset, can be up to 14 days (Bhole et al., 2020). During this time, an infected person is still believed to be infectious, and thus can unknowingly pass it on to others. The large range of symptom severity is also an issue - common symptoms include a fever, cough and shortness of breath, but some develop serious respiratory problems such as difficulty breathing, while others remain asymptomatic (Esakandari et al., 2020), which is a major issue for mitigating transmission (Cevik et al., 2020a).

In a hospital setting, airborne transmission via aerosol generating procedures (AGPs) is most concerning. This is where infected respiratory droplets <5μm in diameter are disseminated and 105

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remain suspended in the air over long distances and time. The exact nature of these aerosols is still being debated - which medical procedures produce them, and whether transmission can occur without AGPs in poorly ventilated areas, for example (World Health Organisation, 2020b).

Burden of disease is defined as the “cumulative consequences of a disease… includ[ing] health, social aspects and costs to society” (Hessel, 2008). The COVID-19 pandemic has created healthcare needs that go beyond the capabilities of healthcare systems (Emanuel et al., 2020), hence the significant consequences for these systems. The high transmission rate, which has led to a growing number of COVID-19 cases, has made the pandemic a burden to global healthcare infrastructures. It has been shown that when COVID-19 cases exceed the treatment capabilities of hospitals, the medical system becomes overwhelmed with insufficient staff, a shortage of intensive care facilities, and non-COVID-19 cases being deprioritised (Miller et al., 2020). Furthermore, the rationing of medical equipment and the reduced requirements for protective gear (Emanuel et al., 2020) demonstrate the burden that the COVID-19 also has on hospital facilities and resources.

Healthcare workers (HCWs), especially those in patient-facing roles, are a vulnerable group during the pandemic because of their proximity to disease in the workplace. There is evidence that HCWs encompass a substantial and disproportionate percentage of infections and deaths from COVID-19 around the world compared to the general public (Nguyen et al., 2020; Papoutsi et al., 2020).

Infection susceptibility and risk of severe outcomes is further stratified by profession and specialty, workers’ exposure to patients and aerosols, occupational health policies, provision of routine testing, and staff availability and by demographic characteristics such as gender, age, and race and ethnicity and diagnoses of underlying conditions (Bandyopadhyay et al., 2020). Adverse impacts on workers’ mental health have also been evident, with contributing factors including the traumatic 106

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act of making significant moral decisions about resource allocation, lack of social support, a stressful working environment, and a fear of infecting loved ones with the virus (Moreno et al., 2020).

A significant modifiable factor in COVID-19 risk for healthcare workers is their use of and access to protective equipment. Personal Protective Equipment (‘PPE’) is the term used to describe items to be worn or used for protection against health or safety risks (UK Government, 2020). In the context of the COVID-19 pandemic, it is primarily required for the purposes of guarding against transmission “between people through close contact and droplets” (WHO, 2020). For the purposes of this paper, PPE includes medical masks, gloves, and eye protection – items which are distinguished from the face coverings that the general public is advised to wear (WHO, 2020). PPE is particularly important for healthcare workers, whose jobs involve prolonged contact with patients who have suspected or confirmed symptoms of COVID-19 (UK Government, 2020).

Sufficient PPE can prevent transmission between patients and HCWs, HCWs to patients, and HCWs to HCWs alike.

This research investigates the relationship between PPE guidelines and healthcare worker mortality from COVID-19 in the United Kingdom, the United States, Germany, and New Zealand from first outbreak dates in the respective countries until July 1st, hypothesising that stricter guidelines are correlated with fewer deaths, and seeks to highlight shortcomings in protective equipment usage policies and suggest future measures to prevent loss of life in this crucial occupational group. These nations were chosen because despite their similar levels of healthcare resources and governmental structures, they had drastically different responses to the pandemic and did not constitute a

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homogeneous sample. Furthermore, their PPE policy and healthcare worker mortality data was more readily available and was in English or could be easily translated by the research team.

Literature Review We have reviewed the experimental and observational literature on PPE effectiveness during both the current pandemic and previous respiratory infectious disease outbreaks, as well as some qualitative studies of HCW experiences during the current pandemic. These inform our approaches to classifying PPE guidelines and analysing our results.

PPE Evidence from Previous Coronaviruses It may be helpful to review the literature surrounding evidence on PPE policy effectiveness during outbreaks of previous coronaviruses, namely Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS).

In a 2003 case-control study conducted in five Hong Kong hospitals, it was concluded that the use of masks was effective in protecting hospital staff from SARS (Seto et al., 2003). The statistical analysis revealed that while surgical and N95 masks were “significantly associated with noninfection”, paper masks did not demonstrate the same results (Seto et al., 2003). A later study found, however, that even surgical masks did not provide significant protection. The 2004 study revealed that, as compared to N95 masks, surgical masks are not sufficiently effective in filtering ambient particles – even when multiple are layered on top of each other. Thus, surgical masks should only be used when N95 masks are unavailable (Derrick and Gomersall, 2003). This conclusion was reflected in the Centers for Disease Control and Prevention (CDC) and the World 108

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Health Organization (WHO) guidelines, which stated that healthcare workers should wear N95 masks or higher-level protection during all contact with suspected SARS patients (Derrick and Gomersall, 2003).

Nevertheless, the results of two studies – one conducted in Hong Kong and the other conducted in Vietnam – demonstrated that masks alone were inadequate in containing and eliminating SARS transmission among healthcare workers (Lau et al., 2004; Nishiura et al., 2005). As such, it was crucial to consider other potential risk factors. The Hong Kong study investigated these risk factors and subsequently identified that the likelihood of SARS infection for healthcare workers was strongly associated with three main issues: first, perceiving the amount of PPE to be inadequate; second, having less than two hours of infection control training; and third, inconsistent use of gowns, caps, and goggles (Lau et al., 2004). The Vietnam study affirmed the third risk factor and concluded that the use of other PPE in addition to masks, such as gloves and gowns, was significant in containing transmission (Nishiura et al., 2005). The results further suggested that “rapid improvements in behavior and isolation would increase the probability of [virus] extinction.”

(Nishiura et al., 2005).

The academic literature of PPE policy effectiveness for the transmission of MERS is accompanied by the general understanding that, given its phylogenetic and immunologic similarities to SARS, the infection control guidelines developed during the SARS outbreak could also be followed for MERS cases (Chung et al., 2014). In other words, it was accepted that the PPE precautions used in 2003 could be extrapolated to apply to future coronavirus outbreaks. According to a 2013 study which conducted a review of those guidelines, however, the policies are not as straightforward as they may seem, perhaps because they come from more than one source. For instance, while the 109

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CDC recommends respirators whether the situation is classified as low or high risk, the WHO only recommends them in high-risk situations, opting instead for the use of masks in low-risk situations (Chughtai et al., 2013). It is worth noting here, however, that this inconsistency may be related to the CDC’s position as an agency in the United States, which is a high-income country with more advanced resources.

Experimental PPE evidence for COVID-19 Continued research into the effectiveness of PPE provisions on the transmission of SARS-CoV-2 has been conducted during the pandemic and have supported the same conclusion made by literature surrounding its effectiveness on previous coronaviruses. Official UK government guidance previously claimed that surgical and respirator masks provide 80% protection against SARS-CoV-2 (Public Health England, 2021). However, the claim was based on a systematic review analysing seasonal influenza and was conducted in 2017 prior to the emergence of SARSCoV-2 (Offeddu et al., 2017). Therefore, as SARS-CoV-2 has been found to be both more transmissible and for fatal compared to seasonal influenza, there is no guarantee of the ability for such masks to protect healthcare workers to the same extent (Petersen et al., 2020).

Systematic reviews have however continued to justify that previous research regarding PPE precautions for previous coronavirus pandemics could be extrapolated and applied to the current situation. Chu et al.’s (2020) systematic review and meta-analysis of 172 observational studies across 16 countries, with COVID-19, MERS, and SARS being considered, found the use of disposable surgical masks, reusable 12-16 layer cotton face masks, as well as N95 and similar respirators were associated with a significant reduction in risk of infection, with a RR of 0.34.

Stronger associations were found in healthcare settings, with the value decreasing to 0.30.

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Additionally, eye protection was found to be associated with a 16% increase in protection to infection as well, further suggesting the need for increased PPE provisions for healthcare workers.

Various case-control studies have been conducted across multiple countries and support the efficacy of facemasks in reducing the rate of infection in healthcare workers. A retrospective casecontrol study based in Thailand using contact tracing records reports that wearing masks all the time during contact, independent of handwashing and social distancing, where COVID-19 patients were negatively associated with the risk of SARS-CoV-2 infection with an adjusted odds ratio of 0.23 (Doung-Ngern et al., 2020). Similar findings from a case-control study based in India analysing the vulnerability of healthcare workers to acquiring a SARS-CoV-2 infection also found mask use to be associated with a reduced odds of 0.35 of becoming infected (Chatterjee et al., 2020).

A simulation of COVID-19 transmission using a smoke chamber model to simulate a hospital environment was conducted by (Douglas et al., 2020), where smoke; with a particle size of 0.1 μm was used to simulate exposure to SARS-CoV-2; with a particle size of 0.12 μm. A mouthpiece sensor was then placed under the mask to present the quantity of smoke contamination. The study found that fluid resistant surgical and FFP2 masks provided no protection to respiratory particles, with only FFP3 being effective at providing respiratory protection to the user. An analysis of 119 healthcare worker deaths using NHS workforce statistics supports these findings and found that staff working in the high risk specialties of intensive care and anaesthetics, and were provided with FFP3 masks experienced no mortality compared to specialties that were provided with weaker PPE provisions (Cook, 2020). Similarly in China, an analysis of 493 medical staff from a Wuhan hospital found that 0 of the 278 staff 111

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who were prescribed N95 masks were infected by SARS-CoV-2, whereas 10 of 213 of those in the no-mask groups were infected (Wang et al., 2020).

However, conflicting evidence has been published, such as a systematic review and meta-analysis of randomised trials by Bartoszko et al. (2020), where for viral respiratory infections, the effect of N95 respirators on reducing infection rates compared to medical face masks was negligible, with an OR of 1.06 in favour of N95 respirators, suggesting that both medical masks and N95 respirators provide similar protection against viral respiratory infections such as COVID-19. The limitations of this study must be considered though, as the meta-analysis only includes one trial that studied coronavirus infections individually comparing both forms of PPE, with other sources being based on other viral respiratory infections that may not be as generalizable to SARS-CoV2. Moreover, aggregate data was used rather than individual data, meaning accommodating for confounders, co-variates, and outcome definitions were not possible. FFP3 and and N95 respirators should therefore continue to be prescribed to healthcare workers whenever possible given the significant quantity of evidence suggesting its superior efficacy in protecting the transmission of SARS-CoV-2. However, further research should continue to be conducted in order to further validate this claim.

Qualitative Studies of HCW Experiences during COVID-19 All literature concerning the experiences of HCWs has highlighted the high levels of stress, anxiety and fear that they experience while working during the COVID-19 pandemic (Wu et al., 2020).

Many causes have been identified including uncertainty over the length of the crisis (Wu et al., 2020); misinformation about the disease (Schwartz et al., 2020); difficulties balancing the need for social distancing and wanting to support families; the lack of availability and quality of PPE gear 112

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(Nguyen et al., 2020), coupled with inadequate training in its use (Hoernke et al., 2020). These stresses on HCWs are not unique to the COVID-19 pandemic and have been recorded during previous pandemics such as during the Ebola crisis of 2015 (Billings et al., 2020). Of particular importance to this paper are the experiences of HCWs concerning PPE. One impact of not prioritizing the safety of HCWs is their increasing unwillingness to report to work, in which information regarding and access to PPE plays a significant role (Almaghrabi et al., 2020).

The particular experiences of HCWs surrounding PPE during the COVID-19 pandemic have been highlighted in all the literature as causing and exacerbating an already stressful situation. These issues range from physical discomfort to distress and anxiety caused by issues related to PPE (Billings et al., 2020).

The accounts of many HCWs have demonstrated a distinct lack of adequate PPE equipment and the inconsistent guidance that is provided on its use. A study of Italian physicians demonstrated that the perceived risk of contracting COVID-19 was influenced by physicians receiving adequate information on PPE use (Savoia et al., 2020), therefore explaining the associated decline in mental health experienced by frontline HCWs during the pandemic. Billings and colleagues (2020) demonstrate that inadequate PPE exacerbates the fears of HCWs across multiple pandemic situations.

Substandard infection controls not only increase the risk of contracting COVID-19 but also have negative effects on the mental health of HCWs. Insufficient PPE increases spread within hospitals and the news of which causes higher levels of fear and anxiety in HCWs (Vindrolo-Padros et al.,

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2020). This demonstrates the two-fold consequences of inadequate PPE: higher risk of infection, and the mental health consequences on HCWs.

A study (San Juan et al., 2020) based on interviews with UK HCWs highlighted the following issues with their experiences of PPE: 1) difficulties communicating through PPE, 2) a lack of information compounded by a lack of PPE, and 3) physical discomfort such as ill-fitting PPE, dehydration and overheating. This demonstrates that experiences of PPE are multi-faceted and new policies surrounding the use of PPE must consider a range of issues from communication, information, physical comfort and personal wellbeing.

Studies from a teaching hospital during the 2003 SARS outbreak demonstrated that transparency from leadership teams and direction regarding hospital processes and provision of supplies, particularly during shortages, was important in mitigating HCWs reactions based on fear (Wu et al., 2020).

Methodology We detail below the methods and sources used to compile and standardise healthcare worker mortality data, as well as the process of compiling PPE guidelines for the four countries.

Collecting Total Healthcare Worker Data For the purpose of establishing the size of the healthcare workforce in each individual country (United States, Germany, New Zealand, and the United Kingdom), the following data sources have been consulted.

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For the United States, the U.S. Bureau of Labor Statistics the Occupational Employment Statistics (OES) survey (2019) distinguishes between Healthcare Practitioners and Technical Occupations and Healthcare Support Occupations. An estimated 15.194.930 people work in these two fields.

This does not include ambulance drivers which are categorized as Transportation and Material Moving Occupations. If we were to include their numbers in the healthcare work force the estimated total would be 15,209,670. Furthermore, there are 70,100 janitors and cleaners working in hospital settings (U.S. Bureau of Labor Statistics 2019). This does not include orderlies which are classed as Healthcare Support Occupations. The occupational categories are based on a combination of the Office of Management and Budget’s 2010 and 2018 Standard Occupational Classification (SOC) systems.

The survey classified employment as ‘the estimated occupational employment (not including selfemployed) for that industry’ (2019). The technical notes state: ‘OES estimates are constructed from a sample of about 1.1 million establishments. Each year, two semiannual panels of approximately 180,000 to 200,000 sampled establishments are contacted, one panel in May and the other in November. Responses are obtained by mail, Internet or other electronic means, email, telephone, or personal visit. The May 2019 estimates are based on responses from six semiannual panels collected over a 3-year period: May 2019, November 2018, May 2018, November 2017, May 2017, and November 2016. The unweighted sampled employment of 83 million across all six semiannual panels represents approximately 57 percent of total national employment. The overall national response rate for the six panels, based on the 50 states and the District of Columbia, is 71 percent based on establishments and 68 percent based on weighted sampled employment’ (2019).

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The sampling method is subject to sampling and nonsampling errors (inability to obtain information for all establishments in the sample, differences in interpretation of survey questions, inability or unwillingness to provide correct information, errors made in recording, coding, or processing data). Quality control measures were used such as checking questionnaires for data consistency, follow-up mailings, emails and phone calls are sent out to nonresponding establishments to improve survey response rates (U.S. Bureau of Labor Statistics 2019).

The United Kingdom estimates were based on publicly available survey data accessed through the Nomis database. The latest available data collected by ONS (2020) was used covering figures for the period July 2019- June 2020. The relevant professions were selected from the dataset and used for the purposes of our research. The numbers provided by ONS (2020) are estimates and not an exact reflection of the healthcare workforce.

In the case of Germany, the database of the Federal Statistical Office was used. The table used was ‘Health workers: Germany, years, employment relationship, gender, occupations in Healthcare’ (Code: 23621-0004) (Destatis, 2018). The latest data available was from 2018 and data was selected for full-time as well as part-time employees, unlike in the United States and United Kingdom datasets where the data shown was for full-time equivalents and headcounts. An estimated 5,651,000 people work in the German healthcare system. The dataset provides details for ambulance workers that are not qualified paramedics (categorized as Helpers in the Ambulance Services). No data is provided on cleaners and domestics or hospital porters.

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The methodology section of the Federal Statistical Office provides quality assurance. Their datasets use the EFQM (European Foundation for Quality Management) Excellence Model. Quality reports are also conducted for all federal statistics (Destatis, 2021).

In the case of New Zealand, 2018 occupational census data was consulted (Stats NZ, 2020). The exact dataset consulted was ‘Occupation-2018-census-csv’(Stats NZ, 2020). The original data was collected as part of the 2018 Census for Population and Dwelling. Quality assessments were conducted and only data that met a certain criteria were included in the topic tables of the New Zealand census. According to the Data quality ratings for 2018 Census variables, the occupation variable was found to be of moderate quality by Stats NZ and of poor quality by the external data quality panel (EDQP) (Stats NZ, 2020). The end results were based on census response data and statistical imputations, but final figures may have been inflated (Stats NZ, 2020). The results of this study will be affected by this as well and therefore can only serve as estimates of the New Zealand healthcare workforce.

The occupations selected were based on the ONS estimates of exposure to generic disease and physical proximity to others. Their classification was based on the results from the 2019 Annual Population Survey. For the purposes of our research, we have included occupations with average responses of “physical proximity to others” question greater than “slightly close”. We have also included the exceptions of hospital cleaners and porters, who we hypothesise are at much greater risk from SARS-CoV-2 environmental exposure due to aerosols and fomite surfaces during the pandemic (ONS, 2020).

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Therapy professionals n.e.c.

Pharmacy and other dispensing assistants Pharmacists Occupational therapists Pharmaceutical technicians Physiotherapists Ophthalmic opticians Nursing auxiliaries and assistants Nurses Midwives Dental practitioners Medical practitioners Ambulance staff (excluding paramedics) Dental nurses Figure 1a – Occupations with average responses of “physical proximity to others” question greater than “slightly close”.

Cleaners and domestics Hospital porters Figure 1b – Other occupations with high risk of exposure to COVID-19.

Collecting Healthcare Worker Deaths Data Medscape: Data from Medscape (timestamp: July 1) was web-scraped using a data mining tool (data-miner.io) and inputted into an Excel sheet. Deaths were then categorised by country (with subnational categories included for the United Kingdom and United States).

Official sources: Data from United Kingdom and New Zealand government sources respectively were compiled for the study period, with the latter examining cause of death data given the lack of a single data source for healthcare worker deaths from COVID-19.

Kaiser Family Foundation/Guardian memorial: Data from an unofficial investigation of healthcare worker deaths in the United States was captured during the study period.

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Standardising Healthcare Worker Deaths Data Raw counts of healthcare worker deaths during the study period were divided by the total number of healthcare workers in the respective countries and multiplied by 100,000 for ease of display.

Compiling Standardised COVID-19 Case and Death Counts We directly compiled population COVID-19 case and death standardised counts for the duration of our study period from Our World in Data.

Compiling and Coding PPE Policies National PPE guidelines were obtained from respective government and health authority websites in the United Kingdom, United States, Germany, and New Zealand. Because changes in guidelines had occurred over time, a web archive tool (https://archive.org/web/) was used to compile website snapshots at or around July 1st, the last day of the study period. When this was not possible, guidelines that were verifiably consistent during and after the study period were taken from more recently updated sources. Guidelines were quantitatively coded as follows, with larger values indicating a more rigorous approach.

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Criterion description

Coding

Non-AGP mask use What type of mask was suggested when caring for suspected or confirmed COVID-19 patients in a hospital environment without the use of aerosolgenerating procedures (AGPs)?

1 = FFP2/3/N95 respirator

AGP mask use What type of mask was suggested when caring for suspected or confirmed COVID-19 patients in a hospital environment while performing aerosolgenerating procedures (AGPs) as classified by the country?

1 = FFP2/FFP3/N95 respirator

AGP classification of CPR Was cardiopulmonary resuscitation (CPR) OR chest compressions classified as an AGP by the country’s guidelines?

1 = classified as AGP

AGP classification of sputum induction Was sputum induction, or the induction of a cough, classified as an AGP by the country’s guidelines?

1 = classified as AGP

Extent of eye/face protection To what extent was eye/face protection, such as goggles or visors, recommended for HCWs treating suspected or confirmed COVID-19 patients through non-AGP procedures?

Use of gowns What types of gowns/aprons were recommended for HCWs treating suspected or confirmed COVID-19 patients through non-AGP procedures?

0 = Fluid-resistant surgical mask

0 = Fluid-resistant surgical mask

0 = not classified as AGP

0 = not classified as AGP 1 = eye/face protection completely recommended 0 = eye/face protection recommended depending on risk assessment 1 = long-sleeve gowns recommended 0 = elbow-length plastic aprons recommended

Figure 2 – Coding descriptions of PPE guidelines.

Results Figures 1 and 2 detail the total number of healthcare workers by occupation in the four countries studied. Though information on occupation was not available for most healthcare worker deaths, these profession proportions may be useful for when reporting practices improve, allowing us to analyse which sectors of the healthcare workforce are at greatest risk of COVID-19 mortality.

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Country

Occupations with average responses of “physical proximity to others” question greater than “slightly close”

United Kingdom

United States

Germany

New Zealand

Therapy professionals n.e.c.

298,500

835,160

149,000

9,603

Pharmacy and other dispensing assistants

81,900

109,610

52,000

2,667

Pharmacists

65,500

311,200

171,000

3,576

Occupational therapists

52,200

186,120

63,000

2,520

Pharmaceutical technicians

30,000

417,780

80,000

2,418

Physiotherapists

74,300

153,390

63,000

4,482

Nurses

1,031,800

5,343,880

961,000

51,492

Midwives

49,800

6,930

25,000

2,742

Dental practitioners

44,800

734,680

676,000

5,106

Medical practitioners

477,000

3,572,240

1,031,000

32,478

Ambulance staff (excluding paramedics)

28,600

14,740

7,000

624

Dental nurses

49,800

N/A

N/A

N/A

Cleaners and domestics

539,500

70,100

N/A

N/A

Hospital porters

18,900

46,990

N/A

1,059

Total

2,842,600

11,802,820

3,278,000

118,767

Other occupations with high risk of exposure to COVID-19

Figure 3 –Table of healthcare worker total population estimates (data collected 2018-2020).

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Figure 4a – United Kingdom healthcare workers by occupation.

Figure 4b – United States healthcare workers by occupation.

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Figure 4c – Germany healthcare workers by occupation.

Figure 4d – New Zealand healthcare workers by occupation.

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Figures 5 and 6a demonstrate that although the United States experienced the greatest number of HCW deaths during the study period, the United Kingdom had the highest death toll after standardisation by healthcare worker population. Germany’s standardised mortality count was more than ten times smaller than those of the former two nations. As no HCW deaths attributed to COVID-19 were recorded in New Zealand, standardisation did not change counts.

Country

Number of HCW deaths

Sources consulted

United Kingdom

310 206

Office for National Statistics Medscape*

904 305

The Guardian + Kaiser Family Foundation Medscape

20 3

Robert Koch Institute Medscape

United States

Germany

0 Medscape 0 WorkSafe Data Centre *Medscape counts include disputed records and retired staff.

New Zealand

Figure 5a – HCW deaths by country and reporting source, respective first COVID-19 case - July 1st study period (ONS, 2020; The Guardian/KFF, 2021; RKI, 2020; WorkSafe Data Centre, 2021; Medscape, 2020).

Figure 5b – Bar chart.

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Country

HCW deaths/100,000 HCWs

United Kingdom

11

United States

7.6

Germany

0.61

New Zealand

0

Figure 6a – After standardisation: number of healthcare worker deaths from COVID-19 per 100,000 healthcare staff (non-Medscape sources used).

COVID-19 deaths per 1 million country population

COVID-19 cases per 1 million country population

596.28

4,201.40

386.38 107.30 4.56

7,982.05 2,332.40 316.87

Country United Kingdom United States Germany New Zealand

Figure 6b – COVID-19 deaths and cases during study period by country (Our World in Data 2021).

Figure 7 classifies six categories of PPE guidelines in each country by stringency, including suggested uses of respirator masks, eye and face protection, and gowns, as well as the classification of aerosol-generating procedures (AGPs). Presuming that each category is equal in weight, we note that the United States recommended the strictest guidelines for PPE use, with Germany advising similarly stringent use with the exception of its non-classification of sputum induction as an AGP. Though the United Kingdom and New Zealand vastly differed in terms of HCW mortality, they advised similar use of PPE during the study period, with the only difference between the two countries shown in New Zealand’s more universal suggestion of eye and face protection (i.e. goggles and face shields). The relationship between these guidelines and HCW mortality is explored further in the below discussion.

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Coded PPE guidelines Country

Non-AGP mask use

AGP mask use

AGP classification of CPR

AGP classification of sputum induction

Extent of eye/face protection

Use of gowns

United Kingdom

0

1

0

1

0

0

United States

1

1

1

1

1

1

Germany

1

1

1

0

1

1

New Zealand

0

1

0

1

1

1

Figure 7 – Table of PPE guidelines coded (Public Health England, 2020; CDC, 2020; CDC, 2021; Exner et al., 2020; Ministry of Health, 2020). See Fig. 2 for methods.

Discussion These results appear to disprove our hypothesis that more stringent PPE guidelines are associated with fewer healthcare worker deaths. However, when considering overall pandemic outcomes with respect to each country (Fig. 6b), a more complex picture emerges. Though New Zealand had the second-least stringent guidelines and the lowest HCW mortality, it also had up to one-tenth of the COVID-19 cases of the other three countries, suggesting that PPE recommendations were in line with limited community transmission. Germany and the United Kingdom demonstrated more expected patterns, with the former having relatively low cases and deaths, stringent PPE guidelines, and fewer HCW deaths while the latter experienced higher proportions of cases and deaths, less stringent guidelines, and the most HCW deaths of all countries examined. The United States, however, recorded substantial HCW mortality despite strict guidelines; the below sections may provide explanations for this anomaly.

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Factors adjacent to healthcare authority guidelines significantly dictate access to PPE and general protection for healthcare workers. This section first describes the legal requirements for the distribution and use of PPE in the study countries, which reinforces the necessity of addressing the question of sufficient protection. Then, overviews of country-specific approaches to PPE provision are given. Finally, interventions combined with PPE to improve HCW workplace safety during the COVID-19 pandemic are considered.

Legal Requirements for PPE The legal frameworks which regulate PPE usage and provision from the four countries are relatively similar in their requirements for employers to not only provide PPE, free of charge, to their employees, but also to arrange training in regards to the usage and care of the items, including proper handling, disposal, and storage.

In the United Kingdom, these duties are set out in the Personal Protective Equipment at Work Regulations 1992 — a piece of national legislation enacted to implement the European Union Directive 89/686/EEC — as well as the Health and Safety at Work etc Act 1974 (Cowper, 2020).

For the United States, the legal framework at the federal level is governed by the Occupational Safety and Health Act of 1970 (‘OSH Act’), which contains a "general duty clause", imposing obligations on employers to make PPE available where necessary (CDC, 2020). Under the Act, individual states are permitted and encouraged to adopt their own occupational safety and health plans. For instance, PPE regulation in the state of New Jersey, one of the hardest-hit states towards the beginning of the pandemic, operates under their own PEOSH Personal Protective Equipment Standard which follows the standards set out in the OSH Act (OSHA, 2020).

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Germany also transposed the European Union Directive into a piece of national legislation, known as the "Ordinance on Safety and Health Protection when Using Personal Protective Equipment at Work", which is now the primary legal authority on the selection, provision, and training processes in relation to PPE, although the Safety and Health at Work Act 1996 establishes employers’ statutory duties for those measures (BAuA, 2020).

New Zealand, much like the other three jurisdictions, similarly imposes duties on employers where PPE is to be used to minimise risks to health and safety under its own legislation, namely the Health and Safety at Work (General Risk and Workplace Management) Regulations 2016 (WorkSafe, 2020).

In addition to having similar provisions for the usage and provision of PPE, another common element between all four legal frameworks is the characterisation of PPE as a “last resort” measure.

It is placed at the bottom of the hierarchy, below technical and organisational measures such as engineering controls and creating safe systems of work (BAuA, 2020; CDC, 2020; Cowper, 2020; WorkSafe, 2020). However, according to James Down, a partner at the law firm Hempsons, the “last resort” of PPE often becomes the first line of defense in healthcare settings (Cowper, 2020).

This emphasis on the importance of PPE particularly in the reality of the healthcare context is further articulated by the United States Center for Disease Control and Prevention, where it is published in their Guidance for the Selection and Use of PPE in Healthcare Settings that “while PPE is last in the hierarchy of prevention, it is very important for protecting healthcare workers from disease transmission.” (CDC, 2020). Evidently, the legal frameworks in these four countries illustrate that the provision of sufficient and suitable PPE is not only morally justifiable but a codified legal obligation, and further demonstrates the importance of effective PPE policy.

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Respirator Fit-Testing Information on regulations and protocols regarding face mask fit testing varied across the countries investigated (3M, Dräger, Great Britain: Health and Safety Executive, 2019, Konradin Media Group, 2018, United States. Department of Labour, 2004, §1910.134 Appendix A).

Face mask fit-testing is the process of checking the sufficiency of seal between a respirator facepiece and the wearer’s face, including the make, model and size. The exact definition varies slightly by country, for example the US is less specific regarding including the model of mask, but all are mostly equivalent.

In both New Zealand and the US, fit testing should be performed at least annually, and New Zealand, the US and the UK all require a fit test upon any change in the equipment being used (size, materials, type, model) or in the wearer (piercings, weight loss/gain). The UK only requires fit testing under these changes, and it is not required otherwise. As of 2018, Germany had no centralised requirement for the fit testing of masks, and the decision was made by each individual company, though many had made it mandatory. The decision on how often to repeat the test was based on either a time interval or changes in the mask or person, the same as for other countries.

In terms of strict regulations, in New Zealand, there is no requirement for the fit test administrator to be certified, only to know how to conduct a test, recognise invalid tests, and properly clean and maintain equipment. Further, there is no requirement the administrator is certified in the UK, though accreditation is available, and no clarification is given at all for who can conduct a fit test in the US.

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The fit test cannot be performed if the subject has facial hair of any kind which crosses the boundary of the mask, i.e., it interrupts the seal between the mask and skin. The test performed is then one of a Qualitative Fit Test (QLFT) or Quantitative Fit Test (QNFT). A QLFT (only sufficient for disposable and reusable half masks in the UK), involves a pass/fail score, and the subjective assessment by the wearer of if they can detect the presence of some aerosol test agent as a result of leakage. This is specified as possibly Saccharin, bitrex or isoamyl acetate in the US and New Zealand (though the latter cannot be used for certain respirators, being an organic agent). In Germany, again while guidance differs by organisation and region, bitrex is also commonly used in the QLFT. In the US, the subject cannot eat or drink 15 minutes before the test, and in the UK, cannot eat, drink (except unflavoured water), smoke or chew gum 30 minutes before.

All countries detail a procedure involving a sensitivity test for the aerosol agent, donning the mask and performing a fit check, then 7 simple exercises to perform while wearing the respirator, including normal and deep breathing, rotating the head horizontally and vertically, and both talking and bending over. These exercises are also specified for the QNFT in Germany, the UK and the US (the US guidance is especially thorough, with the QNFT including a grimace as a further step, and detailed regulations on the test agent preparation and delivery). The administrator monitors the subject, and if they deem at any point the subject can detect the test agent during the exercises, the test is deemed a fail. In the UK, it is specified the QLFT should be performed while standing.

The QNFT provides a numerical value for the quality of seal and is compared against a predetermined “fit factor”, depending on the standard of mask, to award a pass or fail. Germany and New Zealand provide little detail on the exact regulations for these tests, except that New Zealand specifics they can be either a generated aerosol test, or an ambient condensation nuclei 130

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counter test (CNC). The US uses these two test types also, and the UK accepts the CNC or a controlled negative pressure test, though this may only be used for half and full face masks (nondisposable).

For New Zealand, a fit factor of at least 100 is required for half-mask respirators and a minimum fit factor of 500 or 1000 for a full facepiece negative-pressure respirator depending on the protection factor required in use. In the UK, a fit factor of 100 is required for all masks except full face masks, which require 2000 (for either test). In the US, again 100 is the pass mark for most masks, but 500 for the full face mask. While in Germany the pass mark varies depending on the provider, 3M offers a QNFT there with fit factor thresholds of 100 for half masks, and 2000 for full masks, similar to the UK.

In the UK, the test must be performed while either walking on a treadmill, using an exercise bike, or performing a stepping exercise, and the subject cannot eat, drink (except water), smoke or chew gum for the preceding hour.

Overall, the US guidelines by the OSHA are exceptionally thorough, however in terms of quantitative standards to meet in the fit testing procedure, the UK typically has higher thresholds to meet than other nations. Ultimately though, from looking at the countries we investigated, there seems to be general consensus on what the gold standard of face mask fit-testing is in practice.

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PPE Provision: United Kingdom An examination of the large-scale questionnaires published by national health organisations and academic researchers found that the availability and stringency levels of PPE in the United Kingdom were inadequate from mid-March to late June. The overall data suggests that while PPE provision for healthcare workers improved each month, the numbers remained concerning.

A national questionnaire published in the Elsevier Public Health Emergency Collection which surveyed NHS healthcare professionals during the first two weeks of April revealed that “twothirds of the respondents were of the view that there was not enough [PPE] available.” (Iqbal and Chaudhuri, 2020). A later survey carried out by the Royal College of Surgeons of England (2020) from April 23 to 28 revealed that almost one-third of the respondents, which were made up of surgeons and trainees across the UK, “did not believe that they had an adequate supply of PPE in their Trust enabling them to do their jobs safely.” The shortages they experienced were not only limited to FFP2 or FFP3 masks and respirators but also included other items of PPE such as fluidrepellent surgical gowns and full-face visors (Royal College of Surgeons of England, 2020).

The lack of PPE continued to be a problem for a significant percentage of healthcare workers during the next four-month period. However, there were some signs of improvement as time went on. For instance, according to the first survey published by the British Medical Association (BMA) on April 6, only 44.64% of the respondents reported that they never felt pressured when working in an AGP area to see a patient without adequate protection (British Medical Association, 2020). In the June 18 report, this percentage had increased significantly to 74.90% (British Medical Association, 2020). Due to the increase in cohort sizes and the changes made to survey questions, a direct comparison of the data collected from these BMA surveys may not be entirely accurate or 132

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conclusive. However, given that the results are reported in the form of numerical percentages, an analysis of the progress from one survey to the next still reveals meaningful insights. For example, a similar trend of improvement can be found in the BMA reports for whether healthcare workers had adequate supplies for FFP3 masks and respirators, though the increase is much smaller. 39.09% of the April 6 cohort reported having adequate supplies, which increased to 43.27% for the June 18 cohort (British Medical Association, 2020). There was also a jump in the percentage of participants who reported feeling fully safely protected from coronavirus infection in their place of work, which was only 2.07% in the April 6 publication, compared to 40.97% from the June 18 cohort (British Medical Association, 2020). This increase may be attributed to the fear and confusion surrounding a novel virus but, nevertheless, there is an evident trend of improvement in the way the healthcare workers surveyed by the BMA perceived the adequacy of protection from April to June.

This optimism is also reflected in the results from a study conducted by various NHS health professionals and researchers, which demonstrated “a positive and significant adaptation of PPE in response to change in [official] guidance” between mid-March and mid-April (Shirodkar et al., 2020). The study claimed that although healthcare professionals were initially expressing “confusion and vulnerability”, most Trusts have adapted quickly and effectively (Shirodkar et al., 2020).

In spite of this progress, PPE supply and stringency remained insufficient. The Royal College of Nursing highlighted this point when comparing their own survey results. The percentage of participants who said “there is not enough eye/face protection for them to use for the duration of the shift” decreased from 30% in April to approximately 20% in May (Royal College of Nursing, 133

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2020). Though an improvement, one in five respondents remained concerned about the supply of crucial PPE items – a proportion that clearly illustrates an inadequate level of PPE provision.

In addition to revealing the shortcomings of PPE provision in the UK, these large-scale questionnaires also reveal the lack of adequate PPE training. The BMA April 6 survey reported that only 40.86% of the respondents received both advice and training. Furthermore, for the participants who received only one of the two, most of them only received advice (33.26%), which emphasises the lack of training (British Medical Association, 2020). The data from the Elsevier Public Health Emergency Collection and Journal of Public Health studies referenced above are consistent with the BMA survey results, demonstrating that approximately 50% and 44% of the respondents, respectively, did not receive adequate training (Iqbal and Chaudhuri, 2020; Norton et al., 2020). There were similar concerns with fit-testing, given that it severely impacts the efficacy of PPE use. According to the Royal College of Surgeons survey, 14.9% of the cohort reported being pressured to “undertake procedures on COVID-19 positive, or suspected COVID-19 positive, patients without an appropriate level of properly fitted PPE.” (Royal College of Surgeons of England, 2020).

Most of the questionnaire samples in this section were reasonably geographically representative, with respondents from across the UK. Furthermore, while their sample sizes varied, they remained relatively large and ranged from 1,200 to 16,000 respondents. The respondents’ occupations fell within the list of occupations with greater than “slightly close” “physical proximity to others” set out in the Methods section of this paper, including nurses, medical practitioners, and ophthalmic opticians.

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PPE Provision: United States The provision of PPE within the US over the course of the COVID-19 pandemic has been insufficient to meet the demands of the healthcare industry. Several federal agencies and healthcare workers’ associations have highlighted the scale of the shortages.

As early as February 2020, the pre-emptive calculated demand for N95 respirators was assessed to be around 300 million units, while federal stockpiles were falling short of this significantly (Congressional Research Service, 2020). The federal government had been able to determine early on in the onset of the pandemic in the US that the reserves and stocks of crucial PPE would not be able to meet demand. As disruptions in the global PPE supply chain as the pandemic began to take hold, they exposed the gaps in the way PPE is sourced in the country, and thereby its susceptibility to acute shortage and dependence on foreign providers. The US imports significant proportions of medical supplies from China, with the Chinese government nationalising the distribution of such supplies, including PPE equipment, in February, in response to the COVID-19 emergency. Due to this, the supply chain that the US stocks relied upon faced hindrances (Congressional Research Service, 2020). These forms of responses were undertaken by several nations struck by the pandemic in order to protect domestic supply.

The Federal Emergency Management Agency (FEMA) undertook strategies to attempt to bolster production as well as distribution in response to the huge strains of demand. In March, distribution of PPE equipment remaining in the Strategic National Stockpile across the US took place (Congressional Research Service, 2020). However, according to logistical documents, an aggregate of 11.7 million N95 respirators were shipped, a very small fraction of projected requirements (Maloney, 2020).

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In order to accelerate PPE delivery to the US, “Project Airbridge” was initiated with the aim of bolstering domestic supply through accelerating the transport of foreign privately manufactured equipment (Congressional Research Service, 2020). The project was halted in June, citing increases in domestic and international production and procurement; however, associations of nurses have continued to report shortages post this bringing the project’s success into question.

According to a survey carried out by the US Conference of Mayors in March to highlight the extent of the urgent need for federal level assistance, mayors and city officials reported 88.2% of (186) mayors and city officials did not have an adequate supply of personal protective equipment (besides face masks) to protect medical personnel and first responders (2020). A survey was conducted on 23rd - 25th March among infection preventionists, professionals like nurses, doctors, epidemiologists etc. who ensure healthcare workers and patients are as protected as possible from the spread of infection (Who are infection preventionists? - APIC, 2021). The results revealed that 48% of respondents reported being almost out of, or out of, respirators while 49% said the same for face-shields and 31% for masks. Further, 28% of respondents highlighted being almost out of, or having no, gowns (Association for Professionals in Infection Control and Epidemiology, 2020).

The survey highlights that PPE provisions were limited from the onset of the pandemic in the country, leaving healthcare workers exposed and in danger.

The second wave of a national survey conducted by the National Nurses United (2020), covering the period from April 15 to May 10, highlights some stark figures reported by nurses across the US. 87% of respondents reported extremely high levels of reuse of PPE equipment, specifically respirators or masks intended for single use only, while 72% reported they had provided care for suspected or confirmed COVID-19 patients with exposed skin or clothing. Over a quarter, 27%, of 136

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nurses additionally reported that they had been exposed to confirmed COVID-19 cases without full or stringent enough PPE and had worked within 14 days of this exposure. 28% of nurses also reported that they were reutilizing at least one single use item, such as respirators, post a decontamination process. This process does not have a well documented basis of proof of effectiveness. The third wave of this survey was carried out in July (National Nurses United, 2020) wherein the percentage of nurses reporting reuse of PPE items stayed at 87%. A further breakdown of this figure reveals that 57% of respondents reported having to reuse N95 respirators. 54% reported that their employers were conducting decontamination procedures on at least one single use item, a steep hike from the previous wave data, pointing to a continued strain on supplies.

In July, the CDC published guidelines for healthcare workers to optimise PPE equipment when facing limited or depleted supply in the form of recommended alternative practices (Centres for Disease Control and Prevention, 2020). The guidelines suggest various interventions in order to extend the life of the equipment pieces such as limited number of donnings for reuse of N95 respirators, specified as a maximum of 5 donnings, in critical situations. These alternative practices are significantly different from the accepted general procedures in times of normal supply and highlight the precarious nature of the situation given that even official guidance points to reuse of PPE equipment and attempts at increasing their longevity as much as possible, if the situation so demands.

Crucial PPE items including gloves, gowns and surgical apparel, have consistently been estimated as being in short supply for the course of the COVID-19 public health emergency, according to the FDA’s published list of items on short supply (U.S. Food and Drug Administration, 2020).

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Some strengths and limitations of the surveys cited are important to highlight. The results of the survey of infection preventionists were based on responses from 1,141 infection preventionists across the US, all of whom were members of the APIC. The sample represented all 50 states and the District of Columbia. However, the survey is limited in its sample size and by specificity of the occupation/s it includes. The respondents of the survey carried out by the US Conference of Mayors comprised mayors and city officials from across the US. The final responses spanned 213 cities from 41 states and Puerto Rico. The cities ranged in population size from 2000 to 3.8 million. This proves geographically representative. However, it is important to note that the respondents were responding to questions regarding general PPE supply for medical personnel as well as first responders. This may create some lack of specificity in responses with regards to the supply for medical workers in particular. Moreover, the respondents were mayors and other city officials and not medical workers directly, raising questions as to the level of insight they might be able to provide. The National Nurses Survey’s waves’ surveyed 23,000 and 21,000 nurses from across the country, proving both geographically representative and robust in size. However, it involves only nurses, not providing insight into the experiences of other healthcare workers.

PPE Provision: Germany At the beginning of the pandemic, Germany had in place several plans to prepare for future pandemics. These included the “Act for Protecting the Public in an Epidemic Situation of National Importance”, which was implemented on 28th March and grants the Ministry of Health to take measures regarding the provision of PPE. Additionally, Germany’s “Pandemic Preparedness Plan”, based on influenza pandemics in 2005 and 2009 and updated for COVID-19, aimed at containing, protecting against, and mitigating the virus (Winkelmann & Reichebner, 2020).

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The German Bundesregierung recognised the importance of protecting HCWs with sufficient PPE from the start of the pandemic (Bundesregierung, 2020) and put in place measures to support this.

The Federal ministry of Health established a Procurement Task force, on 30th March 2020, with the aims of coordinating the procurement of PPE. Additionally, the Ministry of Economic Affairs and Energy introduced a task force aimed at building up national and European value chains for PPE (BMWI, 2020).

Despite these measures, a review of newspaper articles, government announcements and medical guidance has demonstrated that at the beginning of the pandemic Germany suffered from a lack of PPE availability. This was demonstrated by doctors protesting their vulnerability to COVID-19 while they had insufficient PPE (Connolly, 2020), and reports of scam products being bought due to the pressing need doctors faced in requiring PPE (Levine, 2020). Germany attempted to avoid these supply shortages by preventing the export of medical equipment in March (Reuters, 2020).

However, the case of St. Antonius Hospital in Eschweiler in April (Blech et al., 2020) demonstrates that this attempt was unsuccessful. The hospital was forced to ask the public to sew them fabric facemasks so that their staff had some form of protective face covering.

In the event of PPE shortages, Germany published guidelines for HCWs on how to optimise PPE by using it for longer periods of time, safely (RKI, 2020). Additionally, extensive information was made available on how to use and then remove PPE safely, and in which situations PPE should be used (Querbach & Heim, 2020). HCWs were provided with information outlining how and when to use particular PPE, including in patient rooms, moving between rooms and moving to waste disposal. The guidance suggests not wearing PPE outside of these areas, such as break rooms and

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doctor’s rooms (Spinner et al, 2020). Guidance was also provided for how HCWs can safely transfer and interact with corpses that died from COVID-19 (TU Munich, 2020).

PPE Provision: New Zealand New Zealand’s PPE supply is managed by its Ministry of Health (2021). PPE is included within the national reserve supply which covers the H5N1 pre-pandemic influenza vaccine, antiviral medication, respiratory PPE masks, syringes, sharps bins, body bags, antibiotics, district health board (DHB) stored PPE, and disposable linen (Ministry of Health, 2020).

Pre-pandemic, the national reserve was co-managed by the Ministry and DHBs. As such, some supplies were stored exclusively by DHBs and some by the Ministry. Both DHBs and the Ministry store P2 respirators and general purpose masks as well as Tamiflu. PPE (aprons, gloves, eye protection), clinical equipment (syringes, giving sets, IV fluids, etc), and pandemic antibiotics were stored by DHBs exclusively. Vaccination supplies and body bags were held by the Ministry (Ministry of Health, 2013). No exact records were held showing available PPE supplies before the pandemic. The Controller and Auditor-General (2020) has assessed the management of PPE in response to the COVID-19 pandemic and is the most comprehensive source to date assessing the PPE supply in New Zealand.

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PPE item

On hand

Ordered

N95 mask

9,926,543

11,732,800

Procedure mask

20,524,102

107,802,044

Isolation gowns

516,287

3,817,900

Disposable apron

1,293,414

2,803,000

Glasses/goggles

190,958

1,015,201

Face shield

753,851

8,400

Nitrile gloves

25,649,454

123,000,000

Figure 8 – PPE on hand and on order - 29 April 2020 Estimate

Figure 8, adapted from results collected in the Auditor’s report (p. 33), shows an estimate of the available PPE supply as of the 29th of April 2020. The available on hand supply shows the total amount between DHBs and the national reserve. In terms of funding, the Cabinet had agreed to a $500 million contingency to cover the costs of the public health response, $200 million of which would be allocated to PPE (p. 47).

The overarching principle for provision is that PPE is supplied to those who require it but there are levels of priority based on how essential a service is considered. As such, all critical essential services, tertiary and secondary services - those for whom PPE is a legislative or mandatory requirement to conduct their work - receive priority in receiving PPE at all times. Following this category are essential community health services that are publicly funded and receive a full supply of PPE at no charge depending on Alert levels. PPE is also provided in the case of outbreaks in a facility. Core essential health services that are publicly funded also benefit from a full supply at Alert level 2 - 4 when the request is supported by robust evidence of demand. At any other Alert Level, provisions have to come from commercial suppliers. In all other circumstances, PPE will 141

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not be supplied from the central supply unless it concerns an essential service (includes categories like hospital porters or cleaners)(Ministry of Health, 2021).

The national reserve of PPE in New Zealand was established as a result of the bird flu pandemic by the Ministry of Health and DHBs. The main problems with PPE provisions in New Zealand were caused by the decentralised system (lack of coordination between the Ministry and DHBs), increasing global demand, stock counting inconsistencies, and inaccurate estimates of stock and demand. This made it harder to provide PPE in adequate quantities to meet the demand caused by the pandemic (Controller and Auditor General, 2020).

Several intervention plans were in place before the onset of the pandemic including the National Health Emergency Plan, the New Zealand Influenza Pandemic Plan, the National Health Emergency Plan: Infectious Diseases (the Infectious Diseases Plan), the Operational Policy Framework and health emergency plans developed by DHBs (p. 12). These plans require health boards to manage their supplies of PPE and have stockpiles readily available.

According to the report, the problem of adequate supply emerged because DHBs had a high level of autonomy in emergency planning and the Ministry did not have a formalized process for assessing individual boards’ plans. This led to confusion over the amount of available PPE held by DHBs at the onset of the pandemic (p. 26). This was further exacerbated by the fact that as of 2016 DHBs were no longer required to report stock levels, expired, and expiring stock (p. 29) resulting in the Ministry not having a clear picture of the national reserve held by the DHBs. PPE Asia Pacific (2020) reports that in June, DHBs received masks that posed potential concerns. Their circulation was put on hold while quality assurance was conducted. In another instance, two DHBs 142

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reported faulty N95 masks resulting in 360,000 being recalled and five thousand being found unfit for use (p. 30).

A further issue highlighted was the fact that emergency planning focused on PPE provision exclusively for hospitals (p. 22, 24), omitting the expectation that in the case of a pandemic, other providers would also expect the Ministry to provide them with PPE (such as essential community health services, core essential health services, other non-essential health services, or essential services that were not clinical).

Outdated plans may have also impacted PPE provision. The COVID-19 response was heavily based on an influenza scenario. This meant the PPE supply was prepared to deal with the transmissibility of influenza, not that of COVID-19. The stock of PPE was also based on population characteristics from 2005 but the population has increased by 19% since then (p. 25).

Additionally, during the beginning of the pandemic there were staff members voicing concerns about PPE access and prioritization. While there had to be distribution of PPE in order to make sure the national reserve supply would last, there were those concerned over PPE not being available when staff felt at risk. Kerri Nuki, of the Nurses Organisation kaiwhakahaere has said that PPE was being rationed rather than being “freely accessible to members should they request it and should it be needed” (Radio New Zealand, 2020).

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PPE Provision Strengths and Limitations First, some of the strengths when it comes to the information available about New Zealand: the management of PPE in New Zealand has been well documented and addressed in the Audit Report commissioned by New Zealand’s Ministry of Health. The report addresses very important concerns when it comes to PPE provision and consults a variety of health providers and health boards. The availability of this data has made the task of researching PPE provisions in New Zealand significantly easier.

There are of course limitations - first one being the over reliance on one single source of information for the assessment of PPE provision in New Zealand. The Report may have missed information and only addresses the PPE stockpile available up until the 29th of April. Limited information is available after this cut off period on exact amounts of PPE available in the national stockpile and district health boards. Other unofficial sources have called into question the stringency of PPE (PPE Asia Pacific, 2020). However, they do not report on these concerns with the same rigour of an official report.

Other Factors Impacting Healthcare Worker Infection and Mortality during COVID-19 Finally, though the primary focus of this research is the impact of PPE policies on the safety of healthcare workers during the COVID-19 pandemic, other hospital-wide and nationwide policies can also affect infection and mortality in this population.

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Testing Widely scaled testing of healthcare staff has been suggested to counter absenteeism during the pandemic (this may enable those self-isolating unnecessarily to return to work) and keep workers safe. However, there is substantial variation in global testing policies for both frontline staff and the general public (Black et al., 2020).

The UK’s National Health Service began sending twice-weekly rapid home testing kits to all staff from November 2020, citing this as an important method of surveillance to ensure that staff do not transmit the virus. Though initial doubts of its efficacy were raised, the programme continues to this day (Rimmer 2020; NHS England and NHS Improvement 2020). In the United States, the CDC has recommended for health and social care workers to be given priority in testing in general, as well as offering tests to those exposed to the virus in community settings and symptomatic personnel (2020). Germany’s regular testing system for the entire population and healthcare workers is considered one of the most successful in Europe (Reintjes, 2020, Scherer et al., 2020).

New Zealand has taken a risk-based approach where healthcare workers are considered vulnerable to contracting COVID-19 and are therefore the target of more focused testing efforts (Ministry of Health, 2020).

Other Infection Prevention Considerations Literature from both previous coronavirus outbreaks and COVID-19 has revealed diverse approaches to infection control in healthcare facilities when combined with the use of PPE. The creation of different “zones” for infected, suspected, and non-infected patients during the 2003 SARS outbreak in East Asia significantly lessened HCW infection by allowing staff to avoid highrisk areas without adequate protection and has also been adapted for COVID-19 (Schwartz et al., 145

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2020). Regular environmental disinfection, especially of frequently touched surfaces and mobile devices, is necessary to reduce disease risk (Tan et al., 2020). Furthermore, hand sanitising, standard infection control coughing and sneezing procedures, and social distancing where possible are important for HCWs as they are for the general public (Ferioli et al., 2020).

Occupational Mental Health Lastly, it is paramount to consider the mitigation of adverse psychological effects on healthcare workers during the pandemic so that morale and resilience are maintained. Signposting staff to mental health services, providing training in self-care, management of difficult emotions, and reducing social stigma can support staff wellbeing (Blake et al., 2020). These measures, as well as interventions to reduce workload, enforce break times, and educate HCWs about COVID-19 and the pathogen that causes it, can also improve adherence to infection control guidelines (Gan et al., 2020).

Strengths and Limitations This research has, for the first time, taken a direct quantitative approach to comparing PPE guidelines during the COVID-19 pandemic across countries and linked this to healthcare worker deaths. Its strengths lie in its detailed examinations of AGP classification, eye and face protection, and fit-testing availability in the United Kingdom, United States, Germany, and New Zealand, four nations with heterogeneous responses to the outbreak, as well as in its standardisation of HCW deaths within a defined study period of first COVID-19 case to July 1st. These analyses, though unadjusted for adjacent infection-control-related measures, allow readers to detect a possible

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relationship between the stringency of protective equipment guidelines and occupation-specific mortality.

Though care was taken to strengthen data quality and completeness in this analysis, some limitations remain. These are primarily characterised by possible inaccuracies in HCW deaths figures, difficulties in interpreting across-country PPE guidelines, and opportunities to expand upon the limited scope of this paper.

We classified professions that were most at risk as ‘patient-facing’ roles. This categorization poses some limitations. As there is no universally agreed upon definition of what ‘patient-facing’ constitutes, the roles we classed under this category were those with an above average physical proximity to others. This poses the risk of having omitted healthcare workers that do not work at the same level of physical proximity with patients from our standardization. Furthermore, our categorization was based on responses to the ONS Annual Population Survey (2020) which is a survey conducted with UK respondents. Had the same survey been conducted with the workforce of a different country, our classification of ‘patient-facing’ roles may have been different.

Then there is the matter of incompleteness of total staff numbers. The totals were gathered from census data and population surveys in the countries within the scope of our research. The datasets we consulted are themselves estimates of the composition of the healthcare workforce and may suffer from inaccuracies which would have been translated into our study.

Furthermore, there may have been differences across the countries when it comes to the roles they collect data for. For instance, the category ‘dental nurses’ was only included in the United Kingdom workforce survey. The United States, Germany, and New Zealand did not provide employee totals 147

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for this category in the datasets consulted. The standardization of healthcare worker deaths will also have been affected by this. In addition, the reporting of healthcare worker deaths may have been delayed (a lag in data is inevitable, so the actual number of deaths during the study period may have been underestimated) or misclassified.

Several limitations arose when gathering information on PPE guidelines across the 4 countries.

Firstly, we have not acknowledged the possible changes in PPE policy during the study period; it perhaps would have been more thorough to have looked at changes in guidelines during the period and documented those which were in effect for the longest time. However, even if this was included, it is not certain all healthcare professionals would be aware of changes as soon as they were published. Furthermore, it is quite likely some information on German guidelines, particularly on AGPs and fit testing, was missed due to the language barrier. The difficulty in both searching and navigating German government websites this imposed may have resulted in the most reliable sources being neglected.

Regarding which medical procedures were classified as AGPs, most of the sources found only listed examples of AGPs - only the UK gave a comprehensive list, which means it is difficult to make concrete deductions as to whether the guidance had an effect on when healthcare workers wore PPE. Use of PPE during certain procedures is also difficult to assess, by nature of the fact AGP classification in each country is only a guideline. One of the most notable limitations is the fact that the source for AGPs in New Zealand is from outside the study period, 7th July 2020.

Finally, for face mask fit testing specifically, adherence is again an issue due to regulations only being guidance on how to conduct tests, not strict rules, so there is leeway in both the ability and 148

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diligence of the administrator, in addition to the fact face mask effectiveness can be severely reduced by improper fit caused by the wearer regardless of mask fit testing.

Scope of the Research There are some limitations that need to be acknowledged with regards to the scope of this research.

This study has been limited to four high-income Western countries. The impact of the pandemic on PPE provision and healthcare worker deaths in other regions of the world which differ substantially with regards to demographic make-up, income and other factors. has not been considered. Thus, the results of the analysis may not be directly generalisable to countries with different characteristics. Also, healthcare worker mortality and PPE provision information was not stratified by profession due to data limitations, reducing the applicability of this analysis to all types of HCWs. Additionally, the definitional precision adopted when specifying the workers this analysis has adopted leaves out certain groups of workers who may also be at risk. Social care workers who have faced similar issues with PPE supply and work on the frontline have not been considered. Furthermore, the study period has been defined from March to July 2020. However, important developments and changes in the spread and impact of the pandemic have occurred beyond this period, the inclusion of which might yield different results.

Finally, due to the observational nature of this analysis and possible omitted variable bias, we cannot infer certain causation for the investigated association.

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Conclusion This paper has examined the relationship between PPE guidelines and healthcare worker mortality in four Western high-income countries (the United Kingdom, United States, Germany, and New Zealand) during the COVID-19 pandemic, deriving a quasi-quantitative coding method to numerically compare healthcare authority specifications. In our study period of first case to July 1st, we have found an unclear relationship between the stringency of protection recommended by governing bodies and personnel deaths, with this inverse association appearing the strongest for the United Kingdom and Germany. In the United States and New Zealand, where the relationship between studied variables was inconclusive, other pandemic-related factors such as PPE provision and country-wide management of the outbreak must be taken into consideration in combination with the influence of PPE guidelines on healthcare worker mortality.

Nevertheless, following our review of the current literature, we assert that governments should prioritise the safety of their most essential workforce by following and disseminating the most rigorous scientific evidence on appropriate PPE. Moreover, they must generate the political will to procure sufficient and high-quality equipment, ensure transparency of reporting when shortages are prevalent, and continuously monitor PPE availability. Finally, we call for greater completeness of reporting of healthcare worker deaths related to COVID-19, including investigations of the circumstances of death and whether the source of infection was community or occupation-related.

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Recommendations The research conducted on HCW experiences demonstrates key areas that would improve HCWs’ experiences during the pandemic, beyond a sufficient PPE supply. For example, the research demonstrated having consistent PPE guidelines (Vindrolo-Padros, et al., 2020) and access to more knowledge (Billings, et al., 2020) was important to HCWs. When this information was frequently and well-communicated (Hoernke, et al., 2020; Wu, et al., 2020), using clear, consistent and compassionate speech (Billings, et al., 2020), HCWs reported feeling less stressed and safer in their work environment. In addition to receiving information on PPE guidance, it is recommended that receiving practical training in PPE use is crucial (Savoia, et al., 2020). A lack of breaks was also reported as being a key factor in the negative experiences of HCWs during the pandemic: a lack of PPE meant that workers were reluctant to remove and ‘waste’ PPE by taking breaks. VindroloPadros et al. (2020) recommended that breaks be taken every two hours to ensure that HCWs do not suffer unnecessary, additional mental stress.

In the long-term HCWs have reported that they would like system level changes to occur, that include safe hospital policies and resource provision considerations (Wu, et al., 2020). These changes, in addition to increased disaster preparation (Almaghrabi, et al., 2020), would play a vital role in effectively reducing the stress experienced by HCWs at work.

Improving health policy to tackle these key areas has the potential to drastically improve the experiences of HCWs: improving the physical safety of HCWs has the additional effect of reducing burdens to their mental health.

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Further Research Research into sustainable PPE options is necessary not only for the positive environmental impact in reducing waste disposal but also to prevent future PPE shortages.

Single-use PPE becomes a big problem during disposal. During the pandemic more PPE is used, and hospitals are producing more waste than normal. Safely disposing of contaminated PPE is difficult and most of it ends up in landfill sites (Cobb, 2020). Reusable PPE has the potential to be an environmentally beneficial solution. Our research regarding inadequate PPE supplies also highlighted that many policies also make recommendations for reusing PPE supplies. Rather than reusing single-use PPE and endangering HCWs, we suggest that more research is needed into examining options for multi-use PPE. PPE that is designed to be reused after being safely sterilised is the better option to keep HCWs safe. Furthermore, reusable PPE is incredibly important when facing scarcity of resources as these items are more likely to always be available and therefore act as a safeguard against PPE shortages during future pandemics (Cobb, 2020).

Furthermore, some large-scale questionnaires, including one conducted by the Royal College of Nursing (2020) in the United Kingdom, have revealed that ethnic minority healthcare workers are being disproportionately impacted by inadequate PPE provision. For instance, the Royal College of Nursing (2020) survey reported that approximately 40% of BAME respondents said they had “enough fluid-repellent surgical face masks for the duration of their shift,” which is much lower than the percentage of their white British counterparts who made the same claim (59%). Therefore, it is clear that deeper and more targeted research must be conducted to look into PPE access for ethnic minority healthcare workers. §§

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U.S. Bureau of Labor Statistics (2019) May 2019 Occupational Profiles [online]. Available from: https://www.bls.gov/oes/current/oes_stru.htm#29-0000ist of SOC Occupations (bls.gov) (Accessed 8 February 2021).

UK Government (2021) Shops and branches - Working safely during coronavirus (COVID-19) - Guidance [online].

Available from: https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19/shops-and-branches (Accessed 8 February 2021).

United States Conference of Mayors (2020) Shortages of COVID-19 Emergency Equipment in U.S. Cities [online].

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United States Department of Labor (2004) Occupational Safety and Health Standards (§1910.134 Appendix A) [online]. Available from: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134AppA (Accessed 8 February 2021).

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Vindrola-Padros, C. et al. (2020) Perceptions and experiences of healthcare workers during the COVID-19 pandemic in the UK. BMJ Open. [Online] 10 (11), e040503. [online]. Available from: http://bmjopen.bmj.com/ (Accessed 8 February 2021).

Wang, X. et al. (2020) Association between 2019-nCoV transmission and N95 respirator use. medRxiv p.2020.02.18.20021881. [online]. Available from: https://doi.org/10.1101/2020.02.18.20021881 (Accessed 7 February 2021).

Winkelmann, J. & Shuftan, N. (2020) Policy Responses for Germany [online]. Available from: https://www.covid19healthsystem.org/countries/germany/livinghit.aspx?Section=3.1 Planning services&Type=Section (Accessed 8 February 2021).

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WorkSafe (2020) Information for workers [online]. Available from: https://www.worksafe.govt.nz/managing-healthand-safety/novel-coronavirus-covid/covid-19-information-for-workers/ (Accessed 8 February 2021).

World Health Organisation (2020) Rational use of personal protective equipment for coronavirus disease (COVID19) and considerations during severe shortages: interim guidance. [online]. Available from: https://apps.who.int/iris/handle/10665/331695 (Accessed 8 February 2021).

World Health Organization (2021) Timeline of WHO’s response to COVID-19 [online]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline (Accessed 8 February 2021).

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Wu, P. E. et al. (2020) Mitigating the psychological effects of COVID-19 on health care workers. CMAJ 192 (17) p.E459–E460. [online]. Available from: www.cbc.ca/news/ (Accessed 8 February 2021).

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Appendix Appendix A: Table of AGP Classification by Country Across the four countries we investigated, availability of information on AGP classification differed widely. By far the most comprehensive guidance for which procedures were AGPs was by Public Health England for the UK, which listed all the AGPs they thought were “associated with an increased risk of respiratory transmission.” Next was New Zealand’s, which gave a more extensive definition, but only a large list of example AGPs. The German Society for Hospital Hygiene also gave an example list, however, the breadth of information given was much smaller. The USA’s Centers for Disease Control and Prevention, on the other hand, stated that due to “limitations in available data” a comprehensive AGPs list was not possible, so instead gave a list of commonly agreed upon AGPs. Below is a table which compiles the medical procedures which do or do not classify as AGPs in the respective countries.

Medical Procedures

UK

Germany

US

Intubation and Extubation Procedures

Tracheal

Tracheal intubation alone

Endotracheal

New Zealand

Key

Respiratory Tract Suctioning During Upper ENT Airway Procedures

Green = Classified as AGP

Open Suction of the Respiratory Tract

Including upper respiratory tract

Bronchoscopy

Red = Not classified as AGP Orange = Classified as AGP under specified conditions.

Upper Gastro-Intestinal Endoscopy Involving Open Suction of the Upper Respiratory Tract Tracheotomy or Tracheostomy Procedures

WHO

Insertion or removal

Insertion or removal

Blue = Uncertain as to whether AGP White = Not mentioned

Non-Invasive Ventilation (NIV) Bi-level Positive Airway Pressure Ventilation (BiPAP) Continuous Positive Airway Pressure Ventilation (CPAP)

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High Frequency Oscillatory Ventilation (HFOV) Before intubation or bronchoscopy

Manual Ventilation High Flow Nasal Oxygen (HFNO) Sputum Induction

Using nebulised saline

Cardiopulmonary Resuscitation

Surgery/Post-mortem Procedures with HighSpeed Devices

High-speed cutting, if tract/ paranasal sinuses involved

Dental Procedures (Using High Speed Devices)

e.g. Ultrasonic When they bear scalers or high the risk of airborne speed drills transmissions.

e.g. Rotary handpieces, triplex syringes or ultrasonic scalers

Nebulised or Aerosol Therapy Administration of Humidified Oxygen Chest compressions

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Appendix B: Table of Eye Protection by Country COVID-19 Status Scenarios

UK

US Germany

New Zealand

Care in community based healthcare settings, including a person's place of residence.

Care in hospital (including emergency departments and wards).

Aerosol generating procedures

Visors are worn.

In operating theatre, only those within 2m.

Surgical Procedures, e.g. in vascular surgery, orthopaedics (cutting work on bones) Endoscopic Investigative Procedures

Caring for or contact with suspected or confirmed COVID-19 patient.

Punctures of Arteries

If splashing or spraying of potentially infectious materials or liquids is expected during an activity and technical measures do not provide adequate protection.

Intubation, Extubation, Care and Changing of Tracheal Cannulas Cleaning of Contaminated Instruments by Hand or With Ultrasound Activities in Pathology e.g. during work using hand-operated equipment or during Compression of the Chest of a Deceased Person Due to Lifting and Relocation.

Caring for or contact with any patient.

Key

If blood and/or body fluid contamination to the eyes or face is anticipated or likely.

When cleaning and disinfecting instruments or equipment manually.

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Instability and Violence in the Levant: Foreign Involvement and its Impact on Inter-Religious and Intra-Religious Conflict

By Deema Alsaied*, Gianluca Beninati, Maria Iosif, Arina Naaz Khan, Taeu Kim and SolEnrique Perez

*

Research Team Leader 166

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Table of Contents Introduction ............................................................................................................................................................... 168 Historical Context ...................................................................................................................................................... 169 The Ottoman Era ................................................................................................................................................ 169 The British and French Mandates ...................................................................................................................... 170 Post- World-War II ............................................................................................................................................ 171 Literature Review ...................................................................................................................................................... 172 The Ottoman Era ................................................................................................................................................ 172 The British and French Mandates ...................................................................................................................... 172 Post- World-War II ............................................................................................................................................ 178 Theoretical Framework ............................................................................................................................................ 180 Results ......................................................................................................................................................................... 181 The Ottoman Era ................................................................................................................................................ 181 The British and French Mandates ...................................................................................................................... 182 Post- World-War II ............................................................................................................................................ 183 Analysis ....................................................................................................................................................................... 183 The Ottoman Era ................................................................................................................................................ 183 The British and French Mandates ...................................................................................................................... 189 Post- World-War II ............................................................................................................................................ 196 Methodology ............................................................................................................................................................... 209 The Ottoman Era ................................................................................................................................................ 209 The British and French Mandates ...................................................................................................................... 210 Post- World-War II ............................................................................................................................................ 210 Limitations in Methodology............................................................................................................................... 211 Recommendations and Limitations ......................................................................................................................... 212 Conclusion .................................................................................................................................................................. 215 Bibliography ............................................................................................................................................................... 216

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Abstract: The Levant is a region in Southwest Asia which encompasses modern-day states of Syria, Lebanon, Jordan, Israel, and Palestine. Throughout history, the Levant has undergone various rates of violence and instability. However, the violence has been especially prevalent throughout modern history, with much of it being inter-religious and intra-religious conflict. Observing the conflicts in the Levant, it is evident that foreign powers and influence are much likely to be heavily attributed to the instability in the region. In this paper, we look at the extent foreign interference in the Levant has caused the regional violence, as well as how the interference may or may have not increased the instability.

Introduction The Levant has endured and continues to endure inter-religious and intra-religious conflict, which has resulted in devastating impacts on the local population. Syria has undergone a civil war during the last eleven years that has created in the largest refugee crises in the world 1Lebanon experienced a fifteen-year long civil war that resulted in further divisions, and Israel-Palestine experienced continuous violence and diplomatic conflicts between each other. While observing these neighbouring nations, we took notice of a common characteristic in their conflicts - heavy foreign interference. Since the Ottoman Era, the Levant has been under direct or indirect control of foreign actors - whether it be governments or anti-government militant groups. We argue that the Ottoman Empire, the British and French Mandates, and the wide variety of interference postWorld War II has resulted in increased instability in the region. This is due to different religious (sometimes ethnic groups that are also part of a religious minority) groups being either strengthened or weakened by the foreign actors. In our approach, we examined primary and secondary sources (e.g. government agreements) regarding governance and involvement of inter and intra-religious relations within the Levantine population. We also analysed studies with quantitative data regarding views of governance/authority in the region in order to interpret how the desires of the Levantine population are met in their governments. The purpose of heavily analysing archival sources is to understand how historical and contemporary institutions were 168

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impacted by foreign influence and how that has resulted in inter and intra-religious conflicts. In this paper, we separated our research into three divisions - the late Ottoman Era, the British and French Mandates and post-World War II era. The intention of this division was to carefully analyse the political situation and institutions throughout modern history, which then allowed us to come to a sufficient recommendation to policy makers and conclusion to our findings. The rest of this paper will follow a format which will first discuss the Ottoman Era, then the British and French Mandates, then the post-WWII era.

Historical context The Ottoman Era The Ottoman Empire stood for more than 600 years as one of the most powerful dynastic politics in modern history, controlling a large breadth of territory and incorporating several distinct enthoreligious communities as it expanded. Considered the last well-recognised Islamic Caliphate, the Ottomans were responsible not only for assisting the spread of Islam but for instantiating complex systems of administration of Islamic law and recognition of alternative law for the significant numbers of non-Muslims that resided within their territory. As such, the Ottoman Empire has tremendous significance for any understanding of current ethno-religious relations within any of its former territories - the Levant being one of these.

Sultan Selim I first occupied Syria in 1516 (Mui and gradual expansion saw the entirety of what we now call the “Levant” under Ottoman control not long after. By the Young Turk revolution of 1908, it had enjoyed full consolidation under the Empire and several degrees of local recognition both legally and culturally. For centuries, the millet system, a legal recognition of the rights of 169

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ethno-religious minorities to judge their own cases in exchange for payment of a religious tax to the Empire, maintained steady relations between the state and its various minority groups. We argue that it was the failure of imperial authorities to develop a multi-ethnic state in the wake of the string of nationalist uprisings that emerged in the nineteenth century that ultimately broke the peace within this region and established a legacy of violence and subjugation that has mired Levantine religious relations ever since. When observing the Ottoman Era in particular, we will show this through a thorough analysis of the major historical ethno-religious groups of the Levant: “Greek” Christians, Assyrian and Armenian Christians, Jews, Palestinians, and Arabs.

The British and French Mandates After the fall of the Ottoman Empire, the inhabitants of the Levant fell under the authority of another foreign power - Great Britain and France. The British and French Mandates controlled modern-day Syria, Lebanon, Israel-Palestine, and Jordan from post-WWI to the end of WWII. The formal, public intention for the British and French Mandates was to set up governmental institutions that would eventually have Levantines be autonomous after centuries of control under the Ottoman Turks. However, by observing legal documents and survey data from the years 1916-1923, the King-Crane study, it is evident that both the British and French directly ruling a part of the Middle East established further political dominance on the international stage3. Thus, it was in the self-interests of the two countries to obtain more foreign land, hence the Mandates being created.

As it is widely acknowledged in the literature, the Great Britain Mandate in charge between 1921 and 1948 had failed to set the conditions for a remarkable improvement in the life quality of the people inhabiting Palestine4. Rather, the inability in effectively meeting the demands of both the 170

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Hebrew and the Arab communities (other than those of minorities such as the Christian religious community) had contributed to set the stage of a conflict that has extended to the 21st century, and that it is still tearing apart what is today a geographical area divided between an extending Israel and a shrinking Palestine. Along with the case of Syria and Lebanon, being former French Mandatory holdings, we argue that the intra and inter-religious conflict and instability in the contemporary states partially result from the ‘divide and conquer’ tactic.

Post- World War II The end of the British and French Mandates brought the official sovereignty status for Syria, Lebanon, Israel, and Jordan. However, Palestinians have not possessed an official, independent state since the end of the British Mandate. Despite the Levant now being mostly-autonomous, external intervention in the region is still present, along with past external intervention that still presents an impact on the region. Israel is an example of past external intervention - Britain's creation of the Israeli state - that continued to contribute to inter-religious conflict in the region.

We argue that both inter- and intra-religious conflict within the region has been increased by foreign interventions since the Cold War period.

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Literature Review The Ottoman Era The literature from the Ottoman era concerning the issues of inter-religious tensions and conflict is notoriously controversial, with major political implications for modern Turkish history. Turkey, along with several other countries, refuses to acknowledge the genocides committed during this period as such, and as a result, much of the literature from Turkish analysis is focused on refutation and reframing of the events at hand. A similar reality applies to the literature concerning the Arab Revolt and its context. Whilst western historians have begun the process of reanalysing the history of this period and recognising in particular British imperial interest in the manifestation of this revolt, many western and Arab scholars are given to emphasise the persecution faced by Arabs under the Ottoman regime and glorify the revolt as a movement of national liberation, a narrative that does not live up to the facts. As a consequence, the research on this era has focused primarily on the most recent historical overviews and dissertations.

The British and French Mandates When analysing literature from the era of the British and French Mandates, we looked at primary sources from the French and British governments, along with a study conducted shortly before the Mandates began. We read an agreement that is known as the Sykes-Picot Agreement, which was finalised on May 16th, 1916 (Sykes-Picot Agreement, 1916, p.1). The Sykes-Picot Agreement was a plan for the two colonial powers to obtain more land if the Allies won the war, giving them an advantage over an Ottoman Empire that would be very likely to fall. In the agreement, France expressed its desire over Lebanon and parts of Southeast Turkey (which it eventually did not obtain most of the Turkish territory it hoped for), and a separate Arab state in modern-day Syria (ibid., 172

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p.2). The UK expressed its interest in Haifa and Acre as port cities, along with Palestine and Transjordan (ibid., p.2). The agreement declared that the UK and France would have the right to establish institutions in the mandates that they believe would be beneficial for authoritative purposes. Regarding how the Mandatories will be represented on the international level, the agreement states how France and UK will be representing the local population in treaties, along with holding control of the importation of arms (ibid., p. 3). France obtaining control of Syria and Lebanon, and Great Britain possessing authority of Israel-Palestine and Jordan was not a spontaneous decision after being victorious after World War I, but rather was secretly planned with the British, and with the approval of Russia, in 1916.

In 1919, the American King-Crane commission produced an exhaustive report containing exclusive demographic data together with an assessment of the public opinion of the multiple religious and ethnic groups living in Palestine. King and Crane recall Art. 22 of the Covenant of the League of Nations defining Palestine as a country unable to autonomously implement a process of modernisation and, as such, "entrusted to advanced nations who by reason of their resources, their experience or their geographical position can best undertake this responsibility" (Covenant of the League of Nations, Art. 22). The commission reported a unanimous rejection of the Arab community toward the foreign power and the mistrust in regard to what promised in Art. 22 of the Covenant and in the 1915 MacMahon-Hussein correspondence. However, the Jewish community, a population size significantly smaller than the Arab community, proclaimed their support toward Jewish immigration and Balfour's ideal of the “Jewish National Home”. Two years after the KingCrane commission report, due to the riots which took place in Jerusalem during the Nebi Musa festival, the British Government established the Palin commission to investigate the reasons behind the Jewish acts of violences that resulted in hundreds of injured individuals (McKay, 2020).

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The report described the Arabs as very tolerant of the Jewish community until 1915, when the conclusion of the first great conflict generated a massive flux of Jewish immigration into Palestine.

The public opinion assessment of the commission reported the fear of the Arabs of being excluded from the process of economic development, the role of the Jew in quality of economic competitors in the agricultural sector (main economic engine of the country), the condemnation of anarchic ideals allegedly spread by East European Jewish and the disappointment for the unfulfilled promise of the British Government. The report also presented significantly high disapproval rates of a French Mandatory being established in the Levant, with only favourable rates being presented amongst the Lebanese Christian community (King-Crane, 1919, p. 9).

At the time of the Palin commission, tensions between the two communities were quite high 90% of the Muslim population rejected the British administration (McKay, 2020). The PanArabism ideology spread across the Arab world and called for a unified Levant under Muslim rule, whereas the Nationalistic supporters of the Jewish community organised themselves into the Haganah, a defence organisation informally established in 1920. The Haganah was formalised in 1948 as the official army of Israel. The 1930 report published by the HopeSimpson commission of inquiry reconfirmed what happened ten years prior, but from a different perspective: at this time, the Jewish had dispossessed the Arabs of almost all the arable land available, the implementation of labour policy limits the employment of Palestinian Arab citizens causing rampant unemployment. Hope and Simpson consequently recommend new policies that could rebalance the land tenure between the two biggest communities living in the country. The problem of the never-ending immigration is again called into attention by outlining policy proposals that could retain the immigration rate while reframing policies on labour rights and land possession. Despite the deflationary trend caused by an excess in 174

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available capital, the Arab low-income section of the population is unable to access basic goods and services. For such reasons, Hope and Simpson recommended the adoption of state subsidies. Amidst these serious concerns, the Arab population once again expressed their sympathy toward the other Muslim territories, calling for a unified country under a Pan-Arabic ideology. Seven years later, following the six-months long Arab strike, the Peel commission, publicly discussed the Arab turmoil as a consequence of the infeasibility of the British Mandate System in the area. The commission reported, among others, the Arab alarmism and mistrust toward the Jewish community, demands of independence and closer political collaboration with Syria and the Emirates of Transjordan. Also, it outlined how the British Administration had never directly taken responsibility of the clashes between Arabs and Jewish not only on an unbalanced policy level, but also on an institutional level where representative institutions from either sides, namely the Jewish Agency and the Supreme Muslim Council and the Higher Arab Committee, had never reconciled their vision for mutual collaboration but rather expressed the views of the sections of the population they were called to represent which had done nothing more than incrementing opposition toward each other. In 1937, Palin stated that no common ground exists between Arab and Jewish and that a partition of the country was considered as a solution for a peaceful transition (ibid.).

The Official Documents for the Mandate of Syria and Lebanon, drafted by the French government, was submitted by France to the League of Nations for the Mandate to be approved.

In this document, how Syria and Lebanon were intended to be governed was written, including providing a system that allows the two states to eventually become autonomous (The French Mandate of Syria and Lebanon. 1923, pp. 177-182). The document also covered the system of governance that will be established in the Mandate, with Arabic and French being set as the 175

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official languages of the Mandatories (ibid.). France also committed to writing an annual report to the Council of the League of Nations to provide the progress of the Mandatories (ibid.). The document states that if provisions are to be made to the document, the Council would need to approve (ibid.). Regarding places of worship, France affirms that it will not interfere with religious management, and that the authority lies with religious leaders in the community (ibid.). Treaties that were present before France’s control are to remain present, and that once the Mandatory is in effect, France will be in charge of all foreign relations (just as expressed in the Sykes-Picot Agreement) (ibid.). A judicial system was also given by the French, and it was a system for locals and foreigners to be guaranteed their basic rights, regardless of their religious backgrounds (ibid.).

In ‘Syria and Lebanon: The States of the Levant under French Mandate’, authors M.B and H.G.L discuss the history of the relations between Syria/Lebanon with France, along with providing France’s perspective on the Mandate. The ties between France and the Levant go back to the era of the Crusaders during the Mediaeval Ages, as France led its fellow European neighbours during the Crusades to the Levant. Lebanese Christians in particular have a favourable connection with the French since the Crusades, with the French feeling a moral obligation to protect the Lebanese Christian community (M.B. and H.G.L, 1940, p. 843). The purpose of the French obtaining control of the region was not to strengthen France’s economy, nor was it to utilise excess natural resources in the region, but rather to maintain its position as a global power, imposing influence within the Middle East, and take advantage of the ports and roads connecting the Middle East to Europe and Asia (ibid.).

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Once the French returned to the region in the early 20th century, it was found that various ethnic and religious groups were segregated within Levantine society, thus presenting fragility within the region (ibid., pp. 843-846). The French observed that the minority communities, which included Kurds, Armenians, and Assyrians, were typically contributing communities within Levantine society. Thus, the French claimed that protecting those groups was a necessity (ibid.).

As a result, the French divided the ethnic and religious groups into governantes that were more segregated than the contemporary state borders in the Levant. The Druze, Alawites, Sunni Arabs from Damascus, Sunni Arabs from Aleppo, and Arab Christians all had their own governantes during the French Mandate (ibid.). Despite the Mandatory being divided between 5 regions, the French High Commissioner of the Mandate of Syria and Lebanon ruled the region as a single economical and customs unit, with the seat of the High Commissioner being situated in Beirut, Lebanon (ibid.).

While the French claimed to have a desire to assist the Syrian and Lebanese people with eventually becoming autonomous, both states were not granted independence until 1946 despite both drafting constitutions in 1926 (ibid.). There were various revolts that occurred as a result of the local population demanding for independence from the French, such as the 1925 Druze revolt, 1935 riots in Damascus, and the 1925 Hama uprising (ibid.). Regarding the governantes that consist of the current Syrian state (The Druze, Alawites, and Sunni Arab governorates), it was generally demanded they have a unified Syrian state, which was granted by the French. The moral goal of the French was ensuring the existence of a Christian Arab state – Lebanon. The treaties between the French and Syrian/Lebanese promoted and protected French rights regarding economic and financial issues, along with historical and educational interests (ibid.). This was evident when French became an official administrative language in both Mandates.

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Post- World War II Since the end of the Cold War and the emergence of the Responsibility to Protect Norm, the debate on foreign intervention gained a new dimension. In the context where the definition of sovereignty has changed, the leaders are no longer permitted to commit severe abuses against their civilians without facing international backlash or in extreme cases, even foreign intervention. In the Levant region, foreign intervention and superpower support for different factions fighting within the state is nothing new. In the light of increased tensions between the Israeli government and Hamas that have led to multiple violent attacks and the ongoing crisis in Syria where Sunni Muslims are persecuted by the incumbent regime, it is important to ask the question whether these unfortunate events are connected to foreign intervention.

Rørbæk (Rørbæk, 2019, p. 24) analyses the political and social in the Middle East context using Wehrey’s argument (Wehrey, 2014) according to which illegitimate domestic institutions characterised by unequal access to power have led to increased identity conflict across a region.

Rørbæk uses the third Version of the Ethnic Power Relations Dataset and finds that in the Middle East religious differences are predominant when determining group membership. Using the same data set, he also finds that the level of identity based inequality was higher in the 2000s than the 1960s. An example of systemic identity-based inequality is Jordan where the regime wanted to frame widespread demands for a more democratic approach of the governing process in terms of economic problems caused by corruption within the Palestinian community. These identity divides were intensified by the US-led 2003 invasion that destroyed the balance of power between Shia and Sunni Muslims and the U.S.S.R. support for the coups in Syria that would pave the way for Al-Assad which would empower the Alawi community. Rørbæk’s analysis presents and answers some of the questions regarding the grievances in the MENA region (which includes 178

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the Levant region), but the last data used was from 2012. Since then, the situation has severely aggravated in the area.

Fox et al. (Fox et al., 2009, p.163) ask something similar to the reverse of our research question: whether ethnoreligious groups attract more foreign intervention than other ethnic minorities in the Middle East and Northern Africa. He uses the MAR dataset that contains information on ethnic minorities until 2003, whereas the data used on intervention covers only the period from 1990 to 1995. Our main criticism concerns once again the recent developments in this area that could have influenced the analysis. One important finding that could explain Iran’s support for Shiite militias such as Hezbollah and the state's involvement in other conflicts is the fact that Islamic States intervene mostly on behalf of Islamic minorities (ibid., p. 177).

These papers show that in political science there has been increased attention for religion as a driving force behind inter-religious violence and never-ending civil wars like the one in Syria.

However, foreign intervention, either political or military, has played an important role in supporting movements that advance religious reasons in order to justify their violent acts.

Therefore, it is impossible to analyse one without the other.

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Theoretical framework To observe the prominence of violent conflict in the contemporary world would result in concluding that a majority of the world’s instability is found in the developing world, which are typically formerly colonised states. This includes Latin America (e.g. Colombia, Guatemala), Sub-Sahara Africa (e.g. Sudan, DR Congo), South Asia (e.g. conflict in Kashmir), and as this paper focuses on, the Middle East (mainly the Levant). Thus, it is important to reflect on the history of a region with ongoing conflict between identity groups, as it may provide information on institutions emplaced by foreign colonisers that continued to prevail post-independence.

Between all three eras - the Ottoman Era, the British and French Mandates Era and post-WWII era - that we have researched, we theorise that foreign involvement has increased the likelihood of the instability that we currently find in the Levant. The people of the Levant have not been autonomous for centuries, and were not given independence until the British and French ‘assisted’ them with self-governance. Despite the official independence the majority of the Levant currently holds, the significant influence foreign powers continue to have in the Levant maintains the legacy of religious and ethno-religious division within the region.

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Results The Ottoman Era The results of our Ottoman-era research have shown varying degrees of culpability for interethnic violence as a consequence of domestic state and foreign state activity. What is evident is that violence was driven by certain key factors: (1) political and emotional revenge on the part of the Ottoman state; (2) geopolitical strategy and destabilisation tactics by foreign actors; and (3) nation-preserving tactics on the part of the Ottoman Empire in the wake of rising nationalist sentiment from other groups, most notably Christians.

The historical/religious drives towards violence appear to be less significant than political/secular drives. Only the indirect violence exacted against the Lebanese Christian population during the wartime famine appears to have been driven by particularly cultural or religious disdain for the populations living there, and it must be recognised that the Ottoman Empire’s wartime economy also made this a militarily favourable, as well as culturally sanctioned, option. Characterised by a desire to establish the Empire as a trans-national state enterprise inspired by Enlightenment ideals of cosmopolitanism, the CUP inadvertently intensified growing national sentiment within its territories by the gradual abolition of millet rights. Resistance was increasingly responded to with violent measures until after the World War I, national questions appeared resolvable only by the outright elimination of these national groups and their replacement by Muslims. The hardest hit by these targeted persecutions were Christians, who were seen as possible traitors supporting the Entente cause. Levantine Christians were especially remembered for their relationship with the French government and subsequently suffered violent relocation, isolation and negligence.

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The British and French Mandates The analysis of primary sources for the French and British Mandates demonstrated that the two colonial powers had obtained control of the Levant in order to benefit their business interests, along with maintaining influence in the region (thus exerting power on the global stage). In official documents that were used for external use, the French and British demonstrated a desire to assist the local population with enforcing the protection for human rights and democracy. The external documents also portrayed an image of hoping to ensure the local populations will have beneficial institutions and systems emplaced that would continue to be utilised once the French and British removed their authority from the region. Overall, if one were to solely observe the external documents from the British and French during that era, it could have been perceived that they genuinely had the interests of the Levantine people considered, hoping they would successfully and smoothly achieve autonomy. However, internal documents and secondary sources present that the British and French ruled the Mandates according to their own political and economic interests, and had little regard and respect for the desires of the local population.

As a result of the French and British ruling the Levant in their own self-interests, the ‘divide and conquer’ method was executed in the Levant, as they were in other former British and French colonies (e.g. British India). Jews and Palestinians were given their own states rather than sharing land, Christian Arabs were given their own state, and during the French Mandate, Syria was divided between Alawites, Druze, and Sunni Arabs. Considering the tensions between religious groups being already-present due to the former Ottoman authorities, the British and French further maintaining the divisions with official borders and varying treatment between the religious groups would explain the contemporary instability and violence between the groups today.

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Post- World War II The ideological conflict between the United States and the Soviet Union had a significant impact on geopolitical relations in the twentieth century, and the Levant was not immune to its consequences. Although in this period both superpowers tried to increase their influence in the area by supporting financially and militarily different regimes, they were unable to modify the existing balance of power (Hanau Suntani, 2017, p. 97). The region presented a significant difficulty in their conflict since all parties were eager in acquiring access to the territory's oil reserves, which were considered critical for postwar reconstruction (Daigle and Kalinovsky, 2014, p. 171).

Analysis The Ottoman Era For much of the early modern history of the Ottoman Empire, minority groups in the Levant and elsewhere had been dealt with through what is known to historians as the Millet system, a series of “ad-hoc agreements [between the Muslim state] and the heads of religious communities” (Barkey and Gavrilis, 2015, pp. 25-26). In practice, distinct communities of primarily Greeks, Armenians and Jews, were allowed to appeal to their own courts and were recognised as protected groups in return for the payment of a tax known as cizye (ibid.). This system is often the subject of romanticisation, considered by some to be a golden age of multicultural settlement, however, it was far from perfect, and carried within it the seeds of disunity (ibid.). This came to a head in the nineteenth century as growing nationalist sentiment sparked by the Greek War of Independence (1821-1832) outlined the major threats of such clear legal distinctions between Muslim and non-Muslim subjects (Evans, 2017, p. 54). In 1839 the Gülhane Hatt-ı Şerif

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(“Supreme Edict of the Rosehouse”), or Tanzimât Fermânı (“Imperial Edict of Reorganisation”) began a process known as the Tanzimât Reforms, during which followed several royal proclamations or promises of judicial reform. These attempts at modernising the Empire included the de jure dissolution of the Millet system and in its place the recognition of both Muslims and non-Muslims in the Empire as subjects equal under the law (Cleveland and Bunton, 2009, p.

84).The Tanzimât Reforms proved unsatisfactory to many citizens, with the previously protected millets uninterested in the legal obligations they carried and Muslim citizens unhappy with receiving equal treatment to the minority groups (Eissenstat, 2015, pp. 437-438). It is in this context of inter-ethnic tension, exacerbated by the attempts of the Ottoman Empire to reform itself into a nation-state, that the Young Turk revolution took place in 1908.

Subordinated in the aftermath of the Ottoman Empire’s conquest of Constantinople, the Rum Millet (who largely recognised themselves as simply “Christians”) (Karpat, 2002, p. 17), were made up of the large number of Eastern Orthodox Christians that lived under Ottoman rule. In spite of their more general millet classification, over time, and particularly during Tanzimât, this millet was broken up into smaller ethnic categories (for instance, the Bulgarian Orthodox Millet was recognised as a separate group in 1860) (James and Goetze, 2001, pp.159-160). The Eastern Orthodox millets were recognised as some of the best organised and most powerful in the Empire (Barkey and Gavrilis, 2015, pp. 26-27) and the position of Patriarch of Constantinople continues to this day in modern Turkey. In the Levant, this group was largely represented by the Patriarchates at Antioch and Jerusalem (Colak, 2015, pp. 22-23). In his dissertation on the subject, Colak highlights that relations between the Patriarchates at Antioch and Jerusalem with the Ottoman authorities were generally well adjusted (Colak, 2015, pp. 144-145). It is not clear to what degree Levantine Greek Orthodox Christians were persecuted by the authorities during the 184

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Second Constitutional Era and war. Little evidence suggests the same degree of persecution took place against Eastern Orthodox Christians in the Levant. Roman Catholics, primarily Lebanese Marionites, on the other hand, faced far greater punishment during the First World War. A devastating famine between 1915 and 1918, largely exacerbated by Jamal Pasha’s deliberate barring of crops entering Lebanon from Syria, (Ghazal, 2015) killed an estimated 150,000300,000 Lebanese, approximately half of the region’s population (Tenielian, 2016, p. 6). This was not the first sign of Ottoman resentment of Lebanese Christians, a region that had for many years been one of the most prosperous in the Empire (Khalaf, n.d.). It is arguable that primarily French financial involvement that dealt only with Christians (Raccagini, 1980, p. 367) in the region exacerbated tensions between Christians and non-Christians in Lebanon, and as a consequence, public sentiment was geared negatively towards Lebanese Christians, the main victims of the indirect violence of the famine. Indeed, French financiers controlled 62.9% of the Ottoman Public Debt at the eve of the First World War and acted as the Ottoman Empire’s greatest foreign trading partner until its outbreak (Shorrock, 1970, p. 134).

Despite the fact that both Arabs and Turks were recognised legally as Muslims, not all Arab populations in the Ottoman Empire felt recognised as equals with Turks. Indeed, a major driving force behind the Young Turk revolution was resentment of Sultan Abdulhamid II’s Arab court most notably in the influence of the Malhame family (Hanssen, 2011, pp. 27-31). Pan-Arabist, nationalist sentiment had been growing among Arabs since at least 1821, however, it had been largely satisfied by high representation in the Ottoman parliament. These members of parliament largely supported the countercoup against the CUP in 1909, the failure of which led to the establishment of the First Arab Congress in Paris in 1913. However, Erol Urker has emphasised that the source of discontent between Arabs and Turks was not primarily characterised by a 185

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conflict between Turkification and Arabification, or Turkish nationalism and Arab nationalism, but rather centralisation and decentralisation, respectively (Ulker, 2005, p. 614).The ambition, for instance, of establishing Turkish as a universal language was less a direct assault on Arab or otherwise ethnic communities, but a genuine, albeit negligent effort to centralise the Ottoman state (ibid., pp. 620-623 ). These efforts, moreover, do not seem to have disproportionately affected Arabs, and it is evident that the success of the Arab Revolt owed more to western-backed tribal political ambitions than mass responses to direct persecution. Indeed, E. Karsh and I. Karsh have gone so far to assert that most Arabs “viewed the [Arab] revolt with total indifference or even hostility” (Karsh and Karsh, 1997, p. 267). In this regard, it is evident that violence was caused primarily by foreign state actors, with direct implications.

In his piece on the Second Constitutional Era states that “it can no longer be denied that the CUP [party dictatorship of the Empire post-Young Turk revolution] instigated a centrally controlled policy of extermination” (Zurcher, 1993, p. 116). As stated above, the main targets of these genocides were Christians in the Empire. In Anatolia, these were primarily Greek Christians, (ibid.) but Armenian and Assyrian Christians (notably distinct from the Eastern Orthodox / Greek Chrisitan groups) suffered the most (ibid.). This was in large part the product of a desire to “solve” the Eastern Question by eliminating all non-Muslim, non-conformists in the Empire’s heartlands and maintain imperial stability. Many factors can be thought of as reasons for the genocides, from increasing fragility and Christianophobia in the Empire during the First World War, to the economic disparities between Armenian/Assyrians and Turks, and so on and so forth. What is evident is that between 1915 and 1917, between 600,000 and 1.5 million Armenian and Assyrian Christians were killed in the Ottoman Empire (Morris and Ze’evi, 2019, p. 1). Armenians and Assyrians in the Levant did not face concentration camps and genocide as elsewhere, but many 186

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were forcibly relocated, coerced into converting to Islam, and used for labour during the war effort (Kevorkian, 2011, p. 673-674).

The establishment of the Ottoman Empire in 1299 meant that Greek lands were under Turkish Rule. Especially for the Greeks, who fell under the rule of Ottoman Turks and also lost their statehood. However, even the liberation movements of Greece in the 19th century did not help sell the Ottoman rule of Greece, and the majority of the Greek population continued to live within the Ottoman Empire territory. The Greeks belong to the Millet-i Rum in the Ottoman Empire, with the Greek Patriarch of Constantinople as the head of the millet, who was seen as the leader of the nation. He later also became a member of the Ottoman bureaucracy (Verdanyan, 2017, p. 278-284).

All non-Muslims, including Armenians and Greeks, were presented with dhimmi legal status; meaning that these were people who lived under Islamic rule, as long as they submitted themselves to pay the tribute (ibid.).

After the passing of Ottoman rule, Greeks and Armenians were collectively deprived of rights, which only worsened towards the end of the nineteenth century. There was unequal treatment towards the Christian population, which led to the expansion of the conflict. For example, this was clearly evident within the judicial system where discrimination and inequalities were prominent as there was a clear difference in treatment between Christians and Muslims (ibid.).

The western Asian region between the period of 1519 until the end of World War 1, was all part of the Ottoman Empire. The Ottomans carefully made sure to continue the Muslim tradition of 187

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tolerating Christian interests in Palestine (ibid.). The Ottoman Empire welcomed thousands of Jewish refugees that were fleeing persecution from several different parts of Christendom.

Since the late 19th century, when Zionism developed, its supporters have extensively debated the existence of Palestine and questioned whether Palestinians are “real” people. Some argue that the Palestinian identity only emerged after the development of Zionism. However, numerous research and studies depict how the Palestinian identity existed pre-World War One. This is seen through the comparison between the Jews and the Palestinians in the Late Ottoman Era. The focal argument with this is that following the Young Turk revolution in 1908, Palestinians and Jews had their own political communities with their own identities, but ultimately had the same desire of claiming the homeland. The work of Louis Fishman demonstrates how there is evidence of Palestinians’ identity before World War One, and also suggests that both Jewish and Palestinian communities “placed their Faith” in Istanbul and that neither community could anticipate the fall of the Ottoman Empire.

Fishman also suggests how during the beginning of the 20th century, Palestinians were more patriotic than nationalistic and that the term “Palestinian Jew” was not used to define themselves, and therefore should not be used either way (ibid.).

The Jewish community living in Palestine during the 20th century is quite diverse. Fishman argues how the Jewish community transformed itself into a national community creating a division of communities between Palestinians and Jews. This is because Jewish nationalism can be seen as a reaction to the emerging Palestinian identity.

The renegotiation of the Millet system after the revolution in 1908 established a division between the Palestinians and the Jews. The author does not explicitly state whether this is as a result of the Ottoman regime, but that either way, the new civic identities developed and that both communities 188

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were focused on claiming Palestine as their land. Lastly, Zionism was not seen as a threat to the Ottoman elites and was mainly worried about its disruptive nature. Some Zionists even believed that the Empire would be able to help create a Jewish entity.

The British and French Mandates The Sykes-Picot Agreement presents how the self-interests of the colonial powers, the British and the French, were prioritised over the needs of the local population. This was evident due to business and economic interests of the two countries being explicitly written in the agreement (Sykes-Picot Agreement, 1916, pp.1-4). The agreement was drafted in secrecy with no official from the Levantine present at the meeting and no Levantine being a part of the agreement. The impact of a lack of Levantine representation in an agreement that determined the fate of the Levant for the following ~20 years is an obvious one - decisions will be agreed upon that may go against the desires of the local population. With analysing the results of the 1919 King-Crane Study, and finding that a majority of Levantines preferred a united Syrian state (which would include present-day Syria, Lebanon, and Israel-Palestine), it is presented that the terms and agreements of the Sykes-Picot Agreement contradict what the local population preferred in terms of leadership. This type of behaviour of colonial powers carelessly drawing borders from the perspective of local populations was also seen across Africa and South Asia. This common theme of utilising land for exploitation, along with drawing borders that do not benefit the population in the long-term, is evidently the case in the Levant. The British and French attempting to create a Christian state, creating a Jewish state, and separating other sects and Sunni Muslims is a division observed today within Levantine societies.

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By analysing and interpreting the Sykes-Picot Agreement, we came to the conclusion that how the Mandatories were governed were not from decisions discussed within a short period of time, but rather the French and British were carefully determining how they will control the local Levantine population a few years before they held authority in the region. In writing, the goal of the mandates is to have the Levantines be given the institutions created by the Europeans to eventually become autonomous. Essentially, this agreement demonstrates the lack of consideration of the local population when the borders were originally planned by the foreign powers (UK, France, Russia). Also, based on a clearly outlined definition of the economic interests pursued by the above-mentioned western countries, this source shows how the colonial powers’ self-interests would be the priority over a beneficial policy-making aimed at improving the conditions of the indigenous population. The limitations of utilising this source is that it does not portray the in-person discussions while drafting the agreement, along with how often the local people were considered while defining the terms of the agreement.

The Official Documents for the Mandate of Syria and Lebanon, which was submitted to the League of Nations, presents the various contradictions of French Mandate authorities. Within the documents, the French advocated for equal treatment of all groups within Syria and Lebanon.

History has proven this statement to be incorrect given the French’s unequal treatment towards the Christian population versus the Muslim population. The Mandatory was also divided more than Syria and Lebanon are officially divided today. The Alawites and Druze being given their own sovereign area from the Muslim and Christian populations during the Mandate. While this may be observed in a favourable manner, by coming to a conclusion that this may have protected the minorities, statistical data conducted in 1919 presents that the majority of the region did not want a divided Syria and Lebanon, but rather for Lebanon to be a part of Syria. A separate 190

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Lebanese state was only found to be favourable by Lebanese Christians (Bou-Nacklie, 1998, p.

280). The document also contradicts itself when it expresses its desire to allow Syria and Lebanon to eventually govern independently in a stable and peaceful manner, yet eventually expresses that the institutions France will set up will have to be repaid once Syria and Lebanon become independent states. Essentially, Syria and Lebanon would automatically be in debt to France.

Considering the wealth and power France had (and continues to hold) during this era, and the wealth Syria and Lebanon lacked, it places the governments of the two in a vulnerable position to pay debts for institutions they may have not afforded to establish in the beginning. A struggling government often leads to a struggling population due to the government having the inability to provide its people with required services. This also serves as an issue, with the 1919 study presenting the local population to be highly unaccepting of French rule, meaning they were given institutions that the majority did not initially request or likely agree with from France.

France affirming its right to self-defence and maintaining order in the document also serves to be a failure for the local population, given the 1925 Hama Revolt, which resulted in further oppression and deaths in the civilian population in Hama, Syria (ibid., p. 275). Both Beirut and Damascus have a “martyr's square”, partially contributing to the murders committed by French troops towards those who rebelled against the Mandate. Capital punishment does not align with “self-defense”, however it may arguably be used to justify “maintaing order”. However, the mandate was created to “assist” the local population with governing themselves, and further establishing a precedent from the Ottoman Era (that those who rebel are to be punished by death), does not dissolve into a desirable government.

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The reports of the commissions of inquiry established between 1917 and 1937 represents useful benchmarks to frame the public opinion of the Palestinian population during a new governance cycle, which would have lasted three decades. Two major breaking points emerged: exclusion of the Arab community from the political and economic life of the country. Discussing of political isolation, Kelidar (Kelidar, 1993) suggests that a fundamental problem of the British Mandate System was the lack of acknowledgment of the cultural and political differences between the Western and Levant way of intending the sovereignty principle underlying the institutional architecture of the country (ibid., pp. 316-335). Traditionally, in the Levant Muslim countries, the sovereignty principle rests on God whereas in Western countries the founding principle legitimising the ruler’s power rests on people (ibid.). Kelidar, relying on publications by Wilson and Gertrude Bell, presents the British administration as a despotic power in which “interests and aspirations could not find favour, and were hardly expressed” (ibid.). A country where the mode of governance has been imposed rather than subjected to popular scrutiny. This has created an institutional and bureaucratic organisation unable to understand the social dynamics present in the country and consequently to target causes and solutions of domestic political conflicts (ibid.) The Arab community is represented as a proud population whose identity had never matched that of the foreign conqueror, whether the Ottoman Empire or the Western power. The British administration could simply not be unilaterally decided for the indigenous population. Kelidar has no doubts that only a deep understanding of the ethnography of the administered areas could allow the Western power to efficiently meet the demands of the local Arab factions (ibid.). As a matter of fact, The High Commissioner represented the country's highest political office, depositary of the executive power, to which the public officials in charge of the administration of the districts, as well as the Executive Council and the Legislative Council were accountable. No other institution, representative of other communities, would be placed at the same level as that of the 192

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High Commissioner. The political figure of the Grand Mufti of Jerusalem could exercise an executive power as outlined by the British Authority, minimising the scope of action of the Mufti.

The judicial power of the Supreme Muslim Council, the most representative of the Arab institutions, was restricted to religious and civil rights matters. The lack of representativeness in the political realm led the Arab community to organise themselves into the Muslim-Christian Associations. The Palestine Arab Congresses organised by such associations had the aim of influencing British policy, in contrast to the Zionist Commission which would provide the administration with policy recommendations based on ethnographic surveys of the day-to-day life.

The Jewish exodus into Palestine was another remarkable key points of the Arab public opinion assessment across the 1917-1937 reports. To understand the reason for such concern, it is necessary to introduce basic demographic data. At the onset of the Mandate system in 1920, the proportion of Arab population to Jewish people resident in Palestine was 11:1. By the end of 1948 the same proportion was now 3:1. In numerical terms, the Palestine population in 1922 amounted to 700.000, mainly living in rural areas, whereas approximately 260.000 inhabited major towns.

Of this 700.000, 81.000 were listed as Christian and a round 80% of individuals as “Moslem” (Mandate for Palestine, 1921). In 1948, the Palestine population counted 1.900.000 of which 68% was Arab/Christian (1.330.000) and 32% Jewish (approximately 570.000) . In 1928, Leonard Stein described Western Palestine as larger compared to the Eastern counterpart, predominantly occupied by Moslems (625.000) with roughly 125.000 Jews and 75.000 Christians. Eastern Palestine is mainly inhabited by roughly 200.000 Moslems of which a good percentage are Bedouins (Stein, 1928, pp. 687-690). The Aliyah, the Jewish immigration into Palestine, is considered as the driving force of the Arab insurgence to contrast both the Jewish community and the British Empire. The immigration process was supported by the British administration since Jewish immigrants could bring the capital needed to finance major infrastructure projects which 193

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ultimately made them the real beneficiaries in economic terms. Moving to the economic exclusion argument, Halevi (Halevi, 1983) argues that the increase in capital inflow, capital formation and per capita income in Palestine was due to the exogenous factors of the Jewish immigration phenomenon, promoted by the British administration by implementing the “absorptive capacity” policy (ibid., pp. 464-465). This concept refers to a basic assessment of capital availability and/or skill set detained by the prospective Jewish immigrants, which would allow them to either invest in major public projects (mostly privatised) or to be employed in a relatively short time (ibid.).

Based on Halevi’s account, citrus production, housing construction, and infrastructure construction (mostly in the form of hospitals, schools and roads) were the economic activities that mostly boosted the country’s economy, all of them financed by Jewish capital (ibid.). Anderson (2018) focuses his attention on the land dispossession at the expense of the Arab community.

Anderson argues that a long-standing tradition of laissez-faire has been handed down from commissioner to commissioner, resulting in a rapid acquisition by the Jewish community of every inch of available land, mostly divided between Jewish capitalists and wealthy Arab Muslim families (Anderson, 2018, pp. 186-328). The low-income rural population, as a result, poured into the cities, causing the formation of urban slums, increased unemployment and a decrease in living standards (ibid.).

Anderson's

argument

gravitates

around

the

concept

of

“settler

developmentarism” based on which the Jewish superior culture and capital availability could properly support the British institutions in achieving the modernisation of Palestine as laid down in the Balfour Declaration and inspired by the principle of self-determination (ibid.). Khamaisi (1997) discusses the development of planning policy in Palestine, starting with the enactment of the 1909 statutory town planning in Great Britain (Khamaisi, 1997, pp. 323-328). The emphasis of the argument lies on how the introduction and application of the same policy in Palestine was conducted without considering a merging of the policy principles with those of the local planning 194

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development policy tradition (ibid.). Furthermore, Khamaisi, who provides a descriptive analysis of the planning policy framework rather than a partisan account of it, observes how the bureaucratic organisation of the central and local authority responsible for examining planning proposals was entirely represented by Jewish individuals (ibid.). The author focuses on the period 1921-1935, the time span between the first and second town planning order (TPO), during which a greater increase in building construction in Jewish colonies and a high rate of planning projects rejections advanced by Arabic citizens is recorded (ibid.). Norris (2017) emphasizes the propaganda ideal of Palestinian development, observing how infrastructure projects have always served British expansionist objectives. In particular, the need to accommodate the pressures of the British manufacturing industry to export raw materials and the incessant demands of the Europebased Zionist communities to speed up the migration process (Norris, 2017, p. 270). Norris applies the Nils Gilman’s concept of "thin development" to the Palestinian context to define how welfare programs, beneficial for the indigenous communities, have always been delayed in favour of large infrastructural projects that could increase trading of goods and services in the country which ultimately translated into an increase in intra-Jewish trading and capital increase (ibid.).

The British Empire Government, to secure its own interests, attempted to respect the terms of previously published public statements, informal agreements, and international agreements which contradictorily supported both the Arab independence and the establishment of a Jewish state.

What followed was a policymaking unable to meet the political and economic demands of two communities which, in the eyes of the unreliability represented by the British Administration, clashed in a clearly defined sectarian conflict that vehemently drags its legacy until the 21st century. In line with the mutually exclusive nature of the various International agreements concerning Mandate territories, every piece of Mandate legislation hardly simultaneously met the 195

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needs of the two communities but rather systematically disadvantaged one of the two. For instance, in between 1918 and 1921 the Palestinian Land Development Company and the American Zionist Commonwealth purchase the entire Jezreel Valley and Haifa Bay (known as the Sursock Purchase) causing the displacement of 1178 Arab families as the new agricultural policy enacted by the British Administration categorises the Arab rural citizens as “tenants” in the Jewish lands. The furious response of the Arab Community to this episode has consolidated in the formation of Haj Amin Al-Hussein’s Arab Club and the Palestine Arab Congress. These two respectively informal and formal institutions encouraged Nationalistic sentiment among the Arab community, which culminated in the 1920 riots led by Al-Hussein in Jerusalem. Two months later, the Haganah, precursor of the regular Israeli Army founded in 1948, was established. As we can notice, there is a clear snow-effect pattern in the Arab-Israeli relationship during the Mandate period. This backand-forth process of retaliation between Jewish and Arab communities at the expense of each other culminated with the resignation of her majesty’s Government from the role of Mandate power of Palestine, the 1948 Israeli Independence Declaration, and the first Arab-Israeli conflict won by the newly established Jewish Country.

Post- World War II World War II had a major transformative role on the geopolitical landscape of the Levant. The balance in dominant external powers shifted dramatically, from Britain and France who retained influence during the 1960s and 1970s, to the USA. The writer mentions both the reason how the US started to exercise a greater influence and why Britain decided to withdraw from the area.

There are four different trends that helped the USA come to play a dominant role in the area.

Firstly, the establishment of police and military links during and after World War 2 with some states. Secondly, a rising US interest in oil, which has become a major economic prize in the 196

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middle east. Thirdly, the closer relationship between the US and Israel. Lastly, a strategic concern against the USSR, the newly influential, and potentially ‘forward’.

For Britain, the balance before and after the war had dramatically shifted. The belated knowledge on the fate of the Jewish in Europe, the increased engagement of the USA and the USSR on the side of Zionism, the Jewish guerrilla campaign against Britain in 1946, and Britain’s general weariness on the area after an global war, all made British announce in 1947 that they would withdraw from Palestine. Britain’s decision not to make any political successor arrangements led to the foundation for the conflict between Jews and Arabs within Palestine beginning in 1947q.

Israel represents one of the most salient U.S. partners in the Middle East. The support offered by the superpower in the past made it possible for Israel to develop one of the best defence systems in the world. Since the end of World War II, Israel has received an impressive amount of foreign assistance that rounds up to around 127,4 billion dollars in bilateral assistance. It is essential for our discussion to mention that almost all bilateral aid came in the form of military assistance (Gutfeld, 2017, pp. 934-936).

The financial support for Israel in this period could be traced back to President Truman. In the 1958 Jordanian crisis, Israel proved not only to be a devoted ally, but also a strategic one, as they heavily contributed to the preservation of the pro-Western regime of King Hussein of Jordan. In the following decade, during Kennedy’s mandate, Israel started to receive advanced weaponry, but this was only extended to arms considered defensive in nature, such as the Hawraftk anti-craft missile systems. These sales offered the opportunity for the Israel Defence Forces (IDF) to develop. A changing point in this relation was the Six Days War which was sparked in 1967 (ibid.).

The Six-Day War was the result of the acerb competition among Israel, Syria and Jordan from 197

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1964-1967. Other causes invoked for the spark of this conflict were the conflicts that were constantly recurring within the demilitarised zones between Israel and Syria and the competition between the Egyptian President, Nasser, and other Arab dictators for leadership in the Arab World (Wolf, 2015, p. 158). Everything started when a false report was sent to Nasser from the new Syrian Baath regime, through the Soviet Union, that Israel had deployed armed military forces at the Israeli-Syrian border. Although Syria’s main aim was to convince Egypt to deter a potential Israeli invasion, the situation turned to their surprise in the opposite direction and on the 6th of June, the Israeli’s government attacked the Egyptian air force which was largely unguarded. This action enabled them to secure the Sinai Peninsula, the West Bank and the Golan Heights (ibid.).

After this episode, the U.S. started to provide Israel with not only defensive weaponry, but also technologically superior offensive military equipment which resulted in a shift in the balance of power in the region. The main aim of the US was to prevent wars between Israel and the neighbouring Arab countries, as any conflict could negatively affect the confrontation between the U.S. and U.S.S.R. (Gutfeld, 2017, p. 935). The side effect of the war and the increased military support led to an escalation in the anti-Zionist feelings in Syria and a deteriorating relationship between Jordan which in the following years would be the main motivation for the creation of non-state ultra-right-wing movements such as Hezbollah and Hamas that contribute to this day to the escalation of inter-religious violence in the Levant.

The consequences of the Six-Day War were dire for Jordan due to the US support for Israel that enhanced their military capabilities. In the short conflagration, Jordan lost the West Bank which included the City of Jerusalem. Apart from the symbolic importance of the West Bank, the region contributed to up to 40% of Jordanțs GDP, it included half of the Kingdom’s inhabited land and industrial capacity as well as its farmable land. Moreover, in its aftermath, Jordan was forced to 198

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host 175,000-200,000 Palestinian refugees. The Palestinian Liberation Army used this opportunity to conduct their raids against Israel from Jordan which increased the likelihood of Israelian retaliation (Wolf, 2015, pp. 161-162).

The rise of the Likud party in Israel in 1977 and their re-election in 1981 was a clear movement towards a right-wing approach in the Israeli-Palestinian conflict which disregarded the “Jordanian option” put forward by the previous Labour government (Susser, 2021, pp. 434-444).

After the end of the Six-Day War, the Israeli Labour Party envisioned Jordan as a solution to acquire independence. They were more eager to negotiate with Jordan as the main representative of the Palestinian people. Jordan was viewed as being easier to demilitarize parts of sovereign territory, the Jordanian-Palestinian formula would have also allowed relocating the refugees on the Eastern side of the Jordan River (Anon, 2015, pp. 247-248). The rise of right-wing parties that were inclined towards the annexation of the West Bank and Gaza, raised concerns about the high number of refugees that would cross Jordan’s borders and the fear that many Palestinians would be sent there (Susser, 2021, pp. 444-445). Therefore, King Husein expressed Jordanian support for securing Palestinian rights outside his state. In order to further distance themselves from the idea of a shared identity with the Palestinian people, in 1988, King Hussein stripped Palestinians in the West End of their Jordanian citizenship (ibid.).

The U.S. had a proactive role in creating a peace treaty between the two countries. As the prospect of war between Iraq and the U.S. emerged following the Iraqi invasion of Kuwait in August 1990, Jordan feared that it could become the target of both Israeli and Iraqi attacks and that it would give incentives to Israel to exploit the solution “Jordan is Palestine”. After Iraq's defeat, Jordan shifted its support towards the Israeli-American axis in the absence of the Soviet 199

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Union as a major player in the region at the end of the Cold War, King Hussein believed that the US was the only country that had a decisive role in the area, therefore, the keener to negotiate a peace treaty. The Oslo Accords resulted in the signature of the Peace Treaty on the 26th of October in 1994 (Susser, 2021, p. 446).

Since the establishment of Israel, the U.S. has worked hard to serve Israel through the establishment of the UN Resolution 181. UN Resolution 181 was regarding establishment of an Arab state, so that the Arab-Israeli conflict could be resolved through the partition. On one hand, this was to give Palestinian refugees resettlement, return, rehabilitation and reparations. One the other hand, they believed the existence of Israel as a custodian of U.S. interests could block Soviet expansion in the Middle East.

The United States considers Israel as a strategic base for U.S. interests in the Middle East, and their role remains considerably influential in spreading peace and security in the conflict between Israel and Palestine. The Zionist influence on American policy agenda setting can be witnessed in various examples, and the failure of Nixon’s special envoy is one example. Nixon sent a special envoy to the middle eastern countries claiming that US policy should be more balanced. However, Zionist lobby succeeded in pushing Nixon to support Israel eventually.

The U.S. policy continued like this during the 1960s, when John F. Kennedy was in presidency.

Their aim was to keep the Israeli presence and to prevent any Arab threat against it. Also under president Johnson, the American-Israeli friendship flourished. Johnson was personally sympathetic with Israel, which represents the American national sympathy with the people in Israel regarding the world war. Also, during president Nixon and Ford’s administration, the US 200

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did not recognize or negotiate with the PLO as the organisation kept refusing Israel’s right for existence.

During the Carter Administration, U.S. foreign policy entered a new dimension by attempting to solve the Palestinian cause. After President Carter, his successor President Reagan came up with a somewhat new position onto the conflict: the US decided to be neither support Israel trying to occupy territories nor the Palestinian state and their establishment. Although there has been no notable success in leading to the peace in the area, American policy continued on this course throughout his term.

Since President Clinton’s Clinton Parameters, successive administrations have proposed their own plans for a two-state solution: George W. Bush’s Road Map to Peace, Secretary of State John Kerry’s Six Principles, and Trump’s Peace to Prosperity. ‘Road Map to Peace’ was that Palestinian terror was the primary obstacle for an Israeli–Palestinian peace agreement, so dismantling of the current Palestinian leadership was a prerequisite for a Palestinian state. During this era (2001-2008), the U.S. policies aimed at pushing the Arab countries into many negotiations with Israel. For the first time, a U.S. administration declared that solving the conflict would require the establishment of a sovereign and geographically coherent Palestinian state with Jerusalem as the capital of both states.

‘The Six Principles’ from Barack Obama and his Secretary of State John Kerry led the entry of a cycle of inaction. His administration did not actually make tangible progress, maintaining the status quo. Obama’s position indicated that he was consistent with the dominant American vision of maintaining Israel as an important strategic ally. Trump abandoned the US role as an honest 201

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broker between the two states and firmly adopted pro-Israel stance. Under the plan Peace to Prosperity, too few concessions are required from the Israelis while imposing too harsh requirements on the Palestinians. However, he tried to make peace treaties like Abraham Accords countries surrounding the area.

The 1973 Yom Kippur War between Israel/Syria/Egypt is often considered a cornerstone of the United States’ even more dominant position in future diplomacy in the Middle East, because it created a confrontational relationship between the Soviet Union (armed with Egypt and Syria) and the United States (supporting Israel). However, it was the US Secretary of State Henry Kissinger under Nixon administration who took a role as an intermediary between the Arab states and Israel, which then led to a deescalation of the war. As Kissinger wrote in White House Years'', it is crucial “for any American leader to accept the fact that in some conflicts opposing positions are simply irreconcilable.” The key to his success was a realistic evaluation of what could and could not be accomplished in the circumstances. He thought that the ‘comprehensive’ solution to the conflict’s conundrums and piecemeal approach can plausibly begin to unravel the regional knots (Cohen, 2021).

In 1978, President Jimmy Carter hosted the Camp David peace talks between Israel and Egypt. It was in line with his new dimensional U.S. policy which tried to solve the Palestinian cause. The idea of establishing a Palestinian homeland for refugees was part of American project for the first time. This was important in two ways as foundations of later Middle East diplomacy. The first was calling for talks involving Egypt, Israel, Jordan, and the Palestinians about Palestinian selfrule in Gaza and the West Bank. The second was calling for a peace treaty between Egypt and Israel, which the two governments signed in 1979 at the White House. Though Jordan was also a 202

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party in the 1973 war, it did not join the talks, fearing condemnation from other Arab nations. A separate Israel-Jordan peace treaty was signed in 1994 (Robinson, 2021).

According to the David Pollock’s research on how Palestinian views on war and peace with Israel, the way Palestine public views the US was expectedly unfavourable. The research was conducted in association with the Palestine Center for Public Opinion based in the west bank. The “hard data shows that the Palestinian public has also clearly moved away from the classic compromise peace deal with its neighbours,” even more than before since the Trump Plan. Palestinians are generally opposed to the two-state solution now, and believe that peace agreements would not assist with ending the persistent conflict.

When it comes to the relationship with Israel, although Palestinians in the West Bank and Gaza have become increasingly pessimistic towards Israel, they want to pursue various forms of shortterm cooperation with Israel . Palestinians in Gaza, the West Bank, and East Jerusalem have a discordant attitude between short-term or medium-term issues and very long-term national goals.

In short-term, for example, the majority support various specific forms of economic cooperation with Israel even now substantial minorities are backing certain controversial concessions like “permanent status” issues, ceding the refugee “right of return” to Israel, or recognizing it as “the homeland of the Jewish people”.

Also, the tactical flexibility at the popular level has been witnessed, as the majority of Palestinians even support resuming negotiations with Israel without preconditions. They are opposing their own governments’ diplomatic boycott of Washington and preemptive rejection of the ‘Trump peace plan’. The public is also divdied over continuing payments to prisoners, rather than 203

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Palestinian officials’ claim to unite behind the provocative polic. From the research David Pollock conducted, he claims that street’s opinions in Palestine are notably more moderate than elite political leaders’ (Pollock, 2020).

More recently, the paradigm shift among the Palestinian public opinion had taken place after Sheikh Jarrah Evictions in 2021. Since sheikh jarrah forceful evictions in late spring 2021, the support for Hamas and the armed struggle has increased amongst Palestinians, resulting in further divisions and poor views of the Jewish population (Cleveland, 2021).

Khalil E. Jahshan, Palestinian executive of American think-tank said that the Arab public opinion does not seem to be taken seriously by American policymakers in their deliberations and pursuit of US interests in the Middle East. Arab opinions are completely absent from the American policy for the region. Not only Palestinians the but the over three-quarters of the population in the Arab world agrees the Palestinian cause. Overwhelming majority (88%) of Arabs would disapprove of recognition of Israel by their home countries, with only 6% accepting formal diplomatic recognition. Moreover, when asked to explain on the reasons for their positions, respondents who were opposed to diplomatic ties with Israel mentioned it’s because of Israel’s expansionist policies and its racism toward the Palestinians and persistence in expropriating Palestinian land. In addition, one-half of those who accepted recognition of Israel by their governments made such this conditional only if an independent Palestinian state has been established. Similarly to what occurred in the French and British Mandates, the U.S. continues to take foriegn policy action that further divides the Palestinians and Jewish population.

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The rise of ultra-right wing movements in the Levant was a direct consequence of violence and discrimination towards different religious minorities. For the remainder of our analysis, we will focus on cleavages within the same religion or between two different faiths after the end of the Cold War that led to the creation of ultra-right wing movements such as Hezbollah, Hamas and ISIS (Islamic State of Iraq and Syria). These groups are contributing today to the escalation of both inter-religious and intra-religious violence.

Hamas was created in 1987 and when the first Palestinian uprising began, it became an outgrowth of the Plestinian branch of the Muslim Brotherhood (Bureau of Counterterrorism, 2019, p. 261).

The driving force that led to its creation was the general discontent with the Palestinian Liberation Army with regards to their lack of eagerness to promote Palestinian self-determination, the hesitancy to publicly oppose the Israeli occupation, as well as the high levels of corruption among its ranks (Lecocq, 2020, p. 1071). Apart from the armed element, the Izz al-Din al-Qassam Brigades, Hamas has the role managing a plethora of ministry activities that include charities, schools, clinics, youth camps, fundraising and political activities. In 2006, Hamas won the the Plestinian Legislative Council elections in January 2006, Hamas extended its power over numerous Palestinian Authority ministries in Gaza, such as the Ministry of Interior. The following year, Hamas expelled PA from Gaza in a violent takeover (Bureau of Counterterrorism, 2019, p.

262). Hamas has also contributed to the escalation of inter-religious conflict in Israel. A report created by the Bureau of Counterterrorism (ibid.) showed that before 1005, Hamas was responsible for multiple anti-Israeli attacks, such as suicide bombings, rocket launched, IED attacks and shootings. When it successfully expelled the PA from Gaza in 2007, the Gaza borders were closed, and Hamas successfully used tunnels to smuggle weapons into Gaza through the Sinai and other maritime routes. Moreover, it also fought a 23-day war with Israel at the end of 205

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2008. Four years later, the tensions between the Israeli government and Hamas led to another.

The main sponsor of Hamas is Iran and the Shiite militia, Hezbollah, that had an important role in training Hamas fighters after the first Palestinian Uprising (El Husseini, 2019, p. 811).

Hezbollah was formed in 1982, after the second Israeli invasion of Lebanon and follows the ideological principles instilled by the Iranian revolution and the teaching of Ayatollah Khomeini (Bureau of Counterterrorism, 2019, p. 266). It is essential to understand the political and social context that led to the creation of this organisation in order to continue the analysis. In Lebanon, the Maronites and the Druze were considered historically the powerful rulers of the Lebanese mountains and enjoyed Western support. After the end of the Second World War, the Lebanese President would always be a Christian-Maronite. The interests of the Sunni population were represented within the government, while the Shiites, which were more numerous, secured politically the position of Speaker of the Parliament. However, clerical leaders claimed that the Shitte-inhabited areas lacked infrastructure and state services such as healthcare and education103.

Hezbollah aimed to protect the marginalised Shia communities in Southern Beirut, the Bekaa valley and Southern Lebanon from the sectarian policies imposed after the declaration of Lebanese independence and openly opposed the neo-liberal economic order (Lecocq, 2020, p. 1071).

Many of Hezbollah’s founding clerics had studied under the supervision of Iran’s future leader, Ayatollah Ruhollah Khomeini in Kom and Najat, the new movement endorsing his supreme political authority in accordance with the wilayat al-faqih (rule of the supreme jurist) and turned to Iran for help. Moreover, the clerics were prominent personalities within Shia political circles, and they did not encounter problems in terms of mobilising popular support for the movement.

Even though Iran came to their help, the fact that they did not bring new leaders increased the 206

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legitimacy of the movement (Devore and Stähli, 2014, pp. 337-342). Iran did not hesitate to use this opportunity to create a new powerful ally that would help in the mission of challenging Israel to become a regional hegemon. Therefore, it did not spare any expense and provided a generous annual allowance of approximately 140 million dollars during the 1980s which was lowered to 100 million in the following years (ibid.). Moreover, during the summer of 1982, Iran sent 5000 members of its Islamic Revolutionary Guard Corps to the Bekaa Valley and offered safe havens within its borders.

However generous these gestures may seem, Iran did not stop here. It started lobbying Syria to contribute to the movement’s progress. Syria recognized in this group a valuable military instrument that could help them challenge the Israeli authority, but it also considered them dangerous in terms of diminishing its influence over Lebanon. The process of negotiating the deal with Syria proved to be more difficult than initially envisioned by Iran. Hafez-al-Assad was only convinced to allow Iranian aid to freely transit its territory after he was promised an annual provision of nine million tons of free oil. Whereas the relationship with Iran was preserved in relatively good conditions, the one with Syria was rather tumultuous as there were multiple clashes between Hezbollah and Syria’s armed forces and its Lebanese clients (ibid.).

ISIS is a predominantly Sunni militant organisation that has emerged after the US withdrawal from Iraq. In the beginning, it operated under the umbrella of Al-Qaeda and kept a relatively low profile and focused on attacking foreign troops instead of locals. However, in 2011, the group began attacking the Nouri Al Maliki-led government (Shia dominated government). The SunniShiia divide determined its creation. In 2003, the US tried to impose a democratic regime which brought most Shiites into positions of power, this change in policy fueled sentiments of injustice among the Sunni population. Given the fact that the Shia minority was oppressed under Sadaam 207

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Hussein’s regime, they tried to get revenge and impose their authority in every aspect of social life, from politics to education (Anon, 2015, p. 3).

The Syria-Iran collaboration allowed Sunni Islamist groups to establish bases in Damascus and provided them with sanctuary, tactical information, intelligence, and training. In exchange these groups strengthened the Syrian regime: as they opposed Israeli and Western occupations, they helped the regime create the image of an important promoter of Arab nationalism and it enabled Syria to continue to maintain control over the Islamist militancy within Syria. This collaboration has its origins in the 1990s, when Al-Qaida, Iran, the Syrian regime, and Sunni militants worked together to support Sunni fighters and Al-Qaeda operatives. However, when the Civil War broke out in Syria in 2011, ISIS turned its back to the incumbent regime and tried to gain as much control as possible (Khatib, 2018, p. 208).

ISIS has proved to be very efficient in terms of managing its finances and compared to Al-Qaeda is not as reliant on rich-donor countries to sustain its activity. One of the most profitable sources of income that it has at its disposal is oil. ISIS has the capacity to produce 25,000 barrels a day which generates approximately up to 1,2 million dollars daily. However, throughout the years, ISIS has received very important contributions from the government and private sources in the rich oil monarchies of Kuwait, Qatar, and Saudi Arabia. Turkey also played an essential role in the development of ISIS through either undeclared policy or neglect. As the violence increased in Syria, the weakened Kurds and Assad’s regime were more profitable than investing in operations that would halt their advancement in Syria.

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Methodology The Ottoman Era Owing to the relatively scant legal documentation of the period and lack of translation, we have focused our research on larger historical compendiums, mainly journals, articles and books detailing specific issues regarding the Levant at this time. Barkley & Gavrills’ piece on the Ottoman millet system proved especially helpful in providing the backdrop for our work (Barkey and Gavrilis, 2015). In recognising the millet system’s decisive role in ethno-religious relations across the former Empire, even to this day, we chose to structure our reading and analysis around the parameters set by this model to better understand its implications for the period at hand, and for the present. Weighing the relative weight of historical information regarding Second Constitutional treatment of these religious groups in the Levant, and the degrees to which violence typically embodied this, has been the key methodological approach to our assessment of how much (1) Ottoman state policy led to violence; and (2) foreign state actors impacted violence. Here we have taken violence to mean any expression of physical harm caused to human beings by other human beings, directly or indirectly.

The British and French Mandates Our approach for the methodology utilised for the British and French Mandates era is similar to our methodology used when we studied the Ottoman Era. We analysed historical documents and events and interpreted quantitative data on public opinion immediately before the implementation of the British and French Mandates. We collected the information and data that would assist with answering our research question of how foreign involvement contributed to destabilisation of the region. The quantitative data we analysed was from a 140-page study conducted in 1919 by two 209

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American researchers, Charles Crane and Henry King (The King-Crange Commission Report, 1919). By interpreting the calculations from this survey, we were able to apply that information, along with what the British and French authorities were officially writing on government documents, to secondary sources (primarily academic journals) regarding the British and French Mandates. These secondary sources included explanations on why the French or British were interested in obtaining control of the Levant, the challenges faced by the French and British while governing the local people, and the violence seen as a result of the Mandates (e.g. riots).

Post- World War II When we researched sources specifically pertaining to the Levant post-WWII, we analysed modern policies, treaties and reports created by the parties involved in the conflict, allowing us to better understand how the region was affected. We combined the observation of historical documents with the interpretation of quantitative data on public opinion from the disputed territories in Gaza.

We observed and analysed official documents written and ratified by the U.S., the U.S.S.R and states such as Syria, Israel and Jordan during the Cold War. One example is the Peace Treaty between Jordan and Israel which was signed in 1994. By examining what the documents were conveying, we broadened our perspective on the alliance system during the Cold War using the study of Daigle and Kalinovsky (2014) which represents a valuable historical secondary source.

Moreover, in order to understand the religious divides in the region, we analysed the quantitative data from the report “A nation divided: Palestinian Views on War and Piece with Israel” conducted by the Washington Institute for Near East Policy. We also assessed the data from the Arab Opinion Index gathered by the American think-tank, the “Arab Centre Washington DC''. This enabled us 210

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to put together the pieces of different religious identities and study how foreign powers have tried to take advantage of them in order to mask their hegemonic aims. Furthermore, in order to determine the role of ultra-right wing movements in the escalation of violence and who are their main supporters we used reports issued by the U.S. State Department on Counterterrorism and the Syrian Network for Human Rights. We also took advantage of the Freedom House Index to examine the level of violence and repression against certain religious minorities in Syria. Although these resources are extremely valuable as they provide the most up to date information that we have about this issue, it is important to note that they might contain an American bias.

Limitations in Methodology Within our three divisions of research subtopics, we experienced the limitation of heavily relying on qualitative data. The inability, at the time of writing, of navigating through publicly available online archives made the identification of original official documents reporting the amount of casualties, wounded and arrested individuals in each protest, revolt, terrorist act event in order to compute them and carry out a quantitative analysis. The hardships in retrieving data and documents of demographic nature concurred to divert the research trajectory towards secondary sources.

Although statistical data for conflicts that occurred post-WWII are more accessible online, it is extremely difficult to find data after 2012. Even though most foreign powers have led foreign interventions in the area, the extent of their external economic and military support is unknown and therefore could not be quantified.

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Recommendations and Limitations Due to the structure of our paper, we will present our information in chronological order in terms of historic era.

Concerning the Ottoman policy’s bearing on both subsequent and present-day conflict between ethno-religious groups in the Levant, we are forced to conclude that the empire’s failures to respond adequately to rising nationalist sentiment have had and continued to have long-lasting impacts on ethnic relations in the region. The CUP’s [party dictatorship of the Empire post-Young Turk revolution] active promotion of violence and negligence towards particularly Christian populations established a precedent of ethno-religious conflict in the Levant that is yet to subside.

It is evident that the nation-state building project that the CUP was pursuing, in line with the earlier Tanzimât Reforms, heightened the nationalist sentiment of subject populations, especially that of Armenian/Assyrian Christians and Jews. Secularisation and centralisation were the main intensifiers in this respect, in line with similar case studies of the time (the Habsburg Empire faced remarkably similar complications).

It should be noted that the degree of CUP persecution of ethno-religious minorities of the Levant was far less severe or direct than in other regions, indicating perhaps that greater responsibility for current conflict falls on the involvement of later powers in the region. However, it cannot be denied that atrocities such as the Lebanese famine will continue to incentivise ethno-religious discrimination and violence. The difficulties in secularising a state already legally predicated on ethno-religious divides were by no means overcome by the CUP, and the continued existence of millet-esque legal structures across the Levant today are testimony to the intense historical weight 212

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that underlies the ethnic divides there. Governments would be hard-pressed to “secularise” the region considering the inseparable reality of faith and ethnicity to local populations.

Britain and France’s involvement in the region was particularly geared at intensifying ethnic conflict for the sake of destabilising the region. French intervention on the behalf of Christians within the empire helped increase general Christianophobia in the region. French intervention had also resulted in further division between Muslim sects. British involvement in the Arab Revolt stoked intra-religious tension and violent national ambitions which may not have emerged without it. The subsequent failure of Britain to live up to promises made to certain populations in the aftermath of the empire’s collapse cannot have played a positive part in easing tensions in the region. The animosity toward Levantine Christians and the programmatic attempt at eliminating them from the region continues within the programmes of terrorist groups today,112 and locating its origins in the late Ottoman Empire’s initial attempts will prove vital for future attempts at understanding and mitigating further persecution of Christian minorities.

The British and French Mandates' attempt and partial accomplishment of dividing the small region into various states on the basis of religious and ethno-religious identity continued the Ottoman Empire’s tactic on the management of the Levantine population. The lack of consideration of the desire of the local Levantine population, other than the Jewish migrants and Lebanese Christians, presents the harm in institutions being established without input from the population. However, the British imposing favourable policies for the Jewish population resulted in increased tension from the Arab population and the French dividing the Muslim and Christian population caused further The long-term impacts of enforced religious division by the British and French in the Levant include violence and instability, which have been the centre of discussion in this paper.

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The increased influence of the US in the area and the surge in Israeli’s capabilities made other states like Iran, Syria and the U.S.S.R. to take action against them. Iran sponsored the creation of Hezbollah, in Lebanon, after the second Israeli invasion in this country. It exploited the fact that in Lebanon, Shia Muslims were highly discriminated against and fuelled the divide between Shia and Sunni Muslims. It also convinced Syria to offer safe havens to this group across its borders.

Hezbollah is proactively participating in the Syrian War which led to the increase in the duration of the conflict and the suffering of the people. In a similar way, ISIS took advantage of the grievances of the Sunni Muslims after the US invasion in Iraq. In 2003, the U.S. tried to impose a regime that put Shia Muslims in power. Given the fact that this population was oppressed during the Sadam Hussein’s ruling and tried to get revenge which fuelled the feeling of injustice among Sunni, therefore it was easy for ISIS to get a strong base of supporters.

We recommend that policy reflect the desire of ethno-religious groups to be treated as such, and a recognition that concerted efforts at applying western notions of “human rights” will not wholly be responded to positively by the region. Hegemonic and totalising moral and legal structures, particularly those based on western democratic ideals, cannot reflect the ideals and ambitions of ethno-religious groups’ identity, particularly in regards to their legal structures. At the same time, the irreconcilable nature of certain beliefs and doctrines within other ethno-religious groups cannot be ignored as a cause of extreme violence, and in this regard, policies seeking peace must be centred around mediation rather than intervention. It is clear that the legacy left behind by western intervention has had detrimental effects to the perceptions of western states in the Levant by both governments and people, and as such neutral bodies such as the UN should be expected to fulfil these obligations of mediation and containment of violence in order to preserve peace and prevent the growth of radical terror cells.

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Conclusion After conducting research regarding the question of the extent foreign involvement has impacted instability in the Levant, we have found that foreign actors are heavily responsible for the instability in the region - specifically, the inter and intra-religious conflicts that are seen persisting in the region. The trend of widespread violence and instability throughout a region once colonised by external powers is found to be the cause of the instability in the Levant, thus bringing to light the importance of addressing the history of a formerly colonised region when drafting a policy that may impact the region and its inhabitants. It is likely that is the Levant had not endured a significant amount of foreign interference, it may present a more peaceful, coexisting religious society in the present-day.

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Syrian Network for Human Rights., 2013. The Shifting Realities of Areas of Control between Syrian Regime and the Free Army in the Syrian Revolution. <https://sn4hr.org/wp-content/pdf/english/2013/areas_control_arabic_en.pdf> Tanielian, Melanie, 2012. The War of Famine: Everyday Life in Wartime Beirut and Mount Lebanon (19141918) The End of the Jordanian Option, 1988. Journal of Palestine Studies, 18(1), 246–249.

The Hope-Simpson Commission Report, 1930. <https://balfourproject.org/hope-simpson-report/> The King-Crane Commission Report, 1919. The King-Crane Report - World War I Document Archive (byu.edu) The modern Middle East: State formation and World War., 2005. The Middle East in International Relations, 75–96.

Ulker, Erol; Contextualising ‘Turkification’, 2005. Nation-Building in the Late Ottoman Empire, 1908-18 in Nations and Natioalism, 11.4 613-636 US State Department. 2020. 2020 Report on International Religious Freedom: Syri. OFFICE OF INTERNATIONAL RELIGIOUS FREEDOM. https://www.state.gov/wp-content/uploads/2021/05/240282-SYRIA-2020-INTERNATIONAL-R ELIGIOUSFREEDOM-REPORT.pdf Verdanyan, Gevorg, 2017. Genocide in the Ottoman Empire: Armenians, Assyrians and Greeks, 19131923 What do Palestinians want? The Washington Institute. (n.d.). <https://www.washingtoninstitute.org/policyanalysis/what-do-palestinians-want> Wolf, A.B., 2015. The Arab Street: Effects of the Six-Day War. Middle East policy, 22(2), pp.156–167.

Zurcher, Erik-Jan, 2013. Turkey: A Modern History

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Exploring the Digital Divide Associated with the Increasing Use of Transformative Technologies in Southeast Asia

Nur Shahidah Azmi*, Linge Guo, Nadya Mykhaylevskyy, Leila Naim, Antoine Roux de Luze

We would like to sincerely thank Ms. Silvia Binenti from the UCL Department of Geography for taking the time to review our work and provide helpful, honest and detailed feedback. Her comments were instrumental in helping us improve the quality of the finished product. Special thanks to Professor Kentaro Toyama from the University of Michigan for kindly participating in an interview with our team to discuss his work on the Law of Amplification.

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Table of Contents Introduction ............................................................................................................................................................... 222 Methodology ............................................................................................................................................................... 225 Analysis and Discussion ............................................................................................................................................ 226 1. Rising Importance and Presence of Digital Technology in Asia Style ......................................................... 226 Recent Technological Sector Development in Asia .......................................................................................... 226 Digital Technology in the Era of COVID-19..................................................................................................... 227 2. Examining the Digital Divide in Southeast Asia ............................................................................................ 230 The Impact of Existing Income Inequalities on the Digital Divide ................................................................... 230 Inequality Caused by Exclusion from Digital Networks ................................................................................... 231 The Impact of Inequalities Arising from the Digital Divide on Other Social Inequalities ................................ 232 The Law of Amplification: Technological Advancements and the Digital Divide ........................................... 234 Addressing the Digital Divide During COVID-19 ............................................................................................ 236 3. Obstacles to Closing the Digital Divide ........................................................................................................... 238 Digital Accessibility: Barriers to Entry .............................................................................................................. 238 Monopoly of Information: Public Health Concerns .......................................................................................... 243 Limitations ................................................................................................................................................................. 247 Conclusion .................................................................................................................................................................. 248 Bibliography ............................................................................................................................................................... 250

Last but not least, we would like to express our gratitude to Ms. Xuen Rong Chin from the UCL Division of Biosciences for her editorial support in the final draft. *

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Abstract: Governments across Southeast Asia have recognised the importance of technological development for not only economic growth and national competitiveness, but for the improvement of education and quality of life for their citizens. The COVID-19 pandemic showed the world how adopting transformative technologies could benefit society, and simultaneously highlighted the consequences of the digital divide. In this collaborative article, we explore primary and secondary literature on case studies across Asia, along with an interview with international development researcher Kentaro Toyama. We found that while digital technology can have massive benefits to populations, its widespread implementation without policies that effectively tackle existing societal inequalities could simply leave communities behind and exacerbate the problem.

Introduction As we approach the end of the first quarter of the 21st century, digital technology seems to have become a must in many sectors. In the Association of Southeast Asian Nations (ASEAN) region, it is emerging as an important factor in economic development objectives and, as such, is receiving increasing attention and resources from governments. The ASEAN is a political, economic and cultural organisation comprising the ten countries of Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam. In the literature referenced in our paper, this geographic focus has been referenced as “ASEAN region” and “Southeast Asia”.

The COVID-19 pandemic has shown how crucial digital technology and data processing skills are, through their use in the fight against the virus. The most successful responses to the pandemic in East and Southeast Asia have indeed made extensive use of digital technology: China, South Korea and Singapore are examples of efficient management of the pandemic - although admittedly debatable in their respect for privacy. Taking advantage of these new data processing technologies, they set up tracking and quarantine systems that allowed the pandemic to be brought under much tighter control. Conversely, countries less familiar with new technologies or with fewer resources, 222

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such as Cambodia, Laos and Myanmar were hit harder at the peak of the crisis, being unable to implement such methods (Clavier and Ghesquiere, 2021).

It is important to note that the field of digital technology should not be viewed as an isolated sector, but as a multi-relational one, with strong links to economic, political and socio-cultural factors. Its prevalence depends on the health and stability of these factors, which are the keystones of successful digital development. As explained by Kentaro Toyama’s works on the Law of Amplification, "technology's primary effect is to amplify human forces" (Toyama, 2011). Digital technology is therefore a means to further develop an already existing incentive, or an already sufficiently stable sector, but it cannot be the key to a given problem by itself. It is a contribution of unprecedented scope, but a secondary contribution nonetheless. In line with this theory, this paper considers that new technologies are not a quick fix to the problems faced by developing countries, but an opportunity for development that must first and foremost be based on sound economic and social foundations that are favourable to its emergence and use. The development of digital technology in countries where it is not yet widespread should follow a clear plan, avoiding the common pitfall of seeing it as a miracle solution to all ills. Digital technology comes with its own shortcomings.

Indeed, while the digital age seems to be well under way, it carries with it new inequalities, both between and within countries. These digital inequalities are generally grouped under the term “digital divide”, defined as “stratification in the access and use of the Internet” (Ragnedda and Muschert, 2013, p.1). The digital technology sector is closely linked to the economic, political and socio-cultural situation of the country in which it is considered. It can therefore reproduce and amplify existing inequalities: “Social inequality and disadvantage is being reproduced and 223

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reconfigured within the networked society” (Ibid., p.26). In developing countries in particular, unequal access to digital technology and adoption of digital devices are both consequences and causes of social inequality. A consequence, because of its interaction with other divides such as rural-urban, age, gender or social class divides. A cause, because the digital divide brings a new dimension to the problem, in which these inequalities are rehabilitated and reinforced: people without access to digital technology are excluded from the information society, which discriminates against them even more. It’s worth mentioning that the“digital divide” is a term only recently coined by the UN. Our paper also references the situation in Southeast Asia as what has been referenced as a “digital inequality”, “digital literacy divide”, and so on.

This paper is a collaborative article exploring this topic as a starting point for a wider discussion, and the different sections examine the use of transformative technologies and digital divide from distinct angles. We begin by looking at the benefits of transformative technologies in Southeast Asia. We assess their importance and growing presence in Southeast Asia, with some examples from China as well. It is worth noting, however, that there exists substantial differences in the economic, geographic, and population structure between mainland China and Southeast Asia (ASEAN) region, that have notably weighed in their solutions to COVID-19. Looking at these solutions, we investigate the role of digital technologies in the COVID-19 era. In the second section, we address the central theme of this paper: the digital divide. We begin by stating our belief that more digital technology by itself cannot be the solution to closing the digital divide, following the principles of Toyama's Law of Amplification. We then examine the links between the digital divide and other existing social inequalities, before analysing the digital divide in the context of the COVID-19 pandemic.

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The third section deals with the obstacles to closing the digital divide. We divide these barriers into four different categories, according to those used in The Economist's Inclusive Internet Index (The Economist, 2021): digital accessibility, internet relevance (which includes language barriers), internet readiness (digital literacy and digital education provided) and internet affordability. These barriers are discussed in relation to the case of Indonesia, a country with great potential where digital technology is increasingly prevalent, but which is nevertheless emblematic of the inequalities that can arise from the digital divide. Following this, we discuss the monopoly of information and the subsequent spread of misinformation. We put our findings into perspective in relation to the recent pandemic, investigating the impact such monopolies can have on healthcare.

Methodology This paper chooses a pragmatic stance in articulating the digital exclusion various communities in Southeast Asia face, and how such difficulties faced were connected to the technological national strength in development and internet skills index. To articulate the status quo and impact objectively, mostly quantitative data, graphs and figures are employed in the discussion of the digital divide. Reports, surveys and questionnaires from OECD Development Centre, WHO, World Bank Group, UNICEF, and East Asia Forum are included, as well as research papers from various forums, such as Asian Economic Papers, Humanities and Social Sciences Communications, which are navigated for comparative studies on Asian countries.

Apart from the two main types of evidence sources, the paper also takes a qualitative approach.

One methodological highlight for the paper is the interview we conducted with Professor Kentaro

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Toyama in January 2022, to understand his insights on the Law of Amplification and its relation to the digital divide.

Analysis and Discussion 1. The Rising Importance and Presence of Digital Technology in Asia Recent Technological Sector Development in Asia Over the past few decades, Emerging Asian economies (Southeast Asia, China and India) have demonstrated a growing rate, reported by the data from the OECD Development Center (2014).

Mahmood and Singh hypothesise two theories behind the positive growth trends: accumulation and assimilation. The former centres on the possible technological investment from high savings of Asian economies, the latter proposes the learning and entrepreneurship that resulted in innovation (Mahmood & Singh, 2003). Both are potential contributors to the rising significance of technological development in Asia in recent years.

In the era of COVID-19, digital technology is becoming more pervasive, for example, in Singapore.

In an article for the Business Times, Chia defined and predicted digitalisation as “a permanent fixture of everyday life and will likely grow in importance in coming years”. By taking large-scale surveys of 202 business decision makers, along with 219 workers within a longitudinal study, the study concluded “nearly three in four” Singaporean organisations accelerated their pace of digitalisation in response to COVID-19 (Chia, R., 2020). According to Tan, “As mobile services proliferate, the national goal is to have 100% of Singapore’s government services digitised and 95% of citizen-to government transactions done online by 2023 (Tan, n.d.) .” This implies the rising presence and significance of digital technology in Singapore, by the demand and prediction 226

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of the integration of digitalisation in people’s daily lives. This implication and the trends could be extended to other Asian countries as well.

Even outside of Southeast Asia, neighbouring countries such as China have had a significant uptake in digital technology to solve issues in digital inclusion. An article by WHO has outlined varying aspects of how China harnessed digital technology to “integrate” the society, especially in coping with the digital divide of elders because of the digital barriers they faced. Elders (aged 60 or above) in China comprise 18 percent of the population, and the number is predicted to reach 500 million in 2025 from 254 million in 2019 (Xinhua, 2020). COVID-19 revealed a high degree of digital exclusion creeping in every society. The use of digital health code as one mobility measurement has obliged the elderly to efficiently use applications such as Alipay in almost every public space.

For the seniors who might lack the cognitive capability in figuring out how to navigate the application, the government assistant checking the digital health code at passenger transit stations will help the elders to ensure the digital barriers presented would not prevent them from travelling and accessing their daily activities. The Chinese usage of digital technology assisted in helping the older population to adapt to the “pervasive digitization”, reducing the digital gap between the younger generation and the elderly counterpart (Lei, 2020; WHO News, 2021).

Digital Technology in the era of COVID-19 Since the beginning of the COVID-19 pandemic, the role of digital technology in healthcare has had a profound progression, and has been used as a way to both measure and mitigate the transmission of the highly contagious respiratory disease. Asian countries, in particular, provide rich data and clues as to how digital technology can contribute to these efforts, as they have been at the forefront of technological development for decades, and have managed highly contagious 227

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disease outbreaks in the past. Southeast Asia’s responses to SARS and H1N1 in 2002 and 2009 have built a framework for epidemic preparedness that includes both digital and non-digital responses across the region. Testing these across the continent’s diverse cultures, geographies, and economies have determined the extent to which technological efforts reduce the human and economic impact of the pandemic, and how much they depend on existing efficient health systems.

The consensus is that countries that have accompanied their contact tracing, surveillance, and viral testing with digital solutions have had the lowest COVID-19 per-capita mortality (Clavier and Ghesquiere, 2021). The use of digital technologies have simultaneously accelerated collaboration across local and national governments, research databases, medical professionals, and society as a whole. The ASEAN region, in particular, focused especially on strengthening their COVID-19 response with digital technology. According to the World Bank, digital solutions served primarily seven purposes: digital contact tracing, self-reporting, communication, decision making, aid distribution, behaviour change, and economic recovery (Ibid.). As seen in the figure below, numerous applications, online marketplaces, web platforms, and other digital solutions have been distributed and utilised across the region.

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Figure 1 – Country Distribution and Main Functions of Digital Solutions Used in the ASEAN.

Region during the COVID-19 Pandemic (Clavier and Ghesquiere, 2021, p.2) 2020 and the advancements in digital technology since are extremely exciting for the future of healthcare. The widely adopted use of digital solutions means that now technological companies, individuals, and governments have seen the potential for these applications, and can be incorporated in other areas of healthcare such as the fight against chronic disease. Singapore’s health tracing system is a perfect example of successful implementation of digital technology and the potential of the implementation of digital solutions in healthcare. In this situation, crisis can be seen as an opportunity, and the COVID-19 pandemic has certainly proven that (Fauzi, et al., 2020).

It is important to note, however, that the success of digital tools depends highly on an already successful and productive health infrastructure. As we will discuss in further sections, the Law of 229

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Amplification suggests that digital technology alone can’t be a universal solution to unresolved issues such as a fragmented or underdeveloped health system. This idea is proven in what is known as the “Digital Divide”.

2. Examining the Digital Divide in Southeast Asia The Impact of Existing Income Inequalities on the Digital Divide As Melody (1987) wrote, “a major challenge for public policy will be to find methods to ensure that developments in the information and communication sector do not exacerbate class divisions in society and that its benefits are spread across all classes” (p.1336). Yet, a few years later, Van Dijk defines the digital divide as “stratification in the access and use of the Internet”, therefore ”inevitably t[ying it] with the concept of social inequalities” (Ragnedda and Muschert, 2013, p.1). Indeed, the digital divide is often seen as building on existing social inequalities, perhaps even widening them: elites enjoy the benefits of digital technologies, while the excluded classes are denied these benefits.

As Ragnedda and Muschert put it, “Social inequality and disadvantage is being reproduced and reconfigured within the networked society, specifically as digital divides.” (2013, p.26). It would thus be a catalyst for social disintegration that would exclude certain groups from the information society, a perspective that runs counter to the original idea of cyberspace as a space open to all and where all are equal.

The particularity of digital technology is that “it cannot be utilized without other resources such as education, language and writing skills, and good socio-economic conditions” (Ibid., p.26). These other resources mentioned by Ragnedda and Muschert are therefore all necessary conditions for

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the full use of digital technology. All of them also form the basis of an individual's social status.

Consequently, the level of digital use by an individual depends on his or her social position and living conditions, according to which he/she is endowed with a number of resources that enable him/her to make use of digital technology or not (Ibid.).

Moreover, digital technologies are becoming increasingly important in our interactions with society, whether in the economic sphere, for political engagement, access to culture, education etc.

Being disconnected from this information society is therefore all the more discriminating. It is this discrimination that reinforces the existing inequalities, because of which one cannot access the digital one the first place, thus creating a vicious circle (Ibid.).

Inequalities Caused by Exclusion from Digital Networks Digital inequalities fall into two categories: the first order divide, dealing with inequalities in access to the internet, and the second order divide, dealing with inequalities in the adoption and use of new technologies (Dewan and Riggins, 2005).

When considering the first order divide in relation to social inequalities, economic ones matter the most. More than GDP per capita, the most important factor here is income distribution: if high class inequalities are in place, then it is likely that the disadvantaged part of the population cannot afford access to digital technologies (Fuchs, 2009).

This view of the digital divide must be contrasted, however: although the most extreme inequality is between those who have and those who do not have access to digital technologies, there are much finer degrees between these two extremes. Thus, particularly in developing countries, it is quite 231

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common that even "among those with web access, there are nuances to the digital divide" (Ragnedda and Muschert, 2013, p.2).

Today, interest in the divide over internet access is shifting to interest in the divide over internet use. This is where the second order divide, relating to the disparities in the use of ICTs, is involved.

By definition, having access to the Internet is not enough: sufficient digital knowledge is required to properly make use of the advantages it offers. Here, the level of education and the resulting digital skills are crucial: people with “good education and high skills are more likely to [...] be capable using them [ICTs], to benefit from this usage [...] than people who are endowed with only a little amount of economic, political or cultural capital” (Fuchs, 2009, p.47). The way forward in reducing digital inequalities would therefore necessarily include a focus on digital empowerment of disadvantaged populations.

The Impact of Inequalities Arising from the Digital Divide on Other Social Inequalities Van Dijk separates the impact of the digital divide on social inequalities into two different categories: absolute inequality and relative inequality (Van Dijk, 2020). The first refers to the inclusion or exclusion of an individual or group of people from a certain sector of society because they do or do not possess the necessary attributes to be connected. In practice, this 'absolute' inequality means that the group of people in question, if they do not have access to digital and the skills to use it, are excluded from the processes that require it: job application, online commerce, public and government services. The second is not the impossibility of access to a given service, but the advantage possessed by the "information elites" through their extended access to digital. In that sense, existing social inequalities are reinforced, as these elites enjoy the benefits of these new tools to which the less fortunate do not have access: the gap widens.

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Figure 2 – Tripartite participation in the network society. (Van Dijk, 2005, p.179).

With regard to the participation of the population in the digital domain in a network society: First, there is the core, the 'information elites': a privileged minority that has the best opportunities both in terms of access to the digital sphere but also in terms of its use.

Then comes the majority of the population, which has some access to the digital world, but less than the information elites. Finally, outside the circle of participation are the so-called disconnected, excluded minorities. These groups of people are the most disadvantaged by their preexisting social condition: they have difficulties in accessing the Internet, whether economic or geographical (rural areas, etc.). Moreover, they are also deprived of the skills often necessary to

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use technological tools, notably because of their cultural situation and their less advanced level of education.

This stratification of access to and adoption of digital is a case of the Matthew effect, which can be summarised by the well-known adage: 'the rich are getting richer' (Merton, 1968). The information elites experience better conditions than the majority in their use of new technologies. These resources enable them, in turn, to improve their position and strengthen their social superiority.

This has the effect of consolidating the social hierarchy and keeping the less advantaged at the bottom.

The Law of Amplification: Technological Advancements and the Digital Divide The Law of Amplification stands in opposition to a widespread view of technology; that it is a quick fix. The literality of which is highlighted by the words of Dane Scott stating that the term “technological fix” “has become a common rhetorical tool in debates over emergent technologies” (2010). Although the digital divide is defined distinctly from social issues of poverty, inequality etc, they are inextricably linked. The Law of Amplification highlights the connection between other social issues and the issue of the digital divide. Other social issues enhance the digital divide and the digital divide enhances them right back. The Law demonstrates how the advancement of technology not only leaves many members of groups facing poverty, inequality in the dust but can also act as a tool of distraction for them instead of as a tool of productivity.

Firstly, we will explore the belief that technology is, in itself, a transformative superpower capable of saving us from social scourges. In his essay, Technology as an Amplifier, Toyama briefly mentions the “One Laptop Per Child'' project (2011). On their website, the project claims to be a 234

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service providing “more than a laptop. We are a social transformation program through learning.”

The founder, Nicholas Negroponte’s, claims that “kids in the developing world need the newest technology, especially really rugged hardware and innovative software”. The use of the word “needs'' implies a necessity to technology, labelling it as a requirement. Are laptops really what children of LEDCs need? Surely there are more pressing pedagogical needs? Classrooms, resources, qualified teachers are all a critical foundation onto which one can then add technology to accelerate the already-started process of improvement. Providing digital gadgets to the underprivileged is nothing more than a band-aid on a bullethole- the case of education will be examined in more detail below. The Law of Amplification aims to show that this project is the sort of proposal involving technology that actually harms the cause it is attempting to aid.

Essentially, the Law of Amplification is the theory that “technology’s primary effect is to amplify human forces.” Building on previous theories, Kentaro Toyama writes that technology “can indeed have a significant impact, but it is not guaranteed” (Ibid.). This impact is a positive one when the pre-existing conditions are already of a ‘good’ standard; technology “has no independent will and so cannot be the cause of anything” - it is a tool humans use to facilitate their everyday lives.

Capacity and intent are two necessary ingredients to positive results, technology “can only amplify existing human capacity and intent: it cannot act as a substitute where human capacity and intent do not exist” (Ibid.). Toyama uses the example of technology being unable to change the intent of the government to govern a country without corruption. Technology only “creates” good when the people using it are both capable and willing to use it productively. In the context of social issues, it will only amplify the existing problems- widening the gap between those suffering and those not suffering from the issue in question. The Law of Amplification is not a wholly new concept; below are previous theories that have suggested a similar notion.

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In his essay, “Real-Time Politics: the Internet and Political Progress”, Peter Agre writes “the internet changes nothing on its own, but it can amplify existing forces, and those amplified forces might change something” (2002). Although he specifically applies the amplification model to the internet’s role in politics, we can use this line of reasoning for social divides. For example, the internet allows a platform for the creation of groups whose members want to protest the systematic racism of the legal system. This unification allows for a deeper and wider exploration, critique and hence fine tuning of ideas due to the increase in diverse viewpoints and discussion/debate. Then, these improved plans are what actually might change the prejudiced legal system.

Addressing The Digital Divide During COVID-19 As mentioned previously, the digital divide is clearly evident in the different success rates of COVID-19 health protocol which utilised digital solutions across the ASEAN region Populations who lie in the “unconnected and excluded minorities” group (Van Dijk, 2015) are at the highest risk for being disproportionately impacted by COVID-19, and at an increased risk of contracting the disease itself, according to the social determinants of health.

In addition to the digital readiness divide across countries in the region, a stark division lies within countries, and further evident between urban and rural populations. This means that while successful digital solutions may exist within countries, if they are solely successful in urban areasa large majority of the country’s population is left behind. GrocerDel, a Cambodian online grocery delivery service, has seen extreme success over the pandemic and has seen sales shoot up nearly 165% (UNCTAD, 2020). The ability to receive groceries at the front door helps individuals abide by social distancing and quarantine measures. The downfall is that this platform is only available in the capital city of Phnom Penh. This also means there are less employment opportunities for 236

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those living in rural settings. The also prevalent socio-economic divide within Cambodia is closely correlated to the urban-rural divide, as “99% of the lowest wealth quintile residents live in rural areas” (Nit et al., 2021). Those living in rural areas have less access to the internet, as fixed-line networks are not readily available.

Figure 3 – Total Population in Urban Areas in ASEAN (Kusumastuti, A. & Nuryani, A., 2020).

Figure 4 – (Dahlgren G., Whitehead M., 1991).

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Looking at this issue from a population health perspective, the digital divide is indeed a risk factor for poor health. As discussed, lower levels of digital literacy during COVID-19 prevent individuals from maintaining social and community networks in lockdown, and negatively affect living and working conditions as well as education. The urban-rural divide and generational divides are examples of those socio-economic, cultural, and environmental conditions that impact health.

These risk factors are all cumulative, affecting health in everyday life and beyond the pandemic (See Figure 4).

3. Obstacles to Closing the Digital Divide Digital Accessibility: Barriers to Entry Internet access for all is far from being a reality. Many inequalities in access and use of these new digital technologies remain, forming a gap between digital technology 'haves' and 'have-nots' known as the digital divide. In this section we explore digital accessibility and the barriers that exist to digital inclusion. To illustrate these barriers, we will use the case study of Indonesia looking at the four criteria employed by the Inclusive Internet Index developed by The Economist: internet availability, internet relevance, internet readiness and internet affordability. We will elaborate on these criteria as we discuss them further. In terms of Internet availability, Indonesia is ranked 59th out of 120 countries (The Economist, 2021). Although statistically Indonesia ranks well, suggesting it has a satisfactory internet penetration rate, this does not accurately reflect reality, as we shall see below.

The first criterion is internet availability, which analyses the quality and extent of the infrastructure necessary for optimal internet availability. It can be divided into four sub-categories: usage, which

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measures the proportion of the population that is connected; quality, which assesses the quality of the network provided; infrastructure, which evaluates the availability of connectivity and the extent of access to the internet; and electricity, which examines the presence of basic infrastructure necessary to use digital tools (Ibid.).

First of all, the scarcity of the infrastructure puts Indonesia’s network stability at risk. A recent incident shows the fragility of this still nascent network: in April 2021, the submarine cable linking the Sulawesi region to Papua broke, causing internet problems for months, before the network was - only partially - restored in June 2021. Papua's capital, Jayapura, and two other cities, Keerom and Sari, were the hardest hit. (Freedom House, 2021) The Indonesian network is still fragile, and vulnerable to any incident that might affect it.

Secondly, there is the question of the divide between urban and rural areas of the country. As Freedom House's 2021 report on the Indonesian Internet states, “despite increasing penetration rates and improved infrastructure, connectivity remains highly concentrated in the western part of the archipelago, particularly on the more urbanized island of Java”. (Ibid.). Indeed, a study carried out in late 2020 by the APJII (Indonesian Internet Service Provider Association) indicated that the island of Java alone accounted for 56.4% of Internet users, followed by the island of Sumatera with 22.1%. At the bottom of the ranking are the easternmost, rural regions of the country: Sulawesi, Kalimantan, Bali-Nusa Tenggara and Maluku-Papua, which account for 7, 6.3, 5.2 and 3% of Internet users in Indonesia respectively. The divide is clearly visible here, as almost 80% of the country's internet users reside in the more urbanised islands of Java and Sumatera in the west (APJII, 2020).

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Finally, it is important to define the notion of internet access. Indeed, for millions of Indonesians, the Internet connection they have access to is a 2G connection using satellite technology. Their use of digital technology is therefore limited to mobile. In addition, their limited internet connection restricts them to applications like Facebook and Whatsapp that require low levels of connection.

This limited internet connectivity does not even allow them to use a search engine, yet they are counted among those who have access to it (Tapsell et al., 2017).

The second criterion of interest, internet relevance, looks at the notion of language in digital access.

For example, is internet content available in the local language? Similar to previous statistics, Indonesia ranks 56th out of 120 countries polled in 2021. The main issue here is the pervasiveness of English in the digital world, which is already a barrier for many Indonesians, especially, again, in rural areas.

The third criterion, internet readiness, is particularly relevant to the case of Indonesia. It focuses on the skills to use the internet rather than physical access to the resource. It is a question of determining whether the level of "digital literacy" in the population is satisfactory. This is indeed very important, as physical access alone is not enough: one must have the necessary skills to use it. In The Economist's ranking for 2021, Indonesia is ranked 74th out of 120 this time (The Economist, 2021). Indeed, an interesting phenomenon is at work in Indonesia: Indonesians, especially the younger generation, are growing up as social media 'natives' but are not digitalliterate. The country's capital, Jakarta, is considered the Twitter capital of the world (Lipman, 2012). Further, more than 7.5% of the world's tweets in 2013 came from Indonesia (Asia Research, 2013). In 2020, almost 59% of the total population of Indonesia was actively using this application, amounting to over 160 million people (Kemp, 2020). Interestingly, it has been observed that the 240

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younger generation in Indonesia is growing up as 21st century digital natives, yet this 'status' does not lead to satisfactory levels of digital literacy. This deficiency is felt in the world of work: the UNICEF report states that by 2020, only 19% of the Indonesian workforce was applying digital skills, and only 6% had advanced digital skills (UNICEF, 2020, p.7). This confirms our finding from the section "Inequalities caused by exclusion from digital networks" that digital education must be a key component of any wide-scale effort to reduce digital inequalities.

The Indonesian school system seems to bear an important part of the responsibility: schools often fail to properly educate students in digital matters. This problem is linked to two other criteria: internet availability, mentioned earlier, and internet affordability, which we discuss below. Due to the lack of internet availability, schools located in rural areas in particular suffer from reduced or non-existent connectivity, which naturally prevents them from teaching students to use digital technology, since it is not functional in their area (Ibid., p.11). These very low digital literacy rates are therefore a very challenging problem for Indonesia, especially as it is closely linked to the equally challenging problems of internet availability and affordability.

However, according to our findings from the section "The Law of Amplification: Technological Advancements and the Digital Divide", introducing digital technology in such resource-scarce schools would be detrimental. To overcome this lack of digital education, the first step would be to improve the teaching conditions in these schools, which are often located in remote areas and isolated from urban areas.

The final criterion, internet affordability, addresses the cost of internet access relative to income, as well as the level of competition in internet services. In this category, Indonesia ranks 84th out 241

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of 120 countries: its worst ranking of all criteria. Indeed, the price of internet access is a huge barrier for many Indonesians, preventing them from accessing it. Towards the end of 2019, the price of a gigabit of data was around US$0.4, which is roughly equivalent to 6,000 Indonesian rupees (Statista, 2019). With the lowest salary threshold hovering around Rp 3,250,000, this would mean that for a 20GB package, one would have to pay Rp 120,000, not to mention the extremely expensive investment that the purchase of a mobile phone represents.

The Freedom House 2021 report highlights "the high costs of internet subscription plans". These high prices are also reinforced by the rural-urban divide: it is much easier to find cheaper alternatives in the more populated cities of the western islands than in Papua, Nusa Tenggara, Maluku etc. As demand is lower in these less populated areas, PT Telkomsel, the largest digital company in Indonesia, has a monopoly on supply in these areas. This monopoly is much less present in the big cities, where other firms can thrive because of the large number of customers (Freedom House, 2021).

In spreading digital technology to their entire population, governments in other SEA countries should therefore first aim to make digital access affordable. This requires more control over Internet providers, in order to prevent the formation of monopolies. At the same time, governments should deploy incentive-based projects to extend internet services to rural areas. This would kill two birds with one stone: providing all citizens with internet access at the most homogeneous rates possible, as well as increasing the reach of national internet coverage.

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Monopoly of Information: Public Health Concerns Monopolies significantly impact the health sector and influence the spread of public health information to the population. This relationship has proven to be especially dangerous following COVID-19. This divide has been caused by the rampant spread of misinformation, and vaccine rollout inefficacy, both of which have been enabled by big corporations and monopoly powers. The spread of COVID-19 misinformation is lethal, and has taken the lives of millions around the world.

Misinformation causes vaccines to go unused, a lack of sufficient testing, noncompliance to social distancing and lockdown measures, and the subsequent spread of the virus.

Both socio-economic and urban and rural divides present themselves yet again, as misinformation and distrust is more likely to exist among those living in poorer, rural areas with lower literacy rates. In parts of the world where literacy rates are low, health information is not as salient. Basic understanding of biology, such as viral infection, transmission, asymptomatic infection, and vaccines, for example, must be understood by civilians to distinguish between true and false information. Health literacy is a form of literacy, and those who are illiterate are more susceptible to believing, practising, and spreading health misinformation.

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Figure 5 – Which platforms do you usually use? (Volkmer, 2021)

The presence of social media monopolies are extremely prevalent across the Asian continent as a whole. The globalised social media monopoly Facebook is extremely relevant in Southeast Asia, with Whatsapp, Facebook, and Instagram the most used social media apps in the region (see Figure 5). Facebook has found loopholes in the system to strengthen their power in rural areas by lobbying for their “Free-Basic '' scheme which offers free internet use to its users. The trade-off, however, is that users are only able to access the internet through Facebook-owned sites, further solidifying their presence and monopoly power. Those who are unable to afford or access the internet are the ones who are being targeted by this campaign. Despite Facebook’s attempted information “verification” process, a study found that misinformation on health and vaccines continue to gain an astounding 3.8 billion views (Marzouki et al., 2021). The moderators behind this verification process are often outsourced by Facebook through contracting companies across the world, shifting 244

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the accountability for the spread of misinformation away from the company. In the global south, the main concern of the moderators is to review information and material in English, as per instruction from Facebook to prioritise media in the global north. According to Abhishek, “There are disproportionately low content moderators for massive linguistic groups in the Global South” (2022), a concern that weighs heavily considering the huge proportion of its user base actually reside in those countries. This exploitation of labour reinforces the power dynamic of big monopolies and corporations, and leaves countries in the Southeast Asian region vulnerable, specifically among poorer populations with low levels of literacy.

Understanding the way countries interact with social media, especially with such a heavy presence of Facebook and its owned apps, is essential in preventing the spread of misinformation. In a study conducted by the UN, almost the same percentage of Indonesian respondents trusted the World Health Organization for their COVID-19 information as those who trusted their social media community, 39.8% and 36.8% respectively (see Figure 6 below) (Volkmer, 2021). These numbers represent a serious threat, as social media applications have become almost as trusted as credible organisations like the WHO. Unsurprisingly, studies have shown that 26% of Indonesian respondents reported they believed COVID-19 is “biased”, 24% believed social distancing and hygiene measures are unnecessary, and 29% have “stopped paying attention” to COVID-19 information (Ibid.).

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Figure 6 – (Volkmer, 2021).

Governments across Southeast Asia should work harder to regulate monopoly presence, especially those which threaten the spread of COVID-19. This is possible by lowering barriers to entry for other companies to enter the market. While this may be easier said than done, governments should place restrictions on large corporations like Facebook regarding information regulation regardless.

In terms of vaccine development, governments should fight for the removal of intellectual property protections on COVID-19 vaccines, so that vaccine manufacturing and rollout is more successful, and that at-risk populations in the region are protected against the virus.

In conclusion, the presence and power of monopolies in Southeast Asia is largely responsible for such large-scale spread of misinformation, and to an extent, responsible for the rapid spread of COVID-19 in rural populations. When misinformation spreads on a wide-scale, to susceptible populations, people become less likely to trust health professionals and their governments, and

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public health measures are not followed. This, in combination with a lack of vaccines available, the virus will continue to spread, and more lives will be lost.

Limitations It is important to first recognise the limitations of our findings. As mentioned previously, terminology throughout our paper was not consistent. This is due to the relatively new nature of the subject and therefore no universal definition of terms such as “digital divide”. Other terms used to address countries of the “ASEAN region”, such as the “Global South”, were used in literature referencing a specific country that overlaps with the same definition. While potentially confusing, these terms are meant to address the same thing.

Establishing a uniform measurement of outcomes across countries is also difficult, as the data we use varies in certain variables like currency (Yuan vs USD) which are representative of their respective countries. We mention this in regards to cross-country comparison, across the ASEAN region but also globally. We recognize that while longitudinal conclusions can be drawn on the effect of transformative tech in Asia over the past decades, certain areas of research such as the effects on COVID-19 are extremely volatile and subject to change within a relatively short period of time following the publishing of this paper.

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Conclusion The digital sector is becoming increasingly prevalent in the Asian continent and the ASEAN region. The emerging economies of South Asia, China and India have been conducive to the rapid development of the digital technology industry in these countries in recent years. So much so that today, Asia is positioning itself as a leader in e-commerce and fintech (Tahsin, 2018). In the most digitalised countries such as China and Singapore, digital technology is increasingly ubiquitous: while the former uses computer surveillance, facial recognition and biometric data systems as part of its social credit system, the latter is seeking the complete digitalisation of government services (Tan, n.d).

The COVID-19 pandemic has acted as an indicator of the usefulness of these technologies, but also of the strong inequalities they encourage. Indeed, as explained in the section “Digital technology in the era of COVID-19”, the countries best equipped with new technologies were able to put in place effective health tracing systems to both measure and slow down the advance of the pandemic: the result was better crisis management. Conversely, less well-equipped countries, such as Laos and Cambodia, were unable to implement these methods and were hit harder by COVID. However, it is by no means the presence of digital technologies that ensures the good performance of a health system. This principle is explained by Kentaro Toyama in his Law of Amplification: digital technology is a tool of a secondary nature that cannot solve a problem in itself (Toyama, 2011). It should therefore not be seen as a quick fix, but as part of a well thought-out development strategy.

Countries currently at the forefront of the digital technology sector, such as Singapore, developed it on a sound economic foundation at a time when the Singaporean economy was flourishing.

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If the link between new technologies and economic and social factors is present at the national level, it is also present at the individual level, in the form of strong social inequalities. Indeed, the “digital divide” as we know it is often seen as building on existing social inequalities, perhaps even widening them. In the process of accessing the Internet, many inequalities are present: income inequality, rural-urban divide, digital literacy divide. The distribution of the use of new technologies therefore obeys the existing social order. Subsequently, the digital 'haves' find themselves at an advantage as members of the information society, compared to the digital 'havenots' who are excluded. This is a case of the Matthew effect, where the privileged have the opportunity to further consolidate their social position, further deepening social inequalities.

In order to reduce the digital divide, a number of obstacles need to be overcome. First, there are the four criteria used by The Economist in their Inclusive Internet Index: internet availability, internet relevance, internet readiness and internet affordability (The Economist, 2021). These criteria, discussed in detail in the first section of “Obstacles to Closing the Digital Divide”, are all issues that must be addressed if greater 'digital equality' is to be achieved.

In addition, tech companies and governments also have their share of responsibility for the digital divide. In the context of the COVID pandemic, these 'information monopolies' encouraged what the WHO called 'infodemic': the spread of COVID-19 related misinformation, resulting in lower than desired vaccination rates as well as non-compliance with social distancing and containment measures (WHO, 2021).

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