This article is reproduced from the Postgraduate Medical Journal 25 August 2021. Please click on link for references.
Medicine and politics are inseparable. This applies from the very beginning of medical training and throughout doctors’ careers. In most countries, the young people selected to go to medical school are predominantly drawn from a social elite. (The state-educated 94per cent of the school population in the United Kingdom, for example, were given fewer than half the offers for medical training in Oxford).1 They will generally share the experiences, assumptions and values of the privileged backgrounds from which most of them come. As they go through training, medical students almost everywhere will receive an intense grounding in the scientific and technological aspects of medicine but vastly less in the social and political determinants of health. They may be exposed to some of this information (such as the difference in life expectancy between the least and most deprived deciles in England of 9.5 years for males and 7.7 years for females.)2 However, the teachers who impart these facts are equally unlikely to have come from deprived backgrounds themselves, or to imbue them with the sense of outrage that such figures should evoke.
Once qualified, most doctors will begin to understand that some of the frustrations they encounter at work arise from political decisions rather than ones made by clinicians and service managers. These decisions may include limitations on budgets, and performance targets. Many will complain about politicians, but they may be unaware how far their own practice, including the use of hi-tech investigative technologies and expensive medicines, has been massively influenced by political lobbying. (In 2020, the pharmaceuticals and health products industry in the United States spent more than any other sector on lobbying efforts, totalling around 306.23 million US dollars)3 Few will campaign for government funds to be spent outside the health sector altogether—on social care, nutritional support and housing assistance—where these would demonstrably have more impact.4 They will probably not question the structural inequalities which lead to their earning incomes that may be ten times the median income of their patients.5 6
To set against this, there is also a long and distinguished history of individual doctors (and nurses) who have chosen to be political campaigners. Such people have seen their vocation as not only treating patients but fighting on the political front for the welfare of under-privileged groups, communities or society as a whole. Famous activists from the past in the United Kingdom include Thomas Wakley, John Snow, Florence Nightingale and Elizabeth Garrett Anderson. More recently, the physician Sir Douglas Black and the socialist general practitioner Julian Tudor Hart had a considerable influence in orienting the profession towards population and community health as well as individual care.7 8 (For over 20 years I had the privilege of practising alongside Ron Singer, an ally of Tudor Hart, a fierce campaigner for the original values of the National Health Service, and a role model for combining clinical and political commitment).9 Across the world, notable activist doctors have included Franz Fanon, a guiding light of the Algerian independence movement, who wrote of how the medical profession were complicit in the oppression that colonialism brought about. Che Guevara became a revolutionary in Cuba after being profoundly affected by his experiences as a medical student. Sun Yat-Sen was instrumental in bringing down the last imperial dynasty in China and became first president of the republic.
While such activism is not new, there has been a notable upsurge recently in the number of influential voices from within the medical profession arguing that every doctor has a duty to move beyond their clinical work and challenge the current political realities. In an essay entitled ‘The moral determinants of health’, the leading US physician Don Berwick has pointed out: ‘No scientific doubt exists that, mostly, circumstances outside healthcare nurture or impair health.’10 He makes a passionate plea for doctors, nurses and their professional organisations to become involved in campaigning on issues such as racial discrimination, women’s equality, human rights, climate change, the criminal justice system, hunger and homelessness. Countering objections that this campaign list might seem out of character for many health professionals, he argues bluntly: ‘Healers are called to heal. When the fabric of communities on which health depends is torn, then healers are called to mend it. The moral law within insists so.’
In a similar vein, David Kopacz of the University of Washington writes of medical activism as ‘a foundation of professionalism.’11 He quotes Robert Jay Lifton, who studied how U.S. soldiers could participate in war atrocities and how German doctors participated in the Holocaust: ‘As citizens, and especially as professionals, we need to bear witness to malignant normality and expose it… That inevitably includes entering into social and political struggles against expressions of malignant normality.’12 Kopacz also cites educator Parker Palmer, who speaks of a new kind of professional: ‘a person who not only is competent in his or her discipline but also has the skill and the will to resist and help transform the institutional pathologies that threaten the profession’s highest standards.’13
Failings of governments
Doctors are also speaking out with growing urgency and frankness about the failings of governments to address the health and social needs of their citizens. Kamran Abbasi, executive editor of the BMJ, has written a blistering attack on the British government’s ‘politicisation, corruption and suppression of science’ during the COVID-19 pandemic.14 Rachel Clarke, a palliative care doctor, has become a bestselling writer and contributor to social media, drawing attention to government mismanagement of the pandemic, and the human consequences. While occasional voices are still raised in support of the notion that doctors should only treat patients and keep their noses out of everything else,15 such views are increasingly likely to seem blinkered and outdated.
As health and social inequalities widen, and we learn more about the power held over human lives by an ever-diminishing number of individuals and corporations,16 I predict that more doctors around the world will be drawn inescapably into political campaigning. Doctors who believe that medicine and politics are entirely separate will be seen as fundamentally out of touch with medicine or politics, or both.