Medicine & STate power
As the 1930s dawned on Italy, the tendrils of fascism wrapped ever tighter around public and political life. Despite popular support for Prime Minister Benito Mussolini’s crusade to restore the glory of Rome, the dictator agonised over the softness and sentimentality of the workers and peasants at his feet. As he saw it, Italian culture, romantic and artistic, was incompatible with the true fascism of blood and steel. Thus, Mussolini set out to mould a New Man - virile, anti-intellectual, and boorish, typified by Il Duce himself. To harden the hearts of the people, Mussolini knew that he would require more than his existing, impressive support from the press, the police, and the military. On 28th January 1932, he opened the Italian National Congress of the Trade Unions of Fascist Physicians with a speech to obeisant doctors from all corners of the boot. He implored their collaboration in delivering this New Italy. The good doctor, he stressed, must act as arbiter of right and wrong, and should consciously communicate party policy to patients. For instance, in order to develop autarchia, national self-sufficiency, patients should be educated on the health benefits of consuming rice, a robust and abundant domestic crop, over pasta, a soft food manufactured from imported foreign wheat. Contemporary negative attitudes to childbirth should be challenged in the clinic to boost birth rates and supply the army and workforce with a new generation of sturdy fascists. The physician, he asserted, is like the priest, tending the flock from the cradle to the grave.
The patient trusts the physician to heal the body and soothe the soul, thus Mussolini considered medicine a fulcrum for consolidating state power. He was right. Doctors, like the clergy before us, would prove to be indispensable in underwriting, justifying, and perpetrating brutality in service to authority during the subsequent grisly century of Never Events. For too long, we have failed to address the finer points of this grim legacy. In 2013, during my first year at medical school, a respiratory lecturer informed the class that Clara cells, important cogs in the apparatus of the airways, would henceforth be known as Club cells. The medical establishment decided at last that the discoveries of enthusiastic Nazi Party member and anatomist Max Clara were sufficiently offset by his collusion with genocide to warrant the erasure of his legacy; much of the tissue studied by Clara was derived from the bodies of executed German political prisoners without the consent of their families. But the case of the Club cells is just one lens with which we can examine the historic crimes of the medical profession. Throughout modern history, we find that wherever the boot stamps on the human neck, an esteemed physician lurks on the sidelines.
In 1932, the same year as Mussolini’s address to physicians, a shadowy longitudinal study commenced in Alabama. In this, the Tuskegee Experiment, we find a perfect example of violent state power and white supremacy wielded by unquestioned medical authority. Under the guise of “free healthcare”, proven medical treatments and information were deliberately withheld from around 400 black male subjects with syphilis in order to observe over time the natural progression of the illness to its advanced stages. Over 100 participants died from the disease or related complications and many of their partners and children suffered health effects from the spread of the insidious bacterium. The project was only terminated in 1972 after details were leaked to the press and it was not until 1997 that a formal apology was issued by President Bill Clinton. On the other side of the Iron Curtain, in the 1960s, Stalinist psychiatrist Andrei Snezchnevsky, likely under the supervision of the KGB, devised the theory of “sluggish schizophrenia”; the bogus diagnosis was used to label political dissidents as mentally ill in order to justify their incarceration in asylums. And, of course, in Nazi Germany’s concentration camps, doctors conducted unspeakable experiments on Jewish, Romani, disabled, and Polish victims in order to further the cause of fascist race science and break ground in combat technology. The Austrian doctor Aribert Heim, also known as Dr. Death or The Butcher of Mauthausen, worked for 6 weeks in the Mauthausen-Gusen camp. His reputation swiftly became shrouded in darkness due to his predilection for performing operations without anaesthetic and for subjecting victims to various forms of torture, such as injecting lethal compounds directly into the heart. After a brief period of internment in a US POW camp, Heim was released. He worked for a short time as a gynaecologist in the Black Forest and then, feeling which way the wind was blowing, made a break for it. He has never been brought to justice. Meanwhile, the aforementioned Max Clara was officially denazified; he was able to procure a cosy teaching job at the University of Istanbul.
These crimes stand in stark contrast to the ethics instilled in us at medical school: justice; respect for patient autonomy and consent; beneficence, or do good; non-maleficence, or do no harm. I see these values put into practice every day by amazing colleagues on the wards. Indeed, over the past few years we have witnessed just how much the British public values its hard working doctors. While the bungling ruling class negligently failed to prepare for or react to the coronavirus crisis, doctors across the country took matters into their own hands. The most stable and chronic patients were discharged in anticipation of the coming Covid hordes, rotas were hastily re-written to fortify round-the-clock support from senior clinicians, and we were brought up to speed on available clinical knowledge with ad hoc peer education. The NHS weathered the storm with no thanks to those in power; but due to the efforts and passion of the workers on the frontline.
For every cautionary historical tale about medical evil, then, one could find an inspiring case of doctors standing up to authority on behalf of their patients, or countless everyday examples of excellent care delivered in a universal, free system. It may be tempting to linger on these honourable achievements. However, in order to deliver healthcare which is high quality, equitable, and transparent, it is necessary to excise the purulent tracts from our history. If we take a closer look, perhaps we can find the cure.
According to a 2017 report by the Social Mobility Commission, over the last few decades medicine has become more deeply entrenched as a profession of the elite - 61% of medical students in 2017 were privately educated, compared to 51% in 1987. In cultivating the flow of young people from wealthy families into medical schools, the subterranean ties from medicine to capital and, therefore, to power, are cemented. One major step in democratising healthcare and addressing the imbalance of power between doctor and patient, then, will be to erode the class differences between the two parties. Doctors should be grossly representative of the population we treat. Who knows better about the health needs of specific communities than the people who have grown up in them? The Glasgow REACH Programme, a widening participation project which provides application support, teaching weeks, interview preparation, and relaxed entry requirements for working class students in the greater-Glasgow area (and to which I owe my medical degree) is one excellent example of an attempt to redress this imbalance. As is Melanin Medics, a charity that offers support and outreach to encourage people of colour to study medicine in the UK. While these projects are badly needed and well-delivered, they are superficial fixes for a problem with deep roots.
There have been more radical attempts to address authority’s unstable monopoly on medicine. In the 1970s, as part of the struggle for Dual Power, radical doctors and healthcare workers from the Black Panther Party established free medical clinics in cities like Chicago, Portland, and LA. The centres sought to treat the “people, body and soul” of the black neighbourhoods which had been criminally underserved or outright ignored by the American health and social care system. From the clinics, BPP doctors and volunteers offered medical care, provided free socialising space for the neighbourhood, and conducted public health campaigns to raise awareness of diseases primarily affecting the black community, such as sickle cell anaemia. The party picked up the slack from the deliberate negligence of the American state and, for a time, established its own radical infrastructure.
More recently, closer to home, Docs Not Cops was established in response to Gordon Brown’s 2009 policy of charging migrants for use of the NHS and the subsequent tightening of these restrictions under the coalition government. DNC is a network of healthcare worker activists who break down barriers to accessing healthcare for migrants, refugees, and asylum seekers. Strategies deployed include training days for healthcare workers combatting the hostile environment in everyday clinical settings, multilingual resources to help patients navigate health bureaucracy, and signposting to “safe” surgeries where passport checks will not be conducted.
As well as the Hostile Environment, medicine as practised in the UK of 2020 must confront austerity as a powerful driver of illness. The Scottish Deep End Project is a network of GPs working in the country’s most deprived areas. Partaking practices share resources and advocate for the patients most savagely affected by cuts and deindustrialisation. Together, they examine the multifactorial socioeconomic engines driving the dire health outcomes of the communities in which they work.
The 2016 BMA junior doctor strike was a key moment in the history of medicine in the UK. Despite the backdrop of prestige and elitism overshadowing the profession, the row exposed the practical realities of a physically and mentally demanding job with long hours and a seemingly endless workload. Here, doctors were not seen as powerful gatekeepers; but rather as tired and angry public sector workers willing to flex some economic muscle and withdraw their labour. Although some doctors were dissatisfied with the resolution of the strike, our union continues to carry out good work locally and nationally. Recently, the union has served as a platform for ardent criticism of the UK government response to coronavirus. Colleagues in the BMA have gone to great lengths to highlight the increased risks faced by BAME doctors and patients. In dismantling harmful manifestations of the state within healthcare, the BMA Broad Left internal campaigning group will be key. With a united progressive platform, we have won many victories pushing BMA and UK health policy to the left. Given the huge international crises defining the last decade and the worrying agenda of the UK government, it is more important than ever for us to make a case for a doctors’ union that is democratic, transparent, and radical.
Perhaps the next vital step in unionising and democratising medicine could be to bring down class, prestige, and labour barriers between doctors and our healthcare colleagues from other professions. We share workplaces with nurses, cleaners, porters, and catering staff and therefore we share common goals. Furthermore, the benefit doctors bring to patients would be impossible without this huge network of other workers: the patients wouldn’t last long if there wasn’t a highly-trained nurse on hand to catch a sudden rise in temperature; or a healthcare support worker to provide exhausting, intimate, and essential personal care; without the catering staff to put food in bellies we would have no fuel to work and the patients no energy to heal; with no cleaners to sterilise the wards, they would swiftly become breeding grounds for deadly bacteria. This is where Doctors in Unite could prove to be a useful model for change. Within DiU, doctors organise inside a big union, side by side with other healthcare worker colleagues, around the core aims of tackling NHS Privatisation, the Hostile Environment, Alcohol Harm, Nuclear Weapons, and Climate Change. Rather than maintaining the fallacy of medicine as an aloof and isolated profession, it makes sense for us to coordinate with workers of all stripes for safe workplaces and gold standard patient care. Cleaners and porters, for instance, work just as hard as doctors do; maybe NHS facilities would be better run if we campaigned on a united platform to stop outsourcing their work to cutthroat private companies, pay them as much as we do medical staff, and give them full control of their work environments. This is the kind of message we should push within a broad, radical, campaigning union like Unite. Earlier in the pandemic, I worked with reps and organisers at my hospital’s Unite branch on a campaign to encourage NHS Greater Glasgow & Clyde to continue the improved rest and catering facilities we experienced during Covid-19 when we emerge from the pandemic. These facilities are used by all of us, not just by doctors, and we should defend them together. The Broad Left has been making an argument for a similar approach within the BMA for years, such as our campaign to recruit Physicians Assistants into the union - a cause which has been ruthlessly opposed by those who see medicine as a monolithic career path in an orbit of its own.
While many of us are ready to put in the work, I am unsure whether we can achieve such ambitious aims within the current confines of the BMA or Unite. Regardless of the branding or identity of the vehicle we use, it seems that the scale of the challenge can only be met by a movement that can bring together all healthcare workers. I have been inspired following the UVW strikes at St. George’s, in which mostly migrant and BAME outsourced security staff, porters, caterers, and cleaners have been taking a stand to demand the same conditions as in-house staff, a living wage, and improved Annual Leave and sick pay. Imagine how powerful it could be if they were joined on the picket lines by consultants and nurses.
Unity and solidarity will be vital as we enter a post-Covid reality. For the foreseeable future, all political and economic decisions will be coloured by coronavirus. Leaders like Bolsonaro and Trump shuffled through health ministers and medical advisors on whims, sacking those deemed politically disagreeable. In the UK and many other countries, senior doctors like Professor Chris Whitty became household names for the first time. Medicine continues the story of its queasy relationship with power. To prevent the entrenchment of inequality, we must sever the old medical allegiances to authority and strengthen our existing connections to our patients, the community, and our colleagues from the caring professions. There is a tendency within the field to consider itself to be apolitical; as has become abundantly clear, healthcare is anything but. Cruel and self-serving policy decisions made by a distant ruling class are a public health problem. As are the anxiogenic working lives of the general public and the dire living conditions within the necrotic private rental market. In the quest to cure these ailments, doctors do not belong in musty DWP examination rooms signing “fit for work” notes; we should be on the frontline of the fight to protect and extend our public services, improve the health and happiness of public life, and democratise society.