Affirming medicine as a public good

Medical science has developed hugely powerful technologies that can be used for social purposes. But to achieve this, it needs to be clearly on the side of the people.

The Covid-19 pandemic has reached a grim peak in South Africa. A recent article in GroundUp concludes that it is “highly likely that more than one in every 1 000 South Africans have already died of Covid-19”.

There are a number of new vaccines that have proved to be effective, but there are two broad issues that need to be addressed. The first is that the state needs to act decisively to rapidly make an appropriate vaccine available at scale. The second is that a recent survey has shown that just under half the South African population would not take a vaccine if it were available. Many people, including some with significant social standing and influence, have been attracted to conspiracy theories. 

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In this situation it is worth giving some thought to the previous major health crisis, the Aids pandemic. In a struggle that began in the late 1990s, the Treatment Action Campaign (TAC) was able to defeat both the denialism of Thabo Mbeki’s government and the ruthless profiteering of pharmaceutical companies. It was a brilliant achievement that, in the end, resulted in an effective public treatment programme. More than five million people’s lives and health are currently sustained by antiretroviral treatment. Many consider this to be the most significant success of the post-apartheid government.

That struggle would not have been won without building popular organisation at scale and developing a rich intersection of solidarities including people living with HIV, trade unions, churches, lawyers, scientists and doctors. Bringing doctors into the struggle enabled mutual learning between them and people living with HIV.

Progressive medicine

There is a long and international history of struggle in the interests of public health. Aneurin Bevan, the son of a Welsh coal miner who left school at 13 to join his father in the mine, became the minister of health in the Labour government that came to power in the United Kingdom in 1945. Credited with establishing the National Health Service (NHS), he insisted that “no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means”. 

In an interview published a few days before the NHS came into being, he explained that: “It is on the financial side a vast redistribution of national income. On the active and administrative side, it brings to the individual citizen all the battery of modern medicine, irrespective of the individual’s means. Furthermore, it is not only distributivist but it is perfectly democratic, because it democratises the social consumption of the recent advances in medicine, and it destroys the money barrier which inevitably existed in orthodox capitalist society between the doctor and his patient.”

The NHS is a hugely important social democratic achievement. It has been under pressure from the Right for a long time, but it survives because it is so widely and deeply valued by the British public.

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Extraordinary progress was made in public health after the Cuban Revolution. There was also, famously, an equally extraordinary internationalism, with Cuban doctors working around the world and students from around the world studying medicine in Cuba. To this day, public health in Cuba is better than in the United States. Healthcare is free and the doctor-patient ratio in Cuba is much better than in the US or the UK. In India, the communist-run state of Kerala has the best public health in the country, an achievement owed largely to an extensive system of primary health centres.

There is also a long tradition of radical doctors. Che Guevara and Frantz Fanon are among the best known. There is a significant history of politically committed doctors in South Africa. In 1974  Steve Biko, a medical student, was involved in setting up the Zanempilo Community Health Care Centre in Zinyoka Village, near King William’s Town in the Eastern Cape, as part of a wider project of Black Community Programmes. 

One of the most remarkable doctors in South Africa was Abu Baker Asvat, who ran a practice in Soweto in the 1970s and 1980s and was known as “the people’s doctor”. He would often treat more than 100 patients a day at no cost. During the uprising in 1976, his surgery was protected by residents of a nearby shack settlement. Asvat, who was murdered in his surgery in 1989, left an exemplary legacy of profound commitment to the oppressed.

Today there are a good number of committed doctors and medical scientists who have dedicated their lives to working in the public health care system.

Support for public health 

An effective response to the current health crisis, as well as the wider health issues in South Africa, will require a commitment to a progressive vision of medicine and an articulation between progressive currents within medicine, the lived experience of the oppressed, and popular organisation and struggle. Trade unions remain the largest popular organisations and their support will be critical in advancing a commitment to public health.

The broad outlines of a progressive public health programme are clear enough. There needs to be massive investment in public healthcare including clinics, hospitals, medical schools, research institutes and independent regulatory authorities committed to the public interest. Public clinics and hospitals must be accessible and well-run and equipped spaces where people are welcomed with dignity, engaged seriously and given the best available treatment.

International alliances need to be forged with the aim of ensuring that research into medication, and the modes of its production and distribution, are organised on the basis of public interest rather than private profit.

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The fact that Ugur Sahin, a doctor who played a leading role in the development of the Pfizer-BioNTech vaccine for Covid-19, is the child of working-class Turkish migrants to Germany is a beautiful rebuke to xenophobes everywhere. But he is already the 493rd-richest person on the planet, with a personal fortune of $5.1 billion (R78.4 billion). In a just system, he would be working in a well-funded public university where he would be provided with the resources that he needs to do his work, treated with respect and paid a professor’s salary. 

But along with affirming medicine as a public good – and its practice as a vocation, rather than a set of skills and products developed in the interests of private profit – the growing prevalence of conspiracy theories also need to be confronted. They stem from both the hostility to reason and evidence that marks right-wing populism everywhere, as well as all too real historical and contemporary experiences.

There are important historical precedents for the affirmation of the value of reason and evidence as a political project. There is a long and rich tradition of the Left working to democratise access to scientific knowledge and the technologies it produces. In South Africa, the TAC did excellent work in this regard and was also able to effectively confront denialists, quacks and conspiracy theorists in the public sphere, and to do so on an organised basis. In India, popular science movements work, with significant success, to oppose the Brahmanical obfuscation of the Hindu Right.

Vaccines and resistance 

Following a global drift, we in South Africa inhabit a moment in which conspiracy theories are gathering reach and energy. Many of them have centred on the vaccines developed to inoculate people against Covid-19.

It is worth recalling that vaccines come out of a long history of experience and experimentation, and have proven hugely successful. Biomedicine aims to base itself on scientific understandings of biology and physiology, and standardised and evidence-based treatment, both subject to continuing analysis and discussion within a community of peers. Its roots run back to the Arab world and the ancient civilisations in Greece and Egypt. Europeans first accessed many of the texts that laid the foundations for much of what became biomedical medicine in Arabic during the period in which southern Europe was ruled by Muslims from North Africa.

The practice of vaccination has been traced back to China, where it was used more than a thousand years ago. It was also used in Turkey and Africa well before it began to be used in Europe. In the past 40 years, it has entirely eradicated smallpox, largely eradicated polio and brought diseases like measles under control in much of the world. It offers the best route to overcoming the Covid-19 pandemic.

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But for vaccination to be effective, it is not just the question of access that needs to be resolved. The matter of public perceptions is also important. Dealing with this issue requires a clear understanding that medicine is, and always has been, a site and subject of ethical and political contestation. It has been used for emancipatory and oppressive purposes, and entangled with all kinds of forms of domination, exploitation and exclusion.

Many people have been treated with contempt in public clinics and hospitals and given inadequate care, and many have found themselves in situations where treatment is unaffordable. Medical practice in private healthcare is not immune to the prejudices that saturate wider society. Middle-class people often experience their medical aids as predatory rather than supportive. State austerity and mismanagement, and the capture of medicine by corporate power, diminish public confidence in scientifically formulated medicine.

The history of medicine being both shaped and used as a tool by colonialism and other forms of racism is long and horrifying. One of the most infamous examples is the Tuskegee syphilis study in the US in which, for 40 years, impoverished African-American men were told that they were receiving free treatment from the federal government when in reality they were not receiving treatment so that doctors could study the progression of untreated syphilis.

Incredibly, impoverished Black women have continued to be subject to forced sterilisation in post-apartheid South Africa. Globally, medical research continues to be inflected with racism – along, of course, with sexism and classism. Some people are experimented on so that others can be treated. Research into the production of medication for conditions affecting people who constitute a potentially lucrative market is often prioritised over health issues affecting the majority of humanity.

Living the drama of the people

Fanon offered some particular useful thoughts on the fact that medicine can be used for both oppressive and emancipatory purposes. In his second paper, The North African Syndrome, published in early 1952, he dealt with the racist manner in which the French medical establishment related to migrant workers from North Africa. He wrote that the “attitude of medical personnel is very often an a priori attitude. The North African does not come with a substratum common to his race, but on a foundation built by the European. In other words, the North African, spontaneously, by the very fact of appearing in the scene, enters into a pre-existing framework.”

In Black Skin, White Masks, his first book published later in the same year, he affirmed a humanistic approach to medicine rooted in a radical commitment to mutuality. He wrote that: “Examining this 73-year-old farm woman, whose mind was never strong and who is now far gone in dementia, I am suddenly aware of the collapse of the antennae with which I touch and through which I am touched. The fact that I adopt a language suitable to dementia, to feeblemindedness; the fact that I ‘talk down’ to this poor woman of 73; the fact that I condescend to her in my quest for a diagnosis, are the stigmata of a dereliction in my relations with other people.”

In A Dying Colonialism, written in the heat of the Algerian war against French colonialism and first published in 1959, Fanon examined medicine in the colonial context. He began by showing that in the colonial situation medicine may present itself as a project conducted “in the name of truth and reason”, but in practice the doctor functions, along with the police officer and the soldier, as part of the system of colonial oppression.

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Doctors conduct themselves towards patients from among the colonised as if they are engaged in veterinary work rather than medicine. They are complicit in torture. Even when the colonial medical system offers an objective capacity for diagnosis and treatment, the “harsh, undifferentiated, categorical” manner of the response to colonial domination can extend to a refusal to subject oneself to “the hospital of the whites, of the strangers, of the conqueror”. The result of this situation is that the “truth objectively expressed is constantly vitiated by the lie of the colonial situation”.

But Fanon goes on to show that this is transcended in struggle. When the doctor joins the guerrillas in the mountains, “sleeping on the ground with the men and women of the mechtas, living the drama of the people”, the doctor “was no longer ‘the’ doctor, but ‘our’ doctor”.

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Conspiracy theories can have serious public health consequences. Aids denialism in South Africa is just one example. Another is that in 2003, five states in northern Nigeria rejected the polio vaccine following rumours claiming that it was an American conspiracy designed to make Muslim girls sterile. As a result, polio infections exploded in northern Nigeria and spread from there to a number of other countries. The vaccine was reintroduced and, in August last year, wild polio was declared to have been eradicated across the whole of Africa.

It goes without saying that conspiracy theory must be directly opposed with the best available scientific evidence presented in accessible form. To achieve this, progressive doctors and scientists need to take a place in the public sphere and build alliances with popular organisations. At the same time, prominent conspiracy theorists must not be indulged – as they regularly are in South Africa, including in institutions and publications that aspire to intellectual rigour and public purpose.

But opposing conspiracy theories is not solely a matter of providing credible information. Medicine also needs to be – and be seen to be – on the side of the people. This requires, among other strategies, affirming it as a public good and re-establishing links between progressive actors and currents in organised medicine with popular organisations and struggles. 

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