Civitas recently published a paper entitled Is Coronavirus unprecedented? It’s a good question. The review is subtitled A brief history of the medicalisation of life, and the first six chapters offer a fascinating account of how disease in general and epidemics in particular, have been perceived from the 4th century BC onwards. Evidence includes accounts from Thucydides, Bede, Boccaccio, Machiavelli, Defoe and Camus, describing epidemics such as typhus, bubonic plague, smallpox and cholera. The review encompasses models of medicine, citing Hippocrates, Lucretius, Galen, Chaucer, Bacon and Hobbes. The authors also examine the outcomes of attempts to prevent the spread of disease, such as the forced isolation of infected communities.
The lessons the authors seem to want us to learn are that pandemics are “part and parcel of human existence” (p.19); that the “startled overreaction” of governments to the current Coronavirus pandemic is a result of the “exaggerated pursuit of national health” (vii) and the medicalisation of modern life; and that measures to prevent the spread of pandemics often do more harm than good, There’s some truth in all of those conclusions, but the authors arrive at them only by overlooking several important factors. Let’s take each conclusion in turn.
pandemics are part and parcel of human existence
Until relatively recently, that was true. And people accepted it, but only because there was no alternative; as the authors point out “whether populations grew or shrank had little to do with medicine despite its best efforts” (p.39). But the acceptance of pandemics as a fact of life was a reluctant one, as indicated by historic responses to plagues. Infected individuals, households or communities were isolated, some people turned to strict religious observance, some fled from cities to the country if they could, and if they couldn’t, they’d often abandon themselves to a “‘shameful and disordered life’” (p.12). Plagues, although part and parcel of life, were seen as a scourge.
In recent decades things have changed. In the last 30 years smallpox has been eradicated and progress is being made towards eradicating polio, malaria, syphilis, measles, rubella and rabies. Most people, throughout history, would probably have seen that as a good thing.
the ‘exaggerated pursuit of national health’ and the medicalisation of modern life
Has the attempt to eradicate some diseases led to the medicalisation of modern life? ‘Medicalisation’ of normal life does occur, notably in respect of responses to adverse life events or poor living conditions. People who feel sad or anxious are often considered to have ‘depression’ or ‘anxiety’, and to require medication, when they’re actually experiencing a normal response to circumstances. But doctors can’t always tell whether or not those people will recover spontaneously given time, and often medicate because they don’t have time to diagnose properly in a 10 minute appointment, support services have long waiting lists, and dealing with environmental causes is beyond their remit; at least medication can help patients get on with their lives in the meantime.
But a viral infection doesn’t need to be ‘medicalised’ to damage health – it does so regardless of how people categorise it. And medical knowledge about its infectivity, symptoms, and how to treat them is essential to governments making socio-economic decisions.
The authors seem to see the possibility of eradicating diseases as naively utopian, and as opening the door to authoritarianism: “After 1945, WHO programmes of disease eradication reinforced the authority of science and the medicalisation of life” (p.36). This prompts a rather odd conclusion: “Whether populations grew or shrank …changed utterly after 1945, and in not very well-understood ways” (p.39). On the contrary, the ways in which it changed are very well understood, but have been explored in fields other than theology and political science – the author’s specialisms.
measures to prevent the spread of pandemics often do more harm than good
The review points out that the cordons sanitaires put in place to isolate infected communities and prevent plague spreading, often caused additional problems. Trade ceased and food shortages occurred, triggering civil unrest. If the cordon were policed by the military following a time of conflict, the unrest could also be political (p.27). Isolation measures undoubtedly cause harm and do economic damage. But the authors blithely overlook the catastrophic damage caused by not isolating infected people. The disruption to normal life resulting from widespread death, sickness, and long-term health problems in survivors during a pandemic has been enormous.
The authors see Coronavirus as a “mild contagion” (p.34), and claim “governments embraced an epidemiological prediction of death rates of 1 per cent of the West’s population unless they locked down the economy, quarantined households and suspended all non-essential activity.” (p.viii)
That’s not the case. The mortality rate for Coronavirus was estimated at 1% if nothing were done to prevent it. Lockdown wasn’t the only option. If Exercise Cygnus had been properly carried out in 2016, and national and local plans put in place for responding to a highly contagious virulent infection, the UK could have had the capacity to test and trace, and to manufacture sufficient PPE, so lockdown could have been avoided entirely. But that didn’t happen, probably because in 2016 the UK government was focussed on Brexit rather than public health. The findings of Exercise Cygnus were classified, but were leaked by The Guardian in May 2020. The report indicated that the UK was poorly prepared for a serious epidemic. Lockdown was necessary only where countries lacked test and trace capability. Describing the pandemic as ‘unprecedented’ is a convenient way of distracting attention from that.
It’s also worth noting the review doesn’t mention the Asian flu pandemics of 1957 and 1968, after the formation of the NHS. In the UK, life for those uninfected carried on much as usual (although this Lancet article shows a typist wearing a mask).
There were reasons for the nation just carrying on. In the 1950s and 1960s, epidemics were the norm. There were annual outbreaks of measles, mumps, rubella, whooping cough and chicken pox. There were sporadic outbreaks of smallpox and diphtheria. Intensive care facilities were relatively basic so only a limited number of people would have benefited from hospital admission. In the 1957 Asian flu epidemic, the death rate was estimated at 0.3%, less than a third of the rate for Covid-19, but there were significant economic consequences. Factories, offices and mines closed, and sickness benefit payments amounted to £10m.
Even Alex Tabbarok, a libertarian economist, cites the growth rate the US economy in 1957 following the Asian flu pandemic as -4% in the last quarter and -10% in the first quarter of 1958. But as he points out, many references to this recession don’t even mention the pandemic as a contributory cause.
Pandemics have indeed been part and parcel of human existence, and will continue to be. However virulent or infective they are, they have a devastating effect on human wellbeing, by their impact on mortality rates, health or the economy. We have the technology and knowledge to minimise that damage, as happened in the SARS-CoV outbreak in 2002-4, and in several outbreaks of Ebola since it was first identified in 1976.
Inadequate preparation was identified as a cause for the damage caused by the 1957 flu epidemic and inadequate preparation was directly responsible for the lockdown put in place to limit the spread of Covid-19.
The authors refer to the “anxious insecurity” they claim has been caused by the “medicalisation of life” (p.39) but overlook the anxious insecurity, panic, grief, and economic devastation caused by disease that dogged human beings until the advent of modern medicine.
The authors of this report do something that I’ve seen increasingly recently. They begin with a belief, cite evidence that supports their belief, and overlook evidence to the contrary from relevant fields – in this case biology, medicine and economics. Another case of policy-based evidence, rather than evidence-based policy.
Jones, DM & Webb, E (2020). Is Coronavirus unprecedented? A brief history of the medicalisation of life. Civitas.