Can Europe Make It?

Who should be in charge: doctors or politicians?

How do we know which doctors are right and which are wrong? And who should make this judgment?

Jan Zielonka
21 April 2020
PM with Chief Medical Officer, Chris Whitty and Chief Scientific Adviser Sir Patrick Vallance as NHS England announced that the coronavirus death toll had reached 137 in the UK, March 19, 2020.
PM with Chief Medical Officer, Chris Whitty and Chief Scientific Adviser Sir Patrick Vallance as NHS England announced that the coronavirus death toll had reached 137 in the UK, March 19, 2020.
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PA Video/PA. All rights reserved.

Our lives currently seem to be in the hands of doctors, and this concerns not only those who have caught the corona virus. New regulations on quarantine, social distancing and borders have been dictated to governments by their medical advisors. On April 10 the Italian weekly L’Espresso ran the headline: “Seven most powerful persons in Italy: today at the helm are (only) scientists.” Prime Minister Conte, President Trump and other top politicians are still giving statements, but their messages are being shaped by epidemiologists rather than electoral strategists. Should we rejoice? The answer is: not really.

Of course, ignoring early warnings from doctors and entertaining illusions that Covid-19 is just another flu has led to thousands of otherwise avoidable deaths. However, the relationship between politics and medical expertise is more complex than is currently assumed. This is not only because medical decisions have political implications. In a democracy we want to know that those in charge are elected and accountable. This is the case with politicians, however imperfect - but not with their medical advisors.

Are doctors always right?

We tend to assume that in a crisis like the current one, medical doctors are in a better position than politicians to decide which course of action is correct. This may be so in some cases, but there are some difficult questions about the role of medical expertise which ought to be addressed

First, medical specialists do not represent a unified front because there are different ways of combating Covid-19. Differences emerge from diverse specialisations – clinical doctors have a different perspective than those specialised in health administration, for instance. Even doctors from the same specialisation embrace competing theories and empirical data. Since data regarding Covid-19 are still scarce, these theories often resemble speculations. The “Herd Immunity” theory is the most notable example. So how do we know which doctors are right and which are wrong? And who should make this judgment?

Theories often resemble speculations. The “Herd Immunity” theory is the most notable example.

Second, combatting Covid-19 involves a difficult balancing act between economic and medical factors. Doctors are seldom specialists in economics, and someone needs to weigh the merits of various factors when making the decision on how to combat the virus. Right now, not only factories, but also schools, museums, stadiums, theatres and restaurants are closed. Fields as diverse as services, sport, education and culture are being affected by medical decisions. Moreover, making “rational” calculations is difficult when dealing with ethical issues, and tackling Covid-19 is literally a matter of life and death. Although deaths are caused directly by the virus, they may also be indirectly caused by the “medicine” against the virus which leads to economic hardship.

Third, medical specialists are not immune to corporate and political pressures. Many scientific advisors to governments are appointed along party lines. Others have intimate relationships with big pharma, insurance companies and the healthcare industry. All of these links represent ties to the corporate interests of the medical profession.

Asking these questions is not intended to discredit the merit of medical professionals’ advice. Such advice is of course indispensable during a global pandemic. Rather addressing these questions highlights the danger of drawing a simplistic dichotomy between competent, unbiased doctors and incompetent, partisan politicians. The extent to which this dichotomy reflects reality varies from place to place, and from person to person. I understand why many Americans prefer Dr Fauci over the President to lead the campaign against the virus. However, perhaps this points to the pathologies of the US political system, and does not necessarily apply to other countries.

The politics of healthcare

Politics intervenes in healthcare to make citizens’ wellbeing less dependent on chance, fate or money. Political interventions in the healthcare system are believed to make it more rational and scientific; they are supposed to optimize the use of the newest technologies, collective financial resources and administrative capacities. For example, hard choices have to be made between the use of extremely expensive devices which will save the few, and more traditional ones which will benefit the many. (The poor, migrants, refugees, and disabled are likely to be most affected by the current pandemics.) At times, the medical profession has resisted political interventions in its work, but more often than not, doctors have joined politicians in expanding state intervention in medical affairs. This is because state intervention has often implied more resources for healthcare and increased political influence for doctors.

The problem is that political interventions are seldom non-partisan, and do not always lead to the greater professionalisation of the healthcare system. Right-wingers often argue that personal health is chiefly a private rather than a public matter. They also tend to insist that the market rather than state is better suited to govern healthcare. Left-wingers believe that health policies are a matter for the public and not for individuals to decide. For them, an important aim of the healthcare system is equality, and this aim can hardly be secured by the private market alone.

Moreover, the professionalisation of the healthcare system has often depended more on local, country-specific capacities than ideological preferences. In fact, many right-wing governments have embraced a public health system, while many left-wing governments have overseen the growth of private hospitals and cuts to public ones. The bargaining power of the medical profession and health industry also plays a role here, as do societal trends such as demographics and aging populations.

Although private and public investments in health and healthcare are now enormous across the entire western world, there is no unified solution to deal with them. After World War II, the financing and organisation of healthcare shifted from the private toward the public sector. However, this trend was halted or even reversed in some cases with the arrival of the neo-liberal revolution. In Western countries we have also witnessed the tendency to respect the authority of the scientific and medical professions, and to keep health care insulated from excessive political control. And yet, since the late 1960s the technical authority of doctors has repeatedly been challenged not only by those demanding more “democratic” health care, but also by those unhappy with the soaring health budgets of their respective governments.

Since the late 1960s the technical authority of doctors has repeatedly been challenged… by those unhappy with the soaring health budgets of their respective governments.

The dangers of Technopopulism

The corona virus has frozen political battles and amplified the role of medical expertise. Yet there is the danger of converting serious political, economic and even cultural problems into medical ones. Policies to combat the pandemic re-order our personal and professional lives; they challenge our interests and values, and produce losers and winners. The process of representing and mediating these different interests and values has practically been suspended, and we are in the hands of governments making speedy decisions with historical implications.

The hope that politicians and experts will engage with each other and in the end produce fair, non-partisan outcomes may prove naïve. The key protagonists on both sides are part of the state machine and bound by common interests. The group of medical experts working for governments includes not only physicians, but also a plethora of administrators in charge of the health infrastructure, purchasing medicines and medical equipment, negotiating with doctors, patients and insurers, and assessing the implications of health-related environmental, demographic or technological developments. These civil servants, administrators and experts are often self-interested, prejudiced, and as political as any other professional group close to power. Politicians are dependent on these experts to find a way out of the current crisis. They also need these experts to legitimise all the adopted policies and their huge costs.

Politicians are dependent on these experts to find a way out of the current crisis. They also need these experts to legitimise all the adopted policies and their huge costs.

The danger is that instead of advancing a common good, politicians and experts may form an informal network operating in a mode of “dirty togetherness” by exchanging favours, propagating expedient statistics, and silencing inconvenient truths. Since there is no clear end to the current crisis and the stakes involved are huge, leaders may even face the temptation to rule by decree for a prolonged period of time with little transparency, public deliberation or accountability. This evokes the ghost of technopopulism.

In a forthcoming book on technopopulism, Chris Bickerton of Cambridge and Carlo Invernizzi-Accetti of New York argue that that technopopulists advance an “unmediated”, monolithic conception of the common good, framed as the ‘popular will’, but which is essentially techocrats’ “specific conception of political ‘truth’”. Bickerton and Invernizzi-Accetti’s study of France, Italy and Spain - pre-Covid-19 - already demonstrates closed fusions of populists and experts leading to different local versions of technopopulism. Emmanuel Macron’s La République En Marche was established by a tight-knit group of policy experts to challenge the “remote and self-serving” political establishment. French voters were invited to support an enlightened and effective leader capable of “achieving results” irrespective of ideological biases and parliamentary squabbles. The Spanish anti-establishment movement Podemos, which is part of the current coalition government, is called the “partido de profesores” and offers radical, but fairly pragmatic, if not technocratic solutions to Spain’s political problems. The Italian Five Star Movement which used to campaign against vaccinations and other scientific “truths” is now part of a coalition government led by “Professor” Conte, acting in a highly responsible manner to combat the pandemic.

One would be tempted to believe that experts have a soothing and enlightening effect on populist politicians, but Bickerton and Invernizzi-Accetti argue that this is not necessarily the case. Instead we witness the politicisation of expertise. Technopopulists come forward with alternative scientific “truths” with little effort to establish a scientific, let alone political consensus. In their view “technopopulism increases the conflictuality of democratic competition, while at the same time depriving it of substance.” Technopopulism also “exacerbates the separation of society from politics, while compensating for it with an increased use of the repressive apparatus of the state.”

These processes can now be observed in some countries of Central and Eastern Europe such as Hungary or Poland where populist politicians are utilizing anti-virus emergency measures to augment their powers beyond constitutional constraints. However, even in old democracies the “war” against Covid-19 is giving a platform to technopopulist manipulation. In the crisis caused by the virus, parliaments can hardly work normally and citizens prioritise action over deliberation. In effect, we may erode democracy without strengthening healthcare systems. This could be one of the unwanted side effects caused by Covid-19.

Even in old democracies the “war” against Covid-19 is giving a platform to technopopulist manipulation.

What to do?

Solutions for dealing with this danger are not particularly innovative. We should unmask the myths of national unity and challenge claims that there are no alternatives to the policies of our “enlightened” leaders. Democratic politics is about managing conflicts of interests and values because pandemics, war or economic crashes affect diverse groups of people differently, and these people cherish different values. None of the calamities we are experiencing argue against transparency and accountability. Without observing these principles, rulers will always try to escape responsibility for their behaviour and spread convenient lies, however “scientific.”

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