After a century and a half of astounding advances, public health has much to be proud of. Yet at this point in the 21st century, we seem to be going backward.
We used to think infectious diseases were beaten, or fading fast, and we’d just have to deal with noncommunicable diseases like diabetes and cancer. Instead, diseases we’ve forgotten are coming back at us from the 19th and 20th centuries: cholera, yellow fever, scarlet fever, diphtheria. Polio has been effectively eradicated from all but three countries: Nigeria, Pakistan and Afghanistan — but vaccination teams in Pakistan are routinely murdered in the streets by terrorist hit squads.
Canada eliminated measles in 1998, two years ahead of the U.S. Yet both countries, like many others, now contend with recurrent outbreaks of this highly infectious and sometimes fatal disease. We had 11 cases in 2016, and the U.S. has reported 118 cases in just the first three months of 2018. By comparison, in 1941 B.C. alone had 15,562 cases, with almost 6,000 of them in Greater Vancouver.
Measles outbreaks here are triggered by infected persons flying in from countries with low vaccination rates, but they spread because our own vaccination rates aren’t very high either. And they’re not very high because a lot of well-educated, thoroughly vaccinated adults have decided vaccines are dangerous. Now some of them even think vaccines can make your dog autistic.
Authority? Says who?
Medical authorities are baffled by this attitude toward measles vaccinations and other basic health principles. But some of them are beginning to realize that, in the eyes of many of their patients, they aren’t really authorities any more.
Those patients are suffering from what’s now being called “health populism” — the conviction that since doctors, hospitals, government agencies and, of course, Big Pharma are all out to make a fortune at our expense, we should decide for ourselves about our health care.
Health populists see medicine as the lair of a cabal of predatory “experts,” just like other institutions — the courts, the legislatures, law enforcement, education. They see the experts as in it for themselves alone, wrapping their message in impressive technical jargon but doing no good. So populists like clickbait ads assuring them, “Your doctor doesn’t want you to know about… ”
This attitude has a lot in common with culture shock, where newcomers to a society begin to see it as dedicated to robbing them blind. And it can be argued that over the last 30 years or so the world has changed so fast that we’re all a bit culture-shocked.
Under those conditions, we often turn to those who literally speak our language, offer good news, and seem to have a grip on life that we envy. For millions, celebrities fill that role. We see them on TV and in the movies, they speak understandable English, so we trust them. If the experts damn and blast them, the celebrities thrive all the more. They’re not part of the cabal, after all.
Countless marketers encourage a widespread attitude that you’re responsible for your own health: a new diet or supplement or “cleanse” will get you back on track, quickly and easily, regardless of your neighbours’ health.
So health populism loves evidence-free fads like the Paleo diet and “raw water.” Most “alternative” and “complementary” health approaches are also populist, since standard, peer-reviewed medical science finds little or no evidence for their efficacy. Health populists like terms like “natural,” “wellness” and “healing,” and are happy to pay for such labelling.
The populist distrust of medical science has a certain validity, if only because medical science often sends out conflicting signals. Rudolf Virchow, a 19th-century German doctor and politician, is considered the father of pathology — but he never bought Pasteur’s germ theory of disease. Health research, often funded by interested industries, tells us fat is bad, then that it’s okay, but watch out for sugar; a daily glass of wine is good for you, then we’re told it’s terrible.
Drugs like thalidomide are recommended for pregnant mothers, and drugs like mefloquine are mandated for soldiers in malaria zones, until the disastrous consequences turn up. And opioids? Don’t even go there.
Compounding its errors, medical science too often baffles patients with its obscure technical jargon, in which things you shouldn’t take are “contraindicated.”
Medical slang isn’t so pleasant either: an elderly patient with complicated medical problems is known as a “gomer” (get out of my emergency room) or a “frequent flyer” (someone who often turns up in an ER). A “code brown” refers to a patient who’s defecated away from a toilet.
In political theory, an institution is a group of unelected experts who exert considerable influence over their society: law enforcement, the courts, the media, the military, the corporations. Within their sphere, they know their stuff. But the 18th-century economist Adam Smith included them when he observed that “People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices.”
Unchallenged for some period of time, our institutions may well decay into conspiracies against the public, and the public knows it. Better to listen to a smiling celebrity than a stuffed shirt telling you what to do.
Public health around the world is aware of health populism, and trying to fight it. The World Health Organization last month touted World Immunization Week. But who’s even aware of WHO’s website, and who’s going to plow through its statistics and then accept them?
In its extreme form, health populism erupts in poor and backward countries when doctors arrive to try to help. That happened to Doctors Without Borders in Guinea early in the Ebola outbreak, when rioting young men shut down its treatment centre. In another incident, eight people were murdered in a Guinean village while trying to explain Ebola to the villagers.
Such alienation is part of our own health populism, and may explain some of the continuing violence against health care workers in Canadian hospitals. We have allowed (or encouraged) a widening gap between expert institutions and the people they’re supposed to serve. Poorly educated, frightened, and lacking any sense of control over their lives, they attack the very people trying to help them.
For a doctor to condemn such patients is as pointless as a teacher complaining that “I taught him that, but he didn’t learn it.” Medical experts can’t cure their patients if they don’t fully understand them, start where they are, listen to them, and earn their trust.
And if the experts can’t win over the health populists, they’ll be far less able to care for the rest of us.
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