Perhaps the most putrid specialty in a profession that has more than its fair share of stinkers is public health medicine. A natural bunker for malfunctioning medical Mussolinis and failed physician Pinochets, public health medicine has evolved an alien and grandiose medical culture in which they who practice it are above mere patients. Instead, they have populations. Just as Mussolini engineered a society in which the trains ran on time, so public health physicians would have it that the population abstains from fags fizz and fornication, downs its five fruit and veg a day, and, armed with a faecal occult blood testing kit in its hands, opens its bowels on time. Their vision, like their ideological forebears, the Stalinists and the Nazis, is one of the nation state as a boot camp for health, a vast breeding ground for a pure population free of disease, infirmity and disability, all watched over by health marshals wearing caps emblazoned with the rallying yet blinding cry, Health for All, and All for Health! What could possibly go wrong?
Well, quite a lot, of course. This is the toxic world of health fascism, and its first, and in some ways more developed, cousin, coercive healthism. Health fascism is crude and brutal — the state knows best what is good for the health of the people, and the people must comply — but coercive healthism is subtler, in that it infects the people with a belief in healthism, the notion that the pursuit of health and longevity is a natural good in and of itself. If that was as far as it went, we might be prepared reluctantly to tolerate it, but healthism very quickly mutates into coercive healthism. The coercion comes in two ways. Instead of the people being free to chose whether they want to pursue eternal health and happiness — and in the process become the neurotic automatons of the worried well — the state imposes a moral duty to pursue eternal health and happiness. This duty is sold as benefit to the individual, but its true target is to benefit the health of the nation. This imposed duty then creates two classes: the good, who accept the imposition, even welcome it, and the bad, who reject it, and continue their wicked ways. This in turn leads to the second, more insidious and yet even more powerful coercion, that of the people on the people. Healthism starts to operate like any other ‘ism’, with those on the ‘good’ side marginalising, denigrating and attacking those on the ‘bad’ side.
None of this should come as any surprise, because coercive healthism has been on the rise for decades. We see it every time a Chief Medical Officer stands up and tells us we should drink less, exercise more, and keep slathering on the sun cream. The doctrine underpinning this approach — targeting the population rather than the high risk individuals — comes from a wily old London School of Hygiene and Tropical Medicine Professor of Epidemiology, Geoffrey Rose. By far the most influential publications by Rose are a linked pair of papers, the first published in 1985 and chilling titled Sick Individuals and Sick Populations, and the second, published in 1990, and even more chilling titled The population mean predicts the number of deviant individuals. We can even see the dead hand of healthism at work in the titles: by 1990, 1985’s sick individuals had become deviant individuals, the bad individuals who have failed to embrace healthism.
In these papers, Rose advanced the notion, backed up by some between country comparisons, that average behaviour in a population — for example, average weight, or average alcohol consumption — determines the extremes — for example, obesity, or excessive alcohol consumption. Cleverly labelling any approach that targets high risk individuals, that is the sick and the deviants, as ‘high risk’ strategies (quotes are in the original 1985 paper), he then contrasts these ‘high risk’ strategies with population strategies (no need to bother with that quotes nonsense this time) which target the entire population, and aim to shift the entire population to the left — that is, move the bell shaped curve of the population distribution to the left, and in so doing lower the average behaviour — in the expectation that shifting the average, or mean value, will then drag the deviants in the tail, the obese and the excessive drinkers, also to the left.
This proposal, which Rose found very much to his liking, to target entire populations is of course pure healthism. But the whole doctrine behind population strategies is based on an astonishing leap of faith made most succinctly in a short paragraph (emphasis added) in the 1990 paper: “The results show [the link between the body and the tail of a distribution] to be a geographically world-wide phenomenon. It is hard to see how it could fail also to apply to temporal changes within a population, implying that changes in population characteristics will produce predictable changes in the size of the deviant subgroup”. Rose wisely adds, “This, however, requires confirmation,” — which as it happens, it still does today — but by then the payload had hit its mark. Whole swathes of public health doctors, the malfunctioning Mussolinis and the failed Pinochets, found the doctrine very much to their liking, for it gave them all they needed to go out into the world and pursue the relentless promotion of coercive healthism. The constant barrage of public health messaging to which we as an entire population are now routinely subjected is the inevitable result.
By now, dear reader, Dr No expects you will have joined up the dots. By far the bulk of our national response to covid–19 has been driven by public health doctors, the very same doctors who worship at the altar of coercive healthism, applied at a population level. We can see it clearly in the choice to adopt a population level approach to controlling covid — the population mean level of infection predicts the numbers of deviants (the old and the vulnerable, only they are spared that ghastly title in the public messaging) who get infected. We see the indelible stamp of coercive healthism in the demand that we all take steps to protect our health, regardless of individual risk, in an echo of the demand that we all cut down our drinking, even those who are at no risk from alcohol. We see it again in the instruction that we should all behave as if we have covid, whether we have it or not, a quite brilliant, Dr No has to admit, piece of covid zombification. And worst of all, we see the damage of social division between the zombie good, who follow the rules without question, and the deviant bad, who dare to question.
Just as, no doubt, the Mussolinis and Pinochets in their public health bunker plan their covid schemes and stratagems, crying Health for All, and All for Health, and ask of each other, what could possibly go wrong?