DOCTORS HAVE AN OBLIGATION TO TELL IT AS IT IS
Medicine is a social science, and politics is nothing else
but medicine on a large scale.
Physicians are the natural attorneys of the poor,
and social problems fall to a large extent within their jurisdiction.
Rudolf Virchow (1821-1902)
The universal public health project was born in the eighteenth century, established politically in the nineteenth century, and defined for the modern world in 1920 by Charles Edward Winslow:
Public Health is the Science and Art of preventing disease, prolonging life, and promoting health and efficiency through organised community effort for sanitation of the environment, the control of communicable disease, the education of the individual in personal hygiene, the organisation of medical and nursing services for early diagnosis and preventive treatment of disease, and the development of the social machinery to insure everyone a standard of living adequate for maintenance of health, so organising these benefits as to enable every citizen to realise his birthright of health and longevity.
The definition conceptualises public health as a programme of intervention strategies, requiring knowledge, imagination, political will, policy advocacy, commitment and implementation. Over the last century, public health has gradually evolved as a human right and a means for shaping the conditions and social determinants which will enable health to flourish and health policies to achieve meaningful outcomes.
Today, this implies that public health must courageously confront the powerful forces of globalisation and resist the negative political and economic trends that frame the twenty-first century and undermine human welfare. The pursuit of genuine democracy and human rights is another problematic transition, critical for public health. Democracy, particularly its sense of active engagement in shaping society, is the most appropriate approach in a world where so many people are marginalised, excluded from control of their own lives, suffer a sense of alienation, and are deprived of good health care; where governments, including the Malaysian government, increasingly support the privatisation of health care and repeatedly refer to health care as an industry, an object of tourism, and a mainstream contributor to economic growth, forgetting that health is a human right and health care a social service which governments have a duty to support and provide out of taxation.
Collectively, doctors are respected and influential members of society. If the medical profession really believes in putting patients first, then it should be equally, if not more, motivated to be politically active and contest government decisions which are detrimental to health. Doctors should be more outspoken as a professional body, when taxpayers’ money is being siphoned off to secret bank accounts in foreign countries or diverted to dubious, inflated projects, including the purchase of military hardware.
When politicians make decisions that have far-reaching adverse consequences on people, whose health and wellbeing doctors are entrusted with, doctors have a moral duty to openly challenge such decisions. Such political action would represent a powerful and effective example of preventive medicine. Last year, Greek doctors took to the streets of Athens to protest against austerity measures which would impinge negatively on health care.
Social determinants of health
Studies have shown that health is universally sensitive to social and economic factors and follows a social gradient: the higher the social position, the better the health. Academic research has contributed substantially to understanding the social determinants of health, such as poverty and low levels of education. In attempting to change such social inequalities, the main difficulty has been the lack of political commitment to effecting change.
The end of the Cold War and the fall of the Berlin Wall in 1989 seemed to unleash a new era of unopposed global capitalism, which the American political scientist and author, Francis Fukuyama, called the “end of history.” But neoliberalism and unfettered capitalism have now come under close scrutiny and pressure, with revelations that deregulated market forces and avarice have been the main cause of the 2008 financial crash and the ongoing economic melt-down, which has had devastating consequences for people all over the world. Social inequality has proved to be incredibly toxic and many people have had to endure redundancy and stagnating wages, while banking and business executives have received bonuses and other forms of remuneration that have, on average, increased by 12%.
Unemployment and enforced austerity measures are causing serious physical and mental health problems. The suicide rate in Athens rose by 25% last year and the national rate in Greece doubled to 5 per 100,000 of the population. The number of suicides in the United Kingdom rose 6% in 2008 to 5,766 suicides. Increasing poverty and mental stress will negatively affect mental health, crime, nutrition, substance misuse and other aspects of wellbeing, including morbidity and mortality rates.
The Occupy movement
On 17th September 2011, the Occupy movement exploded onto the streets of New York. By 24th September, 6,705 protesters had been arrested and jailed. Since then, Occupy has spread to hundreds of towns and cities across the world. The movement now occupies the global conscience. Messages of protest have spread from the streets to opinion editorials to political leaders and governments. It is time to wake up!
Occupy is an unprecedented movement that has critiqued and challenged corporate veils and corruption, and has called for greater openness, transparency, accountability, civic participation, equity and democracy. The Occupy movement is a rallying call to change our mode of thinking and forge a kinder, more egalitarian future. Occupy is asking questions and demanding change in top-down governance.
How are the wealthiest 1% in the United States influencing and dominating the lives of the other 99%? Is it not time to separate money from politics and politics from money? How do we redefine basic concepts of economic growth and make them ecologically sustainable in order to reduce inequality, stop climate change, and increase the quality of life for all?
Occupy is people-power that has succeeded in putting everyday inequalities on national agendas and informing public perceptions of income disparity. It has highlighted the plight of the poor and the disempowered, those without a voice, those without hope for changes in a capitalist economy that for decades has been shaped and coded to benefit the rich and the powerful.
Occupy represents a vision of democracy that fundamentally opposes the management of society as a corporate-controlled space that underwrites a political system that serves the wealthy, glosses over the poor, and fails to listen to criticisms and objections by the rest of society. People are now demanding of their governments new solutions and of themselves the effort and inventiveness to create them. This emerging paradigm shift in awareness and confidence is profound, but it’s only the first step towards meaningful transformation.
People are waking up to the reality that change will not come about from someone else or from corporate-linked politicians, or by simply voting for change. The Occupy movement’s radical message is that we have to change ourselves, individually and collectively, by questioning the dominant model and by redefining old ideas, such as gross domestic product and economic growth. Unless we change our mode of thinking and habits of consumerism, future generations will not survive cataclysmic climate change and loss of biodiversity. No one is going to do this for us, not our governments, not our so-called political leaders. As the black feminist poet, June Jordan, said, “We are the ones we have been waiting for.”
The Occupy movement seeks to challenge corporate manipulation of the economy and the concentration of increasing wealth and political power in the 1%, who now control the American political system and ignore the 99% of the people in economic decline. It seeks to discover new forms of participatory democracy that are least susceptible to corruption and profit-motivated corporate entities. Similar scenarios are in play in other countries, including Malaysia.
When Alan Greenspan, former chair of the US Federal Reserve, testified to Congress in the Clinton years, he explained that the success of the US economy and capitalism was based mainly on what he called “growing worker insecurity.” He explained that insecure people, who live precarious lives, are part of the ‘precariat’ and do not make demands in a “healthy” economy. The Occupy movement is the first popular reaction to this great social divide in the United States.
The world is hardening and dividing more and more into the haves and have-nots, between what Noam Chomsky calls the ‘plutonomy’ and the ‘precariat.’ In the imagery of the Occupy movement, the ‘plutonomy’ represents the rich and their affinity for luxury goods, and the ‘precariat’ represents the rest, that is, people who live a precarious existence on the peripheral margins of society.
People distrust those in power
Dysfunctional politics is a global problem. In almost every country, people distrust their governments and are keen for change. The 2012 Trust Barometer study by Edelman, one of the world’s largest independent public relations companies, has revealed a severe breakdown in government trust globally. In Europe, less than 50% of citizens in Ireland, Germany, the United Kingdom, Russia, Poland, Italy, France and Spain trusted their governments. Only 52% of Malaysians trusted their government, while 46% trusted the mainstream media.
The study also showed that there was particular concern with the failure of governments generally to listen and take heed of citizens’ views and needs, to effectively manage national financial affairs, to follow transparent and open practices, and to communicate frequently and honestly. It also showed that voter anger directed against governments often arose from the perception that elected representatives are unwilling to own up to hard truths.
There is a growing conviction that elected representatives have grown too remote, too arrogant, too corrupt and too closely associated with corporate interests to serve the common good. The incestuous cronyism between government and private enterprise increasingly exacerbates suspicions of venality.
In ancient China, each new dynasty launched a ceremonial “rectification” of words and their meanings, bringing together language and the subjects of the new dynasty and clarifying imperial politics and governance. We know that nuanced language, circumlocutions and euphemisms often provide cover and protection for what is wrong and outrageous. By changing the language, it is often possible to to change thinking about the reality of the status quo in order to bring about much-needed reform.
Confucius has this to say: “If language is not correct, then what is said is not what is meant; if what is said is not what is meant, then what must be done remains undone; if this remains undone, morals and arts will deteriorate; if justice goes astray, the people will stand about in helpless confusion.”
Rectifying the true meanings of words used and calling things by their true meanings are the first crucial steps in describing what is wrong before taking action. A doctor must first make a diagnosis before starting treatment. Citizens must begin by describing and recognising what is wrong before taking action. Language and truth matter. Lies are “lies,” not “terminological inexactitudes.” Theft is “theft,” not “inappropriate acquisition.” Murder is “murder,” not “accidental death” or “suicide.”
Political change in Malaysia
People everywhere are beginning to wake up and realise that those in power are ignoring the public interest and are not listening to the cries and protests of citizens. Many voters are rising up, organising street demonstrations and demanding change. The so-called Arab Spring and the Occupy movement are good examples of the actions of desperate, alienated populations.
In Malaysia, people are aware of the deafness of government leaders in ignoring public objections to exposure to industrial waste containing radioactive thorium, which will be produced by the rare earth refinery of the Lynas Advanced Materials Project (LAMP) in Gebeng, Pahang. Such waste will require robust isolation and containment for at least a few hundred years. Civil society groups, Save Malaysia Stop Lynas and Stop Lynas Coalition, have expressed major safety concerns that 700,000 people living within a 35 km radius of the refinery will be exposed to long-term radiation hazards, including ionising radiation from internal emitters following the inhalation and ingestion of thorium particles. This is particularly damning when Lynas has been given a temporary operation licence and has made no public disclosure whatsoever regarding its permanent waste disposal and decommissioning plans.
People are also aware that the Malaysian government has set up the Malaysia Nuclear Power Corporation for the purpose of building two nuclear power plants by 2021, despite public objections to possible nuclear accidents and lethal radioactive contamination of the country, in the face of the recent Fukushima nuclear meltdown in Japan, when other countries are phasing out their nuclear reactors and investing in renewable energy for the future. More than that, as there is no method of safely and permanently disposing of long-lived radioactive nuclear waste, future generations of Malaysians will be exposed to radioactive elements for thousands of years including for example, plutonium which has a half-life of 24,400 years. This is not a legacy we should leave future generations. We don’t need mendacious “experts” or politicians to tell us that nuclear reactors and rare earth refinery plants are safe.
There is a growing number of Malaysians who want to see political change. Business as usual is no longer an option. The same Malay-dominated coalition of ethnic-based political parties has been in power for too long. The Barisan Nasional government has had a good run for their money – in fact, with our money. It has grown fat, corrupt, addicted to cronyism, authoritarian, arrogant, and replaceable. For Malaysia to grow into a united, democratic, multicultural, high-income, developed country by 2020 and a respected member state of the international community, there will have to be many transformations. The most vital, primary change would be to dismantle ethnic-based political parties and replace them with multiethnic, ideological parties, dedicated to good governance, human rights and fundamental freedoms, particularly the freedoms of thought, conscience, religion, expression of opinion, a free media, and peaceful assembly and association. Systemic corruption, arbitrary arrest and detention, police brutality and custodial deaths must be eradicated. The rule of just law and independence of the judiciary must be restored. One of the worst self-inflicted wounds has been the politicisation of education in primary and secondary schools, which has impoverished the country of world-class universities and employable graduates. Many of those who enrol in foreign universities do not return home, a debilitating, unaffordable brain drain for a developing country.
Reforming the Barisan Nasional government, comparable to a lobotomised prisoner confined to a soundproofed cell, is unrealistic. A few years spent in the political wilderness could be therapeutic. Malaysia urgently needs a new government, capable of dispassionately thinking through the emotive and divisive arguments arising out of interpretations of the so-called “social contract” and the term “Ketuanan Melayu” and creating conditions that would nurture a country of twenty-first century Malaysians, believing in a borderless world.
In many developing countries, the ruling classes effectively control the population by influencing and controlling the attitudes and beliefs of people through a public relations industry, made up of a compliant, government-controlled media and special interest groups. In order to bring about change in the status quo, there has to be organised and informed civil society activism. Karl Marx had a famous line: “The task is not just to understand the world, but to change it.” To change the world constructively, you first have to understand it. Understanding the world does not mean just listening to a talk or reading a book. It means learning through long term participation in civic life.
I believe that if we have a human problem, then there has to be a human solution. History recounts the human struggles to abolish human sacrifice, slavery, racial segregation and apartheid. Each time, there was a human cost for change. Many activists were imprisoned, brutalised and killed. Human history is not only about injustice and cruelty, but also about compassion, courage and sacrifice. Nothing will change if we don’t take that first step to bring about change. If we believe that change is not possible before we take that first step, it will weaken our capacity to act and nothing will change. Be the change you want so badly! Great moral victories are often achieved through an infinite succession of countless small actions by unknown people.
The next three or four decades of the twenty-first century will mark a watershed in human history. There are two existential threats to human security, the integrity of the planet, and ultimately the survival of civilisation as we know it. First, the increasing militarisation of diplomacy in a world bristling with nuclear weapons will ultimately lead to catastrophic nuclear war. Second, ecologically unsustainable economic development in a world seduced by materialism will result in irreversible, cataclysmic climate change and loss of ecosystems.
We must learn from the mistakes of the past and forge a common, secure future. The greatest moral challenge of our time is the unthinkable possibility of self-destruction on a global scale in a nuclear war or from cataclysmic climate change. The greatest priority for the future is to ensure that there will be a future.
Doctors are bound by the Hippocratic Principle: First Do No Harm. When they become aware of circumstances harmful to their fellow human beings, they must speak up. It means never turning your face, whispering, or remaining silent in the presence of wrong.
Submitted to ALIRAN magazine for publication in January 2013.