Q J Med 2004; 97: 61-62
© Association of Physicians 2004; all rights reserved.
Editorial |
Politics and health
In a recent QJM editorial,1 Daniels began by stating that medicine and politics are inextricably intertwined, yet concluded that medical journals should publish less ‘political’ material in favour of a more technical agenda. If journals adopt this approach, they are failing doctors, patients and wider society. Many of the issues that influence both health and the practice of medicine are deemed political; it is therefore appropriate for medical journals to inform health professionals about these issues.Even the best evidence-based technical medical intervention will be unsuccessful if the political solutions that allow it to be implemented are not identified. Jones et al. estimate that the implementation of a limited range of interventions could prevent 63% of the worldwide 10 million deaths per year in the under-5 age group.2 The interventions considered in this analysis were selected based on their evidence and feasibility for high coverage in low-income settings. If the objective is to improve global health, we have to look beyond the randomized control trial to what is really impeding progress, even if this leads us into slightly less comfortable ‘political’ areas.
Technical matters are far from being a refuge from politics. Even the most seemingly apolitical and technical medical article profoundly reflects its political environment. As Taracena states, ‘every medical article published is the culmination of a long journey that started from a political decision: devoting resources to medical care and research.’3 For example, the current emphasis on clinical trials in journals reflects the large input of funding into such research by pharmaceutical companies, rather than priority setting based on burden of disease or cost-effective analysis. Indeed, only 10% of the US$70 billion spent on health research and development each year is targeted on the diseases that account for 90% of the global burden of disease—a 10/90 research gap.4
Further, to purport to be apolitical and purely technical is more dangerous than acknowledging political influences where they arise. For instance, Roberts suggests that medical journals may have unwittingly contributed to justifying the war in Iraq by choosing to publish many apparently apolitical articles on the impact of bioterrorism, out of proportion to its relative public health importance.5 Surely a better approach, as adopted by Obuaya, is to recognize that the selection of technical articles is highly influenced by political factors, and to attempt to challenge unjustified publishing bias.6
There is, however, a section of opinion that holds that ‘political issues’ are taboo for medical journals, and that the objective medical profession should not lower itself to such subjective debate. But medicine abstracted from the political realities of health is impotent, since the greatest determinants of health are social, economic, and political. Technical medical interventions play only a minor role in affecting the health of populations. For example, the steep decline of TB prevalence in the developed world preceded the use of antibiotics or Bacillus Calmette-Guerin vaccine, and reflected instead an improvement in living conditions.7 In the UK today, differences in health status across geographical and social groups do not result from differences in medical management, but from determinants such as poverty, income, education, housing, environment, pollution, transport, and nutrition.8 These determinants are amenable to political intervention.
Ultimately, as Bambra et al. state, ‘health is political because power is exercised over it’.9 A purely technical agenda does not acknowledge this reality, and thus sanitizes global inequities in health as purely technical matters, at most the result of individual risk factors and behaviours. For example, much of the research into HIV/AIDS has focused on the identification of individual risk behaviours, rather than examining the wider social, economic and political context that makes people susceptible to infection.10
Thus to maintain that politics and medicine can remain separate is incoherent, both because many of the determinants of health are political, and because the technical agenda of medicine is set by political forces. The artificial distinction between technical and political medicine only masks the fact that what is really being discussed is simply health: its determinants, interventions that improve it, barriers to its improvement, and inequalities in health status.
Rightly, many medical journals have never subscribed to this distinction between political and technical, trying instead to widen their readership's perspective on health. The BMJ's stated aim is to publish ‘papers commenting on the clinical, scientific, social, political, and economic factors affecting health’.11 Similarly, the Journal of the American Medical Association recognizes a ‘responsibility to improve the total human condition’ and to ‘inform readers about non-clinical aspects of medicine and public health, including the political ... ’.12 Thomas Wakley, MP and ‘medico-political polemicist’,13 founded the Lancet with the aim of introducing a ‘radical slant’ to the ‘corrupt medical establishment’.14
This approach does present some difficulties. One problem is that political bias may creep into a profession that requires objectivity. Maintaining high standards of evidence can guard against such subjectivity. Yet the current evidence is that many high impact general medical journals ignore major medico-political issues altogether. Since September 2001, neither the New England Journal of Medicine, nor the Annals of Internal Medicine, has published any article containing the text word ‘Afghanistan’ or ‘Iraq’. In contrast, other general medical journals have attempted to examine the health consequences of these conflicts and have actively encouraged debate on the nature of their coverage of the ‘war on terrorism’.15 The suppression of important health issues is even more worrying than the threat of subjective bias, which can be countered.
A further danger is that doctors and medical journals overstate their expertise and authority in debates where health is not the only concern, such as debates over poverty or smoking. Nevertheless, as a profession we must strike a balance between non-engagement and hubris, since we have expertise in health, and we would fail the sick poor, or the dying smoker, if we failed to engage with these issues.
The histologist, pathologist, clinician, and politician Rudolf Virchow wrote: ‘It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation.’ Ignoring the political realities of health, particularly global health inequities, is one way of habituating them. Medical journals have a manifest and necessary role to play in countering this process through objective debate. For medical journals to remain silent over these issues would be an unacceptable—and political—act.
; lynda.fenton{at}doctors.org.uk; d.edwards{at}ucl.ac.uk
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International Health Advocacy Group International Health and Medical Education Centre University College London e-mail: davidadambarr{at}hotmail.com; lynda.fenton{at}doctors.org.uk; d.edwards{at}ucl.ac.uk
References
1. Daniels A. The politics of medicine. Q J Med 2003; 96:695–7.
2. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003; 362:65–71.[CrossRef][Web of Science][Medline]
3. Taracena GH. We cannot be apolitical. Br Med J 2003; 326:820.
4. Global Forum for Health Research. The 10/90 Report on Health Research 2001–2002. Geneva: Global Forum for Health Research, 2002. [http://www.globalforumhealth.org/pages/index.asp?ThePage=page1_00060008_1.htm&Nav=00060008]
5. Roberts IG. Propaganda or science? Biological warfare and the people of Iraq. Hong Kong Med J 2003; 9:307–8.[Medline]
6. Obuaya CC. Reporting of research and health issues relevant to resource-poor countries in high-impact medical journals. Euro Science Edit 2002; 28:72–7.
7. McKeown T. The medical contribution. In: Davey B, Gray A, Seale C, eds. Health and Disease: A Reader. London, Open University Press, 2001.
8. Acheson D. Independent inquiry into inequalities in health report. London, The Stationary Office, 1998.
9. Bambra C, Fox D, Scott-Samuel A. Towards a new politics of health. Politics of Health Group Discussion Paper no. 1, 2003. [http://www.liv.ac.uk/PublicHealth/Publications/publications01.html]
10. Wolffers I. Biomedical and development paradigms in AIDS prevention. Bull World Health Organ 2000; 78:267–73.[Medline]
11. About the BMJ. [http://bmj.bmjjournals.com/aboutsite/aboutbmj.shtml] Accessed 18 October 2003.
12. The key and critical objectives of JAMA. [http://jama.ama-assn.org/about_current.dtl] Accessed 18 October 2003.
13. Froggatt P. John Snow, Thomas Wakely, and The Lancet. Anaesthesia 2002; 57:667–75.[Medline]
14. Hutchinson M. How The Lancet made medical history. BBC News Online 2003, October 6. [http://newsvote.bbc.co.uk/mpapps/pagetools/print/news.bbc.co.uk/2/hi/health/3168608.stm] Accessed 6 October 2003.
15. Delamothe T. How political should a general medical journal be? Br Med J 2002; 325:1431–2.
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