Is there a health crisis?

Roy Porter

  • The Public Health Challenge edited by Stephen Farrow
    Hutchinson, 160 pp, £12.95, November 1987, ISBN 0 09 173165 8
  • The Truth about the Aids Panic by Michael Fitzpatrick and Don Milligan
    Junius, 68 pp, £1.95, March 1987, ISBN 0 948392 07 X
  • Dangerous Sexualities: Medico-Moral Politics in England since 1830 by Frank Mort
    Routledge, 280 pp, £7.95, October 1987, ISBN 0 7102 0856 1
  • Medicine and Labour: The Politics of a Profession by Steve Watkins
    Lawrence and Wishart, 272 pp, £6.95, May 1987, ISBN 0 85315 639 5

Are we, or are we not, in the throes of a health crisis? Read some of what is said, and it seems as though our civilisation is about to collapse in an Aids-related catastrophe, at the very moment when the National Health Service is itself suffering Government-administered euthanasia. Listen to others, and all this is made out to be so much cant, cynically orchestrated by interested parties: on the one hand, to bash the gays; on the other, to aggrandise the medical profession still further.

Who should we believe? First, it’s important to look at the date stamp. If any professional body in this country might be expected to be shouting from the rooftops about the Aids threat, surely it would be the Faculty of Community Medicine (the fancy new name for what was always called ‘public health’). Yet Aids hardly even figures on the agenda of ‘the public health challenge’, to judge from the collection of that title just issued by the Faculty: the disease gets just four brief mentions. Why? Not because the public health service thinks it’s all a scare, but because a lot of water has flowed under the bridge since early 1986, when the papers in this (otherwise fascinating) volume were written. It’s crucial to grasp, moreover, that medical politics plays its part in Aids-forecasting as well as in budgeting the NHS. Indeed, political rhetoric wears hardly a fig-leaf in Fitzpatrick and Milligan’s broadside, even though the authors promise us The Truth about the Aids Panic – and we’d better listen because their message carries the weight of medical authority (FitzPatrick is titled ‘Dr’ on the front cover, and on the back we are told he is a GP).

This truth, it seems, is that what we have to worry about is not Aids but the Aids panic. It is all a ‘scare’, ‘officially sponsored by the Government’ and its repressive, puritan and heterosexual mouthpieces, in cahoots with the medical top brass, greedily grasping at ‘more resources for a disease in vogue’. The point of official ‘propaganda’ is to ‘contribute to the anti-homosexual hysteria’, to police individuals’ lifestyles and bodies, and thereby reestablish those Victorian family virtues which Thatcherism requires: ‘the establishment has thrown its weight behind the Aids panic because it recognises how the virus can help it strengthen its faltering grip over society.’ Ignore the DHSS propaganda, proclaim Fitzpatrick and Milligan, the panic, not the disease, is the true health hazard: ‘safe sex’ is a threat to freedom.

Many reactions are possible to this line. One could accept that it simply is The Truth, Or one could admire its advice to gays – a challenge to the Terence Higgins Trust – to keep the sexual liberationist flag flying, admire this as a brave call to go down fighting (nos morituri ...). Or one could deplore it as an utterly mischievous tract whose epidemiological ignorance is exceeded only by its irresponsibility. What is most noteworthy, however, is its ritual invocation of conspiracy theory. They are out to get you – they being a cabal comprising the Government and the medical establishment (self-appointed ‘guardians of public morality’) which is both powerful and evil.

There is, of course, nothing new in radicals – or reactionaries, for that matter – spotting conspiracies where others see epidemics: no less a man of the people than William Cobbett was adamant that Asiatic cholera itself was a fiction invented by the powers-that-be to hold the masses in terror. Indeed, as Steve Watkins underlines in his book, the Left in many of its moods has traditionally suspected that the medical profession is merely the Tory Party in a white coat. Yet even it such diatribes make good agitation, as analyses of reality they are fundamentally flawed. Medical politics have always been, and remain, far more ambiguous. This is deftly shown in Frank Mort’s Dangerous Sexualities, a survey of sexual policing in England since the accession of Victoria. Focus initially upon the Early Victorian years, he suggests, and you see what appears to be an irresistible alliance of doctors, experts, reformers and administrators launching a grand medico-moral clean-up of the polluted – especially the Great Unwashed – in the name of public health, socio-sexual hygiene and state medicine. For reformers such as Edwin Chadwick, dirt, disease and decadence were all of a piece, and all would be washed away by the pure cold flush of the sanitary movement. This Victorian campaign for the control of sin, sex and sickness peaked with the Contagious Diseases Acts of the 1860s, which instituted the compulsory medical inspection and treatment of prostitutes in specified garrison and port towns.

Yet the Acts proved a Pyrrhic victory, for they drew so much flack from so many quarters, ranging from radical feminists to crusty libertarians, that they had to be repealed. And thereafter the cause of sexual reformation through acts of state was permanently eclipsed. Lobby after lobby arose to press for further legislation regulating sexual morals. In the 1890s, feminist-inspired crusades, such as the National Vigilance Association, diagnosing male lust as the root of all evil, demanded legislation against indecency and vice and the raising of the age of consent to 18: but this New Moralism gained few successes on the statute book.

Then, early in the present century, eugenist groups pressed for ‘social hygiene’ laws to prevent the unfit from breeding, but, unlike what happened in the USA, compulsory sterilisation was not forthcoming. Other pressure groups demanded that VD should be made a notifiable disease, and that penalties be introduced for spreading it or for failing to be treated: but the English system of VD clinics set up after World War One was, unlike the Scandinavian, purely voluntary.

Thus, Mort argues, despite the plethora of repressive or reforming discourses, what is remarkable is not how much, but how little, the state has chosen to enforce sexual morality through medical means. Why was this? It was partly a consequence of the often sectarian, cranky and authoritarian leadership of the medico-moral lobbies: New Morality activists won as many enemies as friends and proved politically maladroit. It was not lost on observers, for example, that the real victims of ‘purity league’ campaigns were not aristocratic debauchees but working-class prostitutes. Secondly, it was because the medical profession itself – perhaps aware of having burnt its fingers over the Contagious Diseases Acts – retreated into an ultra-cautious shell, and steadfastly declined to endorse measures for the enforcement of sexual norms which would compromise its own professional independence or violate that holy-of-holies, doctor-patient confidentiality. But, above all, it was because Parliament saw the folly of embroiling itself unnecessarily in those aspects of sexuality which were bound to prove bones of contention. Honourable Members were unwilling to countenance legislation (against prostitutes’ clients, for example) which was liable to make inroads into traditional male licence: in any case, ministers have long understood that votes are lost, not won, through intrusive, prying legislation. It is one thing to raid a few gay bookshops, another to propose using the law to censor page three.

Overall, argues Mort, to invoke the language of conspiracy to characterise medico-moral politics in England confuses rather than clarifies the issue. Over the last century, successive governments, and the medical profession, have dragged their feet: only occasionally have they been spurred into action by scandals and campaigns. Mort’s elucidation helps explain why today it is the ‘punish’ and not the ‘persuade’ brigade who are being kept on the sidelines in the formulation of policy over Aids.

Mort’s historical analysis is neatly complemented by the account of medical politics at the present time which is offered by Steve Watkins, doctor, official of the Medical Practitioners’ Union (part of ASTMS) and Labour Party activist. It is all too easy, Watkins contends, for Leftist ideologues to cast the medical profession in the role of ogre, ancestrally conservative and Conservative, over-paid, over-mighty and over-privileged, disposed not merely to preserve its own position, perks and privileges but also to enforce its own middle-class, hierarchical and patriarchal morality. Granted, certain occurrences lend superficial credence to this view, not least the fact that the crucial disputes and industrial action involving doctors have always taken place under Labour governments. Yet overall it is false.

Not because the profession is truly apolitical or above politics. But rather because its street-wisdom and muscle power lie in astutely maintaining an ostensible post of independence, backed up by appeals to medico-scientific fact and to the almost sacramental status of the doctor-patient relationship. Certainly, the profession has dug in its heels against Labour governments (as over pay-beds). Yet it also has an honourable record in resisting the Tories: a prestigious BMA Board of Science Report drew attention in 1983, not just to the health consequences of nuclear war, but also to the medical nonsense and bad faith of Tory Civil Defence planning, and in doing so cut more ice than any number of pro-CND resolutions. The current success of the profession in mobilising public opinion against the Government in defence of the NHS bears out Watkins’s case perfectly.

So what we see is ordinary, mucky interest-group politics, not some sinister conspiracy. Today, as in the past, governments and the medical profession frequently fail to see eye to eye, and the medical profession should not be credited with more clout or greater unity than it possesses. The medical monster proves as mythical as the wyvern.

One of the great strengths of the radical historical critique of science, medicine and the professions as it has emerged over the last generation has been its debunking of the mystique of scientific objectivity and professional neutrality. The scientific and medical policies pursued by governments typically embody moral priorities too, often masked and mystified through technical languages; professions wield oligarchic, sectional power no less than they serve their clients; and the disciplines they profess, as Foucault stressed, themselves form discourses of power. The danger is that in pursuing such demystification we slip into the equally moralistic language of conspiracy.

At the very least, this shorthand may conflate outcomes and intentions, professions and practice. More seriously, it readily conjures up a highly distorted picture of the agencies of political power, suggesting a monolithic plenitude of power: in reality, what counts for most in an intricate and pluralist society may be the complex arrangement of checks and balances which serves to hamper James Anderton no less than Gay Liberation. Between them, Mort and Watkins offer astute assessments of the scope and limits of medical politics in Britain past and present. In these days of Aids and Aids panic, they offer far more reliable guidelines to an understanding of what has happened than does the shrill rhetoric of Fitzpatrick and Milligan.