The Political Determinants of Health

Euan Lawson

doi:10.3399/bjgp20X713525

Joe Biden will be the 46th President of the US and one of his first actions after winning the election was to lay out plans for his COVID Taskforce. The political and the medical are inseparable. A presidential election is polarising but, increasingly, the calculus of COVID-19 is conducted in base two. Everything is 0 or 1. We argue about the economy or lives; GP practices are portrayed as open or closed; the Great Barrington Declaration is set against the John Snow Memorandum; and we agonise over the false dichotomy of lockdown versus freedom. It’s all black or white. Yet medical practice is colourful, subtle, and complex; nuanced and blotted in uncertainty. Populism’s palette doesn’t extend to such shades.

Sandel sets out to diagnose the root causes of populism and turns his gaze on meritocracy in The Tyranny of Merit.¹ We are immersed in it; the meritocratic drivers in society no more apparent to us than water to a fish. While there is an obvious argument in favour of the most capable being picked for any given role, as Sandel points out there is a dark side to meritocracy: ‘In an unequal society, those who land on top want to believe their success is morally justified. In a meritocratic society, this means the winners must believe they have earned their success through their own talent and hard work.’ In any meritocracy there are losers and they are likely to be humiliated and resentful. The winners have little sympathy and the overall result is ‘corrosive of commonality.’

Professor Ilona Kickbusch from the Global Health Centre in Geneva teased out the political determinants of health in The Academy of Medical Sciences and The Lancet International Health Lecture 2020.² She put forward the association between populist-leaning governments and the ability to cope with COVID-19, culminating in excess deaths. A pandemic stresses the economic, political, and social fracture lines, and meritocratic tenets impact how society respond to people who are undeserving. Benefits for the unemployed or disabled are pared back. And what if you are a smoker? Or you inject drugs or are street homeless? The inevitable and inescapable corollary of meritocratic achievement is personal blame, seldom an effective health strategy.

Importantly, a meritocracy doesn’t address inequalities — it offers self-justification for those on the top of the heap and opprobrium for the rest. Not having a college education is an excellent marker of whether someone would vote Trump (or Brexit) and is bundled with a high risk of drug-related deaths, another epidemic. The post-nominal fetish in medicine confirms how we are beholden to the credentials beloved of meritocrats. We need to be wary of casual discrimination that implies these people are stupid. They are not. Sandel again: ‘… at a time when racism and sexism are out of favor (discredited though not eliminated), credentialism is the last acceptable prejudice.’