Medicine,public health and the populist radical right

2016 and 2017 have thus far witnessed unusual success for the populist radical right electoral victories in rich countries. Elections in Poland and the United States led to victories for the populist right, Austrian presidential elections narrowly avoided a populist right victory and the Brexit referendum in the UK empowered a populist right-wing agenda that stretches beyond opposition to the European Union. While the populist radical right does not win everywhere, its new prominence, influence on agendas, ability to shape mainstream parties and electoral success are all at a high.

What does this rising tide of the right mean for medicine and public health? The ‘populist radical right’ refers to movements that are nativist (believing that there is an ethnically united people with a territory, aka nationalism or ethnocentrism), authoritarian (believing in the value of obeying and valuing authority) and populist (preferring the ‘common sense’ of a unified people to elite knowledge). ¹ These can be characteristics of entire parties, such as the Front National in France or the Freedom Party in Austria, or of tendencies and leaders within larger parties, such as Donald Trump.

Public health research that detects the consequences of inequality, blocked upward mobility and despair can be a surprisingly powerful predictor of the populist radical right’s rise. ² As for the effects, there is a considerable amount of political science research on the actions and implications of the populist radical right.

The implications of populist radical right electoral victories vary with the scale of the victory and the kind of political system. Extreme right parties that are in government thanks to a coalition with other parties, as has happened in Austria, Denmark, Italy, the Netherlands and Switzerland already, often have relatively limited policy effects. Their only lasting policy effect tends to be in immigration policy. ³ Participation in government does not, however, tend to moderate their populism, authoritarianism or nativism. ⁴

The situation is somewhat different in what political scientists call majoritarian democracies. Majoritarian democracies include Westminster systems such as the UK and presidential systems such as the United States and France. These have fewer institutional incentives to form coalition governments. Their electoral rules (such as the UK’s first-past-the-post) can put a single party with just a plurality into office with a legislative majority. Parties in majoritarian democracies can enact policies that entail a radical break with the past.

Referenda, finally, pose severe problems. To begin with, it is far from clear that voters know or care what they are voting on in them. ⁵ In addition, implementing them can be hard. For example, the detailed meaning of Brexit or Italians’ 2016 rejection of constitutional reforms does not follow automatically from the vote. Instead, it emerges from the interaction of the referendum result with the existing government, institutions and parties. While the UK’s only important populist radical right party is the United Kingdom Independence Party (UKIP), the Brexit referendum and subsequent hardening of positions on immigration by both the Conservatives and Labour show how much impact such a party, and the forces it taps, can have on established party policies. UKIP, with only one Member of the 2015–2017 Parliament, has substantially shaped the agenda of British politics. It has done so almost entirely through the adoption of UKIP positions by bigger mainstream parties.

Nativism, authoritarianism and populism have a complex relationship with public health and medicine. For much of its early history, public health had broad nativist and authoritarian streaks of its own, most notably seen in support for eugenics but also visible in other policy areas such as border health, quarantine and hygiene. ⁶ There is still an elective affinity between public health and strong, decisive – authoritarian – government if it means that the government can enact and implement public health policies without getting bogged down in consultations and lobbying. Hungary, for example, while becoming progressively more authoritarian under the Fidesz party, also enacted strong tobacco control policies.

Populism, though, sits badly with the evidence-based style of public health. Mike Pence, the new United States Vice President, has endorsed ‘gay conversion’ therapy that purports to make patients heterosexual and has said that ‘smoking doesn’t kill’, while Trump promotes the idea that vaccines cause autism. Further examples are legion. ⁷

Populist radical right parties long tended to have an economic liberal orientation, promising freer markets, lower taxes and less statism. ⁸ This orientation meant they were not naturally inclined to collective financing of healthcare services or taking regulatory public health measures. More recently, however, there has been a trend towards ‘welfare chauvinism’ among these parties. Welfare chauvinism is the promise to maintain or even expand welfare benefits for the core group while excluding outgroups such as immigrants. Recent examples might include Trump’s pledge during the campaign to defend Medicare, the French Front National candidate Marine Le Pen’s many statements about the need to defend social benefits and the famous bus used by Brexit campaigners emblazoned with the claim that the UK spent £350 million a week on the EU that could be redirected to the National Health Service.

It is an open empirical question whether welfare chauvinism is just rhetoric or heralds actual policies. We do not yet know whether a given populist radical right party in government will support a stronger welfare state (though it is an area of research). ²¹ They might continue to enact cutbacks that affect their supporters while drawing attention to cultural issues (e.g. Brexit or immigration). Trump, for one, put his backing behind a Republican bill that would repeal much of the Affordable Care Act and taken insurance from millions of his own supporters. Even if welfare chauvinism is more than rhetoric, populist radical right politicians in government might fight to defend only specific social benefits of interest to their constituents such as pensions, social health insurance or certain kinds of family allowances. There is no reason to expect them to spend on equalising measures. Instead, their effect on health access is likely to be exclusionary, reducing benefits for migrants or others whom they consider outside the people of their populism.

Since World War II, public health and medicine in many countries has also developed strong commitments to both human rights and vulnerable populations. These assurances are in conflict with nativist, populist and authoritarian policies insofar as they obligate public health practitioners to the defense of just those vulnerable populations who are excluded from the unitary nation of populist imagining.

In other words, the populist radical right is a threat to core values of medicine and public health even when they hold office in a functioning democractic system. Unfortunately, governments led by the populist radical right are also among the administrations most at risk for ‘democratic backsliding’. This happens when democratic governments slide into ‘competitive authoritarian regimes’, in which elections happen but without a realistic chance of them leading to a transfer of power. ⁹ Backsliding has already happened in Hungary and Turkey and is well advanced in Poland. Political scientists see serious risks of it in the United States, which only fully democratised with the civil rights movement of the 1960s. ¹⁰ The Trump administration so far, which has shown how far Republicans are willing to defend a leader of their party, arguably shows that democratic backsliding is a risk in the US but requires a more competent leader than Trump. Democratic backsliding does not only happen or automatically happen under the populist radical right but it has an affinity with the populist radical right. Nationalism, populism and authoritarianism are all at odds with the acceptance of pluralism and contention that marks liberal democracy. ¹¹

The result is that populist radical right parties, more than others, are prone to reduce the importance of opposition, transparency and democratic accountability of the government. With the loss of accountability and transparency in government comes the additional threat of kleptocracy, less competitive elections, ensured by mechanisms such as gerrymandering making it less likely that problems are corrected by the next election. For example, circumventing experts such as non-partisan civil servants can lead to nepotism and the appointment of corrupt officials, while stifling free expression and government transparency can make corruption easier to hide. Once there has been criminality, then hiding it by suppressing free expression and transparency, while making others complicit, allows the regime to survive. This sort of ‘systemic corruption’, in which public office is used to skew political competition and gain private advantage, becomes more of a threat as governments become more authoritarian and institutions less capable of holding them to account. ¹²

There are reasons to expect that growing authoritarianism and democratic backsliding will be bad for healthcare systems’ administration. Health is never one of the ‘power ministries’ that governments depend on to stay in power (such as Interior or Justice). Instead, it is a mechanism to distribute benefits. In a democracy, the thrust of health policy is usually to distribute benefits such as healthcare widely in order to attract voters. In a less democratic regime, where large blocks of voters are excluded from meaningful participation, the obvious way for the government to use a health ministry is to pay off specific supporters by permitting corruption or focusing benefits narrowly on important groups such as the police. ¹³ In much of Europe, healthcare is already a corrupt sector. ¹⁴ If governments entrench themselves by permitting more graft in healthcare by their supporters then the problem, and the healthcare, will get worse. Alternatively, they can let the health sector slide while focusing the agenda and winning popular support on other issues such as immigration or religious symbols.

Likewise, the erosion of the liberal world order that has been so criticised in public health research, with its free trade and capital mobility and American domination, could lead to an alternative that is even worse. Nativism bodes ill for global governance. It is unlikely that populist radical right regimes will take constructive steps to improve the health effects of global institutions such as NATO or the WTO. It is much more likely that they simply undermine them. That certainly seems to be the trend as Trump is questioning NATO and the UN while promising ‘America first’ policies in his 2017 inauguration speech. In the meantime, the Hungarian government and other European parties are cultivating good relations with Russia. ¹⁵ In Europe, the EU has been a particular target of almost all populist radical right parties. ¹⁶

Nationalism and internationalism are often opposed, but nationalists can be internationalist. Throughout history, nationalists and internationalists have often united in opposition to an internationalism with which they disagree such as today’s liberal internationalist order, colonial empires, the Soviet bloc or the pre-World War I empires. We see such internationalist nationalists today in alliances between leaders of the Austrian, French, Dutch, German and UK populist radical right and the Trump administration (or the internationalism of the Breitbart websites) against the liberal internationalist order exemplified by NATO and the EU. However, we do not know what they would do once liberal internationalist institutions are weakened or broken.

What can medical and public health professionals do in this context? ¹⁷ First, be very careful about working with radical right parties and governments. Any elective affinity between authoritarianism and public health would probably undermine our commitment to human rights and fall afoul of nativist and populist politics. Populist radical right parties can easily gain more in legitimacy than health gains from their policies. This is especially true since there is no reason to expect them to be particularly responsive to science, evidence or human rights arguments.

Second, adhere to professional norms. Professions, with their respect for ethics and rules, can be a brake on illiberal practices. ¹⁸ Third, remain focused on promoting broadly egalitarian social policy, including the defense of health programs. Political scientists find that inequality encourages corruption and authoritarianism, and vice versa. ¹⁹ Fourth, labour unions, however weakened, are a working-class alternative to the extreme right and are effective advocates of equality and health. Policies that undermine labour unions undermine a bulwark of liberal democracy. Fifth and finally, remember that institutions such as professions, legislatures, courts, the press and the law are strong when they support each other and collapse quickly when they are isolated. ²⁰ Liberal democracy is at its most vulnerable when its supports can be removed separately.