Autocracy,medicine and health in the 21st century

Autocratic forms of government are spreading and consolidating worldwide. Autocracies pose general challenges to human health and wellbeing in the 21st century. They can also pose specific risks to the medical professionals who must work within them. Autocracies go by many names, have different trajectories and configurations, and can have different relationships with the societies that they rule. Some are classical autocracies or dictatorships, ruled by a single leader. Some have leaders but rely on the support of a regime elite. ¹ Applebaum has argued that in the 21st century autocracies are often not controlled by one man, but are more usually composed of networks of interlinked and dependent financial structures, propagandists, advanced technologies, regime elites, party members, leader(s) and security services. ² Some autocracies are totalitarian, others not. Some are military/police in origin, others political. Some are fascist, others communist, some theocratic and still others capitalist. Some are in fact supported by democracies. What autocracies tend to have in common is a highly centralised political control over a society, whether this rule is focused on and exercised by one man (and they are usually men) or network who have an effectively permanent monopoly over power (at least, until they do not). The leader, or the regime elite who support the leader, are not subject to meaningful regulation or opposition. Alexander ³ has argued that dictatorships are systems where there is a prevalence of thinking in destructive rather than healing terms.

Autocracies pose five fundamental challenges to human health and medical science. Not all autocracies will pose all of these threats, and not all of these threats will be continuously posed by the same regime. The first threat that they pose to health is their use of internal and external violence. Autocracies can use internal violence against their own populations to suppress threats to the regime and to demonstrate dominance. As such, the police – particularly the secret police – and the military can assume key roles. Torture and ‘torture lite’ practices can become embedded. Violence can also be directed at perceived external enemies – including other autocracies – or vulnerable populations, particularly if the autocracy is imperialistic in nature. In certain autocracies, violence can become genocidal. In the 21st century, the possession and possible use of weapons of mass destruction by autocracies pose threats to human survival, and in fact, to most forms of life on Earth. The risks of violence can be accentuated by the concentration of decision-making power within the hands of a few individuals.

The second challenge autocracies can pose to health is their corrosive impact on mental health and wellbeing. Autocracies can place significant psychological stress and pressure upon people who are ruled by them, particularly if those people dissent from the regime’s positions; they can even psychologically oppress external populations who must deal with them or live within their orbit. Autocratic regimes can in fact even psychologically impact the regime’s leaders or ruling elites, leading sometimes, for example, to false and, ultimately, destructive feelings of omnipotence and hubris. If a dictatorship becomes totalitarian, whereby it tolerates no opposition or dissent even within the private sphere – and possibly within the minds of the population that it controls – feelings of atomisation and terror will become widespread. ⁴ In the extreme, the psychological damage that totalitarian autocracies can inflict can become what has been referred to as menticide.

The third challenge is the risk of the subversion of the health professions. There can be a quick and significant decline in professional ethics under autocracy. ³ Medical personnel can come to see the regime’s values as their own professional values, and more important than universal codes such as the Hippocratic Oath. Medical professionals can, effectively, come to see themselves as servants of the state more than anything else, and use their skills to support the regime’s values and goals – possibly, ultimately, using their medical skills to dispense with the enemies of the state. Psychiatry has been used by some autocratic regimes to discredit and to imprison dissidents; in other systems, medical doctors have effectively become soldiers, torturers and killers to better serve the dictatorship’s needs. ⁵ Some fascist autocracies have relied significantly upon medical expertise to further their sciences of ‘ktenology’, the science of death and murder. ³

The fourth challenge is the politicisation of healthcare and medical science under autocracies. Because the autocrat, or regime elites, may say that they have authority over all aspects of life within the state, any medical or scientific discovery within the state – which is unexpected, threatening or dangerous – can potentially challenge the regime’s legitimacy. Autocracies may therefore suppress medical investigation into events such as regime mismanagement of disease response. Medics and scientists, aware of the limits of what they can professionally say or do, may self-censor or focus solely on the technical aspects of healthcare to avoid crossing regime red lines. Even apparently fairly innocuous health service or medical activities or studies, however, can quickly become politically risky if they raise the question of who in the state is responsible for health service or professional failures. Alexander noted that almost invariably science under dictatorship becomes subservient to the political goals of the regime. ³

The final challenge is the presence of health inequalities in autocracies. Almost by definition autocracies are unequal. Elites are only elites because they have unequal access to power and resources. Autocratic elites, who may control the majority of the economic resources within a state, may be unwilling to economically redistribute their wealth to support population health services. ⁶ Ordinary people may have little money to buy, or opportunities to access, medical care, and be subjected to diseases of despair such as alcoholism and drug use. The erosion of the spirit of the rule of law can lead to widespread corruption, which can undermine the effectiveness of public health services and programmes. Overall, autocratic forms of government appear to have negative impacts on population life expectancy, health spending and health service coverage. ⁶ These unequal impacts may be especially pernicious for populations or groups who are considered to be enemies of, or at least a threat to, the state.

As noted, not all autocracies will present all of these threats to all of their populations and medical personnel, at least not all of the time. Some, for example, may spend money on health services, for example, out of a sense of national pride, paternalism or in order to keep their populations docile. Some may be quite effective at improving population health, at least on a technical level. It is possible that the top-down command structure of authoritarian regimes may have benefits for public health, at least in certain instances, such as enabling speed and scale of infection management response during pandemics. However, the risk of at least some of the threats identified here is probably always present, even if in a latent form. Even if an autocracy appears to be benign, it is always possible that it can metastasise into something more dangerous, especially if it feels itself imperilled.

A key challenge for health policy in the 21st century will be how doctors, health systems and health professions in democratic systems interpret and interact with more autocratic states and systems. In many respects, public health in democratic states relies – to some degree – on flows from their autocratic counterparts. Autocracies are often the sources of energy, material, research and resources (and in some cases, medical personnel and students) that democratic systems need to maintain the health of their populations. However, it is important that health actors in democratic systems are not either intentionally or unintentionally blind to the risks of depending on autocratic systems to support or maintain their own health structures. This is perhaps especially the case if the risks that an autocracy poses are most strongly directed at its own populations and health professionals, and therefore more easily elided by outsiders. It is also important that researchers and doctors working within democratic systems do not become complacent about the threats that their own systems and forms of social organisation pose to health. The challenges noted here can be presented by democratic systems as well. The history of the 21st century has furthermore shown that the seeds of autocracy are buried deep within many democratic states; and buried shallowly in some. And who knows what flowers might emerge if those seeds begin to germinate.