Medical Imperialism and the Fate of Christmas

No English government has tried to regulate the people’s Christmas since 1655 and 1656 – and that did not go well. After the English Civil War, the country was divided into regions administered by Major-Generals – religious zealots who thought Christmas should be a time for sobriety and reflection rather than joy and celebration. Their suppression of traditional entertainments and gatherings was deeply unpopular. Local magistrates refused to punish people for breaking the new laws. There were riots in places like London, Norwich and Colchester.

In January 1657, the system was abolished. Puritan disapproval continued but the people went their own way. The experience, however, has never been forgotten. It is a lesson in what happens when governments attempt to impose a moral code on the everyday lives of citizens without the consent of those citizens. It is worth remembering today.

Medical sciences are different from other life sciences. Biologists study nature as it is. If one organism damages or kills another, that is simply how the world works. Medical sciences make moral judgements: a virus is a Bad Thing not just an interesting research topic.

Mostly, this moralizing is not a problem. We all prefer to live longer lives, free of pain and suffering. Sometimes, though, ordinary people are willing to tolerate a risk because this brings other benefits. Medical science can struggle to accept this choice because its ideal society gives absolute priority to health.

The result is what sociologists call ‘medical imperialism’, the extension of medical rules over ever greater areas of everyday life. It is paternalist, and often patriarchal. Since the 1960s, there has been a big pushback against this project. Ordinary people have demanded better justifications for medical actions and the right to share in making decisions that affect them. Homosexuality is no longer defined as a mental disorder. Women have taken more control over what happens to their bodies.

But medical imperialism has never really gone away. The emergency response to the COVID-19 pandemic created the conditions for it to re-emerge as politicians deferred to ‘the science,’ which, at the time, was almost exclusively medical science.

We now have a situation where the medical response to COVID-19 is becoming a means of pursuing other goals. Sections of the public health community have long been today’s equivalent of the 17th century Puritans. They would like us all to drink less alcohol, eat a more restricted diet, and take a good deal more exercise. All these things are probably desirable and would lead to longer and healthier lives. The question is whether it is right to use the power of the state to impose these choices without large-scale popular consent.

Public health laws generally come at the end of a long process of discussion and persuasion. Even smokers eventually agreed that it was unreasonable to expect other people to inhale their smoke. The indifference to the fate of the hospitality sector cannot be isolated from the agenda of reducing alcohol consumption. Pubs may be places where the virus is transmitted through loud talking or singing – but the evidence for this is weak and customers might be more concerned about the loss of sociability and the impact on their mental health. When English licensing laws were liberalized in 2005, it was assumed that a European-style drinking culture would emerge, where alcohol was mostly consumed alongside food. This did not happen – so now it can be imposed.

Mass screening for health conditions has come a long way since the 1960s, when it was simply assumed to be a good idea. Some influential medical scientists gradually came to realize that it could do more harm than good. In the UK, we developed a system for regulating screening to be sure that it only happened where it would benefit people. This system has been completely ignored in the rush to mass testing.

The COVID-19 mass testing program has been strongly criticized as unscientific and unethical by scientists of the standing of Sir Muir Gray, formerly the health department’s chief adviser on screening and co-author of the international standard textbook on the subject. Its claimed benefits should not go unquestioned. How has it come to be accepted? Some medical scientists have seen the program as an opportunity to do research without the usual inconveniences of peer review and ethics approval. It is a way to get lots of data about the virus and the population without asking about the justification or the relevance of the knowledge. Others have pushed the argument that testing for COVID might be a pilot for eliminating other respiratory infections.

This is a particularly sinister movement. There is a small, but articulate and well-connected, body of medical opinion that would like to maintain social distancing, face covering and other restrictions indefinitely because this might reduce the transmission of influenza, common colds and other respiratory viruses that we have lived with for thousands of years. The emergency is an opportunity to redesign everyday life around this single goal. Such actions are not scientific but an assertion of the morality of medical imperialism, that any infection is a blot on the face of humanity and must, if possible, be eradicated rather than managed. There is a moral alternative that says we must balance the management of respiratory viruses against the harms of control. Given that most respiratory infections – even Covid-19 – are trivial inconveniences for most people, we also need to think about their wider impacts on social and economic life, on child development, on the stigmatization of people who cannot comply, and on the social conflict that may be generated.

What can be done? The UK government is asking Parliament to give it a blank cheque for its management of the pandemic beyond Christmas. But with the vaccination program beginning, the risks of death and serious illness will be constantly falling. By the end of the first phase, around Easter, 99 percent of the people at any known risk will have been offered the vaccine. There is no plan to phase out restrictions in step with this. All the talk is of retaining restrictions for most of 2021 and beyond even though the groups that have yet to be vaccinated will only be likely to have mild infections. We must start to think in terms of tolerable risk, as we do in other areas of health and safety, rather than zero-risk.

The government would do well to remember the fate of the Major-Generals. Their obsession with imposing a Puritan life on a country that valued its traditional celebrations of family and community crashed and burned in the month after Christmas 1656. What will January 2021 bring?