If Rudolph Virchow’s observation that “medicine is a social science and politics is nothing but medicine writ large” is true, then medicine is bias writ large because politics is nothing but bias on steroids. Virchow’s maxim is now adopted by medical journals which freely mix medicine with politics. No journal has taken this mixology to greater depths than the Lancet. In its pages, you’ll find tomes on the efficacy of statins for primary prevention as well as commentaries on the Iraq War and Israel’s domestic policy. A sub-division of the Lancet, Lancet Planetary Health, is devoted to the health of the planet.
Statins fight plaque in arteries. As important as the Israel-Palestinian dispute is for humanity, it’s not immediately apparent which of Virchow’s triad it addresses. What does the Iraq War, a peerless folly of recent times, have to do with Hippocrates? When did Asclepius switch places with Ares?
People displaced by wars are predisposed to outbreaks, amongst other ailments. Conflicts create medical need and reduce access to medical services. Fortune affects health. Technically recessions, like smoking and motor vehicle accidents, are public health problems because recessions cause bankruptcies which drive people to alcohol which causes cirrhosis which causes hepatocellular carcinoma. But just because recessions create work for doctors doesn’t mean doctors have special insight about stopping recessions. Recessions are doctors’ business and none of their business.
Public health is without borders. It is the only genuine transnational movement. But, as Seneca cautioned, to be everywhere is to be nowhere. If every conflict is a public health issue, the discipline becomes devalued by its enormity. Since the Lancet can’t cover every strife on this planet, it must curate which conflicts to cover. Curation, seldom random, becomes an expression of bias. In mixing medicine with politics, bias is both the ingredient and the final dish.
A recent editorial in the Lancet expressed concern about the future of Kashmir and the health of the Kashmiris. Both India and Pakistan claim Kashmir and have fought three wars over Kashmir. There’s a perennial threat of nuclear war. Second-hand radiation from nuclear war could kill more people than second-hand smoking or misinformation about statins. The Kashmir dispute is relevant to everyone – not just Indians and Pakistanis. Ostensibly, the Kashmir dispute is pertinent in a journal which cares about planetary health. The first question raised by the editorial is its timing. Why now? The Kashmir dispute has been festering for over seventy years.
Recently, the Indian government revoked the special historical status of Kashmir, which prohibited investment and restricted commerce. Sensing that the revocation could lead to unrest and terrorist attacks, the army was sent to Kashmir, and communications and movements were restricted. The Lancet editorial was in response to the actions of the Indian government whose policies could lead to a public health, specifically a mental health, crisis in Kashmir.
Thus, the impeccably-timed editorial seems actuated by noble inclinations. Yet, it upset many doctors of Indian origin. The Indian Medical Association issued a strongly worded letter condemning the editorial for both bias and ignorance. The Indian physician diaspora was upset, too and demanded that Lancet retract the editorial. Is their disappointment with the Lancet jingoism, or do they have a point?
The Kashmir dispute is complex and I can barely do justice to its rich history without introducing my biases, but I’ll try. During the Raj, there were a number of princely states in India which weren’t governed by the Brits but maintained an alliance with the British Raj. Their affairs were managed by their maharajas. When the Brits divided India into India and East and West Pakistan based on demographics (where Muslims were in the majority became Pakistan), they allowed the maharajas of the princely states to decide whether they wanted to merge with India or Pakistan.
Hari Singh, the maharaja of Kashmir (a majority Muslim state), wished to join neither India nor Pakistan but wanted an independent Kashmir – a Switzerland of the East. Shortly after independence, militias backed by the Pakistan army invaded western Kashmir. Hari Singh begged India for help. The newly-formed Indian government selfishly offered the maharaja conditional rescue – help conditional on Kashmir becoming a part of India. The first war between India and Pakistan was partly farcical because the commanding officers on both sides were Brits. Nevertheless, the United Nation (UN) stepped in, and a ceasefire was declared at the line of control – with Pakistan acquiring a third of Kashmir and India two-thirds of Kashmir.
There are no saints in this dispute. To apportion blame is pointless. Though people get wary of “bothsideism,” complex disputes can’t be reduced to the simple “oppressor versus oppressed” narratives people love. Here’s a glimpse of the arguing between the two countries which has the erudition of comments left on YouTube.
(Please don’t try this at home – you’ll lose twenty IQ points)
“Pakistan: India never held plebiscite in the Kashmir it’s illegally occupying.
India: Pakistan never demilitarized the Kashmir it’s occupying – one of the conditions the UN set for plebiscite.
Pakistan: India doesn’t care a whit about the Kashmiris. They’re political fodder for India.
India: What hypocrisy! If Pakistan cared about Kashmir’s autonomy why did they give part of Kashmir to China?
Pakistan: Kashmiris hate India.
India: That’s because Pakistan exports radical theocracy and terrorists. It’s Pakistan’s fault, not ours.
Pakistan: They’re freedom fighters, not terrorists. And mate, if you treat them better, they won’t radicalize.”
The arguing goes on and on.
The Kashmiris say – what about us, surely we’ve a right to self-determination? The Kashmiri Pandits, a forgotten group forcibly displaced from Kashmir by their fellow Kashmiris, say – what about us, surely we had a right not to be ethnically cleansed? Where is the hashtag #standwithKashmiriPandits?
Kashmir is a story of several wrongs, none of which make a right. It’s a story of the oppressor versus the oppressed, of oppressed versus oppressed, of communities living peacefully until made acutely aware of their differences, of larger power brokers using ordinary people as cannon fodder for regional hegemony. It’s a story of a perpetual cause-effect cycle. There are no actions in Kashmir, only endless reactions.
Above all, the story of Kashmir is another lamentable story of homo homini lupus. The Lancet has jumped into this complex rabbit hole which drives even revisionist historians insane, with a sophomoric “oppressor versus oppressed” narrative of the Indian government suppressing the rights of Kashmiris. Indian physicians are annoyed by the editorial not because of what it says but what it doesn’t say. There’s no mention of cross border terrorism, no mention of the plight of the displaced Kashmiri Pandits, no mention that giving Kashmir the same access to investment as other states in India might, just might, benefit the Kashmiris in the long run.
The Lancet will protest that it’s just reporting facts and the fact is that the Indian government has sent the army to Kashmir. Facts are facts are facts are no less factual because they offend. The major question for the Lancet is why it did not express concern about the mental health of the Kashmiris before, such as after the recent attack on Indian soldiers in Pulwama in which 40 soldiers died. Surely the public health of Kashmiris is also affected when cross border freedom fighters attack Indian soldiers. Or, are some causes of public health disturbance more equal than other causes?
An alternative interpretation is that public health concerns are an affectation and the Lancet is opportunistically using public health as a pretext to express its political preferences. That is, the Lancet is using health to play politics rather than politics to promote health. It’s like captioning a picture of a boxer hitting his opponent as “man assaults” instead of “boxing match.” Facts expressed selectively without context is bias even when they pass the fact checker’s fastidious lens. Astute observers will note that my piece is also selective; a superficial and potentially misleading caption of a complex dispute. That I’m a hypocrite for practicing precisely what I’m accusing the Lancet of preaching. Guilty as charged. And my hypocrisy only underscores my point – mixing medicine with politics is bias writ large.
I can understand why the Lancet weighs in on geopolitical conflicts. Scientific disputes in medicine, such as statins for primary prevention or whether to use the t-test or ANCOVA, aren’t terribly exciting and are unlikely to create heroes quoted by poets and historians. Lancet wishes to be genuinely impactful, not just impact factor impactful. But what doctors think about a conflict is seldom more insightful, and arguably less interesting, than what taxi drivers think. It’s possible that neither Imran Khan nor Narendra Modi has even heard of the Lancet, let alone read it.
If the Lancet wants to prevent a nuclear war between India and Pakistan, the ultimate public health triumph of preventive medicine, silence might be the better strategy. Lancet won’t be as consequential to public health with this editorial as it was with the forgettable vaccination-autism case report. However, the editorial won’t be entirely innocuous. It has caused Indian and Pakistani doctors to argue on social media about Kashmir, which is ironic for the journal. The Lancet exudes an anti-imperialistic moral compass and eschews Britain’s colonial past. But it has done exactly what the Brits did in India for over two hundred years – it has divided brown people.
Anti-imperialism, dear Lancet, begins at home.
In hospitals in Britain, U.S., and Canada, doctors of Indian and Pakistani origin rub shoulders daily. They’re often separated only by a degree from the conflict. It isn’t uncommon for a team to have a doctor from Pakistan and a doctor from India, both of whom have relatives in the respective armies facing each other at the border. My senior resident during my internship was a Kashmiri Muslim. I asked him which part of the subcontinent he hailed from. With a cheeky grin on his face, he said, “it depends on your perspective – we call it “Azad” (independent) Kashmir. You call it, “Pakistan occupied Kashmir!”
At that time, India and Pakistan were fighting each other in Kargil. Not once did this Kashmiri doctor bring up the war in our conversations. The war was relevant to him, but irrelevant to us. His family faced shellfire from the troops whose welfare I prayed for. But we were on the same side in the hospital. A truly transcendental profession doesn’t abolish our differences but unites us despite our differences. Medicine unites Indian and Pakistani doctors. Mixing medicine and politics undoes the teamwork. The editorial in the world’s third most prestigious medical journal diminishes medicine’s transcendentalism.
Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad.
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