Medical populism

Abstract

Medical emergencies are staple features of today's 24/7 culture of breaking news. As politics becomes increasingly stylised, audiences fragmented, and established knowledge claims contested, health crises have become even more vulnerable to politicisation. We offer the vocabulary of medical populism to make sense of this phenomenon. We define medical populism as a political style based on performances of public health crises that pit ‘the people’ against ‘the establishment.’ While some health emergencies lead to technocratic responses that soothe anxieties of a panicked public, medical populism thrives by politicising, simplifying, and spectacularising complex public health issues. To demonstrate the concept's analytical value, we offer four illustrative examples. Thabo Mbeki's HIV denialism and the Philippines’ vaccination scandal are examples of the populist logic of forging vertical divisions between the people and the establishment (e.g. the West, big pharma, medical experts). Meanwhile, the Ebola scare and Southeast Asia's drug wars are examples of horizontal divisions that divide the ‘virtuous people’ against ‘dangerous outsiders’ (e.g. racial minorities, drug addicts) whose ‘threats’ have long been overlooked by out-of-touch members of the political and medical establishment. The article concludes by examining the implications of medical populism to health communication and democratic politics.

Full text

Medical populism
Gideon Lasco, MD, PhD
University of the Philippines
Nicole Curato, PhD
University of Canberra
ABSTRACT
Medical emergencies are staple features of today’s 24/7 culture of breaking news. As pol-
itics becomes increasingly stylised, audiences fragmented, and established knowledge
claims contested, health crises have become even more vulnerable to politicisation. We
offer the vocabulary of medical populism to make sense of this phenomenon. We define
medical populism as a political style based on performances of crises that pit ‘the people’
against ‘the establishment.’ While some health emergencies lead to technocratic re-
sponses that soothe anxieties of a panicked public, medical populism thrives by politicis-
ing, simplifying, and spectacularising complex public health issues.
To demonstrate the concept’s analytical value, we offer four illustrative examples. Thabo
Mbeki’s HIV denialism and the Philippines’ vaccination scandal are examples of the
populist logic of forging vertical divisions between the people and the establishment (e.g.
the West, big pharma, medical experts). Meanwhile, the Ebola scare and Southeast
Asia’s drug wars are examples of horizontal divisions that divide the ‘virtuous people’
against ‘dangerous outsiders’ (e.g. racial minorities, drug addicts) whose ‘threats’ have
long been overlooked by out-of-touch members of the political and medical establish-
ment. The article concludes by examining the implications of medical populism to health
communication and democratic politics.
__________________________________
INTRODUCTION!
In the past few years, populism has become a catch-all concept to diagnose the patholo-
gies of political life. While some argue that this term is in danger of concept-stretching,
we find the vocabulary of populism useful in making sense of contemporary health
crises. We introduce the concept of medical populism—a political style that constructs
antagonistic relations between ‘the people’ whose lives have been put at risk by the ‘un-
scrupulous establishment.’ We take a descriptive rather than normative definition,
which is to say that we offer a vocabulary to describe a response to contemporary med-
ical crises without necessarily making judgments on its ethical value.
We begin our discussion by revisiting the literature on moral panics—a concept that has
shaped today’s understanding of the social dimension of medical emergencies. Moral
panics set the scene for two possible responses: (1) a technocratic response which seeks
to soothe public outcry by letting experts and institutions of accountability take over
and (2) a populist response which further spectacularises the crisis and pits ‘the people’
against the failed and untrustworthy establishment. While the literature on crisis gov-
ernance has said a lot about the former (see Cooper and Kirton 2009; Ney 2012; also see
Boin, McConnel and Hart 2008), we find that more can be done to make sense of the lat-
ter.
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The second part of the article puts forward four illustrative examples to demonstrate
how medical populism unfolds in health emergencies. We selected each of these cases to
illustrate how health crises are used as canvas for populist performances.
The first two examples illustrate populism’s ‘vertical dimension’ where ‘the people’ are
held in opposition to the untrustworthy medical establishment (Brubaker 2017: 363).
Thabo Mbeki’s example of HIV denialism demonstrates how his dramatic, yet sincere
anti-Western rhetoric is deployed to unite the Black majority behind his regime. In this
context, Mbeki’s medical populism is deeply embedded in the broader context of suspi-
cion of Western drugs and legacies of the apartheid regime. The second example draws
on the case of the Philippines, where a massive dengue immunisation drive was politi-
cised to cast doubt on the political and medical establishment that failed to protect the
lives of vulnerable children.
The next two examples demonstrate populism’s ‘horizontal dimension,’ where medical
populists claim to speak for the ‘the virtuous people’ against ‘dangerous others’ whose
threats have long been ignored by out-of-touch political elites and medical establish-
ment. The third example draws on the case of Ebola virus in the United States, where
xenophobic rhetoric found medical rationale to halt immigration from ‘the dark conti-
nent.’ In the final case, we demonstrate how drug wars in Southeast Asia, particularly
Thailand and the Philippines, portray drug addicts as ‘sub-humans’—the irredeemable
ones who inflict fear and disorder to virtuous citizens. We reflect on the lessons these
cases offer in the final section, focusing on issues of health communication and democra-
tic politics.
FROM MORAL PANICS TO MEDICAL POPULISM
Medical populism takes off during crises or emergencies—terms we use interchangeably
in this article. The vocabulary of crisis constructs a narrative of a society crossing the
boundary of normal circumstances to exceptional moments of serious threat (Calhoun
2010: 602). They appeal to people’s sense of fear and outrage and create demands
around urgent solutions to avert impending breakdown (Wuthnow 2010: 1-6).
Moral Panics
The concept of ‘moral panics’ has provided the conceptual anchor to examine social reac-
tions to crisis situations. It was introduced in the 1970s to make sense of juvenile de-
viance, satanic rituals, paedophilia, and psychoactive drug use, among others (Cohen
2011). The growing literature on world risk society reinforce the analytical value of
moral panics (Beck 2006: 329-325). As David Garland puts it, ‘if [Stanley] Cohen hadn’t
introduced the term in 1972, it would have been necessary for someone else to invent
it’ (Garland 2008: 9).
Drawing on Cohen’s definition, moral panics take place when a condition, episode, or
groups of people are portrayed as threats to collective values and interests. Moral panics
have four key characteristics.
1. They are constructed by moral entrepreneurs who put forward a narrative of
danger to shared values and identify heroes, villains, and victims. In Cohen’s lat-
er work, he recognizes that moral panics are no longer exclusively elite-engi-
neered. The age of ‘communicative abundance’ creates possibilities for multiple
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forms of expression that are less hierarchical and less centralised (Keane,1999).
‘New panics,’ as Cohen puts it, provide more space to ‘social movements, identity
politics, and victims’ (Cohen 2011: 241). The diversification of avenues for com-
munication allows counter-experts to challenge alarmist claims and activists who
defend ‘folk devils’ (Garland 2008: 17). What remains the same, however, is the
discursive power of moral entrepreneurs to amplify, if not exaggerate deviance,
elicit public reaction, and exercise social control (Ungar 2001: 284)
2. Moral panics gain currency from visceral reactions. Central to moral panics
are media coverage of confrontations such as manhunts and court trials which
define the normative contours of an issue (Cohen 2011: 11). These portrayals ap-
peal to public prejudices, fears, and anxieties (Jenkins 2009: 36). It is not an ac-
cident that the term ‘panic’ is used, for issues at stake mobilize intuitions of mis-
trust, leading to agitation and feelings of uncertainty.
3. At the core of moral panics are questions about shared values. Appeals like ‘all
right-thinking persons would deplore…’ draw on moral claims about acceptable
forms of behaviour (Cohen 2011: 123). While the empirical literature on moral
panics tend to take a critical view on the underlying bases of these moral claims,
it is worth underscoring that moral panics, while normatively-laden, are
normatively ambiguous. Cohen (2011b: 241) cites the example of climate
change which uses the moral panic repertoire of apocalyptic predictions where
sceptics are folk devils. There may be ‘good’ and ‘bad’ moral panics. They can be
malignant, benign or just a waste of time (Cohen 1999: 589). Nachman Ben-
Yehuda’s (1986) work on adolescent drug abuse in Israel serves as reminder that
moral panics can be used to cloak struggles on non-moral issues. The standards
by which we judge these episodes warrant public deliberation on collective val-
ues.
4. Finally, moral panics can lead to political outcomes. There are two (though not
exclusive) responses to moral panics. On one hand are technocratic responses,
where state or other key decision-makers seek the expertise of the medical estab-
lishment to take over the situation to soothe public anxieties. This can diffuse a
politically-charged moment by placing the control of the situation away from
politicians to the experts. Arguably, this is the case with Thailand’s implementa-
tion of a tax-based universal health coverage scheme in 2001, following dissatis-
faction over a broken, prohibitively-expensive health care system: an outcome
which saw both populist promises and reformist goals align (Hughes and
Leethongdee 2007; Tangcharoensathien et al. 2013). Institutions of accountabili-
ty may also play a part, where legal cases are filed, and oversight bodies are put
to work to assign blame and punishment to individuals responsible for the crisis.
The Tuskegee syphilis experiment is a classic example, where a press leak and
the ensuing public outrage led to class action lawsuits against the US govern-
ment - and the passage of a National Research Act that regulated research in-
volving human participants (Jones 1993). In both instances, the political goal is
to temper public outrage and put an end to the medical crisis (see Hart and Tin-
dall 2009).
On the other hand, medical crises can result to populist responses. Populists de-
liberately perform and perpetuate the crisis. Unlike the technocratic response
that seeks to put an end to moral panics, medical populism flourishes in these
situations. Moral panics offer conditions that allow claim-making on behalf of
‘the people’ possible, as well as the legitimisation of spectacular and simplistic
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solutions demanded of ‘extraordinary’ events (see Moffitt 2015: 198-210). We out-
line our definition of populism in the next section and provide illustrative exam-
ples of how medical emergencies are faced with populist responses.
Medical Populism
The term populism, admittedly, has reached the status of ‘journalistic cliché and politi-
cal epithet,’ a catchphrase for many political ills today (Brubaker 2017: 357). Yet concep-
tual precision and definitional debates have been a main preoccupation in the scholarly
literature. Some define populism to be a thin-centred ideology (Mudde 2007), a political
logic (Laclau 2005), or a rhetorical strategy (Canovan 1999), with each of these defini-
tions offering analytical advantages depending on the cases under study.
For the purposes of examining health emergencies, we find the definition of populism as
a ‘political style’ most meaningful (Moffitt 2016). This definition broad is enough not to
be tied to content-related definitions of populism (e.g. nativism, tribalism, nationalism)
but specific enough to characterise a political practice distinct from other responses to
moral panics. Populism as a political style emphasises its embodied, performed, and en-
acted qualities across political and cultural contexts (Moffitt 2016: 3). Medical emergen-
cies take an aesthetic and affective character, where claims are not just articulated
through voice and text, but creatively performed to evoke reactions from a targeted yet
fragmented and globalised audience. Political expression today has become a multi-sen-
sory and mediated experience, where governance permeates the domain of people’s
everyday lives (Moffitt 2016: 7).
Drawing on Benjamin Moffitt’s work on populism as political style, our concept of med-
ical populism takes three characteristics.
1. Appeal to ‘the people.’ At the core of populism is an appeal to ‘the people,’ pit-
ted against ‘the establishment’ or the dominant power structure (Canovan 1999:
3). Populists, simply put, are ‘of the people but not of the system’ (Taggart 1996:
32). The people have been ‘let down,’ ‘ripped off’ and rendered powerless by ‘the
system’ whose failures resulted to the crisis (Moffitt and Tormey 2014: 391).
Medical populism works by creating a shared imaginary of ‘the people’ as ag-
grieved parties, if not victims of diseases due to the system’s neglect. The estab-
lishment, as the illustrative examples below demonstrate, can range from the
state to medical experts, to big pharma to ‘the West.’ While medical populists are
often politicians themselves, they perform the character of an ‘outsider’ to ‘the
system’ who can disrupt dominant paradigms of thought and action.
2. Performance of crisis. Populism scholars consider the relationship between
crisis and populists central to definitions of populism (e.g. Laclau 2005; Mudde
2007). Although the precise relationship between the two has been subject to de-
bate (do populists construct crises or do crises create populists?), these ontologi-
cal tensions can be bracketed by drawing attention to how crises are experienced,
mediated, and performed. As Moffitt puts it, ‘crisis should be seen as internal to
populism—not just an external cause or catalyst for populism, but also as a cen-
tral feature of populism itself’ (Moffitt 2015: 195). The moral panics that come
with medical emergencies provide populists the legitimising narrative to act im-
mediately. Medical crises evoke the ‘deepest atavistic fears of suffering and
death’ (Heath 2006: 146). Couple this with distrust towards ‘the establishment,’
medical populists have justification to take swift and decisive action and eschew
the slow process of deliberation, whether among the public or within expert
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communities. While a technocratic response to moral panics promotes measured
responses that emphasise certainty and stability, facts, not fear, medical pop-
ulists draw power from spectacular and dramatized portrayals of the crisis (Mof-
fitt 2016: 46).
3. Simplified discourse, dramatized performance. Related to the urgency ac-
companying the performance of crises relates to the simplification of political vo-
cabularies. As Rogers Brubaker puts it, the populist style ‘performatively deval-
ues complexity through rhetorical practices of simplicity, directness, and seeming
self-evidence, often accompanied by an explicit anti-intellectualism or epistemo-
logical populism’ (Brubaker 2017: 367). Populists build on the visceral dimension
of moral panics by exaggerating threats and offering of ‘common sense’ solutions
to complex issues. Sometimes, this takes the form of denial of expert knowledge,
in other instances this involves what Moffit describes as the use of ‘bad manners’
or the ‘coarsening of political discourse’ (Moffitt and Tormey 2014: 392) or what
Pierre Ostiguy (2017) refers to as ‘politics of the low’. Medical populists are will-
ing to break taboos and disrupt conventions of the medical establishment by pro-
voking conflict and casting doubt on established medical conventions. This is
feeds in the first characteristic of constructing the antagonistic relationship be-
tween ‘the people’ and the ‘establishment.’
ILLUSTRATIVE EXAMPLES
To contextualize our concept of medical populism, we present four examples that
demonstrate the various ways in which the populist style is performed to support a po-
litical project. Our examples are designed to illustrate how medical populism unfolds in
two dimensions: the vertical dimension which demonstrates the distinction between ‘the
people’ and the ‘medical elite’ and the horizonal dimension which separates ‘the people’
who are insiders from ‘dangerous outsiders’ (Brubaker 2017: 363). In all four cases, med-
ical populists pit the people against the medical establishment, articulated using emo-
tive performances of crises that present solutions that challenge orthodox approaches to
crisis response.
HIV Denialism
South Africa suffers from one of the most severe HIV/AIDS epidemic in the world, affect-
ing over seven million people in 2016 (United Nations, 2016). The spread of HIV is a
legacy of both silence and denialism. In his five-year tenure of Presidency, Nelson Man-
dela was described to have left a ‘legacy of silence,’ referring to his apparent indifference
to the epidemic (Caplan 2015). It was only after his retirement in 1999 when he had
taken up the cause and became an active AIDS campaigner, just as his handpicked suc-
cessor, Thabo Mbeki engaged in ‘HIV denialism.’
Mbeki’s HIV denialism demonstrates the political style of medical populism. He came to
power at a time when HIV/AIDS was at its peak, with about ten percent of the popula-
tion infected with the virus. While Mandela had the option to be indifferent, Mbeki had
little choice but to address the crisis.
Mbeki, to be sure, does not fit the mould of contemporary populists. He holds the image
of a ‘pipe-smoking intellectual’ who infuses his speeches with obscure phrases and clas-
sical references. He is described as ‘distant and often prickly,’ a sharp contrast to his
successor Jacob Zuma—the ‘avuncular, dancing, partying’ leader who embrace ‘a mantle
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of ordinariness’ (Vincent 2011: 4). Mbeki’s HIV denialism, however, demonstrates one
instantiation of the South African leader’s deployment of the populist style. On this is-
sue, Mbeki enacted a political performance that united South African people, particular-
ly its Black majority against ‘the West’ at a time when the country is facing threats of a
lethal epidemic.
Mbeki performed the crisis of the epidemic by challenging the medical establishment.
He made claims that AIDS was not fatal, that HIV did not cause AIDS, that home
remedies like beetroot, garlic and potato can be used as treatment. He pinned blame on
‘the West’ for promoting antiretroviral drugs only to make profit from South Africa.
Poverty alleviation, not western medicine is the cure for AIDS, he declared. In the in-
ternational AIDS conference in Durban in 2000, Mbeki publicly rejected a declaration
signed by over 5,000 experts including Nobel Prize winners and reputable research in-
stitutions around the world that declares HIV to be the cause of AIDS. This declaration,
said Mbkei’s spokesperson, belongs to the dustbin (Sidley 2000).
These claims, on the surface, come across as inane. Indeed, international media cover-
age depict Mbeki as a conspiratorial crackpot whose scapegoating of the west cost over
300,000 avoidable deaths had people only received available AIDS treatment (see Chig-
wedere et al 2008). For some scholars however, what Mbeki accomplished in his rejec-
tion of the medical consensus was a construction of ‘the people’—a relationship of ‘soli-
darity among the Black South African people’ (Sheckels 2004: 71). Mbeki’s anti-western
rhetoric is rooted in the longer history of apartheid, where public health is not immune
from ‘racialisation and conspiracy’ for it, historically have been used as tool to enforce
racial segregation (Fassin and Schneider 2003: 495). Mbeki’s performance was perceived
as both ‘sincere and politically savvy,’ building on his identity as a liberation leader and
champion of pan-Africanism. As Thomas Sheckels argues, Mbeki evoked unity by:
making his listeners identify with each other as ‘The West’s’ victims. Thus, re-
sponsibility for evil in the South African story is to be borne not by his govern-
ment or by his people… Rather, the responsibility is borne by ‘The West’—its
pharmaceutical companies and its governments—who, together, have economic
reasons to insist that HIV causes AIDS (Sheckels 2004: 77).
Through this narrative, Mbeki was able to flip the crisis’ storyline, from a crisis of epi-
demics to a crisis of the West’s dehumanisation of Africans using the language of scien-
tific epidemiology (Wang 2007: 5). Challenging the Western narrative of HIV/AIDS epi-
demic lent a populist storyline that seeks to both pursue ‘better health for all our people
and the recovery of our dignity as black people and human beings,’ while refusing to
‘succumb to pressures that are directed at serving particular commercial and political
interests at the expense of the health of our people.’ These lines were articulated in a
sixty-eight-page pamphlet circulated to the African National Congress in 2002, entitled
‘Castro Hlongwane, caravans, cats, geese, foot and mouth statistics: HIV/AIDS and the
struggle for the humanisation of the African’ (in Wang 2007: 4-5). The AIDS campaign—
whether in its medicalised nature or humanitarian form—was framed by Mbeki as neo-
colonial racism, which serve to further perpetuate South Africans’ dehumanisation.
Mbeki’s denialism was put to an end as activists won a legal battle that forced Mbeki’s
government to distribute antiretroviral drugs through public health services. His minis-
ters also started meeting AIDS specialists whom they previously refused to consult.
Overall, this illustrative example demonstrates how Mbeki’s issue-based medical pop-
ulism has served to provide a counter-narrative to the discourse of the ‘Western medical
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establishment’ while also heeding the call of local activists and decisions of democratic
institutions.
Dengue vaccine scandal
In April 2016, the Philippines launched a dengue vaccination program covering over a
million nine-year-old public-school students. Dengvaxia, the world’s first commercially-
approved dengue vaccine, was considered a public health milestone in a country with an
estimated 794,255 annual dengue episodes (Undurraga et al 2017).
A medical scandal erupted in 2017 when Sanofi-Pasteur announced that the vaccine
carries a higher-than-previous-reported risk of causing severe dengue among seronega-
tives or those who never had dengue prior to the vaccination (see Sanofi-Pasteur 2017).
This reignited a debate in the medical community about the safety and efficacy of the
vaccine. Before the vaccination program was approved, some health experts expressed
concern over the government’s ‘unusual’ decision to administer the vaccine only a few
months after securing regulatory approval (see Geronimo 2016).
Given the complexity of the issue, the Health Secretary suspended the program and
sought the advice of medical experts to determine the proper course of action. An inde-
pendent panel of Philippine General Hospital doctors was commissioned to investigate
fourteen deaths associated to the vaccine. The panel concluded that eleven cases had no
causal relation to Dengvaxia, while three deaths were “consistent with causal associa-
tion to immunization that is vaccine product-related; two (2) of which implicated vaccine
failure” (PGH Dengue Investigative Task Force 2018). ‘We can now breathe a sigh of re-
lief,’ said President Rodrigo Duterte’s spokesperson (Buan 2018).
Expert-led responses, however, were taken over by performances of medical populism.
The Public Attorney’s Office launched their own forensic investigation and filed dozens
of criminal charges against those responsible for deaths (Punay 2018). The Office is
headed by Persida Acosta, a public defender known for her media savvy while handling
high profile cases (if we needed citations for this statement here’s one Inquirer editorial)
Acosta’s medical populism is underpinned by two populist logics. One is to cast doubt on
the credibility of the medical establishment and their knowledge claims. ‘Who owns
them? Whose interests do they protect?’ Acosta said in various venues, interrupting ef-
forts of expert communities to put closure to the crisis (Cabico 2018). She alludes to a
storyline familiar to the Filipino public of a corrupt system where public officials and
multinationals collude to make money, this time from an immunisation program at the
expense of ‘the people’—the hapless children and families who were conned by the elite
and the broader public whose lives are at risk as long public health is left in the hands
of the establishment. ‘I won’t sell my soul!’ she passionately said in a House committee
probe on the scandal, justifying her Office’s refusal to cooperate with the Health De-
partment and Philippine General Hospital by invoking the mistrust of bereaved parents
towards institutions she portrays to have bloodied hands (Cepeda 2018).
Another logic operates on the claim of speaking on behalf of the people by forging an af-
fective bond between her Office and the public. Acosta takes part in choreographed cam-
era-ready public appearances with grieving parents carrying photos of their dead chil-
dren (see, for instance, Ramos and Orejas 2017). This conjures an image of a victimised
citizenry that found support with a public defender who can give voice to injustice. That
the immunization program put over 800,000 children at risk makes this a public issue—
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that anyone’s child could be the next victim. Acosta’s discursive style uses enough
legalese to establish professional credibility (e.g. citing forensic investigation evidence,
identifying the conflict of interest of the Health Department and medical experts in
leading the investigation) but melodramatic enough to respond to the demands of televi-
sual cultures. This dramatized strategy allows her to claim to speak for aggrieved people
in a crisis, much unlike the dispassionate, technical, and perhaps callous language of
the medical establishment that sought to diffuse the crisis.
Months after the height of the Dengvaxia controversy, reports of parents refusing vac-
cines started to emerge (Pazzibugan and Auerelio 2018) and a recent survey showed a
dramatic drop in vaccine confidence, from 93% “strongly agreeing” that vaccines are
important in 2015 to only 32% in 2018 (Larson, Hartigan-Go, & de Figueiredo 2018).
Vaccine scare is a manifest outcome of medical populism, while its political legacies are
worth monitoring in years to come.
The Ebola Scare
What is now known as the ‘West African Ebola virus epidemic’ started in December
2013 in Guéckédou Prefecture, Guinea. While it is considered the most widespread out-
break of the Ebola virus disease in history, it took several months before it was recog-
nized as an epidemic. By March 2014, suspected cases were reported in Liberia and
Sierra Leone. The high case fatality rate—over 70%—caused panic across the world.
Both broadcast and digital media played a role in constructing moral panics about Ebo-
la, making use of ‘scalar narratives’ (King 2004) that linked the ‘microbial’ to the ‘local’
and the ‘global.’ Media coverage intensified after the single diagnosis of the virus in the
United States. As John Finn and Joseph Palis put it, ‘the hysteria in the news media,
especially on cable TV news, and the resulting public (mis)understanding of Ebola had
very little to do with the facts on the ground’ (Finn and Palis 2015: 782). The moral pan-
ic was articulated in the digital sphere, where each Ebola-related report in cable news
instigates tens of thousands of tweets and Google searches (Towers et al, 2015: 10).
The Obama administration sought to soothe public anxieties by assuring them that the
possibility of an outbreak in the United States is ‘extremely low.’ President Obama him-
self posed for the cameras as he embraced Ebola survivor Nina Pham in the Oval Office,
‘just so people have a sense of the science here’ (Jackson and Szabo 2014). The White
House also deployed troops in Western Africa to take the lead in coordinating in-
ternational response. For Obama’s White House, Ebola is both a global challenge and a
national security priority.
Donald Trump and Senator Rand Paul (R-Ky) challenged these responses through pop-
ulist performances that unfolded in both social and broadcast media. Trump’s tweets—
over a hundred of them about Ebola—provide a flavour of their political style in medical
emergencies. Here are some examples (emphasis added).
The United States must immediately institute strong travel restrictions or Ebola
will be all over the United States-a plague like no other! (October 1, 2014)
The U.S. must immediately stop all flights from EBOLA infected countries or
the plague will start and spread inside our ‘borders.’ Act fast! (August 2, 2014)
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I have been saying for weeks for President Obama to stop the flights from West
Africa. So simple, but he refused. A TOTAL incompetent! (October 24, 2014)
First, the crisis is framed as out of control (a plague like no other), which demands ur-
gent and simplified responses (stop all fights). This is a direct contrast from Obama’s
scientific, global, and securitised approach. Second, the tweets, among others, speak to
the construction of ‘the people’ whose health are put at risk not only by foreigners ‘from
Ebola infected countries’—a racist rhetoric that sets Americans apart from dangerous
outsiders from the ‘dark continent’—but also from an ‘incompetent’ political establish-
ment that refused to put the people first. Paul displays a similar political style, claiming
that Obama’s team, ‘from the beginning… haven’t been completely forthright with
us’ (Kessler 2014). He blamed ‘political correctness’ as hindrance for government to
think clearly and made sound decisions to protect the people (Killough 2014).
The populist performance in the Ebola crisis has witnessed various iterations as Trump
entered America’s political centre stage. ‘Ebola,’ as Sharon Abramowitz (2017) suggests,
‘gave tacit permission for the public display of anger, blame, and anti-immigrant senti-
ment that would later play a role in the 2016 US Presidential elections.’ Trump asserted
that ‘infectious disease is pouring across the border’ as much like his rhetoric on illegal
immigration from Mexico (Byrnes 2015). Indeed, once in power, populists continue to
dramatize the crisis response—from building walls, deporting migrants and rounding up
criminals (Brubaker 2017: 366). While the Ebola scare has subsided, Trump has mas-
tered the identification of various crises that ‘crooked politicians’ have long ignored by
their weak policies.
Southeast Asia’s Drug Wars
There is increasing medical consensus that substance abuse disorder is a health condi-
tion (Volkow, Koob and McLellan 2016). This has resulted to policy innovations across
the globe, from decriminalising drug use to scaling up community-based harm reduction
services among those who commit minor drug infractions (see Csete et al 2016). In 2016,
Columbia has taken the lead in coordinating an international campaign to refocus global
approaches to drug control, encouraging world leaders to learn from a country that has
long suffered from narco-violence (Santos 2016).
Despite these developments, Southeast Asia’s ‘drug problem’ has served as fertile
ground for populist performances of a tough-handed anti-drug campaign. From Thai-
land’s Thaksin Shinawatra in the early 2000s to the Philippines’ Rodrigo Duterte more
than a decade later, Southeast Asia has witnessed some of the bloodiest episodes of
drug-related killings justified by his government as a necessary act "to save lives, to
preserve families, to protect communities and stop the country from sliding into a narco
state.” (Cigaral 2018).
The region’s experience posits a case of how medical populism intersects with what John
Pratt (2007) refers to as ‘penal populism’—a political style that exploits collective fear
and demands for punitive politics (see Curato 2016). The intersection lies in how pop-
ulists put forward alternative medical claims to justify violence, which, in turn, delegit-
imise expert communities, human rights groups and institutions of accountability.
Medical populism unfolds in two storylines. First, populists identify failures from previ-
ous regimes, such that the problem has reached a scale that demands the use of force.
This, in other words, is the performance of crisis. Duterte often refers to a ‘drug epidem-
ic’ in the Philippines, quoting inflated numbers such as ‘three million drug addicts’
9

whom he is ‘happy to slaughter’. Government agencies’ own figures belie this claim (see
Lasco 2016) but exaggeration is central to Duterte’s anti-establishment narrative. As-
signing blame and accusing his political rivals as deferential to ‘bleeding heart liberals,’
human rights groups, and corrupt narco-politicians are key to Duterte’s populist style
(Kaiman and de Leon 2016). By establishing his rivals’ failure, Duterte offers himself as
saviour of a country on the brink of fragmentation.
Thailand has a similar experience. Like Duterte, Thaksin prides himself to be a decisive
leader, imposing a three-month deadline to crush the drug industry (Duterte is slightly
less ambitious and promised three to six months). Prime Ministerial Order No. 29/2546
put together guidelines for a ‘concentrated effort of the nation to overcome drugs,’ react-
ing to decades of weak ‘scare campaigns’ against the use of ya ba (‘mad drug’ or
methamphetamines) (Roberts, Trace and Klein 2016; Mutebi 2004). Before Duterte’s ‘I
will kill you’ was Thaksin’s ‘in this drug war drug dealers must die’ (Cumming-Bruce
2003). The Prime Minister authorised the police to use ‘extreme measures’ as Thailand
is described to be the ‘world’s most amphetamine-addicted country’ (Aglionby 2003; see
Thanthong-Knight 2015). In both cases, the violent drug war took off from policies
deemed ‘too soft’ for an existential threat. Thai press reported 2,274 deaths in the first
three months of Thaksin’s drug war. The Philippines, meanwhile, reached a death toll of
1,105 over a comparable period based on police figures, although human rights groups
report a much higher number (see Mangahas et al. 2016).
Second, medical populists pit the people against the establishment by putting forward
alternative medical claims. ‘The world is moving towards a knowledge-based economy,
but our children’s brains are being destroyed by drugs,’ said Thaksin. ‘It’s like cancer
that will further spread and destroy the whole body,’ he added (Baker and Phongpaichit
2003). Duterte made a similar neurological assertion. ‘Remember that [the use of] shabu
[crystal meth], even for six months to one year, will cause the shrinkage of the human
brain,’ he said, ‘that’s why [young addicts] talk back to their parents. If they think that
way, how can they function as fathers?’ (Inquirer Research 2016) Common in Thaksin
and Duterte’s medical rhetoric are appeals to future generations—future knowledge
economy workers and parents. By portraying drug users as ‘brain damaged’ who are ‘no
longer viable for rehabilitation,’ both leaders legitimise draconian measures against citi-
zens with no future.
‘The people,’ meanwhile, are portrayed as helpless victims, the virtuous citizens whose
lives are put at risk by ‘subhuman’ actors (Curato 2016). Both drug wars are under-
pinned by popular support (see Cumming-Bruce 2003; Reuters 2017). Both ya ba and
shabu have caused both anxieties and tragedies in the everyday lives of Thais and Fil-
ipinos, whether it is cases of murder, theft as well as extortion from narco-cops. ‘I don’t
understand why some people are so concerned about [pushers] while neglecting to care
for the future of one million children who are becoming lured into becoming drug users,’
Thaksin said (Cumming-Bruce 2003; emphasis added), much like Duterte’s statement ‘If
you destroy my children, I will kill you’ (Papa 2018). The consistent invocation of the
children serves as a rhetorical strategy to depict the nation’s vulnerability—that ‘the
people’ need to be defended, not only from addicts but also from political actors (‘some
people’) who have long protected the dregs of society with no hope of redemption.
MEDICAL POPULISM: IMPLICATIONS FOR HEALTH COMMUNICATION
AND DEMOCRATIC POLITICS
10

The table below summarizes four illustrative examples of medical populism. These ex-
amples offer insights for both public health and democratic politics on the character of
medical emergencies today.
First, as far as public health is concerned, these examples are reminders that medical
populism is not episodic but a familiar response to medical emergencies. Of course, not
all moral panics invite medical populism. Indeed, some moral panics end up with tech-
nocratic responses. Our goal in mapping instantiations of medical populism is to under-
score how this political style travels across time, from the 1990s to present day, from
distributing HIV pamphlets in the African National Congress to Trump tweeting about
the Ebola crisis. Medical populism is here to stay, and the challenge is to maximize
communicative architectures that deliver the best outcomes for at-risk communities.
Despite the clear dangers posed by medical populism, they serve as reminders of bio-
medicine’s imperative to manage people’s trust in public health institutions. Common
tropes of medical populism such as “Big Pharma”, overpriced healthcare, and weak poli-
cy responses to existential threats are not without basis. These issues erode the credibil-
ity of biomedicine not just in responding to emergencies, but also in getting the public to
critically engage with its preventive, diagnostic, and therapeutic goals. The delegit-
imization strategies of medical populists gain resonance because of broader publics’ mis-
trust with the medical and political establishment. It is not accidental that the drug
wars are anchored on high popularity ratings of medical populists, or that the Ebola
scare turns out to be a precursor to Trump’s bigger political project of taking on the es-
tablishment and winning the White House. Populism, as Francisco Panizza (2005) puts
it, is a ‘mirror’ in which democracies, and in this case, their accompanying institutions of
public health, can contemplate itself, discover its unattractive qualities and shortcom-
ings.
Related to this, medical populism can also call attention to knowledge gaps among the
public in the issues where it is deployed. In the case of drug wars, the narratives of
methamphetamine causing brain damage are the conceptual foundations for a punitive
anti-drug regime. Instead of opposing the resultant policies, responding to these medical
knowledge-claims can undermine the bases for misguided measures. Admittedly, this is
easier said than done, and will require collaboration with communications experts. But
by looking at various health issues through the prism of medical populism, communica-
tion gaps can be diagnosed.
As far as democratic politics is concerned, at stake with medical populism are emerging
patterns of crisis governance. The Dengvaxia controversy and the Ebola scare under-
score the discursive power of further dramatizing public fear and anger to lend voice to
‘the people.’ Constructing ‘the people’ entails an affective storyline of victimhood as well
as blame against ‘the establishment,’ whether it is the neo-colonial project of the West in
the case of HIV/AIDS or the execution of ‘brain damaged’ drug addicts that sow fear
among virtuous citizens. The age of communicative abundance where contesting knowl-
edge claims are constructed and circulated in nebulous ways lends democracies vulnera-
ble to dubious knowledge claims and populist styles (see Speed and Manion 2017).
Following the literature on moral panics, we do not consider it productive to render im-
mediate normative judgment on which political style works best in medical emergencies
for these are contextual questions of collective values. While one could argue that med-
ical populism promotes disinformation and hysteria that result to misguided decisions,
one can imagine instances where medical populism challenge knowledge claims that
perpetuate inequalities in health and demand accountability from powerful actors from
11

the establishment. Similarly, we do not suggest that medical populists are necessarily
more effective than medical technocrats. Just like electoral politics where populist can-
didates do not always win, medical populism’s traction depends on broader conditions
that lend resonance to the populist style.
12

Table 1: Summary of four cases
HIV denial
Dengvaxia
Ebola scare
War on Drugs
Moral panic
context
Uncontrolled
HIV epidemic
Big pharma
admits
oversight
Scalar
narratives of
disease
mongering
A drug and crime
epidemic
Technocratic response
Distribution of
antiretroviral
drugs
Investigation of
independent
panels
Scientific and
securitised
response
Decriminalisation
and health-based
interventions
Medical populist response
The People
The public,
particularly
Black South
Africans
Bereaved
parents and
vulnerable
public
Americans at-
risk of
contracting a
disease from ‘the
dark continent’
The vulnerable
public
The
Establishment
The West –
governments
and
pharmaceutical
companies
Corrupt political
and medical
establishment
Politically
correct Obama
administration
Narco-politicians,
the West,
incompetent
leaders
Performance of
crisis
Capturing the
crisis of
epidemics
discourse to
crisis of
dehumanisation
Dramatization
of grief, casting
doubt on expert
communities
Rhetorical
tropes of ‘the
plague’ and
dramatic
responses like
stopping flights
Exaggeration of
numbers, fear-
mongering,
narrative of ‘saving
the nation’
Knowledge
claim of medical
populists
AIDS is not
caused by HIV
Vaccination
caused deaths
Contagion
justifies
quarantine
Drugs destroy the
brain, drug users
cannot be
rehabilitated
13

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