Translated blog, 6 February 2021, by Jolijn Santegoeds, Mind Rights, Eindhoven the Netherlands
The measures which have been taken in the Netherlands due to the Covid-19 pandemic call for a reflection. There are various fields of tension. Obviously the measures are meant to protect human lives against Covid-19, yet the measures also compromise nearly all human lives. More and more discussion arises, and even riots. Are we doing more harm than good?
Medical model thinking versus the whole person
Every life is worth protecting, of course. It is therefor logical that the government takes measures to protect the health and the lives of people.
But health is more than just the absence of disease. The World Health Organisation (WHO) defines health as: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” So, to really protect health, a medical approach alone is not enough anyway. There also needs to be attention to mental and social wellbeing.
Many people share the opinion that a medical condition requires a medical treatment. And indeed, when you ask the medical sector to come up with a solution for the pandemic, it may not be surprising they come up with medical tools. The focus of the government on vaccination as only solution is therefore in itself understandable, also considering the lobby of the pharmaceutical industry who profile medication as only savior more often (also see my blog series: Mind the Gap , published at EDF website under Disability Realities Blog)
The government promotes a dominantly medical focus so to speak, which leaves other aspects of quality of life out of sight.
Typically enough, we see a similar situation in mental health care, where the medical model also is dominant, with a focus on ‘risk-management’ instead of ‘recovery-management’, and with restrictive measures instead of a focus on new chances. Meanwhile more awareness emerged in mental health care acknowledging that de-escalation is better that deprivation of liberty, and that it is better to constructively support a person to find ways that fit with the person to deal with the challenges of life.
Indeed mental health care is different from fighting a contagious virus. But also regarding the Covid-19 measures, one could question whether a supportive approach would be possible instead of a restrictive approach.
Within the traditional ‘medical model thinking’ fighting the illness is centralized, and the illness is not considered as “normal” and therefore chased away However, under the UN Convention on the Rights of Persons with Disabilities (CRPD) the term inclusion is used, emphasizing that people with disabilities are part of human diversity. Implicitly this also led to a changed perspective on the acceptance of illness in society. It’s part of it. That does not mean that the medical sector is no longer needed, but it means that the doctor is no longer the authority but the person himself/herself is in charge over his/her life. Discrimination based on health status is not allowed (so no forced mental health treatment but instead a right to choice in health care). After all, and above all, a person is a person also with an illness or disability. It is like the UN CRPD lifts all of the fundamental human rights above the medical boxes, which in fact is a revolution. And the Covid-19 pandemic suddenly appeared while this change of paradigm was still on its way. Especially under the current circumstances this is food for thought. It may clarify some friction between various opinions. A shift is happening from ‘medical model thinking’ towards holistic and human rights based approach.
Control and protection
In case of of a pandemic with a high mortality a field of tension arises. Obviously, the right to life and health are evident, both under the ‘medical model thinking’ as under ‘inclusion thinking’. And with a contagious virus it is not only about self determination, but also about responsibilities towards others. Measures to restrict freedoms are based on the assumption that the citizen cannot carry this responsibility by him/herself, but that government regulation is considered needed. That is a paternalistic approach.
In Covid-19 prevention the limitation of physical contacts could also be stimulated in other ways than by measures of freedom restriction. For example by positive stimulation, and innovative solutions. Creating safety is not the same as controlling risks. Constructively creating a climate of safety is not the same as a restrictive policy while waiting for a saviour.
It is the task of the government to protect all its citizens and the right to life, as well as to protect all other fundamental rights. But what is protection? As an illustration: In mental health care I was facing measures of freedom restriction, such as solitary confinement, to prevent me from being able to hurt myself. It was a measure that was in theory meant to protect my health. But it only made me feel worse. I actually felt not protected at all, because I was exposed to a horrible regime and suffering, and that made everything worse. The means missed its goal. Mental health care is different from a pandemic, yet it is good to think about goals and means, and about costs and benefits.
In a justice based state, citizens are protected against the power of the government. In case of measures of deprivation of freedom by the government, according to the Constitution and human rights conventions, this needs to be based on a legitimate and lawful bass, and on the principles of necessity, proportionality (equal) and subsidiarity (least invasive means to meet a goal). There are several laws which allow for the use of deprivation of liberty to protect public health, such as in case of a pandemic.
The Dutch Law Temporary Measures Covid-19[1],[2] grants ministers the competency to impose Covid measures on the population and to restrict the freedom, with conditions such as necessity, proportionality and subsidiarity, so with each measure it needs to be demonstrated that the measures are necessary, that they do not go further than needed and that it is not possible to prevent the spreading of the Covid-19 virus with less far-reaching restriction of freedom.
“No less restrictive alternative”
Also in mental health care proportionalirt and subsidiarity are key principles in the execution of deprivation of liberty. Due to the principle of subsidiarity, the level of deprivation of liberty is in practice depending on the level of availability of less restrictive alternatives, and therefore also on the level of investment in those alternatives, such as good, qualitative, desirable solutions which can prevent deprivation of liberty. The prevention of deprivation of liberty is implicitly a goal of a justice based state, and therefore there is a best efforts obligation on the state to realise the less restrictive alternatives where possible.
By measures such as lockdown and curfew, the government leaves out the other options for e.g. self regulation, individually tailored approach, the 1,5 metre, or the possibility for stimulation by reward instead of punishment, or by support instead of restriction.
The principles of proportionality and subsidiarity require on the one hand a burden assessment of the consequences of the Covid-19 virus, and on the other hand on the measures. The politicians cannot assess this without the population. Moreover because the clinicians and politicians may not be able to see over the fences of their own domain. In assessing the alternatives and risks there is also a difference between the ‘medical model thinking’ and ‘inclusion thinking’, because the conceptual frameworks depart from different values and therefore different norms arise.
ICU-doctors and “wappies”
The letter of ICU doctors of Radboudumc at the end of January 2021[3] shows concerns about the impact of the far-reaching measures, and they question whether this is still proportionate. “Because the indirect suffering of some measures is bigger than the benefits that can be achieved for the Covid-19 patients”. In our society the ‘doctor’s advise’ is commonly given a lot of weight, and this criticism caused a substantial discussion about choices in ICU care.
How different it is for the non-doctors who share criticism. They are derogatory called “wappies”, which appears to be synonym for “unreasonable”. This socially critical group is not taken serious at all, as if they are not persons with an opinion. While actually they do show social and community involvement, although with a different opinion than the government, yet nonetheless. Protest is not an act of madness. Equally often they are portrayed as “a group that opposes anything”, while Dutch culture actually teaches us to question everything and not accept everything indiscriminately without thinking. But there seems to be no room for a dialogue of the population on the government policy. The acute dehumanization of dissenters puts entire groups of people at the sideline of the debate. The oppressed now feel even more oppressed. Paternalism absolutely has gone wild. The word ‘wappie’ actually is an abusive word, and it should be prohibited to nullify people like that. Every voice counts.
Discussion is good. It leads to enrichment. Let’s not avoid that discussion, and let’s especially involve non-doctors in the discussions about dealing with the Covid-19 pandemic in our community. After all, it concerns all of us, not just the doctors. And first of all we are people, not just potential carriers of virus.
The deep philosophical questions that are posed by the pandemic are not dealt with. To what extent are sickness and health part of life? How far do we go in “protecting”? Is fighting Covid-19 more important than anything else? Which type of regulation suits the Netherlands? Do we let fear lead us? Who determines which risks a person may or may not take? Can alternative solutions be devised? Which sacrifices are proportional? These are deep questions that confront us as a society. It is important to talk and find out together where our boundaries lie as a society. The groups that want to enter into this conversation are called “wappie”. That has to stop.
Fear
Without room for opposition, government policy is easily perceived as propaganda and dictatorship. Division is increasing, there is no conversation and the gap is growing bigger and bigger, as if a wedge is being driven between on the one side the doctors and the government, and on the other side the critics. The mutual hardening between critics and government seems to be mainly a product of fear. Fear of the course of the pandemic. Afraid that things will not work out, and therefore all parties are on high alert, ready to defend themselves.
The government seems to be willing to keep order with a tough approach, and clears the way for her plans. The pandemic is stressful for everyone, and the ‘fear of noise’ in the execution of the government plans therefore is somehow understandable. But it is not valid. There is no reason to be afraid for a diversity of voices, as that is actually educative and enriching. And it is a matter of mutual trust that we can work it out together. Eventually we all want the same, namely a future for us all. The one party mainly looks at medical interests, while the other looks at health and well-being from a more holistic perspective. Both visions do not have to be mutually exclusive. We all want to protect the future, and the point of discussion is just in which way.
Mutual respect
Whether you “believe” in the virus’s existence or not, it is clear that many people prefer it being taken into account, and it is a matter of respect to do so. It is also a matter of respect not to call each other wappie, and not to shy away from dialogue and to respect freedom of speech (with respect). We can try to learn to understand each other.
The fact that the situation seems to be polarizing between the critics and the government, and also the doctors, such as with the curfew-riots for example, I find explainable, because clearly there are areas of tension and the dialogue is lacking. I’m not justifying it, because violence is never a solution, but somehow I can understand the youth’s escalation. They are seeking a way to channel their feelings. (also see my previous blog: Better no tough approach to roters (Netherlands), published at EDF-website under Disability Realites Blog). Youth is not “scum”, just as critics are not ‘wappies’.
Balance
It is clear that the strict measures of lockdown and curfew have a major impact on psychosocial and social well-being, for all age groups. In addition, psychosocial support has been scaled down (lockdown). What remains is almost exclusively a medical focus on “life”. Meanwhile, social inequality is increasing. As time passes, society becomes increasingly disrupted and people run up against limits. It could be argued that society is out of balance, and that an overdominant medical focus has emerged, with too little attention to psychosocial and social well-being.
The solution should start with identifying the scope of the purpose of the Covid-19 measures, and the underlying values: Are we purely striving to eradicate the Covid-19 virus (medical model thinking)? At the expense of everything? Or do we strive to maximize the chances of survival for everyone? In a narrower or broader sense? Or do we strive to maximize quality of life even during unforeseen circumstances (living through)? Is there an optimal mix of perspectives possible that does justice to everyone in all diversity? These are questions that should be asked, and which should not be answered by a monodisciplinary team. A common goal can foster connection. Can we find connection? After all, we should all take each other into account.
People themselves usually know what is allowed and possible, and what is not. And they themselves also pay attention to vulnerable people in their environment, who in turn also often pay extra attention themselves. The creative solutions are countless. Yet when the government “prohibits” self-reliance by invoking fines, simply because a uniform measure has been announced, this can also provoke resistance. With a focus on restriction of freedom and not on self-reliance, people are expropriated from control over their own problems, and with that, their sense of pride is impacted. These dynamics can also be placed in the context of a growing emancipation throughout society, as well as in line with the revolution of the UN Convention on the Rights of Persons with Disabilities, which is a historic step towards self-determination, and with which “medical paternalism ”is being pushed back further and further. By contrast, the measures of repression and restriction of freedom reflect a paternalistic government that does not trust its citizens. This invokes resistance and is not really in line with the slogan “Only together can we get Covid-19 under control”.
Nobody wants the ICUs to be overcrowded or other care to be compromised. But in fact, we are now allowing mental health care support to be jeopardized by the Covid-19 measures, even if it is not a vital part of health or life. This also applies to social wellbeing, education and social contacts, sports, work and development. The measures are perceived by a part of the population as “out of proportion” and in other words disproportionate. In a democracy, every vote counts.
Proportionality is a question, and only together we can find the answer.
Resources:
- [1]Mind the Gap – Covid-19 Vaccination in institutions while existing injustices exacerbate https://tekeertegendeisoleer.wordpress.com/2020/12/09/mind-the-gap-covid-19-vaccination-in-institutions-while-existing-injustices-exacerbate/
- [2]Wet Tijdelijke Maatregelen Covid-19 https://wetten.overheid.nl/BWBR0044337/2020-12-01
- [3]College voor de Rechten van de Mens https://mensenrechten.nl/nl/coronavirus-en-mensenrechten
- [4]Bericht Brief van 4 IC artsen: https://www.nrc.nl/nieuws/2021/01/31/maatregelen-eisen-te-grote-tol-a4029894
- [5]blog: Better no tough approach to rioters (Netherlands) https://www.edf-feph.org/blog/better-no-tough-approach-to-rioters-netherlands//
[1] Wet Tijdelijke Maatregelen Covid-19 https://wetten.overheid.nl/BWBR0044337/2020-12-01
[2] College voor de Rechten van de Mens https://mensenrechten.nl/nl/coronavirus-en-mensenrechten
[3] Bericht Brief van 4 IC artsen: https://www.nrc.nl/nieuws/2021/01/31/maatregelen-eisen-te-grote-tol-a4029894