Now is the time for revolution, not just reformation.
An essay by Agnes Arnold-Forster
The BMJ
Agnes Arnold-Forster
BMJ 2021;375:n2892
healthdataueurope
Throughout history, humans have turned to utopian visions to deal with the aftermath of cataclysmic events.
Agnes Arnold-Forster explores what can be learnt from these hopeful visions and whether new utopias will emerge in the wake of the pandemic
As soon as the covid-19 pandemic started, commentators began to predict the radical social, political, and cultural changes that would come in its aftermath.
This has plenty of precedents, as forward thinking has been a fundamental part of public debate for centuries.
The most obvious, and most entertaining, form of forward thinking is the utopia. Coined by Thomas More for his 1516 book of the same name, a utopia is an almost perfect imaginary society, city, or community-one that promises a range of highly desirable attributes for its inhabitants. 1
Principally used to describe a fictional world, “utopia” can also refer to an actual experiment where people unite to reconfigure how they live, in radical and comprehensive ways. The term “utopian” can also be synonymous with “impossible,” “delusional,” or “unrealistic,” and it’s a playful genre: More’s Utopians, for example, used gold only for their chamberpots.
But utopias aren’t always just flights of fancy, and fundamental questions about the future of health and healthcare have often been addressed through fictional utopias. These alternative medical worlds have much to offer us, particularly as we look ahead to a post-pandemic world.
Table of Contents (TOC)
- Eradicating disease
- Alluring fantasies
- Imagining a new world
- Jaded and traumatised
- The present foreseen
- Imagining a new future
Eradicating disease
H G Wells climbed the late Victorian social ladder, pulling himself out of relative poverty to become a remarkable predictor of clinical and military developments, an innovative writer of science fiction, and a populariser of science. 2 In 1923 he wrote his utopian novel, Men Like Gods.
The society Wells imagined in that book had left behind the medicine and chaos of the 20th century, “the Age of Confusion.” In this new society, infectious disease had-”by isolation, by the control of carriers”-been eliminated.
“The fatal germs had been cornered and obliged to die out,” he wrote. “Most infectious and contagious fevers had been completely stamped out.” Some diseases had been easier to eradicate than others, and-foreshadowing the lockdowns of this year and last-some had been “driven out of human life” only by proclaiming “a war” and by “subjecting the whole population to discipline.” 3
The whole healthcare system had also been reimagined. “The monstrous multitude of general and fever hospitals, doctors, drug shops, and so forth that had existed in the Age of Confusion had long since passed out of memory,” wrote Wells.
“There was surgical service for accidents and a watch kept upon the health of the young, and there were places of rest at which those who were extremely old were assisted.” 3
Alluring fantasies
After the dystopian horrors of the covid-19 pandemic, the world that Wells imagined may sound appealing, and medical utopias have long been tempting to general readers.
But, while stories such as these have been produced and consumed by all kinds of people for centuries, they’ve been a particularly alluring genre for doctors.
Whether they’ve published full length books or just brief essays in The BMJ, healthcare professionals have spilt considerable ink elaborating fictional medical futures.
These fictions align with ideas that are fundamental to the ideologies of modern medicine: powerful notions around medical progress and the inalienable belief that what lies ahead is better than what’s happening today.
Such stories also give doctors the freedom to step away, at least intellectually or imaginatively, from the daily grind and to speculate about what the future might hold.
The physician Benjamin Ward Richardson, for example, wrote Hygeia, A City of Health in 1876. Delivered as an address to the Social Science Congress in Brighton, it described a utopian, imaginary city with a population of precisely 100 000. The inhabitants lived in 20 000 houses, built on 4000 acres of land, with an average of 25 people per acre.
Richardson’s plans for the city ranged from the prescient to the quixotic. 4 On the one hand, he sensibly suggested that the roads were to be kept safe, unpolluted, and free from traffic by a system of underground railways. On the other hand, he was insistent that there was “not permitted to be one room underground” because cellars, basements, or “other caves” were “savage” and “loathsome.”
Much of Hygeia was, perhaps surprisingly, preoccupied with interior design. The walls of all household rooms were to be grey, as it was the colour “most agreeable to the sense of sight,” although the author did concede that “various tastes prevail.” 4
Imagining a new world
Some philosophers suggest that humans have an inherent orientation towards an improved future, and utopias have been a regular feature of fictional and medical writing for centuries. Nonetheless, medicine has sometimes been particularly forward looking.
Richardson was writing towards the end of the 19th century, when doctors were obsessed with the promise and achievements of their age and the sharpening skills of their own profession. A magazine article published in 1856 was particularly effusive, stating, “Truly this may be called ‘the iron age’: and is it not fast approaching to ‘the golden’ one?” 5
The 19th century was repeatedly framed, by doctors specifically, as a period that had seen unique progress in science, public health, and medicine. In 1891 the journal Science reported, “Emancipated from the thraldom of authority in which it was first bound for centuries, medicine has progressed with extraordinary rapidity, and even within the present generation has undergone a complete revolution.” 6
Considering the developments in bacteriology and surgery that had taken place in the second half of the century, it’s not too surprising that Victorian medical professionals were smug about the present and excited for the future.
Even so, the late century increase in life expectancy-and the decline in infant mortality-had little to do with clinical or scientific innovations or interventions and much more to do with social transformations such as housing and nutrition. 7
War, pestilence, pandemics, and other catastrophic events can also prompt people to think about how the future might be different, and times of crisis and rupture have often paved the way for imagining a new world order. Wells wrote his medical utopia just after the first world war, and he wasn’t the only one turning to utopian projects in the 1920s and 30s.
But cataclysmic experiences can also provoke fatalism and pessimism, deadening the imagination.
In the 1950s and 60s, the decades immediately after the second world war, utopian thought lulled. In 1957 Judith Shklar pronounced that “the urge to construct grand designs for the political future of mankind is gone,” arguing that the war had caused “the last vestiges of utopian faith required for such an enterprise” to have “vanished.” 8
Jaded and traumatised
Similar things were said about the fall of the Soviet Union, and the sociologist Krishan Kumar argues that the late 1980s saw the end of the literary utopia. 9 Late 20th century people were thought to be too jaded and traumatised by the failure of so many social projects to think positively about the future or imagine alternative realities.
From the mid-20th century, medical utopias in particular became harder to imagine.
With the foundation of the NHS, healthcare in Britain became more closely tied to political cycles, and as a result creative thinking has become increasingly difficult.
Today, many of the bold statements about the future come not from healthcare professionals themselves but from marketing campaigns, political manifestos, and fundraising charities.
Cancer Research UK, for example, is still searching for a “cure” for cancer-a utopian vision if ever there was one.
Too much future thinking, of course, presents problems.
Policy makers and politicians who spend their time looking ahead rather than back can risk recycling old ideas, revisiting ones that didn’t work the first time around and probably won’t work now.
Critics of utopias also caution that too much enthusiasm about new technologies can be dangerous.
Alongside utopian visions of medical and scientific futures there are also plenty of examples of techno-dystopias in mainstream culture, such as Aldous Huxley’s Brave New World and George Orwell’s Nineteen Eighty-Four.
Like science fiction, utopias often also present a technocratic vision of future change. Such a vision tends to highlight the scientific at the expense of the social, while insisting on “magic bullets” or technological fixes for social and political problems.
In his (particularly optimistic) 1872 utopian essay published in The BMJ, William Stokes wrote, “The power of science will be brought home to all men, as to everything that can influence health, food, drink, labour, residence, occupation; and, as it touches each of these considerations, will lead mankind to higher thoughts and purer lives.” 10
The present foreseen
Yet utopias still have their uses, especially now, as we look beyond our current crisis.
Covid-19 has placed unprecedented pressure on the NHS, revealing pre-existing problems in how Britain’s healthcare is staffed, run, and delivered.
The service needs repair, and this moment offers us an opportunity to rethink how it should work, bring about positive change, and reshape the medical world for the better.
After all, some of what the authors of past utopias predicted has come true. Sounding very much like a vision of the NHS, an 1899 letter from G B Jacobi to The BMJ described a medical utopia in which people would pay an annual sum to the state.
The amount would be determined according to individual means and would fund the community’s medical care. People would pay regardless of whether they visited the doctor themselves or were treated for ill health. 11
Other suggestions made by 19th century utopias remain pertinent.
Richardson understood, for example, that a healthy city isn’t the responsibility of doctors and nurses alone but relies on good quality housing, unpolluted streets, accessible education, and a more equitable distribution of wealth.
Yet current efforts to reconfigure the future of the health service, such as the NHS long term plan, don’t cover social care and public health-which, as covid-19 has reminded us, are critical for a healthy and resilient society.
Imagining a new future
The fact that some past utopias have come to pass doesn’t mean that we should go mining them all for good ideas, and most of the suggestions wouldn’t work for the healthcare of today.
Instead, utopias should be understood more as a method than as a goal.
Healthcare change has never happened as the result of a single innovation or one inspired individual-it has required vision and creativity.
Take the foundation of the NHS as an example. Its origins are complex and multifaceted, but they did depend on a radical notion, supported by people committed to a thorough transformation of state and society.
The service also emerged in the aftermath of a cataclysmic global event, the second world war.
That post-war period also brought all sorts of other radical ideas about healthcare futures.
Second wave feminists championed the importance of self-care and community led services, and they critiqued the power imbalance between doctor and patient-ideas that have since become more or less mainstream.
If we want the post-pandemic world to be better than what came before, we need to think big.
We need our own utopias, as well as our own alternative visions of a healthcare future. Now is the time for revolution, not just reformation.
Originally published at https://www.bmj.com on December 14, 2021.
About the author
Agnes Arnold-Forster
London School of Hygiene and Tropical Medicine
Agnes Arnold-Forster is a historian of science, medicine, and healthcare and a research fellow at the London School of Hygiene and Tropical Medicine.
She has a PhD in modern history from King’s College, London.
Her first book, The Cancer Problem: Malignancy in Nineteenth-Century Britain, was published by Oxford University Press in 2021, and she is currently co-principal investigator on the Wellcome Trust funded project Healthy Scepticism.
Now is the time for revolution, not just reformation.
An essay by Agnes Arnold-Forster
The BMJ
Agnes Arnold-Forster
BMJ 2021;375:n2892
Throughout history, humans have turned to utopian visions to deal with the aftermath of cataclysmic events.
Agnes Arnold-Forster explores what can be learnt from these hopeful visions and whether new utopias will emerge in the wake of the pandemic
As soon as the covid-19 pandemic started, commentators began to predict the radical social, political, and cultural changes that would come in its aftermath.
This has plenty of precedents, as forward thinking has been a fundamental part of public debate for centuries.
The most obvious, and most entertaining, form of forward thinking is the utopia. Coined by Thomas More for his 1516 book of the same name, a utopia is an almost perfect imaginary society, city, or community-one that promises a range of highly desirable attributes for its inhabitants. 1
Principally used to describe a fictional world, “utopia” can also refer to an actual experiment where people unite to reconfigure how they live, in radical and comprehensive ways. The term “utopian” can also be synonymous with “impossible,” “delusional,” or “unrealistic,” and it’s a playful genre: More’s Utopians, for example, used gold only for their chamberpots.
But utopias aren’t always just flights of fancy, and fundamental questions about the future of health and healthcare have often been addressed through fictional utopias. These alternative medical worlds have much to offer us, particularly as we look ahead to a post-pandemic world.
Table of Contents (TOC)
- Eradicating disease
- Alluring fantasies
- Imagining a new world
- Jaded and traumatised
- The present foreseen
- Imagining a new future
Eradicating disease
H G Wells climbed the late Victorian social ladder, pulling himself out of relative poverty to become a remarkable predictor of clinical and military developments, an innovative writer of science fiction, and a populariser of science. 2 In 1923 he wrote his utopian novel, Men Like Gods.
The society Wells imagined in that book had left behind the medicine and chaos of the 20th century, “the Age of Confusion.” In this new society, infectious disease had-”by isolation, by the control of carriers”-been eliminated.
“The fatal germs had been cornered and obliged to die out,” he wrote. “Most infectious and contagious fevers had been completely stamped out.” Some diseases had been easier to eradicate than others, and-foreshadowing the lockdowns of this year and last-some had been “driven out of human life” only by proclaiming “a war” and by “subjecting the whole population to discipline.” 3
The whole healthcare system had also been reimagined. “The monstrous multitude of general and fever hospitals, doctors, drug shops, and so forth that had existed in the Age of Confusion had long since passed out of memory,” wrote Wells.
“There was surgical service for accidents and a watch kept upon the health of the young, and there were places of rest at which those who were extremely old were assisted.” 3
Alluring fantasies
After the dystopian horrors of the covid-19 pandemic, the world that Wells imagined may sound appealing, and medical utopias have long been tempting to general readers.
But, while stories such as these have been produced and consumed by all kinds of people for centuries, they’ve been a particularly alluring genre for doctors.
Whether they’ve published full length books or just brief essays in The BMJ, healthcare professionals have spilt considerable ink elaborating fictional medical futures.
These fictions align with ideas that are fundamental to the ideologies of modern medicine: powerful notions around medical progress and the inalienable belief that what lies ahead is better than what’s happening today.
Such stories also give doctors the freedom to step away, at least intellectually or imaginatively, from the daily grind and to speculate about what the future might hold.
The physician Benjamin Ward Richardson, for example, wrote Hygeia, A City of Health in 1876. Delivered as an address to the Social Science Congress in Brighton, it described a utopian, imaginary city with a population of precisely 100 000. The inhabitants lived in 20 000 houses, built on 4000 acres of land, with an average of 25 people per acre.
Richardson’s plans for the city ranged from the prescient to the quixotic. 4 On the one hand, he sensibly suggested that the roads were to be kept safe, unpolluted, and free from traffic by a system of underground railways. On the other hand, he was insistent that there was “not permitted to be one room underground” because cellars, basements, or “other caves” were “savage” and “loathsome.”
Much of Hygeia was, perhaps surprisingly, preoccupied with interior design. The walls of all household rooms were to be grey, as it was the colour “most agreeable to the sense of sight,” although the author did concede that “various tastes prevail.” 4
Imagining a new world
Some philosophers suggest that humans have an inherent orientation towards an improved future, and utopias have been a regular feature of fictional and medical writing for centuries. Nonetheless, medicine has sometimes been particularly forward looking.
Richardson was writing towards the end of the 19th century, when doctors were obsessed with the promise and achievements of their age and the sharpening skills of their own profession. A magazine article published in 1856 was particularly effusive, stating, “Truly this may be called ‘the iron age’: and is it not fast approaching to ‘the golden’ one?” 5
The 19th century was repeatedly framed, by doctors specifically, as a period that had seen unique progress in science, public health, and medicine. In 1891 the journal Science reported, “Emancipated from the thraldom of authority in which it was first bound for centuries, medicine has progressed with extraordinary rapidity, and even within the present generation has undergone a complete revolution.” 6
Considering the developments in bacteriology and surgery that had taken place in the second half of the century, it’s not too surprising that Victorian medical professionals were smug about the present and excited for the future.
Even so, the late century increase in life expectancy-and the decline in infant mortality-had little to do with clinical or scientific innovations or interventions and much more to do with social transformations such as housing and nutrition. 7
War, pestilence, pandemics, and other catastrophic events can also prompt people to think about how the future might be different, and times of crisis and rupture have often paved the way for imagining a new world order. Wells wrote his medical utopia just after the first world war, and he wasn’t the only one turning to utopian projects in the 1920s and 30s.
But cataclysmic experiences can also provoke fatalism and pessimism, deadening the imagination.
In the 1950s and 60s, the decades immediately after the second world war, utopian thought lulled. In 1957 Judith Shklar pronounced that “the urge to construct grand designs for the political future of mankind is gone,” arguing that the war had caused “the last vestiges of utopian faith required for such an enterprise” to have “vanished.” 8
Jaded and traumatised
Similar things were said about the fall of the Soviet Union, and the sociologist Krishan Kumar argues that the late 1980s saw the end of the literary utopia. 9 Late 20th century people were thought to be too jaded and traumatised by the failure of so many social projects to think positively about the future or imagine alternative realities.
From the mid-20th century, medical utopias in particular became harder to imagine.
With the foundation of the NHS, healthcare in Britain became more closely tied to political cycles, and as a result creative thinking has become increasingly difficult.
Today, many of the bold statements about the future come not from healthcare professionals themselves but from marketing campaigns, political manifestos, and fundraising charities.
Cancer Research UK, for example, is still searching for a “cure” for cancer-a utopian vision if ever there was one.
Too much future thinking, of course, presents problems.
Policy makers and politicians who spend their time looking ahead rather than back can risk recycling old ideas, revisiting ones that didn’t work the first time around and probably won’t work now.
Critics of utopias also caution that too much enthusiasm about new technologies can be dangerous.
Alongside utopian visions of medical and scientific futures there are also plenty of examples of techno-dystopias in mainstream culture, such as Aldous Huxley’s Brave New World and George Orwell’s Nineteen Eighty-Four.
Like science fiction, utopias often also present a technocratic vision of future change. Such a vision tends to highlight the scientific at the expense of the social, while insisting on “magic bullets” or technological fixes for social and political problems.
In his (particularly optimistic) 1872 utopian essay published in The BMJ, William Stokes wrote, “The power of science will be brought home to all men, as to everything that can influence health, food, drink, labour, residence, occupation; and, as it touches each of these considerations, will lead mankind to higher thoughts and purer lives.” 10
The present foreseen
Yet utopias still have their uses, especially now, as we look beyond our current crisis.
Covid-19 has placed unprecedented pressure on the NHS, revealing pre-existing problems in how Britain’s healthcare is staffed, run, and delivered.
The service needs repair, and this moment offers us an opportunity to rethink how it should work, bring about positive change, and reshape the medical world for the better.
After all, some of what the authors of past utopias predicted has come true. Sounding very much like a vision of the NHS, an 1899 letter from G B Jacobi to The BMJ described a medical utopia in which people would pay an annual sum to the state.
The amount would be determined according to individual means and would fund the community’s medical care. People would pay regardless of whether they visited the doctor themselves or were treated for ill health. 11
Other suggestions made by 19th century utopias remain pertinent.
Richardson understood, for example, that a healthy city isn’t the responsibility of doctors and nurses alone but relies on good quality housing, unpolluted streets, accessible education, and a more equitable distribution of wealth.
Yet current efforts to reconfigure the future of the health service, such as the NHS long term plan, don’t cover social care and public health-which, as covid-19 has reminded us, are critical for a healthy and resilient society.
Imagining a new future
The fact that some past utopias have come to pass doesn’t mean that we should go mining them all for good ideas, and most of the suggestions wouldn’t work for the healthcare of today.
Instead, utopias should be understood more as a method than as a goal.
Healthcare change has never happened as the result of a single innovation or one inspired individual-it has required vision and creativity.
Take the foundation of the NHS as an example. Its origins are complex and multifaceted, but they did depend on a radical notion, supported by people committed to a thorough transformation of state and society.
The service also emerged in the aftermath of a cataclysmic global event, the second world war.
That post-war period also brought all sorts of other radical ideas about healthcare futures.
Second wave feminists championed the importance of self-care and community led services, and they critiqued the power imbalance between doctor and patient-ideas that have since become more or less mainstream.
If we want the post-pandemic world to be better than what came before, we need to think big.
We need our own utopias, as well as our own alternative visions of a healthcare future. Now is the time for revolution, not just reformation.
Originally published at https://www.bmj.com on December 14, 2021.
About the author
Agnes Arnold-Forster
London School of Hygiene and Tropical Medicine
Agnes Arnold-Forster is a historian of science, medicine, and healthcare and a research fellow at the London School of Hygiene and Tropical Medicine.
She has a PhD in modern history from King’s College, London.
Her first book, The Cancer Problem: Malignancy in Nineteenth-Century Britain, was published by Oxford University Press in 2021, and she is currently co-principal investigator on the Wellcome Trust funded project Healthy Scepticism.
