To the Editor — Looking back, the initial spread of COVID-19 in early 2020 illustrates that clinicians, epidemiologists and behavioral scientists around the world greatly underestimated the scope and intensity of resistance to mitigation measures that would follow. Many in the medical community have remained wedded to the view that direct observation of the soaring volume of death and morbidity associated with coronavirus infections will convert most people into adherents of mitigation measures. Hence, most public health communications on mask-wearing, social distancing, and vaccination stubbornly focus on and attempt to leverage efficacy data, patient testimonies, and the clout of clinicians, politicians, athletes and social media influencers, to increase public uptake1.

Grappling with the nature and scale of resistance to COVID-19 mitigation measures requires an intimate and nuanced understanding of personal and medical autonomy. This reckoning must acknowledge the fusion between anti-science and personal liberty movements that can be described as the ‘medicalization of freedom’.

COVID-19 is currently ensnarled in the most consequential culture war of our times. At the heart of this social flashpoint is a thorny question on the nature of freedom: what it is, who it belongs to and how to preserve it. Freedom, as an ideal and social aspiration, has long occupied a virtually unimpeachable — and axiomatic — position in Western society.

Resistance to COVID-19 mandates fits in a lineage of freedom in Western society, where freedom has always had a subjective, shapeshifting quality. Global so-called freedom movements have considerably undercut efforts to disrupt the pandemic, as public health advocates have wrestled with how to get upstream of a deluge of anti-science while addressing downstream outcomes of increased infections and the need to preserve institutional legitimacy.

Arguments against COVID-19 mitigation protocols are enmeshed in freedom ideology and are invoked as a way to maintain, or promote, the ‘health’ of an individual’s freedom. Arguments against mitigation protocols include: stay-at-home policies to curtail the movement of individuals to otherwise accessible and desirable spaces; business shutdowns or restrictions that severely limit economic activity and recovery potential; mask mandates that violate personal standards for ease and comfort (and may operate inefficaciously); and vaccine mandates that are an assault on the body and the notion of bodily autonomy (and may present an undue health risk or inconvenience).

Freedom can be seen as an extension of an individual’s psyche — psyche being a psychological state reflecting a feeling of (looming) social or medical vulnerability. As such, the medical community should consider how freedom can best be problematized as a medical phenomenon and how its manifestations can be treated. There are four primary steps needed to effectively address this medicalization of freedom as part of clinical engagement and public outreach efforts.

First, bring conversations of freedom into clinical and public outreach spaces, treating freedom as a healthcare paradigm. Clinicians and public health advocates should not shy away from discussions on freedom and the process of medicalization that it is undergoing. Additionally, clinicians should actively encourage discussions of freedom and its meanings when discussing the importance of mitigation options with patients. Freedom should be codified as a discrete health concern, such that certain beliefs around it are situated as a potential risk factor for healthcare disengagement.

Second, seek to understand where precisely the focus on freedom has its genesis and when it manifests. Most centrally, the craving for freedom derives from a sense that one has been wronged or that being wronged — socially, economically, medically or otherwise — is imminent. Hence, the focus on freedom comes from a place of perceived vulnerability and thus operates in both a defensive and offensive context. In this regard, although vulnerability is very much relative, the desire for freedom is a ‘future-oriented’ emotion2, meaning that it is likely most pronounced and resilient when uncertainty is elevated.

Third, recognize the socioeconomic and intersectional richness of freedom in a culturally humble manner, treating it as a social determinant of health. Freedom means different things to different people, prompting the need for cultural humility. For many white people, freedom is perhaps most salient in colonial terms and as a direct means of enshrining personal preferences, expressed as freedom of religion, freedom of assembly, freedom of speech, and so on. By contrast, the freedom of racial or ethnic minorities and low-income people are highly connected to historical trauma; for example, resistance to COVID-19 vaccination can be understood as a tactical response to generations of structural oppression including acts of land dispossession, forced assimilation, genocide and systemic racism3.

Fourth, align the freedom mentality with a humanistic COVID-19 mitigation mentality. Freedoms are most intimately and persistently felt as, and equated with, human rights. However, without strategic integration, freedom becomes an individualistic paradigm focused on personal gain, disengaged from collectivist public health efforts. The embrace of mitigation should be promoted as an expression of freedom and support of human rights, a communal paradigm focused on maintaining personal health and dignity.

The medical community must take seriously the medicalization of freedom and start problem-solving around it to stop the spread of the anti-science movement. Without action, there will be further distrust of the medical establishment, allowing for deepening politicization of other aspects of public health.