Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday July 13 at 1pm PST 4pm EST are Queen of employer benefits Jennifer Benz (@Jenbenz); radiologist Saurabh Jha (@RogueRad), and policy expert consultant/author Rosemarie Day (@Rosemarie_Day1).

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday December 15 were patient safety expert and all around wit Michael Millenson (@mlmillenson); policy expert consultant/author Rosemarie Day (@Rosemarie_Day1); writer Kim Bellard (@kimbbellard), consumer expert Lygeia Riccardi (@Lygeia) radiologist Saurabh Jha (@RogueRad), and Olympic rower for 2 countries and all around dynamo Jennifer Goldsack, (@GoldsackJen). It was a full house and lots of fun, with a lot wrapped round the theme of protecting consumers (or not) online.

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

BY SAURABH JHA

If forced to choose Britain’s two biggest contributions to civilizations, I’d pick the Magna Carta and the vaguely instructional “fuck off.” If permitted a third, I’d choose “managerialism.” Brits are good at telling others what to do. Managerialism is how the Brits once ruled India. Buoyed by the colonial experience, British managers felt they could rule doctors. 

The new Viceroy, the manager-in-chief, is the General Medical Council (GMC). The GMC is a physician watchdog, funded by doctors, which works for the public good and is answerable to…well, I’ll get to that later. Their relevance rose exponentially when the psychopathic Dr. Harold Shipman, a charming, clinically adept, general practitioner, killed over two hundred patients. Never again, said the managers. They promised to keep the public safe from dodgy doctors with aspirations of Jack the Ripper and Sweeney Todd.

Recently, Dr. Manjula Arora, a doctor of Indian origin, was in GMC’s crossfire. Though I don’t know Dr. Arora personally, I’d hazard a guess that she didn’t migrate to the UK to emulate Harold Shipman. It’s also unlikely, and this may surprise some, that she left India for fortune and glory – doctors in India do well fiscally when you factor in the living costs. She may have been motivated by greener educational pastures in the UK, the sort that produces managers and doctors. 

How did the GMC save the vulnerable British public from the “dangerous” Dr. Arora? Her story is part tragic and part comical, and both comedy and tragedy jostle for the upper hand. One evening Dr. Arora asked her healthcare (Mastercall) Information Technology (IT) for a laptop. She said that she had been promised a laptop by the medical director. The IT department e-mailed her medical director (MD) and asked whether she had truly been promised a laptop.

The MD balked at the insinuation that he had broken his promise to Dr. Arora since at no point had he used the “p” word. At this stage let’s reflect on the gravity of the charge. Any parent knows that you never say the “p” word to your kids. I have threatened my kids with mythical monsters when they falsely accuse me of promising. Once, I confiscated their ice cream for accusing me of breaking my promise. The medical director reported Dr. Arora to the GMC for falsely accusing him of using the “p” word. 

The GMC, far from mythical, considered whether Dr. Arora, a first-class doctor with thirty years of experience, was an imminent threat to the public for lying that she had been promised a laptop. For who knows what a doctor who lies about the “p” word can do next? She might administer potassium to her patients and go on a killing rampage. 

The GMC has its own court in which it prosecutes dodgy doctors – the Medical Practitioners Tribunal Service (MPTS), or tribunal. Allegedly independent of the GMC, MPTS is supposed to be GMC’s wise Solomon, dispensing justice disinterestedly on facts and precedence. Busy people assembled displaying their finest lapels and imbibing the wisdom of the Magna Carta decided whether Dr. Arora was fit to be a doctor. On trial weren’t Dr. Arora’s clinical skills, or patient-centeredness, or whether Dr. Arora could manage an acute abdomen. On trial was her understanding of the word “promise.” It was a trial of semantics. Did she lie that the medical director had promised her a laptop? 

It turns out that the medical director hadn’t promised Dr. Arora a laptop. He said she may get one in the next round of purchases. Since “may” comes with “may not,” Dr. Arora was literally wrong that he had “promised” her a laptop. 

The “Promise”

This is what the medical director emailed Dr. Arora. (Emphasis mine) 

“We don’t have any laptops at present, but I will note your interest when the next rollout happens. Technology is advancing, we may soon be able to allow clinicians to use their own computers, watch this space.” 

The “Lie”

This is what Dr. Arora told IT. The medical director is referred to as “Dr. B” in the MPTS’s transcript. The MPTS doesn’t disclose the name of the accusers, only the accused. (Emphasis mine)

“Oh right, because he [Dr B] didn’t have a laptop and he sent me an email that the next time it’s available he’ll give it to me, so you have laptops and I thought it’s best that I take one because I don’t want too many people to be involved, just him and you directly, because it’s my … it’s [Dr B] who has promised it.”

The Trial of Semantics

The tribunal wondered whether Dr. Arora truly understood what “promise” means. Dr. Arora said since English isn’t her first language she doesn’t always get the semantics 100 % accurate. The GMC disagreed and said Dr. Arora was in fact very articulate and had a good command of the language, noting she was “very easily able to answer questions in cross-examination,” that she was “able to formulate arguments very well,” that she could “adapt her evidence as she went along,” that she was “able to anticipate questions.”

Dr. Arora was asked whether the medical director had promised her the laptop, yes or no. She replied, “It’s the connotation that I had taken from it.” 

Then Mr. Carl Hargan, representing the GMC, with all his intellectual might, asked her a question which’d make schoolmarms proud. He asked if there was a “huge leap” between the phrase “note your interest” and a promise. Dr. Arora had no answer. She was stumped by Mr. Hargan’s brilliance. As was the MPTS.

The Verdict

The tribunal agreed with the GMC that Dr. Arora understood the meaning of the word “promise.” The Tribunal, “determined that, in the specific use of that one word, on that one occasion, she had been dishonest.” Which meant that she lied. 

Now, the tribunal had to decide if Dr. Arora was fit to practice medicine. So, it went through case law and sought the Shipman Report. Remember Shipman? Yes, that serial killer. That report states that “dishonesty” is a reason to question a doctor’s fitness to practice. For this “lie,” technically an exaggeration, the tribunal found Dr. Arora unfit to practice and suspended her for one month. 

Kafka meets Edmund Blackadder

Let’s pause and take a deep breath. Britain is a country where the Prime Minister can lie about partying in a lockdown he instituted, but an overworked doctor gets punished because she misuses “promise.” 

At this stage American readers are probably seething in incredulity – what the fuck? You ask. Even if she lied, so what? You may believe that I’m making stuff up. No, this isn’t a Monty Python script. This isn’t Dolores Umbridge holding a kangaroo court in Hogwarts School of Magic. This is the judgment of the tribunal of the watch dog of the most prestigious profession in a once upon a time super power – the one you expelled on the 4^th of July. 

I’ll leave the irony that in a country which gave us Shakespeare, who gave us boundless metaphorical permutations, we have a trial about semantics! I have noticed on Twitter that Brits are increasingly becoming more literal and a tad dafter, as a result. Brits are better off staying metaphorical. But even allowing for these comical secular trends, the trial of Dr. Arora takes stupidity in the British medical profession to a level one struggles to comprehend. 

From protecting patients from murderous doctors, the GMC has gone to protecting the Oxford English Dictionary from brown doctors. The GMC is the best example of the slippery slope. The British public may wonder why the watch dog which was supposed to protect them from bad doctors has deprived them of a good doctor, just when there’s severe staffing shortage in the NHS, and even severer shortage of physician morale, post pandemic. 

There are three breaches of common sense and basic adult behavior. First, the medical director reported Dr. Arora to the GMC for, at worst, an exaggerated interpretation of his generosity. This could have been resolved locally with a stern “no, I didn’t promise.” He could even have confiscated her ice cream. Second, the GMC, instead of throwing the complaint back at the medical director with the scorn it deserved, thought the charge fit to investigate the doctor’s fitness to practice. And third the guilty verdict passed by the MPTS, after an intense academic deliberation. A true Mad Hatter party! 

Why wasn’t the issue left between employer and employee? My guess is that the medical director couldn’t remove Dr. Arora because she’s a good doctor. The only way of punishing competent doctors in Britain is going  after their moral character and reporting them to the GMC.

Why has the GMC become so farcical? One explanation is that the GMC is racist and the treatment meted to Dr. Arora is just another example of systemic racism. There’s certainly merit here but there’s a deeper problem which needs solving and that is the GMC isn’t accountable to anyone. In theory, it works for society, but as Margaret Thatcher correctly understood, there’s no such thing as society. It’s a nebulous entity that’s thrown around but means nothing. Being accountable to the public means being accountable to no one. 

The irony is that the medical director sent Dr. Arora the email “promising” her a laptop on Christmas Eve. It’s the time of the year when even the loathsome Scrooge lightened up. What then emboldened the medical director to be a tattletale? What motivated him to try to destroy Dr. Arora’s career and her family of an income source? Why so much hate in his bosom for his colleague? 

The tempting answer is that he’s a prick of the sort that takes years of mastery. But that doesn’t explain. To understand the medical director’s behavior, we must understand the GMC because the two are linked, causally. The GMC’s power has become absolute both by design and intention. The GMC hides under the carapace of “protecting the patient,” and in this dumbed down, sentimental medical world, nothing is more sacrosanct than the dull truism “it’s about the patient,” a truism so banal that it serves little purpose other than providing assholes moral sanctuary. 

But even here the GMC falls short. How can it claim to be protecting patients when it deprives patients of competent doctors? Instead of treating patients, Dr. Arora was defending her over use of the metaphorical license, thanks to her boss and the GMC. 

The GMC is not only a farce and bully in its own right, but also encourages bullying – this is a feature not a bug. It’s like bellows to ember. It flames toxicity in the workplace. It nurtures vindictiveness and pettiness in the NHS, like agar to bacteria. This is the only example I know of in the modern world of trickle-down vileness. The threat of reporting to the GMC is how the clinical directors control their minions. It’s not about patient safety, it never was. It’s about the power of managers and their control over doctors. 

Mr. Hargan said that Dr Arora had ‘brought the medical profession into disrepute,’ ‘breached a fundamental tenet of the profession,’ and that ‘her integrity could not be relied upon.’ Mr. Hargan said that “that a finding of impairment was necessary in order to maintain public confidence in the profession.”

Let’s unpack this. The other role of the GMC is to protect the reputation of the medical profession. And doctors with unconventional extracurricular interests can certainly damage the reputation of the profession. But if Bashar-Al-Assad, a former ophthalmologist and current Syrian president with a fondness for chemical reactions, doesn’t make people wonder if their ophthalmologists were going to spray tear gas once they dilated their pupils, I’m fairly certain Dr. Arora’s patients won’t second guess her prescriptions because she mistook “watch this space” for “I promise you a laptop.”

Mercifully, even the MPTS accepted “Dr Arora had not set out to be dishonest, and that she had not set out to mislead.” There’s dishonesty – lying about killing your patients (Harold Shipman) and there’s dishonesty – lying about being promised a laptop (Manjula Arora). Are British regulatory agencies too thick to make this distinction, or does this distinction not matter?

Society is better off when the likes of Mr. Hargan are grading high school essays than deciding physician misconduct. I’m certain Mr. Hargan is far too clever to believe his own nonsense. So why does he think doctors will believe his BS? Where does he get the audacity for such contempt of doctors’ intelligence?

To put it bluntly. The GMC doesn’t give a rat’s tail what doctors think. And why should they? All they care is that doctors give them their annual check, which doctors do, religiously. 

What’s the solution? 

Hand wringing and whining, at which doctors excel, won’t work. Despite the outrage, doctors couldn’t reform the GMC when the GMC sued the MPTS, its own judiciary, because it handed Dr. Bawa-Garba her license after her sentence. British doctors need to borrow a slice of timeless American wisdom – follow the money. Americans long realized that logos, ethos, and pathos don’t work with our species. If you want institutions to behave, fund them to behave, and if you don’t like how they behave, defund them. Money, or the threat of losing it, can reform the GMC in minutes. Appeals to their better angels will take eternity. 

Doctors should form a watch dog, run by practicing doctors, which monitors and holds accountable the GMC and MPTS – a meta-tribunal of sorts. If the GMC refuses to submit its decisions to an external agency, doctors shouldn’t pay their dues. Of course, this won’t be easy. Of course, it’ll need organized leadership. And of course, some doctors will opt out of collective resistance because it doesn’t affect them. But it’s the only solution. It’s the only way to tame the GMC. The GMC is a threat to the morale of doctors. The GMC isn’t fit to practice. Reform it or create an alternative. 

@RogueRad is a former NHS doctor

The transcript of the entire circus can be found here

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday May 19 are delivery & platform expert Vince Kuraitis (@VinceKuraitis); policy expert consultant/author Rosemarie Day (@Rosemarie_Day1); & back after a long absence dangerous radiologist Saurabh Jha (@roguerad). Some great conversation about digital health, Roe v Wade, rural care and a deep dive into Saurabh’s trip to Nepal to deliver radiology tech to Everest Base Camp!

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

By @roguerad

I first clashed with authority when I was eight. Every Saturday bunch of brown kids, children of Indian immigrants to Britain with an identity crisis who longed for the culture they left behind, attended a class in the temple about “our culture” taught by a joyless scholar of Hinduism – a pundit – whose major shtick was punctuality. When I turned up late, even by a minute, he’d make me stand outside, even if freezing. Some kids called him “Hitler,” or “Hitler uncle,” the qualifier “uncle” indicated that because he was as old as our fathers, he deserved respect. 

Then, I believed that Hitler meant authority. I preferred calling the pundit “wanker” or “asshole” but the foul language would have gotten me afoul with my parents, my authority figures. “Hitler” amply conveyed disdain for our pot-bellied teacher who exercised his authority whenever he could, without tarnishing our nubile vocabulary.  

Eventually, I understood the significance of Hitler, and of World War 2, the Nazis, and the Holocaust. Though related neither morphologically to the perpetrators nor ethnically to the victims of this ghastly period in human history, I developed a reverence, a sensitivity if you will, to such allusions. The Lord of the Old Testament instructed Moses that his name be not used in vain, lest every blocked sink or traffic jam evoked “oh my God.” I resolved never to use Nazi as an epithet frivolously. 

I was surprised how common Nazi name-calling was in American political discourse across the political spectrum, which peaked during the Trump Presidency. Some likened migrant detention facilities to “concentration camps.” Many saw in the rise of white nationalism during Trump’s reign parallels with the Third Reich. The former White House strategist, Steven Bannon, was compared to the Nazi propagandist, Goebbels. Bannon is loathsome, detestable, a wanker. Goebbels is a mass murderer – no adjectives are needed to describe him further. 

Since the pandemic, hyperbole has become the Lingua franca of the medical community. COVID-minimizers have “blood on their hands.” Lockdowns are fascist. Misinformation kills. Peddlers of misinformation are “mass murderers” and COVID skeptics “enable” the murders. The average citizen has the ignoble choice between fascists and mass murderers. The twist is that fascists can become mass murderers and mass murderers can become fascists. 

We’re drowning in hyperbole. Mask mandates have been compared to women forcible veiled by the resurgent Taliban. Childhood masking has been likened to child abuse. On a related note, Richard Dawkins, the author of God Delusion, was my intellectual hero for his articulate scientific atheism, until he said that teaching children religion is child abuse. The line between being peak wisdom and deep absurdity is thin. I’m no fan of God, but comparing compulsory Church attendance to child abuse is moronic.  

Even close scientific debates such as the net societal benefits of vaccinating teenagers are refereed by hyperbole. Skeptics of universal vaccinations are called “immoral. The skeptics, in turn, believe they’re truth warriors facing persecution, like Galileo, Semmelweis, and Kepler. Galileo, thrown in a cold, rat-infested, prison, was stopped from throwing his toys off the Leaning Tower of Pisa. Modern-day heretics get ratioed – this is when random people are drawn to your provocative tweet like horse flies to fresh excrement. Your notification box explodes and you’re subjected to repetitive dull, righteous, scolding from a herd of mirthless dimwits. Having been ratioed a few times in my illustrious Twitter career I can attest that it’s not fun. My thumbs hurt. I feel helpless as the pile on accrues. And my wife yells at me for being glued to my phone. As unpleasant as that is, I don’t think it’s the same as Torquemada pouring molten oil on your gonads for heresy. I’ll take incivility over death, thank you. 

We’re supposedly in an age of censorship. Scientific discourse has never been in more danger. Yet the channels for bloviation have never been more abundant. Anyone can have a podcast or a Youtube channel, and many do. For every podcast you’re aware of there are ten thousand you have never heard about. Then there’s Tik Tok where you’re allowed 90 seconds of incontinent self-expression. That Tik Tok, which has enriched itself on capacious American “me”ness, is Chinese-owned is delightful irony. Everyone fancies themselves as entertainers, Socrates, Galileo, Gandhi, Keats, Orwell, and their opponents as Nazis or morons. If greatness has been democratized, evil has become plebian. 

If science is being censored it’s not being censored by authority, but noise. There is too much nonsense everywhere. The great poet Ovid was banished from Rome. The e-Ovids are muted or blocked on Twitter and banished from by-invitation-only echo chambers. Discourse is dead because it’s hard distinguishing between the good faith interlocutor and the troll. Even the sincerely curious can get tedious. It’s also hard to be convinced of anything when everyone around you is trying to convince, rather than be convinced. Too many teachers, not enough students. Everyone is hectoring. 

More ominously, there are campaigns to get you fired for expressing views the noisy, energetic, minority don’t like. Employers, particularly corporations with overpaid PR personnel with too much time on their hands, petrified of bad press on social media, reprimand offenders using a mix of good old-fashioned scolding – the sort your parents dished out for telling Auntie Indu that her cooking was awful. And detention. Not the Breakfast Club type of detention – that’d be too much fun. Nowadays detention means taking online modules on empathy and sensitivity.  

Once, someone complained to my employer. I had used an unflattering adjective to describe him. I said “twit,” or “tosser,” I can’t recall. But it was considered “unbecoming of a steward of such a great institute” (his words, not mine). The media department asked me to declare in my Twitter bio that my adjectives were my own. I wrote, “my employer’s views don’t reflect mine.” Our discomfort was mutual. But what the incident showed me is that our greatest enemy isn’t a Stalin-style tyrannical government, but each other. 

We’ve always been petty, self-centered, sensitive, with an overgrown sense of self-importance. And nasty. Social media has scaled our nastiness. The KGB (*) through its labyrinthine auditory network was a patch on the screenshots offered by products of capitalism. Post a screenshot of a passionate conversation you had with a drunk friend with a command of Punjabi expletives, five years after the conversation, just as your estranged friend is about to ascend the pinnacle of their career. As long as you don’t post the post-hangover apology the next day, you could ruin their career. That’s the power we have over each other. We truly are our brother’s keepers. 

Maybe everyone will have their fifteen minutes of shame. Incidentally, an old friend who used to DM me ten times a day suddenly stopped. I asked why. She was concerned that because I was a “high-profile personality,” my phone might be hacked and our conversation leaked to Twitter. I know you’re chuckling at me for falling for an imaginative excuse of the “dog ate my homework” genre. But it sounded imminently plausible.   

Hyperbole is endless. Mike Godwin coined Godwin’s Law, which is that the longer an argument on the internet proceeds, the more likely someone is going to make a Nazi analogy. Having been in a few internet arguments I understand the exasperation of fighting strawman arguments and misrepresentations – the frustration of not being able to convince or be convinced. Ideally, you’d end the argument graciously with “let’s agree to disagree” or “at least we agree that Philadelphia Eagles will blow it again.” But the frustrated internet warrior loses goodwill. When you call your opponent a Nazi you’re really saying the topic is beyond debate and your opponent is immoral. You might as well say “whatever.” Or “moron,” if you’re less charitable. 

Recently, Twitter celebrity physician, Vinay Prasad, warned that the pandemic is ushering dark days for democracy. He was concerned that over-zealous public health measures, egged on by a scientific community with the credentials to alarm the proletariat, could lead to such abundant state power that it could lead to fascism.. He likened our present to the brewing storm in the early days of the Third Reich. Prasad was ratioed. He was accused of insensitivity, historical ignorance, and sensationalism. Many asked his employer to fire him for comparing our public health measures in the pandemic to Nazism.

Aside from the historical inaccuracy, my major problem with Prasad’s thesis was its unoriginality. Et Tu Prasad? Nazi comparisons are dime a dozen. Anything can be a short step to Nazism. Bioethicist and Holocaust expert, Arthur Caplan, called Prasad’s essay “imbecilic, ignorant, and dangerous.” My preferred terms would have been “impetuous” and “disillusioned.” Prasad feels disillusioned by the response to the pandemic which he believes has worsened the disparities he has spent his life fighting to reduce. Whatever the merits of his disillusionment, as one can rebut that it’s the virus that worsened the disparities not the response to it, Prasad is principally guilty of the naiveté of a true believer. I never saw the purity of progressivism that Prasad bucolically recalls. Progressivism always seemed an expedient mix of opportunism, careerism, and hypocrisy, which is how it got stuff done. 

Multiple factors led to the rise of Nazis, notably anti-Semitism. The anti-Semitism didn’t arise overnight. It took centuries to perfect. Which is why Hitler could persuade Pope Pius Pacelli XII to persuade the Christians in Germany to vote for him. The deeply flawed Pope saw in Hitler an opportunity to avenge Jesus of Nazareth’s crucifixion. The frivolous comparisons of any polity we dislike to Nazis reeks of historical ignorance. History is complex. Holocaust was a culmination of historical evil. As Sven Lindqvist argues, the holocaust was the sequel to the African genocide by the European colonialists, notably Belgium’s King Leopold.

To believe that mask and vaccine mandates could lead to the same eventuality as the German hyperinflation caused by the Treaty of Versailles betrays an alarming level of judgment. It is, however, merely a sign of our times where hyperbole is the language of public discourse. Thus, the frivolity with which Nazi comparisons are made is reflective more of our exasperation than anti-Semitism. I disagree with Caplan. I have no doubt that Prasad is in no way anti-Semitic. Accusing him of anti-Semitism devalues the gravity of the charge. In fact, Prasad is likely fervently anti-anti-Semitic which is precisely why he used the Nazi analogy to express his frustration with the pandemic response. 

The Third Reich is too easy a historical metaphor for these times. We should go further back in history. A more apt analogy is the Roman empire which reached depths of churlishness before reaching its own depths. For instance, Emperor Caligula appointed his horse, Incitatus, as consul. He was struggling to find a qualified Roman. When asked his opinion on policy, Incitatus defecated and kicked his feces on his fellow senators. The joke wasn’t on the horse. Historical parallels are never exact. But we have struggled to find an FDA commissioner. We don’t spray horseshit these days but we do take horse paste very seriously. Ivermectin has become the sepulcher of sanity. 

We’re no longer just irritated with each other, we’re “appalled,” “disgusted,” “saddened.” Words have lost all meaning because no meaning was attached to them in the first place. If our vocabulary has been devalued, the issues over which we fight have become marginal. Galileo’s belief in heliocentricity was literally earth-shattering. Today’s Galileos fight over one or two vaccine doses in teenagers, whether the risk of vaccine-induced myocarditis is 1/1000 or 1/10, 000. Nothing encapsulates our pettiness more completely than our probability wars.

It’s tempting to conclude that we’ve lost all fucking perspective. But lack of perspective isn’t the whole story. The reality is that we’re thoroughly bored – a side effect of affluence. This is why we have revolutions in our heads and fight wars on our devices. We storm the Bastille without moving from our couches. Instead of calling each other Nazis, we could just as well say “whatever,” press the mute button and roll our eyes.

(*) I’m aware of the irony of comparing the KGB to I-phone screenshots in a piece decrying hyperbole

@RogueRad is a Twitter commentariat who aspires to be canceled

By SAURABH JHA

Unlike medical meetings, rendering Beethoven’s Ninth Symphony isn’t easy on Zoom, so the local orchestra has been furloughed and their members work for Uber.  The opera house wants to reopen, preferably before we reach the elusive herd immunity threshold. They mandate vaccinations for their artists, not least because the performers can keep their masks off. Should they extend this requirement to their patrons?  

Vaccine passports, proof of immunity against SARS-CoV-2, to work, dine, fly or watch shows, are controversial. Opponents say they blithely disregard decency, are operationally onerous, and hurt liberty. Worryingly, they create a caste system, which wouldn’t be as concerning if based on just immunology. Such a two-tiered system could sadly mirror societal inequities because it’s the poor who may disproportionately be left unvaccinated. Supporters of vaccine passports further the very structural disadvantages they seek to end.

When arguments are too compelling they likely betray an obvious simplicity. Too often arguments against mandates assume they’d be a government fiat. The opponents recline on the country’s inherently liberal streak conjuring visions of rugged individuals fighting unelected bureaucrats. They say with undisguised pride “this isn’t who we are. We’re the US, not New Zealand. We can’t be controlled.”

This narrative is so tightly embedded in right-of-center discourse that it’s now folklore bordering on an Ayn Rand fairy tale. The narrative is nonsense. The state is too incompetent to either govern adeptly or tyrannize efficiently. Case-in-point: CDC’s easily forgeable paper vaccine certificate. If the state were serious about prying on people’s antibodies, it’d have made the immunosurveillance digital.

The obsession with big government should be antiquated. By censoring content, Facebook and Twitter showed that freedom can more efficiently be curtailed by the private sector. Bottom-up censorship is arguably more powerful than top-down censorship because it has buy-in from a segment of the market. It may very well be the private sector which demands vaccine passports, which begs two questions – why and why not?

The scientific arguments against vaccine passports are even more compelling than the deontological arguments. Vaccinations are nearly 100 % effective in stopping infections. The unvaccinated don’t endanger the vaccinated. The unvaccinated endanger only each other and they have a right to accept the mutual risk.

Yet, the opera house may ignore science. For starters, they’d be signaling a safe environment, and even if the safety is excessive, it might be necessary to arrest the inertia of their risk-averse patrons who, having avoided crowds for a year, may need more than science for reassurance. They’d also be signaling a commitment to vaccinations which, despite the hesitancy is some quarters, is now ingrained in public psyche as the path out of the pandemic. A private entity may signal collective virtue for selfish reasons. Adam Smith’s invisible hand works in mysterious ways.     

Even if the unvaccinated implicitly accept the risk of infecting each other, the opera house might not want to be the author of their viral destiny. If the viral spread is traced to the theater, even if the opera house can’t be sued, they’d get bad publicity. Market forces would encourage the establishment to be more prudent than science demanded.   

Couple weeks after receiving my second dose, I was walking to the grocery store in a state of immunological euphoria. In a flash of defiance to the spike protein, I took off my mask to salute my antibodies. A man walking his dog looking disapprovingly at me crossed the road. I wanted to shout “I have been vaccinated, you judgmental Puritan”. Instead of showing him the Kaplan-Meier curves of the Pfizer vaccine, I put my mask back on. I still wear a mask – to protect myself not from the virus, but the judgmentalism of strangers. The alternative is tattooing “I have been vaccinated” on my forehead, but I’m of a shy disposition.

The vaccinated are now hanging out together. After a year of seeing each other on Zoom, they now have dinner at each other’s houses. The mute option has gone. The masks are off.  They’re comfortable because they know they’re vaccinated. An unsaid vaccine honor system already exists. We don’t call it “vaccine passport.” We call it “mutual agreement.”

To understand how businesses might behave, we must understand their clientele and also their costs of obtaining information. All entities try reducing information costs. Discerning between different tiers of risk is costly for both an upscale French eatery and a hole-in-the-wall Schezuan restaurant. The former may enforce vaccine passports so that their affluent patrons feel relaxed sipping Côtes du Rhône wine. For the latter, requiring vaccine passports may drive away their, less affluent, customers.

As more of the more affluent get vaccinated, their urge to normalize will increase. However, this urge won’t rise smoothly. It’ll be preceded by extreme fear, as they’ll feel like they’re walking on landmines. In that inflexion between extreme fear and frontier spirit – which could last days or months – they may demand that the places they frequent mandate vaccine passports.  Upscale restaurants may oblige. Airlines, though not budget airlines, may also oblige. Vaccine passports will segment the more affluent segments of the market.   

Two underappreciated forces in affluent nations are fear and virtuosity, both plentiful here.  The corollary to feeling good about yourself for being vaccinated is wanting to distinguish yourself from the “reprobates” who aren’t. Compliance with masks can be signaled. Compliance with vaccinations, notwithstanding the vaccine selfies posted on Twitter, is more difficult conveying. Vaccine passports unmask our invisible immunology.

Of course, there are legitimate reasons not to be vaccinated. But markets aren’t good at discerning intent – the information costs are prohibitive. Markets may be more nuanced than central diktats but are still not nuanced enough for the heterogeneity of risk and preferences in society. This means we can’t assume that the unvaccinated have entered “I’ll let you infect me if you let me infect you” covenant.

As getting vaccinated gets easier, and more get vaccinated, the already low efficacy of vaccine passports will be even lower. But the zeal for vaccine passports will increase, precisely because getting vaccinated got easier. It’s easier for hotels to turn guests away at 60 % than 25 % occupancy. Why are passports mandatory for international travel, with no exception? Partly because they just are, and partly because anyone can get one.

The incredibly efficacious COVID-19 vaccines made masks redundant. Vaccine passports are the heir apparent to “throw your masks off”. They’ll exist because the vaccinated and unvaccinated are in different risk tiers. And the vaccinated will want their lives to be easier because they’ve been vaccinated.  

Since the start of the pandemic, we’ve tried making restrictions more risk based. We’ve quarantined international travelers, restricted travel from viral hotspots, such as India. The maxim of the operationally challenging “test, trace, and isolate” is keeping people who test positive away from people who test negative. It’s an odd deontology which concludes that it’s ok segregating society on the basis of “has virus” but not “does not have virus”, particularly as the latter is now more within one’s control – one couldn’t as easily have chosen not to be infected as one can now choose to get vaccinated.

No mandate should be judged on its own. It must be judged only in the context of other, more restrictive, mandates.  Weak restrictions create more freedom by displacing stronger restrictions. Presently, Americans require negative COVID-19 test before boarding flights back to the US. Whatever the merits of this restriction, it can make people fear being stranded in another country. Between having a blood test 48 hours before your flight and hoping it’s negative, and showing proof of vaccination, which would you choose? If you’re a frequent flyer would you choose a one-time certificate or a blood test every time you fly?

Across the political spectrum logical consistency has taken a flogging in this pandemic. For instance, consider the Great Barrington Declaration (GBD), which has widespread support amongst conservatives. GBD’s risk-based restriction, “focused protection”, uses the steep age gradient of COVID-19 mortality. Focused protection means we protect the elderly with vigor but not fret about the youth partying. How is keeping unvaccinated granny away from parties in crowded bars, pre-vaccine, categorically different from keeping unvaccinated granny away from the unvaccinated youth in an opera house?  

The scientists will scoff at my conflation. Not all risk heterogeneity is the same. And risk is diminishing – unvaccinated granny is safer now. Vaccinations have flattened the age-mortality-gradient.  My point is that vaccine passports are no more unique in the genre of risk-based restrictions than a Labrador is uniquely canine.

Will vaccine passports reduce faith in vaccinations? It’s certainly plausible that those who don’t want to be vaccinated will resent compulsion. But those at the margins may more likely get vaccinated if vaccinations makes their lives easier.

When individual preferences clash with groups preferences markets segment, which is why we have budget airlines. Vaccine passports may also be a consequence of such tension. They’re not the key to reopening the economy. Rather, they may be the result of their phased re-opening.  Removing the mask mandate will neuter vaccine passports. Vaccine passports will be redundant if the country normalizes today. But many places won’t normalize overnight, or at the same time, and as we creep towards normalization, businesses may use vaccine passports to create sanctuaries of pseudo-normal life, particularly for their employees.

Technocrats think about net benefits of policy, of effect sizes, of uncertainty. Markets aren’t concerned by the algebra of regression equations but governed by the concerns of the time. Perception of risk often lags actual risk. Perception is shaped by multiple entities, such as media, institutions, and television doctors. The closer we reach the end of the pandemic the more impatient markets will become to end the pandemic.

As we’ve been told, markets know best

Saurabh Jha is a long-time contributor to THCB. He can be reached on Twitter @RogueRad

Joining me , Matthew Holt (@boltyboy), on THCB Gang this week were fierce patient activist Casey Quinlan (@MightyCasey), consumer advocate & CTO of Carium, Lygeia Ricciardi (@Lygeia), THCB regular authors radiologist Saurabh Jha (@roguerad) & cardiologist Anish Koka (@anish_koka), with futurist Jeff Goldsmith on hand to keep us all honest. We started with Casey’s current health journey and Anish’s inability to get vaccines for his clinic — and this moved to a really fun and raucous discussion about whether the public sector can work in health care, whether we need to mandate the vaccine and if America is becoming a failed state! Great stuff!

If you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels

By SAURABH JHA and JEANNE ELKIN

Mr. Smith’s pneumonia was clinically shy. He didn’t have a fever. His white blood cells hadn’t increased. The only sign of an infection, other than his cough, was that his lung wasn’t as dark as it should be on the radiograph. The radiologist, taught to see, noticed that the normally crisp border between the heart and the lung was blurred like ink smudged on blotting paper. Something that had colonized the lungs was stopping the x-rays. 

Hundred and twenty-five years ago, Wilhelm Conrad Roentgen, a German physicist and the Rector at the University of Wurzburg, made an accidental discovery by seeing something he wasn’t watching. Roentgen was studying cathode rays – invisible forces created by electricity. Using a Crookes tube, a pear-shaped vacuum glass tube with a pair of electrodes, Roentgen would fire the cathode rays from one end by an electric jolt. At the other end, the rays would leave the tube through a small hole, and generate colorful light on striking fluorescent material placed near the tube. 

By then photography and fluorescence had captured literary and scientific imagination. In Arthur Conan Doyle’s Hound of the Baskervilles, the fire-breathing dog’s jaw had been drenched in phosphorus by its owner. Electricity and magnetism were the new forces. Physicists were experimenting in the backwaters of the electromagnetic spectrum without knowing where they were. 

On November 8^th, 1895, when after supper Roentgen went to his laboratory for routine experiments, something else caught Roentgen’s eyes. Roentgen closed the curtains. He wanted his pupils maximally dilated to spot tiny flickers of light. When he turned the voltage on the Crookes tube, he noticed that a paper soaked in barium platinocyanide on a bench nine feet away flickered. Cathode rays traveled only a few centimeters. Also, he had covered the tube with heavy cardboard to stop light. Why then did the paper glow?

Roentgen’s scientific ethos was replication. Only reproducibility of results could convince him that his eyes weren’t being deceived. The glow wasn’t an artifact because the paper glowed only when the Crooke’s tube was on. Had he underestimated the distance cathode rays travelled? The paper still glowed when placed further away from the tube. Not even a deck of cards stopped the glow. 

By the nineteenth century, physicists had replaced the chemists as nature’s alchemists. Whereas the chemists tried converting metal to gold, physicists created invisible material out of invisible material. One such invisible material were cathode rays, which later turned out to be electrons. Roentgen didn’t know their precise nature. He inferred their properties only by careful experimentation. He didn’t think they were responsible for the distant glow. But cathode rays were somehow responsible for this “new kind of rays”, which were similar to light but could penetrate solid material, which he called “x-rays” – the “x” denoting that their nature was unknown. 

X-rays were discovered accidentally because Roentgen left the fluorescent paper on the distant bench accidentally. But they had been discovered because Roentgen followed his sharp observation with diligent investigation. X-rays might have been discovered sooner had they been noticed. A few years earlier, Arthur Godspeed, a physicist at the University of Pennsylvania, who also experimented with cathode rays, developed photos, some of which had disc-shaped shadows which, unbeknownst, were cast by coins in the path of x-rays. William Crookes, the inventor of the Crookes tube, returned several photographic plates to the manufacturers because they were fogged. After Roentgen’s discovery, he realized that the “damage” he had reported was actually x-rays’ signature.    

Roentgen’s laboratory, like Victor Frankenstein’s study, was a Gothic room with contraptions powered by flashes of electricity. Like Frankenstein, he was unleashing science to unravel the supernatural. With curiosity and doubt, Roentgen spent several weeks experimenting with x-rays. He studied the stopping properties of various metals by observing their shadows. Then on one occasion, when he held a piece of lead in his hand, he saw shadows of his bones. 

Radiology was conceived on December 22^nd, 1895 when Roentgen placed his wife’s left hand in the path of the x-rays. After a fifteen-minute exposure, an iconic photograph emerged. Only bones and a wedding ring cast a shadow. Hitherto, bones were seen only when the dead were opened. Seeing the bones stripped of flesh, naked bones, in the living must have seemed supernatural. Six days later, Roentgen published his findings in a paper titled “On a New Kind of Rays” in the Proceedings of the Wurzburg Physical Medical Society, a relatively obscure publication with rapid publishing time. Roentgen said to Bertha Ludwig, his wife, “now the devil will be to pay.” 

On January 5^th, 1896 the Vienna Presse, an Austrian Newspaper, published Roentgen’s discovery. Even though there was no social media, and only the telegraph shortened distances, news of his discovery became viral. Within ten days, the London Standard and the New York Times ran the story. Science spread by media. The medical journals came late to the party. The press instantly recognized the medical importance of x-rays, noting that they could photograph broken bones and bullets in human bodies. 

The early x-ray enthusiasts were photographers, physicians, engineers such as Thomas Edison, and con artists. X-rays quickly became known for their nefarious potential and became antithetical to Victorian sensibilities. An editorial in the London-based Pall Mall Gazette in March 1896 expressed concern with the “Roentgen Rays” and, cautioning readers of the “revolting indecency” of being able to see people’s bones with the naked eyes, asked that legislature restrict x-ray vision.  

The first medical x-ray in the US was of a Colles’ fracture in a boy who injured his wrist, taken by Edwin Frost, a Dartmouth astronomer in February 1896, for his physician brother. In the same month John Cox from McGill University, Canada, localized a bullet in the leg of a patient that had eluded the surgeons. By the end of the year, x-rays joined the battlefield in the Nile expedition, to help surgeons deal with wartime injuries. Much of radiographic practice today can be traced to 1896, the year clinical radiology was born. 

Before Roentgen, disease was inferred by sound, by percussion and auscultation. X-rays ensured that disease wasn’t just heard but seen. The Frankfurter Zeitung called x-rays “an epoch-making result of research in exact science.” Befittingly, the first Nobel Prize for Physics, awarded to Roentgen in 1901, was for a medical breakthrough. Roentgen made medicine an applied science by bringing physics into medicine. Later, x-rays unraveled another mystery – the structure of DNA – through x-ray crystallography. 

Roentgen dodged fame and declined fortune. He refused to copyright his discovery. He donated his Nobel Prize money to academia. Unassuming in fame, he was unflappable even before his fame. Known for his scout’s honor, he once was expelled from school for refusing to snitch his classmate who had drawn a cartoon of a teacher.

When asked by a journalist what he thought when he saw the glow from the distant paper, he replied, curtly. “I did not think, I investigated.” Roentgen’s legacy to humanity was making disease more visible to doctors. His bequeathal to doctors was the twin act of observation and investigation. 

Further Reading

Farmelo G. The Discovery of X-Rays. Scientific American 1995; 11: 86-91 

Brailsford JS. Roentgen’s Discovery of X-Rays – Their Application to Medicine and Surgery.” BJR 1946; 19: 453-461

Roentgen WC. On a New Kind of Rays. Translation from German to English of Roentgen’s first X-ray publication by A. Stanton. Science 1896; 3: 227 – 231

Saurabh Jha is a radiologist and contributor to THCB. Jeanne Elkin is MS-3 at the Perelman School of Medicine of the University of Pennsylvania

An edited version of the piece was published in Medscape

Matthew Holt (@boltyboy) was joined by regulars: futurists Ian Morrison (@seccurve) & Jeff Goldsmith, surgeon and now digital health entrepreneur Raj Aggarwal (@docaggarwal), radiologist Saurabh Jha (@roguerad), and patient advocate Robin Farmanfarmaian (@Robinff3).

Like the nation we took a big collective sigh of relief. We then talked a lot about COVID vaccinations, what the newly (sort of) Dem-led Senate is going to do on stimulus and health care , and we fnished on all that money pouring into digital health, while the stock market goes crazy. It was all good grist for the #THCBGang’s mill.

If you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels

Episode 32 of “The THCB Gang” was live-streamed on Thursday, November 12th. The video is below.

Matthew Holt (@boltyboy) will be joined by some of our regulars: WTF Health Host Jessica DaMassa (@jessdamassa), radiologist Saurabh Jha (@RougeRad), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), benefits communications leader Jennifer Benz (@jenbenz), THCB’s Editor-in-Chief me (zoykskhan) and guest Jeff Goldsmith, President of Health Futures, Inc. The conversation followed the post-election frenzy around COVID-19 response, the vaccines, the ACA, and what a Dem. president means for the United States in terms of health care.

If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan, producer