On Amnesty - Part 2
Public health overreach, COVID scapegoating, and the authoritarian impulse in modern medicine
Who’s really at fault?
In my previous post, I addressed the article that sparked a lot of conversation on the topic of COVID amnesty. I generally think that the author and people like them should apologize for their errors and then people should move on. There are a few reasons why I feel this way, but the main reason is that most lay people that embraced COVID hysteria didn’t do it because of a deep knowledge of the risks of SARS-CoV-2. They did it because they were frightened by the people that they trust to inform them on their health. It started with the medical field and public health officials who aided in the process of politicization. This group was the source for the media’s constant fear porn and all of the political grandstanding. It’s true that many in our society were primed for the occasion, but politics itself could not have done the damage that it did without the help of the medical and public health community.
A rough start
This might sound cliched, arrogant, or both, but those outside the medical field can’t understand what COVID was like in those early days (unless you witnessed it firsthand in a family member). We had seen bad flu years, lived through the Ebola freakout, and felt like we dodged a bullet with the first SARS outbreak and MERS. The few scenes from China were disturbing both from a medical perspective as well as the severity of the government response but that had been seen before during the original SARS and during periodic outbreaks of bird flu. Then Italy’s outbreak started, revealing that this virus might not be contained like the other recent examples. This one may turn into the pandemic we had all worried about. However, things didn’t really get frightening for me until the outbreak hit New York. Hearing firsthand about the severity of illness that was being seen hits different. Seeing it in person was even more profound.
A lot of people outside of medicine never saw the true severity of the original strains (up to and including delta) of SARS-CoV-2, the virus that causes COVID. The mortality rate in elderly and high-risk individuals was much higher than in most flu seasons. That was bad and heartbreaking to see but even more alarming was the effect it could have on younger people (in this context, younger people are those in the 20-40 age range). Due to a lack of available testing, we’ll never know the true proportion of infection in this age range that resulted in severe disease. It was likely rare, but when it occurred it was striking.
One of the monitors used in normal patient care is the pulse oximeter. This device measures how well your blood is being oxygenated by your lungs. A normal reading is 95% and above, supplemental oxygen is usually given to people falling below 92% (with some exceptions for those with chronic lung disease for somewhat complicated reasons), and if people fall below ~85% it is cause for serious concern. One hallmark of the early COVID strains was patients showing up to the ER with oxygen saturations in the 60-70% range. It was truly like nothing we’d seen before.
At this time, it’s important to introduce the idea of an N of 1. This idea uses the statistical nomenclature of sample size (N) to express behaviors that result from seeing a single case of something. As much as modern medicine has tried to rid itself of anecdote, nothing will be able to replace the mental and emotional effect that a single case can have on a person. This can be both a good and a bad thing. If you missed a diagnosis because you made a mistake and didn’t consider it, remembering that case can help patients in the future. But if the case was an incredibly rare diagnosis or very atypical presentation, it can result in a physician being overly concerned when it isn’t warranted. For many, seeing a 35-year-old with an oxygen saturation of 70% had an outsized effect on their ability to assess risk. Combine that with the degree of uncertainty that existed early on, and you were set up for what was to come.
Initial lockdowns
I’ve said many times, and I will repeat it here, I can forgive essentially anything that happened in the first couple weeks of COVID. Those that know me, know that I strongly oppose any government intervention on voluntary activities. So, I was naturally opposed to the lockdowns. That isn’t to say that I can’t see the arguments in favor of that approach. Even early on, however, the public health justifications were dubious at best. Had they simply decided to close indoor public spaces and schools for a couple of weeks, cut down on travel, and request limited occupancy for businesses such as grocery stores you might have been able to make the argument that it ws justified. That’s not what happened. Instead, they decided that “essential business” could stay open while others had to close. The decisions on what was considered essential was arbitrary. Liquor stores were considered essential businesses that should stay open while some medical clinics were not. Outdoor spaces like public parks were locked down, police arrested people paddleboarding by themselves in the ocean, and skateparks were filled with sand. Much of this was done under the vast authority given to public health officials. The severity of the response frightened people.
I think that this is the first time in my life that I’ve realized how much power had been given to public health officers. These individuals were given the dictatorial ability to declare what business and spaces could be open and from the beginning, they got it wrong. If there was ever a time to encourage people to go outside, it was the early days of COVID. Instead, these spaces were closed. Never mind that this would have been the first respiratory virus in modern memory (maybe ever) that spread easily outdoors. The result of this was to drive people indoors, where COVID really spreads. That was the first public health mistake but wouldn’t be the last.
Public health incentives
This is a good time to point out the incentive structures that exist for public health officials during a situation such as COVID. These individuals are given sweeping authority to take steps to stop outbreaks of infectious diseases, even actions that violate individual rights. Prior to COVID these powers were rarely used. Examples include forced quarantine of individuals with certain infectious diseases and making people take medication under observation. If you read the statutes that convey these powers, it is surprising to see how broad they are. To a person trying to stop an outbreak, that is a blessing a curse. They have these broad powers and if they don’t use it and an outbreak gets out of hand, they will be blamed. If, instead, they are overly aggressive and the outbreak spreads, they can blame bad actors that ignored their instructions.
In most areas, the public health officials chose option number 2 and when it didn’t work, the blaming started in earnest. It was combined with epidemiologic models that were simultaneously overly pessimistic about the results of uncontrolled spread and overly optimistic about the effects of lockdowns. These models provided the statistical cover to both claim that the measures taken were beneficial while also scapegoating the people skeptical of the heavy-handed approach.
This process of scapegoating provided all the cover that was needed for the petty tyrants to take over. COVID was no longer something that just happened, it was people who weren’t following the rules that were at fault. Combine this with the ever-present counts of infections and deaths, conveniently provided by the CDC and other public health institutions, and the self-righteous scolds in our society had all that they needed to cast blame. Even questioning if the approach that was being taken was correct was met with derision. Wanting to see friends or elderly family members was “selfish”. This idea was encouraged by public health officials who were clearly failing in their approach but were unwilling to say that the damage that had been done was all for nothing.
How hard is it to say, “I don’t know”?
Perhaps the most interesting and, in my opinion, the most damaging long-term aspect of the COVID response in the early days was the unwillingness of people in power to admit uncertainty. There is no better example of this than Anthony Fauci stating with certainty that “masks don’t work” only to be followed by masking mandates a few weeks later. Given our lack of knowledge of how COVID spread, the degree of certainty in his statement was absurd. I remember thinking at the time that the statement didn’t make sense. Later on, it was revealed to be an intentional lie to protect the dwindling supplies of masks from being bought out by a frightened public. The rapid pivot to mask mandates did real damage to the credibility of public health in the eyes of those already skeptical of the heavy-handed approach that was being taken. This was compounded by the masking mandates extending all the way down children only 2 years old. The idea of mandating a mask on a 2-year-old should have been ridiculous on its face. It was never based on data, but it became dogma and yet another cudgel that could be used against “deniers”. The stories of people being kicked off planes because their 2-year-old wouldn’t keep their mask on were cheered by people fully gripped by COVID hysteria. They had been convinced that this was the only way to slow the spread and return to normal.
This error was followed by others. Attempts at early treatments such as hydroxychloroquine were dismissed out of hand while others, like convalescent plasma (plasma donated by people that had recovered from COVID), were embraced. Recommendations for and against treatments were seemingly dependent on the politics of the people promoting the treatment (neither of which turned out to work) and the political leanings of the person making the recommendation. If Fauci recommended it, the media reported it positively and millions of people were hopeful that a treatment was finally available. If the recommendations came from the wrong place, particularly if Trump spoke positively about it, it was ridiculed and anyone saying it might have merit was immediately a charlatan. Under normal circumstances, public health officials and the medical community would say that more study was needed but that they showed promise in laboratory studies (a true statement). That didn’t happen and only further degraded trust. This process repeated itself over and over again until it seemed like the CDC and FDA had been fully captured by politicians and pharmaceutical companies.
The unwillingness to admit uncertainty showed itself again in the discussions of school closures. Public health institutions overstated the risks of COVID in children. They did this despite early data being available showing the very low risk of severe disease in this age group and the low likelihood that children would infect adults. At the same time, worries about learning loss were rapidly dismissed. Parents worried that their children weren’t learning properly were dismissed as the parents missing having their babysitters. It was a weird retort for teachers to make but it fit the climate at the time perfectly. The reality was that no one knew what effect remote learning would have on children but, in the end, those concerned about learning loss have been proven right and the damage to children will be felt for years.
A final area where there was an unwillingness to admit uncertainty was in relation to the vaccines. In this area, once again, Anthony Fauci was not up to the task. He expressed certainty that vaccines would not be the answer to getting out of the pandemic, until he expressed certainty that they were. These vaccines were “highly effective” and stopping the spread of COVID (a claim that was never actually studied in the vaccine trials) until they weren’t. We were told there was no risk of myocarditis or blood clots, despite the fact that intermediate and long-term safety data was non-existent. An honest discussion could have placed vaccination in context. Each individual sitting somewhere on the continuum of COVID and vaccination risk. People could have been told what their risk was and that long-term risks weren’t fully known but are expected to be low based on prior experience. Instead, this was another place where even questioning the narrative resulted in denouncements as being anti-vaccine and “anti-science”, whatever that means. Even today, many are unwilling to admit they were wrong in the heavy-handed approach.
The authoritarian impulse in American medicine
Would it have made a difference if the people responsible for COVID messaging had been willing to express uncertainty? I suspect so, but it’s impossible to be sure due to the political landscape at the time. I do have ideas as to why expressing uncertainty was so hard for people in the medical field. I think it comes down to a feeling of secret knowledge and authoritarian impulses.
I’ve discussed before the steps it takes to become a doctor. This process involves ritual rites of passage that to an outsider (and to many in the medical field) seem ridiculous. So why do they continue? In part, it is to maintain the feeling of being part of a special club. With membership comes the unique ability to interpret symptoms and treat disease. Those without the “secret knowledge” are often scoffed at when they express an opinion on a medical topic. In most cases, doctors think they know what’s best for you. To the degree that there is a discussion of options it is within a defined range of what they consider acceptable. This approach has previously been called paternalism, but I prefer to call it authoritarian.
The authoritarian impulse really showed itself during COVID in a many, sometimes cruel, ways. Perhaps the greatest sin committed by medicine during COVID was refusing to allow family members to be with their dying loved ones. This was unjustifiable in my opinion but was so stringently enforced as to think it was legally mandated. There were approaches that could have been taken to protect people from infection and ensure they didn’t contribute to community spread. Instead, thousands of people died scared and alone. If this had happened to one of my family members, there would be no forgiveness. I can proudly say that this is one area where I refused compliance. If someone was dying or I feared they would die in the hospital, I used what little power I had to ensure family was given the opportunity to say goodbye. The degree to which visitor restrictions still exist is further evidence of the refusal to admit error. To everyone that was put through this, I understand why you would want vengeance.
A further example of the authoritarian impulse was the control over medical treatments. The physician as gatekeeper to medication has a long history and the debate deserves more discussion so will have to wait for a future post. This gatekeeping became even more stringent during COVID. Only approved treatments were allowed, even during times that no approved treatments were available. The care approach was so rigid that even dying individuals were denied the ability to try alternative therapies such as hydroxychloroquine and ivermectin. The argument was that it would waste resources, but the excuse I always heard was a “slippery slope” type argument. But it went beyond just refusing to use these therapies in your practice, the authoritarian impulse required demonization of those that disagreed. Nowhere was this more apparent than on social media.
“No license for disinformation”
Debunkers of medical disinformation have existed for as long as doctors have disagreed on treatment practices. Social media gave this group a wider audience than was previously attainable but, despite that, it remained a rather small group. A niche within medical social media. Many of these individuals gained followers by dunking on treatments and diagnostic techniques that were already widely known to be worthless. No deep research was needed because everyone that followed their account already knew the “truth”. This group was joined by the physician activists. These were a combination of the “resistors” that sprung up in the age of Trump and “this is our lane” types that parlayed the social capital associated with being a physician into likes and retweets. Both the “debunkers” and “activists” had the same goal, chasing clout, and COVID was their chance to be relevant outside the small circles of med twitter. People were clamoring for information and these clout chasers were more than happy to provide it in the way of witty quips and anecdotes. Also, TikTok dances. There were lots of TikTok dances.
This was not enough, though. The authoritarian impulse would soon be aimed at dissenters. The first group that was targeted was those opposing lockdowns. Protesting outside put people at risk (until it didn’t). Denouncements would be coupled with stories about seeing someone take their last breath while saying “I wish I had been more careful”. This would later be replaced by “I wish I had been vaccinated”. These stories were mostly absurd, but they got the likes, retweets, and occasional news interviews the clout chasers desperately wanted. Next came the debunking of alternative treatments. You would have thought people were recommending cyanide as a treatment the way hydroxychloroquine and ivermectin were villainized. This approach was mirrored by many of their followers. Most of these “influencers” had no idea that there was laboratory data to support further study of these treatments, nor did they care. There was no room for nuance in these circles.
Finally came the global push against “disinformation”. This catch-all designation ran the gamut from “covid isn’t real” to “maybe healthy 5-year-olds don’t need COVID vaccination”. It was a way to dismiss an idea out of hand and was a signal for others to do the same. There was no need to look into an idea if the person advocating for it was spread “disinformation". I can’t recall one of these accounts admitting when they were wrong. The closest they might come is saying “the data has changed” to justify a change in position. Those taking this small step were promptly be attacked by their previously chummy mutuals.
The world of social media, however, still didn’t provide enough real-world validation for some of these individuals. In these people, the authoritarian impulse led to a crusade against anyone who would question the official narrative. This official narrative was given the designation of being “science” and everything else was heresy. And heresy must be punished, even absent evidence of actual harm occurring. What followed was a series of campaigns aimed at getting individuals fired and their medical licenses revoked. The culmination of this occurred in California with a medical disinformation bill that was recently signed into law (more on that another time).
Forgive and forget?
As far as COVID goes, I’ve been lucky. I still have my job (although I would have lost it if I had refused to get a booster last year) and did not get excommunicated by any close friends or family. Others have not been so lucky. Some lost jobs, friends, and family to COVID hysteria. Most of these hysterics originated by public health professionals or physicians on TV or social media. That is why I think that the medical community carries most of the blame for the excesses of COVID. Maybe it’s that authoritarian instinct in myself that feels that we, of all groups, should have known better.
I am not without blame. I was wrong on the benefits of the vaccine in preventing infection and it remains to be seen if I underestimated the risks. I made my own risk/benefit and got the vaccine, choosing not to fight the mandate out of principle. I am a pragmatist and have no desire to be a martyr. I also told stories about bad cases to friends and on social media as a way to convey the dangers of COVID and this may have contributed to some of the fear that persists to this day. If my actions caused anyone harm, I am sorry. If I could, I would apologize for all of the excesses of COVID but there is no one person that speaks for the medical community as a whole.
I’ve outlined above some of the reasons why I blame the public health and medical communities. These groups provided the cover to all of the excesses of COVID and are ultimately responsible in my opinion. I can understand how, hearing all of the dire warnings, people would take the actions they did. That is why I generally think that amnesty for lay people is warranted. There are always exceptions for individual egregious actions and forgiveness is a highly personal decision. I struggle with how to forgive public health and medicine. The damage that was done will be felt for years. I also think that admitting error is an important part of the process of forgiveness.
I don’t like ending on a sour note, but I have little hope that there will be widespread introspection in the medical community regarding COVID excesses. Even less likely that anyone will be held “responsible” for the most egregious mistakes. This is not how modern medicine works. The power structures that exist will protect themselves and keep grinding forward. New bureaucrats will replace the old ones, but nothing will fundamentally change. I know these systems; I work in them. I do not foresee a large-scale epiphany. More likely is that in 5 years people will look back on COVID and remember it as everything they said it was at the time. The history that has been written in their minds, absent a large-scale unexpected event, will not be changed.
As always, my goal is to provide insight into the medical profession from the inside. I welcome your feedback on this post or on topics you would like me to write about.