Duty

The greatest thing we've lost

One of the tragic declines in our culture is the loss of a sense of duty. I have no respect for people who don't have an internal sense of duty, or worse fail to abide by duty.

I had been seeing patients in person on the wards and in clinic at OHSU when the pandemic struck. I moved to UCSF ( the move was planned before the pandemic) and hammer called the California Medical License Board until they processed my application, and then resumed duties in person at the San Francisco General Hospital, where I continue to attend in clinic and on the wards… in person.

I'm more than happy to attend in person because that's what I signed up for when I became a doctor. Like all doctors, I signed up to attend in person for all viruses— no matter how lethal. During the days of 2020, the panic was real. But as a doctor I have a duty. Instead of retreating, I found a way to do extra shifts, which I continue to this day.

We used surgical masks in rooms that had stagnant air flow, but that was the recommendation of the time, and I never complained. No one said this job is without risk. You learn that the first time you place a central line or do any procedure on someone with a blood-borne illness. Risk is part of the job.

I understood very well that given my age, health, and the actual IFR that the risk was modest. But even if the IFR had been 10 times higher, you wouldn't find me sitting at home because I have a duty in life.

When the school closures hit in the fall of 2020, I use whatever pulpit I had to push on the issue as hard as possible. I knew very clearly it was a foolish decision. As someone who had trained in policy, analyzing that question was easy. But how to persuade others? People who seemed not to be using their brain?

I quickly brought on a steady stream of guest like Carycruz Bueno, Vlad Logan, Alasdair Munro and others to build the case that the harms of school closure far outweighed the benefits. There was professional backlash for this decision. But you don't cry about that. If you sign up to be a professor, and your goal is to improve the well-being of the world, you got to push on the issues that really matter.

In 2021, I turned my attention to the evidence for masking very young children. I read many papers in the topic, and ended up publishing a systematic review with my colleagues from Harvard and the University of Colorado. You don't have to spend much time before you realize the evidence is god-awful. There is literally no credible studies that making a two-year-old wear a cloth mask will help. It also runs counter to basic common sense, and the consensus of most experts pre-pandemic. Europeans and the WHO think it is misguided.

I'm trying not to use the word stupid to describe the people who hold the view that it helps. Instead, I will put it this way. I no longer respect any actual scientist who tells me that that it makes sense to make 2-year-olds wear a cloth mask in daycare except for the two hours they all nap together side by side. Anyone who believes that policy actually slows viral spread can be safely ignored.

But what can I do about bad policy? I thought about it, and slowly over the course of a year advanced a series of articles in places like Medpage today, and the Atlantic on this issue. I tweeted against the AAP when they said deranged things like there is no evidence that kids need to see faces.

This earned me great professional pushback, and headache. But you can't focus on that, you must focus on your duty. My duty, as a professor whose life is the arbitration of evidence, is to encourage people to use their rational, evidence-based medicine skills in pursuit of policy recommendations that benefit people. I can't be dissuaded if a bunch of people who aren’t thinking clearly decide to engage in mob Twitter.

And there were many other issues along the way. I was quick to say J&J should be pulled off the market for VITT . Finally, people have gotten around to that position. A little bit late, and a lot of damage done. But that also didn't earn me friends.

I was one of the first to point out that myocarditis was a clear and concerning safety signal in adolescents. I continue to believe that Moderna should be prohibited by the US FDA for people under the age of 40. Recently, a private health system contacted me saying that they had made that decision internally.

Because I wrote so many op-eds on this issue, I was called anti-vaxxer by people who are not very smart, and just as irrational as anti-vaxxers but just in the anti-anti-vax direction. As a doctor who is personally supervised many vaccines in the post autologous stem cell transplant setting, I found this characterization bizarre. But, I couldn't focus on it because duty.

When the FDA rammed through boosting all people, against the advice of Marion Gruber and Philip Krause, the two FDA officials who resigned, I analyzed the data myself. I quickly came to the conclusion the data was lacking— just like Paul Offit did. And again I pushed on this issue, which also earned me great professional scorn & punishment. But mostly from people who couldn't understand the issues at stake.

When a medical “ethicist” said we shouldn't provide equal care for unvaccinated people, I objected. Views on vaccines interact in a complex way with socioeconomics and race, and denying care to someone for holding different views is a violation of the duty we have as physicians.

Paxlovid in vaccinated people: there is no credible evidence, we will see what the UK panoramic says. Yet, it makes no sense to spend $5 billion dollars without running the trial first. We published this recently. Now more catching on. But it wasn't popular initially. Didn't help my career.

Over the last two years I think I have taken volumes of abuse for well reasoned, soberly made, evidence-based medicine approaches to pandemic policy. Certainly paid some professional price. But that means nothing in the face of my duty as a doctor who sees patients in person at the county hospital, and a professor who has to analyze policy evidence for society.

Being outspoken about at schools is the single most important thing anyone could have done during the pandemic. Yet, it wasn’t easy to do. I know many tenured full professors who lacked the courage to comment about the topic, because they worried about their own station or reputation, or job prospects. Some even study disparities for a living. Can you imagine the irony of sitting out the most important battle of your career. They didn't even have the guts to stand up for Emily Oster, while she took greater abuse than any of us.

Duty

Our ancestors used to know what that word means, but in the modern world it has falling out of favor. Instead his replaced with weakness and cowardice, narcissism and careerism.

So whenever I hear about people who had a duty to do something. Something important. And they just sat idly by, scared for their own safety, like useless fucking cowards, while bad things happened, especially to children, I have no respect for them, struggle to understand how they could do such a thing. No, I actually loathe such people, and I'm sickened by them.

We need more people who understand duty in this world and less people looking out for their own useless selves. If you don't have a sense of duty, don't talk to me. If you won't sacrifice anything—even everything— for something more important than yourself, I don't want to hear your voice or see your face. Our culture is missing a sense of duty, and the harms are incredible.

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Some have asked: Yes, I am also talking about other recent events.