In 2019, O’Neill was barred from working in her native Australia after the New South Wales Health Care Complaints Commission (HCCC) concluded that she was “misleading vulnerable people”. Styling herself as a “natural health educator”, she had told cancer sufferers that their disease was a “fungus” and could be treated with bicarbonate of soda, and she had informed new mothers that raw goats milk was a safe substitute for breast milk. Vaccines, as far as O’Neill was concerned, were poisonous.

Her authority for these pronouncements was the two years she had spent as a trainee psychiatric nurse. She never completed her qualification, though she saw that as no impediment to launching a career in health. A member of the Seventh Day Adventists, O’Neill organized most of her lectures through the church for the benefit of her fellow worshippers. Her advice is a disconcerting mixture of familiar homespun misinformation and disconcerting theology; she is a perfect example of the religion of wellness.

That HCCC’s verdict should have been the end of O’Neill’s professional life. No more lectures. No more “consultations”. No more training packages. Unfortunately, quackery has no respect for borders. O’Neill may no longer be able to practice in Australia, but there’s nothing to stop her doing so elsewhere in the world. Including in Britain: this month, O’Neill is embarking on a tour of the UK.

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For the low, low price of £700, you can experience five days of O’Neill’s wisdom at an estate hotel in Cheshire. Once attendees have had their fill of lectures, workshops, herbal teas and fruit juice, they get to enjoy a dinner dance — “the perfect way to say goodbye”. For cancer patients who go on to attempt the bicarb cure, they may well be saying goodbye to life itself. A group of doctors has published an open letter addressed to venue management alerting them to the dangers of O’Neill’s misinformation.

Not that this criticism is likely to do O’Neill much damage in the eyes of her admirers, who include the feminist-turned-5G-conspiracist and antivaxxer Naomi Wolf, and the Apprentice-contestant-turned-race-baiter Katie Hopkins. For both, O’Neill is a purveyor of truths that shadowy forces are anxious to suppress. “Big pharma,” tweeted Hopkins, “is more powerful than any government. Has more assets than any military.” Both Wolf and Hopkins seemed to be radicalized by the Covid pandemic, which proved to be a boomtime for health grifters such as O’Neill. In the isolation and confusion of lockdown, O’Neill fostered an avid following on TikTok and Telegram — boosted by the perception of her as a persecuted heretic.

O’Neill herself has leaned hard into this image of herself. On her website, you can purchase a book called (modestly) The Assassination of Barbara O’Neill, written by her husband Michael. The HCCC’s verdict, he thunders, was “an unwarranted smear campaign on a truly humble and caring lady”. Not only that, it was “part of a war on natural health more broadly” being prosecuted by powerful agencies against brave individual dissenters — a “modern-day David and Goliath story”.

The Bible allusion is not inadvertent. O’Neill’s her health claims can generally be traced back to a version of the Seventh Day Adventist theology. Adentism emerged from an apocalyptic cult that was disappointed that the world had failed to end in 1863. Like several religious movements of the Victorian period, the Adventists attempted to reconcile faith with rationalism and social purpose. The faith retains a distinctive focus on health and the body: followers believe that “keeping our bodies and minds healthy and fit are acts of service to God and a visible testimony in this world.”

Once you understand that, it becomes a lot easier to make sense of O’Neill’s health advice. Here, for example, is how she begins a lecture on the digestive system: “I’m very thankful to God that he has given us a liver that is able to detoxify us, and today I’m going to explain how the liver does this, and remember Proverbs 14, verse 6: “a scorner seeketh wisdom and findeth it not, but knowledge is easy to him that understands.””

It feels unlikely that anyone in human history has attempted an exegesis of Proverbs 14:6 based on the liver, but, for O’Neill, faith and health are inseparable. God has granted the human body “inbuilt ability to heal itself”, and when we resort to doctors (she says the “doctor” with the same kind of disgust others might apply to “parking enforcement officer”), we are turning our backs on God himself. You must “listen to the voice of your God in your body”. Much of what the voice of God is allegedly commanding is basic old-wives-tale stuff: a raw onion poultice on the foot to cure a cough, potatoes for inflammation. What goes next to the skin can harm as well as heal; she believes that breast cancer is exacerbated by wearing synthetic fabrics.

Some of her advice is merely eccentric. “What can you do if a child’s got autism?” she wonders in one TikTok clip. “One of the best things is the trampoline. The trampoline rebalances the brain.” Some of it is simply dangerous. Feeding babies raw goat milk will make them sick, if it doesn’t outright poison them (O’Neill later claimed she meant goat milk formula, but that isn’t what she said). Co-sleeping, which she recommends without reservation, is a major risk factor for sudden infant death syndrome. Meanwhile, the O’Neill approach to cancer is harrowingly ineffectual: one patient on the Cook Islands following her advice used a combination of baking soda, lemon juice and boiled water in place of chemotherapy. That man died, of course.

Such apparent setbacks do nothing to impinge on O’Neill’s self-belief. Again, you have to understand her faith to understand her. As she says in one video: “A lot of people are sick. They’re sick because the body will heal itself if you give it the right conditions.” By implication, if you don’t get better, it’s because you didn’t give your body the “right conditions”. You didn’t listen to the voice of God inside you. And if you die, so be it. Not all alternative health influencers are openly religious, but O’Neill’s logic of sin and punishment is a clear echo of the wider movement.

However caring they pretend to be, all “natural health” philosophies, are fundamentally without compassion. Think of the “freebirth movement”, which told women they were failures if they couldn’t go through labor without medical assistance, and callously deserted mothers and babies who were harmed or killed by this approach. Or Andrew Wakefield, whose discredited theories of vaccine-induced autism fed families a toxic mixture of blame and hope: blame for vaccinating their child, and hope that a “normal” child existed underneath the purported injury.

O’Neill’s content is rife with implicit accusations: there is little room for grace. Got cancer? Well, it’s your own fault for wearing petrochemicals. Still got cancer despite the baking soda poultice? That’s down to too much glucose in your diet. Child got autism? You probably caused it by allowing them to be vaccinated (or rather “giving them the V-word”, which is O’Neill’s circumlocution to get around YouTube censorship). You’re also probably making it worse by not giving them enough trampoline time. Every ailment is a morality play.

This should be repugnant. But because it comes masked within O’Neill’s grandmotherly manner, the cruelty can be overlooked. What people hear instead is a heartening message of self-determination. “I am the master of my destiny, I am the one who chooses what goes into my body,” says O’Neill in one of her more rousing moments. It’s a promise that, by living right, you can avoid punishment. It’s an assurance that purity — physical and moral — is within your grasp, if you just try hard.

So much of wellness culture is about, precisely, purification. A horror of contaminants. A belief that you can run your body like a gated community and keep the undesirable elements out, with your liver acting as a kind of security service to clean up any invaders that make their way through the barricades. (It’s never explained why the liver is supposed to be instilled with the will of God when it comes to general “toxins”, but impotent against the forces of nylon.)

This is seductive. Wellness adherents pursue the vision of a perfected self. In the language of health, they articulate a longing to be purged of all their sins, baptized in the holy waters of clean living and moderation. All you have to do, as Proverbs 14:6 says, is believe hard enough: “scorners” will be denied the rewards of both heaven and earth. Only the righteous can be saved, from environmental toxins as much as from damnation. The wages of sin is cancer.

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Even when it’s formally secular, wellness carries the imprint of the Christian culture that created it. The yearning for salvation is an understandable reaction to feeling isolated, confused and disempowered — emotions that were rampant during Covid, feeding demand for O’Neill-style influencers. But you don’t need a pandemic to create those conditions. You can also generate them very effectively by exposing someone to social media: that’s why woo-woo thrives in the wilds of the internet.

But though Christianity’s grammar is deeply embedded in our habits and thinking, it also evolves in response to social change. The original Adventists were trying to reinvent their faith for a scientific age. Now O’Neill does the same for the modern world. Her gospel, like our age, is highly individualistic: your duties are to your own body, not to society as a whole. It is a sad, pinched endpoint for the mysteries of faith. It is also a doctrine that seems sure to flourish. Today, wellness spawns cults, but in decades to come there’s every possibility that one of them could become a denomination.

It is hard to save people from their own psychological foibles. Banning O’Neill from shilling in the UK would be the right thing, but it is harder to stem the demand that gives people like her their living than it is to keep one hustler from practicing. The fault of logic that O’Neill exploits in her followers is too deeply human to be expunged. We cannot be made pure, in reason any more than in body. Which is why quacks like O’Neill will always prosper.

Later that day, I searched “Crohn’s disease” on the X app and found someone talking about Dr. Ray Peat. I connected with several sick people who were following a Peat diet, and they helped me one-on-one to build a recovery plan. Their instructions — avoid pork and seed oils (polyunsaturated fats), eat raw carrots, take desiccated cow thyroid — saved me. After I ovulate each month, I take progesterone dissolved in Vitamin E oil. The product, Progest-E by Kenogen, is crafted by Dr. Peat’s widow. The first time I took it, my body was so affected by its immediate tempering of estrogen — a key Peat idea is that estrogen is a driver of disease — that I had to lie down.

My muscles, taxed by estrogen dominance, became so relaxed from the progesterone that I could no longer stand. I still take it. The regimen runs for 14 days post-ovulation until I begin bleeding. I pop aspirin, another Peat hallmark, like candy every day. A few times a week, I take a custom blend of Vitamin D and Vitamin K called Estroban from a Washington, DC, cosmetics lab to offset aspirin’s blood-thinning properties. I eat as much red meat as I want, and my gut inflammation is at an all-time low. Three years later, my Crohn’s disease is no more. I will never try a new medication, I will never get surgery, and I will never stop Peating.

My devotion to Dr. Peat is what’s now being called healthmaxxing. It’s an online trend that, along with the intertwined practice of looksmaxxing, is drawing ire from the online Left, Millennials and Gen X specifically. “Why should so many perfectly healthy young women spend their youth tending to their imagined poor health?” The Cut asks. It’s “warped and wrongheaded” to looksmaxx, according to The New Yorker. In these precincts, taking pride in cultivating your health and personal appearance is coded as selfish and indifferent to Palestine, and women interested in healthmaxxing are targets for ridicule. 

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Women are subjected to shame online and offline. A popular Peat poster, Veronica Hoffman, known online as the mononymous Veronica, is the founder of anti-aging and hormone-safe skincare line Aurabiōm. Veronica is dragged across X as a crackpot anti-vaxx lolcow for her insistence that a cortisol-free lifestyle is required to stay beautiful. Others celebrate her and credit her with changing their lives. 

Many “Trust the Science” Millennial and Gen X women have accepted chronic illness as just part of living in an America under siege by people they disagree with. They brand themselves the permanent victims of obesity and mental-health disorders. Lena Dunham, the self-appointed voice of Millennial women, has recently completed press for her new memoir, Famesick. Like Veronica, she publicly diarizes — but instead of discussing health, she discusses her relationship with her fatness and mental illness. Dunham presents obesity as a feminist victory, a rejection of patriarchal ideals of beauty. Non-famous Millennial women watch Girls and read Famesick and see a stunning and brave heroine theatrically parading the medical interventions necessary to correct health issues that shouldn’t have arisen in the first place. Motivated by these negative examples, my generation, Gen Z, has taken health into our own hands.

Americans are sicker than they have ever been. A 2023 article in the journal Current Opinion in Immunology puts the global figure for autoimmune-disease prevalence at 19.1%, up from the approximately 8% estimated by the Centers for Disease Control and Prevention’s Emerging Infectious Diseases journal in 2004. At that time, 78% of those affected were women. Nobody with a medical degree treats this as an emergency, and the Millennial American treats psychiatric conditions as just another personality quirk.

In an inversion of the days of pro-anorexia Tumblr, the internet has become a solution for sick women. If I had not connected with the Peat community on X, I would be dead — because I refuse lifelong, humiliating interventions for my health condition. Substack and X have become places where hyper-online sick women discuss experiences in and out of the medical-pharmaceutical complex. Many of these women conclude that contemporary illness is tied to hormonal disruptions, such as estrogen dominance, thyroid dysregulation, and progesterone deficiency. They believe that nutrition and environmental conditions contribute to these disruptions, and that seed oils, synthetic additives, urban living, artificial light, lack of sunlight, and the psychic stress of New York City or Los Angeles have negative impacts on our bodies. Contemporary life is incompatible with health, and has created a public-health crisis to which women seem to be the most vulnerable.

Lily Sperry, a brand consultant who runs the popular alternative-health Substack Health Gossip, articulates the environmental side of the issue. Sperry has posted on X about living in Chicago and feeling drawn to more rural environments. “Your approach [must] consider the context that you’re operating in — like, are you living in a city, alone in a studio apartment, not getting sunlight? I think those factors should be addressed,” she wrote me in an email. Sperry’s paid-subscriber chat room functions as a nouveau, female-oriented forum for this philosophy: acupuncturists, energy healers, and the alternative-health-curious post threads asking for infrared sauna recommendations, healthy restaurant lists, and product reviews. Women share what has actually moved the needle for them, not what their doctors suggested.

Balancing hormones is the pillar of this movement, which distances itself from looksmaxxing, though both exist in overlapping internet circles. Veronica and others explicitly identify hormonal balancing as the holy grail, first for female health and second for beauty. Hoffman diarizes her wellness routines publicly on Instagram: European travels under red-light chicken lamps, nibbles of the Mexican thyroid medication Cytomel, and aspirin in between. My own Crohn’s is a case study in what hormonal intervention can accomplish. When I began progesterone supplementation post-ovulation, it deleted my symptoms. My inflammation markers sank quickly. I still see regular doctors, and haven’t given up conventional medicine entirely, but I credit my deep remission to my desire to balance my hormones, and not to my yearly $8,560.32 box of Humira.  

Health is a nobler goal than beauty, especially for women, who are labeled vain if they prioritize the latter. But healthmaxxing and looksmaxxing are intertwined, though they’re also polarized thanks to unhealthy (and fertility-destroying) pharmaceutical looksmaxxing approaches practiced by influencers like Clavicular, who takes meth to stay skinny and uses a hammer to reshape his cheeks. Hoffman coined a phrase now printed on hats: “You’re spiking my cortisol and making me less beautiful.” Chronic stress elevates cortisol, which destroys skin, hair, and body composition. Modern female life is a cortisol machine. Taking action against it is both a health intervention and an aesthetic one. 

The Millennial author Tao Lin, one of the earlier adopters of the health-first philosophy, reached similar conclusions via a different route. Like the healthmaxxing women of today’s timeline, Lin took to the internet to determine what was wrong with him, and self-diagnosed with autism and other disorders. His approach is centered on detoxification — first of the body through garlic and bentonite clay (a detoxifying skin mask), and then of the mind by opting for psilocybin over benzodiazepines for anxiety. In Lin’s 2021 autofictional book, Leave Society, he portrays the protagonist’s healing as a meaningful, spiritual event. 

Still, he says, looks can’t be separated from the overall holistic health approach. “I healed myself to reduce the amount of pain and itchiness and anxiety and depression and autism and other undesirable symptoms,” he told me. However, “most forms of healing make people look better, which can help people motivate themselves to heal themselves, which seems good.” 

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New Mexico podcaster, author, and wellness influencer Chloé Happe frames the movement with characteristic clarity: “The entire basis of alternative health is us calling out into the void, ‘Hey, we’ve really lost ourselves here. How do we find our way back?’” she told me. Happe was raised as a Seventh Day Adventist, a tradition in which health is a religious obligation. The first time she understood that this wasn’t a universal principle, she told me, she was at the state fair with an aunt who hadn’t been raised in the church. Happe, waiting in line for her first hot dog, pointed at an obese man and asked, loudly, why he was so fat. Her aunt was horrified and made her apologize. She felt guilty, initially about the comment, and then about eating the hot dog. “I knew that being fat and eating hot dogs were things to feel guilty about,” Happe says. It’s not allowed in Leftist circles to say so, but she was right.

Ultimately, this has become a political problem. In a scene from Desolation E-Girl, Happe’s debut novel, her protagonist deletes photos of herself wearing a MAGA hat from her X profile because she assumes that it may cost her suitors. For the Left, MAHA-type alternative health-consciousness and Right-wing politics have become almost the same thing, and people are afraid that embracing one means embracing the other. When RFK Jr. joined the Trump campaign, he effectively poisoned the concept of health for most Left-leaning people. Rational engagement with the health question now requires social courage. This, even though many of these impulses — a view of industrial modernity itself as the cause of illness — used to be Left-coded.

What actually drives the healthmaxxing wave is something older than MAHA and even older than the crunchy California Left that RFK channels: a concept as old as the Greeks that beauty is synonymous with health, and that both are good. What’s truly sick is that we can no longer state this without controversy. 

No wonder the “MAHA Mom” has become such a political powerhouse. A satellite of the MAGA movement, MAHA — “Make America Healthy Again” — has been spearheaded by the health and human services secretary Robert F Kennedy Jr, a lifelong campaigner against the rogue’s gallery of toxins which, to varying degrees of plausibility, are apparently making us fat, ill and mental. The MAHA coalition is increasingly reliant on the concerned mother, a particularly incensed slice of the electorate politicized by health concerns around her children. As waves of both paranoia and rational concern have arisen in recent years — over 5G towers, ultra-processed foods, fluoride in water supplies and so on — this otherwise fairly passive contingent has become practically radicalized, coming to see the assault on the American body as a story of venal elites punishing the little guy, in the tradition of MAGA more generally. Amid rough seas — a Supreme Court ruling against Trump’s emergency tariff regime, alongside the Epstein files furor and a general sense of financial malaise — the MAHA Mom looks to be more critical than ever in securing Republican dominance on the Hill.

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All of which turns one of the more minor-seeming news stories of recent days into a potential catastrophe. On Friday Trump issued an executive order protecting the manufacturing of glyphosate, the preferred herbicide for commercial farming and the active ingredient in the domestic weedkiller Roundup. The administration argued that the chemical was critical to agriculture and defense, meaning the decision was a matter of national and food security. Glyphosate has been connected to high-profile lawsuits due to the alleged link with cancer; during his time as an environmental lawyer RFK Jr himself once won nearly $290 million in a case against Monsanto, Roundup’s manufacturer, on behalf of a man who had developed the disease. Only on Thursday did Monsanto’s owner Bayer announce a $7.25 billion settlement to a class-action suit about the cancer claims.

As it happens, glyphosate is also at the top of one very important voter’s hit list. Ken Cook, who leads the Environmental Working Group, called Friday’s executive order a “middle finger to every MAHA Mom”. Naturally, RFK Jr had to lend his support to the capo di tutti capi: in a way that must have stuck in the craw of many a crunchy Trumpette, he aped parental devotion, arguing that Trump’s decision in fact “protect[ed] American families” by warding off trade and security challenges from abroad. One mama-bear, Kelly Ryerson aka the Glyphosate Girl, underlined the irony of the movement’s figurehead agreeing to “expand… the very same carcinogenic pesticide that MAHA cares about most”.

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As one of the Russian dolls in modern American populism (at the center of which is a plump, painted Trump), MAHA has one of the most passionate, yet also precarious, support bases. They are led by furious moms such as Zen Honeycutt, who set up the grassroots group Moms Across America in response to her sons’ struggles with allergies, autism and mental-health problems. Hers is a typical case within the movement: devastated by family misfortunes, she turned to politics as a solution. Honeycutt appeared on CNN on Monday to express her “outrage” at Trump’s “love letter to glyphosate”, a chemical which she blames for many of her children’s ailments (she once claimed to have cured her son’s autism by feeding him only organic food). Her crusade is personal, and her vote rests on a single issue. Honeycutt was not always a conservative voter; she changed tack when she and her mom friends felt “abandoned by the Democratic Party”.

Rather than a single, destiny-defining battle such as those around immigration and abortion, the MAHA movement is a clutch of flashpoints which matter most to the suburban mother, inspired by an Erin Brockovich-style empathetic instinct. Like Brockovich, the MAHA Mom sees what experts can’t or won’t — in that case, a contaminated water supply quietly poisoning an entire community. She is enthused by the same institutional mistrust that drives her fellow populists: where others might have been swept up in the QAnon pizzagate frenzy claiming to expose a baby-killing paedophilic political elite, she might take her placards to the gates of the Centers for Disease Control and Prevention, who insist — evilly, to her mind — that regulated levels of fluoridation in municipal water supplies is good for teeth and not, in fact, turning our brains to flubber.

Her stock is rising because she is often right: few of us would call her daft for being concerned about carcinogenic food additives, ultra-processed slop and, yes, weed killer — but many of us would sniff at her obsession with unpasteurized dairy, chemtrails and heavy-metal chelation treatments for autism. In some cases MAHA Moms’ views are downright dangerous: Erin Elizabeth, wife of uber-rich homeopathic medicine peddler Joseph Mercola and founder of Health Nut News, claims that turmeric is better for cancer patients than chemotherapy. Of course, the MAHA Mom encompasses many thousands of women, and MAHA is as varied a group as MAGA itself. But the underlying facts tend towards shock and alarmism, favoring the most extreme within the movement: obesity rates have more than tripled in the past 60 years, while autism diagnoses have tripled in 20 (helped in no small part by changing diagnostic criteria). If the body politic feels unstable, the body proper is a mess.

Many have made this connection before. The MAHA Mom’s American progenitors shaped public mores with their reformist stances on the body, from the Progressive Era’s fixation with sanitation as a spiritual companion to the cleaning-up of city governments to the Temperance finger-waggers ushering in the Prohibition. Of this last lugubrious lot, Carrie Nation, the most dramatic of the anti-booze brigade, may be a compelling model for the MAHA Mom if only for her theatrical flair: armed with a stash of rocks or a small hatchet, she would maraud illegal Kansas saloons smashing liquor bottles while singing hymns. Were she here today, Mrs Nation may well be found booting bottles of Roundup out of gardeners’ grasps to the strains of Onward, Christian Soldiers. Or maybe she’d be hanging out with Zen Honeycutt, making her children pose moodily by trolleys full of cereal boxes wearing matching T-shirts that say “GMO-free kid”.

It shouldn’t surprise anyone that one of the most furious frontiers of contemporary populism is manned by mothers; the “Farage fillies” backing Britain’s Reform UK have a similarly maternal angle. So much of American family life has been destabilized by the chaotic past decade: identitarianism, gender debates, a pandemic. The body of the child is the most urgent symbol of vulnerability in a state of chaos: protecting it is therefore a true crusade, which has emboldened and ennobled the MAHA Mom.

Some of her reasoning may be shaky but this voter is nevertheless a folk heroine, a final barrier between the family and entropy if only as the gatekeeper of what goes in the lunchbox. In a West where biopolitics — the statistics-driven interventions into public health — is the norm, she asserts a stubborn sovereignty. She feels most viscerally the weird American paradox of the supermarket shopper, which stands in for the broader national malaise motivating MAGA: how can a country be so rich and yet feel so unwell? Given that she represents Trump’s essential channel to the suburban female electorate, her political capital is only likely to grow — meaning it may be crunch time for Monsanto and, if he fails to stick to his guns, RFK Jr himself. Perhaps our worm-brained secretary of health would be wise to heed mother’s advice. And if she deserted him, where would she go? Perhaps many of these not-natively-conservative voters would be enticed by a future radical among the Democrats: in that case, the parties could find themselves in a minimally processed bun fight for the MAHA Mom’s love.

Such boozy traditions are becoming rather old hat. The young, we are informed, are increasingly giving up alcohol in favor of more health-conscious habits. The industry, desperate to keep pace, now churns out non-alcoholic beers and buzz-free approximations of spirits for this increasingly peculiar demographic.

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While “sober-curious” Gen Z have yet to spoil the occasion for us aging drunks, it’s worth pausing to ask the question you’ve been pushing to the back of your mind: is this annual ritual of alcoholic debauchery really justified?

Objectively, of course, alcohol is a disaster. The cause of numerous afflictions from liver disease to seven types of cancer, booze fuels a litany of social ills including domestic violence, public disorder, accidental death, car crashes and infidelity. Worst of all, it makes you fat!

Yet like all hopeless addicts we persist in constructing elaborate apologetics. We tell ourselves that it’s all about balance, that one has to consider alcohol’s compensating virtues along with its vices. It’s a “social lubricant” which brings us all together in a pleasantly warm buzz. It lowers our inhibitions to allow us to be our true selves. The poet Panyasis praised wine as “like fire, an aid and sweet relief” which “wards off all ills and comforts every grief”. Notorious booze-hound Simone de Beauvoir romanticized drunkenness as an “an exaltation of the moment and a complicity with other men”. Scottish novelist Robert Louis Stevenson offered perhaps the most charming defense when he described wine simply as “bottled poetry”.

However, this sentimental view collapses quickly under scrutiny. While downing a few drinks no doubt provides some pleasure, its primary effects are anesthetic not empathogenic. Alcohol does not reveal our authentic selves, it dissolves the self. It loosens the tongue by dulling the mind, and provokes an urge to dance and sing by temporarily paralyzing the parts of the brain designed to preserve our dignity. For this temporary sedation, we are rewarded the next day with pain, vomiting and regret.

Alcohol’s virtues don’t come from reinvigorating the spirit, but by numbing the senses. There is a much darker side to our favorite drug. As Charles Bukowski famously put it when drunk: “the world was still out there, but for the moment it didn’t have you by the throat.” The joy in drunken revelry is really the relief which comes from escaping our miseries. Our lust for libations masks a deeper thirst for the void.

For a more honest account of our poor habits, one has to swallow some difficult realities. The pessimist philosopher Arthur Schopenhauer, a true Commissar of Curmudgeons, insisted that life is not a steady ascent toward fulfillment but an endless slog that “oscillates like a pendulum between pain and boredom”. Consciousness, in his telling, is a curse, a biological catastrophe which places man at war with the blind, ceaseless striving of the “Will” — the metaphysical force which underlies all existence. Yet Schopenhauer also believed in rare, sacred moments where this torment loosens, most notably in the experience of beauty, especially music, which dissolves the self and grants “a liberation from the individual will and its torments”. While he had no time for drunkards, Schopenhauer did concede that alcohol, properly consumed, could provide such temporary transcendence.

There is something refreshingly pagan about decadent, supposedly Christian, drunken festivities. In antiquity, this dark undercurrent of intoxication was idealized in the figure of Dionysus, the god of ecstasy, frenzy and dissolution. His festivals were ritualized descents into chaos, moments where the self loosened its grip and individuals dissolved into a primal, undifferentiated swarm. The same daemonic drive persists to this day: generous servings of egg nog and mulled wine are ostensibly offered out to enable partakers to “unwind” and “relax”, but secretly the enactment is an ancient, ritualized ode to oblivion. Even the most tepid office celebration carries the faint scent of Dionysian madness.

On balance the pains brought by alcohol both to the individual and society far outweigh the pleasures. Yet the desire to drink isn’t merely a hedonistic impulse; it is a far more esoteric half-conscious urge to slip the chains of the Will and dissolve, however briefly, into something beyond ourselves.

We turn to “bottled poetry” because modern life lacks the touch of the sacred mysticism and beauty which nourished us in the past. The old forms of exalted communion — in shared prayer, ritual and awe — are now substituted with shared chemical escape. Alcohol steps into the vacuum as a cheap, fast and brutally effective sacrament. Behind every third glass of prosecco is an urge to avoid thoughts of mismatched desires, loneliness and the never-ending torment of time.

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This self-destructive urge has some value. In many ways drinking culture acts as a counterbalance against the far more pernicious modern obsession with “self-optimization” regarding health, longevity and productivity. We are currently swimming in propaganda marketing by fitness companies and wellness influencers, who tell us that we should fixate on every calorie, heartbeat and hour of sleep. Amid the modern tyranny of healthism, downing a Class 1 carcinogen to quiet one’s thoughts feels like a tremendous act of rebellion.

It’s no surprise that as we’ve seen a dramatic decline in alcohol consumption amongst the young, we’ve also seen a dramatic spike in mental health problems, celibacy and risk aversion. Raw dogging consciousness was always going to produce frayed nerves and quietly miserable lives.

Sobriety may be suitable for certain temperaments, particularly those for whom bacchanal joy can quickly descend into foolishness and bastardry. But for the romantic, one who demands more from life and can finely balance civilized restraint and pagan excess, a suitable dose of intoxicated ecstasy can offer genuine spiritual solace in a cold world.

Drinking is not healthy. It is not admirable. It is, however, a reprieve. As the booze apologist and conservative philosopher Roger Scruton once put it: “wine, drunk at the right time, in the right place, and the right company, is the path to meditation.”

So Merry Christmas, Evoe Dionysos. Raise a glass to temporary oblivion!

Social media gently mocked Dowd when her column first appeared: silly Boomer, she didn’t dose it right — couldn’t handle the ride. Momentum for legalization was gathering back then, driven by the anti-antidrug Left, the free-market Right, and lobbyists and entrepreneurs who could just hear the cha-ching sounding from the next big vice industry. Twenty-three states plus the District of Columbia would follow in Colorado’s footsteps in the decade that followed.

The picture of weed shared by many older Americans, drawn from their own college years, helped ease the path of legalization. Weed, the mellow drug. The Cheech-and-Chong drug. The Grateful-Dead-road-trip drug. The munchies drug. The drug that, if anything, makes you overly cautious behind the wheel. Dowd thought of marijuana along similar lines — that is, until she tried the legalized stuff for herself and nearly lost her ever-loving mind. 

Since then, weed potency has only intensified, with some concentrates reaching near-pure levels of THC, the plant’s primary psychoactive compound. Only now are policymakers and opinion elites reckoning with what Big Weed has wrought: “turning a drug that used to be 5% THC, and made people pass out for a few hours and eat Cheetos, into one that triggers psycho killers,” as Kevin Sabet, a former drug adviser in successive Democratic and GOP administrations, tells me.

Sabet admits that such talk can make him sound like Reefer Madness, the classic anti-weed propaganda film from 1936. “But if you look at almost every single mass shooting in this country, there are many common denominators, and one of them is a substance. And it’s not alcohol, and it’s not meth, and it’s not fentanyl. So you can guess what it is. It’s marijuana.”  

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Take Robert Westman, the 23-year-old who murdered two children and wounded 30 people in a gun rampage at a Minnesota Catholic school in August. In his diaries, Westman, who both used weed and worked at a dispensary, blamed the drug for his violent tendencies. “Gender and weed fucked up my head,” he wrote. “I wish I never tried experimenting with either. Don’t let your kids smoke weed or change gender until they are, like, 17.” 

A 2025 study, published in the East Asian Archives of Psychiatry, found a definite and growing link between US mass-shooting perpetrators and the use, possession, and distribution of cannabis. Moreover, the researchers found that younger mass killers are more likely to be involved with marijuana. They concluded that the drug is particularly harmful to “subgroups of individuals” prone to such violent eruptions.

Even if they don’t go full Columbine, young people who regularly use today’s high-potency varieties are at elevated risk for psychosis, per a 2019 study published in Lancet Psychiatry. King’s College London, home to the lead author, sums up the grim finding: “In cities where high-potency cannabis is widely available, such as London and Amsterdam, . . . a significant proportion of new cases of psychosis are associated with daily cannabis use.”

Things have gotten so bad that The Guardian, which once pooh-poohed concerns about weed, now regularly runs warnings about its adverse effects on health (it doubles the risk of heart death, to mention just one recent finding). Most recently, the paper took readers inside a pioneering London clinic specially dedicated to addressing cannabis psychosis. It’s a crisis that goes far beyond a typical “bad trip,” shattering minds and leading many users to take their own lives.

“We are dealing with a fundamentally different drug,” says Sabet, “that has been genetically modified and bred by a powerful industry that we are now sanctioning and encouraging, and allowing to contribute to inaugurations.. . . The fact that we are allowing this, to me, that’s immoral.” Despite bipartisan opposition from a pro-weed lobby led by the likes of John Boehner, the former Republican House speaker, Sabet’s calls for limits have begun to break through.

Most notably, Sabet has led the campaign urging President Trump not to remove marijuana from Schedule I, the most serious category in the federal government’s scheme for classifying drugs. As he wrote in a widely read UnHerd essay, reclassification wouldn’t mean federal legalization. But it would grant the drug a false federal “imprimatur of being safer,” thus allowing Big Weed to enjoy tax deductions from which they are currently barred. 

So far, Sabet’s campaign seems to have stayed Trump’s hand, even as the president has floated the idea of Medicaid coverage of marijuana products as a stress and pain balm for seniors. “This [reclassification] isn’t a priority for the president,” Sabet tells me. “But on the other hand, there are some lobbyists and maybe friends of his son-in-law and others in the business” who would benefit from rescheduling and its associated tax deductions, meaning Sabet’s work is far from over.

Kevin Sabet came to the drug problem from an unusual personal angle. Born in the Midwest to a Bahai family that left Iran before the 1979 Islamic Revolution, he remembers a childhood in which he didn’t know anyone who so much as drank. (The Bahai religion, which is persecuted by Iran’s ruling Islamists, preaches the unity of all faiths — and total abstinence). When he moved to Orange County as a teenager, his perspective was radically different from that of his peers. And what he saw of addiction encouraged him to fight it. 

As an undergrad at the University of California, Berkeley, in the mid-’90s, he says, “I saw the influence of the [drug] culture. I saw marijuana shops before that was even a thing.” Then the rave culture arrived, giving rise to what he describes as a “mini-epidemic” associated with the hallucinogen ecstasy, also known as MDMA. As a student, he’d go to clubs and hand out postcards showing scans of drug-addled brains on one side, and a call-for-help number on the other.

His activism won him some attention in the press — and then a phone call from Barry McCaffrey, the retired US Army general then serving as President Bill Clinton’s drug czar. “I thought the call was fake,” Sabet recalls. But it wasn’t. Gen. McCaffrey was offering him a job as a speechwriter. Sabet accepted and moved to Washington before heading to Oxford to earn a master’s degree in social policy.

After 9/11, many of Sabet’s friends went off to Afghanistan in defense of the homeland, and he felt guilty writing papers at “Oxford, of all places, a comfortable place.” As it happens, the White House called again — this time, the George W. Bush administration with an offer to hire him as a senior speech writer on drug policy. “ ‘We want you to serve your country,’ ” he remembers the caller saying. “ ‘We know you’re not a Republican, but we also know you’re not a Democrat, and that’s fine with us.’ ” (His politics, as far as I can tell, are: whatever will stop this scourge.)

Yet another White House stint came during the Obama administration, which tapped him as senior drug-policy adviser (by then he’d finished his master’s and a doctorate at Oxford). It was around that time, the 2010s, that marijuana legalization went from a pothead’s dream to a serious business and political enterprise. Weed, the legalizers said, is harmless. Sabet disagreed, and he published a book, Reefer Sanity, to push back against the complacent mythology.

The book, in turn, led to his founding of a restrictionist advocacy group, Smart Approaches to Marijuana, or SAM, today the most visible drug-policy organization in Washington (a telling indicator of the growing concern about Big Weed).

But why the focus on marijuana? Why not the likes of fentanyl or heroin? Marijuana, Sabet answers, “is the most dangerous drug in my mind because it’s the most misunderstood.” There was a time when one could “experiment” with pot as part of the transition to adult responsibility and success. “The marijuana of today is doing the opposite,” he says, potentially derailing a person for life. “It’s causing violence, it’s causing erratic people to lose any sense of reality.”

And it’s addictive, a truth that Americans are still reluctant to accept. Sabet recalls speaking to a large group about the addiction angle, only for a member of the audience to tell him during the Q&A portion: “I use it every day, Kevin, and I’m qualified to tell you it’s not addictive.” 

The numbers say otherwise. As the Associated Press reported on Tuesday, regular use of marijuana has now outpaced drinking, with 18 million Americans reporting daily use, up from fewer than 1 million in the 1990s. In tandem, there has been an explosion in diagnoses of cannabis-use disorder — an insatiable craving for the drug that leaves people incapable of fulfilling ordinary responsibilities; 1 in 3 pot users suffers from it, with symptoms classified from mild to severe.

But aren’t alcohol and tobacco just as destructive? Why not call for a new Prohibition and extend it to cigarettes for good measure? 

“The reason I would say that Prohibition wasn’t sustainable as a policy in America is because alcohol has been so ingrained in Western civilization, since before the time of the Old Testament.” Then, too, alcohol is associated with human sociality, and for most people, the substance and its effects leave the body after 24 hours. Not so with weed, which lingers for much longer and at a cellular level. Sabet thus dismisses the argument that we shouldn’t restrict marijuana until alcohol is under control: “That’s like saying my headlights are broken, and just to be consistent, I’m going to break my tail lights, too.”

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As for smoking: “Ninety percent of the people who built the Brooklyn Bridge were smokers. They were smoking at the time they built the Brooklyn Bridge. They could function. Maybe it even made them concentrate better,” Sabet says. The cigarette — unlike tobacco itself — “is a relatively new invention.” 

Lung-cancer deaths before the 1920s were almost unheard of. Only with the rise of a cigarette industry did the smoking crisis appear. And that, he says, is also what’s happening with legalized, industrial weed, a product hawked by growers chasing ever higher THC yields — mental health be damned. Moreover, as cigarette smoking rates decline, Big Tobacco is looking to enter the weed market, Sabet says.

So what to do now, beyond restriction (a cause that’s already lost in half of US states)? At the root of the drug crisis, Sabet thinks, is a “moral and spiritual breakdown.” Drugs, he suggests, offer too-easy answers to the search for meaning; or else they palliate the pain associated with modern life. Even so, Western societies can erect guardrails, for example by hindering the spread of weed advertising to ever-younger audiences. 

As for those already trapped, Sabet sees a role for behavioral incentive systems, such as programs that offer cash rewards for addicts who don’t use — or ones in which they face a choice between doing time or going to rehab. 

“I’m calling for a new effort on drugs,” he says, aware of the odium attached to the War on Drugs. “I don’t love the war analogy because wars have defined ends, or they should. And this will never stop. We will never stop having to stop drug use among young generations. . . . I embrace aiming for a drug-free society, even if it’s not possible. We’ve never had a violence-free society, but that doesn’t mean that we don’t want to aim for that.” 

A Gallup poll last week found that only 54% of American adults drank alcohol in 2025. Drinking among Republicans is in a rapid collapse, with only 46% of Republicans reporting that they drank in 2025, down from 65% two years ago. (Democrats, by contrast, are drinking only slightly less than before, 61% this year, down from 64% in 2023.) The phenomenon seems to be, at least in part, mimetic: President Trump doesn’t drink. RFK Jr. abstains. Charlie Kirk preaches sobriety. Tucker Carlson is sober.

This might seem like a winning issue for the Right — and one that unites the Trump coalition, since the tech libertarians who now finance the party don’t drink, either — but anyone who cares about human conviviality should be skeptical. 

Republican teetotaling is part of a general decline in having fun; partying — drinking, sex, going out — has slumped since the pandemic (during which public authorities told Americans that physical alienation from each other is a responsible social pattern). It turns out that when you lock up members of an already atomized, lonely society, people don’t easily recover the sociality that Aristotle taught is one of the fundamental characteristics of the human animal. Restless un-leisure — doom-scroolling, scrambled attention spans, ordering in — has gradually become more normal than being together. 

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Across the board, alcohol consumption is declining — men, women, white, nonwhite, rich, poor. Biohackers like Bryan Johnson or self-optimizing influencers like Andrew Huberman believe no level of alcohol is safe. Sobriety or “California sober” — no alcohol, but plenty of cannabis — is another emerging trend and is increasingly normal among Gen Z and millennials, who prefer stimulants, nootropics and nicotine. GLP-1 drugs like Ozempic are also reducing consumption in general, drinking included.

Against the backdrop of a broad decline in social trust and socializing, the general decline in alcohol consumption becomes relevant — and the more specific decline in drinking among Republicans is especially ominous. 

To some extent, the embrace of sobriety on the Right is a reversal, since lately it’s been progressives who are anti-pleasure. But in the longer historical perspective, it’s a return to form. Over the last 150 years, temperance has been a consistently Republican virtue. The reputation for drinking and “fun” belonged to Democrats. 

It was the Republicans who were the “drys” during Prohibition, casting themselves as the party of sobriety, order, and Protestant reform, while Democrats were associated with saloons, ethnic political machines, and speakeasies. The old Republican rallying cry “Rum, Romanism, and Rebellion” — caricaturing Democrats as the party of booze, Catholic immigrants, and Confederate nostalgia — was first uttered by a Protestant minister during the 1884 presidential campaign. 

Excess drinking and alcoholism are deadly, to be sure, and some people should never drink. For many others, not drinking is super fucking lame; moderate drinking is fundamental feature of a good life. Certainly, that’s been the position of Western civilization both before and after the advent of Christianity. “Mix stronger wine,” Achilles commands in Homer’s Iliad, “a cup for the hands of each guest — / Here beneath my roof are the men I love the most.” Wine is used for cooking, at meals and during religious rituals in the poem. The guests in the Platonic dialog The Symposium negotiate how much they’ll drink at the beginning of the evening — and then go on to imbibe more than planned, joking about their drunkenness and referring to each other as “o my companions in drink.” 

Christianity, of course, incorporates wine in the central mystery of the Eucharist, though sometimes some of the more dour denominations have substituted grape juice. Medieval paintings by Pieter Bruegel the Elder portray village life as scenes of rowdy and joyous drunken revelry, and the still life tradition in the 1800s showed tables laden with glasses, bottles and carafes. Private drinking parties made life tolerable, for me personally, during the pandemic; good dive bars are part of what justify the price of rent in New York City — or any other big city.

Anything that unites — even accidentally — the neuroticism of tech optimizers, progressive scolds, and rightoid incels is probably bad. Americans need convivial practices like drinking with friends. The decline of drinking is a decline in spending time with other people, learning about them, and knowing them. Temperance promotes isolation and alienation.

Politically, the neo-temperance movement also threatens the plurality and energy of the Trump coalition. Part of Trump’s appeal was his basically liberal attitude toward the good life (he doesn’t drink, but doesn’t proselytize about it, either). The better aspects of Trump-era populism implied solidarity, community, revelry, and a good time, and stood against the dominant qualities of the Left: moral superiority, hyper-rationalism, fear of the body, fear of spontaneous community, fear of mixing it up, fear of confession, fear of the local, the street, the bar, the friend. Drinking promotes a neighborliness and bonding essential to a conservative view of the polis.

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Republican neo-temperance, moreover, not only smacks of a 19th-century purity and social stiffness, but a 20th-century clubbiness and suburban rejection of blue-collar values of the union hall or the bar — and even of the emotions that emerge from working class people in the tempo of drinking. Temperance culture is repressive.

Similarly, a Calvinist-in-spirit shunning of imbibing and inebriation — the spurning of the social and even moral uses of alcohol — is suggestive of a larger rejection of courtship, reproduction, and communal behaviors. There’s something about energy drinks and Zyn that seems suited for staring at a screen, for locking in to a kind of isolated work practice, but not conducive to talking, flirting, boasting, taking pleasure in free-spirited afterwork hours.

The Trump coalition will endure if it stays chill. An abstemious, Puritan attitude threatens the gains of the post-pandemic counterrevolution against progressivism and Bidenism, against the antisocial, judgmental, unpragmatic, and anti-communal behaviors of late progressive culture. Neurotic liberals have already driven less-neurotic liberals out of the Democratic Party; Republicans should remember that those voters can move the other way.

Moreover, temperance is, whenever enacted, unpopular and a losing position. Sermonizing conservative Protestant neuroticism about drinking resembles sermonizing liberal post-Protestant neuroticism about everything else. If conservatives embrace and accelerate accidental temperance, they risk creating a mirror image of the progressive Left: afraid of doing things, afraid of the world, afraid of irrationality.

In the 2020s, a good rule of politics, policy, and culture might be: normal is good. Most of what people were doing 40 or 50 years ago was better than the antisocial mores of today. Social drinking is a traditional good that conservatives ought to be conserve.

Sir Robert Wade-Gery, the deputy cabinet secretary she tasked to help draw up the battle plans, told Lady Thatcher’s biographer Charles Moore how the idea of picking a fight with Arthur Scargill’s union was dismissed in the corridors of power. “The woman’s mad,” he recalled people saying. “You can’t win miners’ strikes. All you can do is buy them off.” Yet, as we now know, Thatcher’s preparatory tactics — which included building coal stocks around the country, passing laws to curb union strength and appointing a ruthless ally in Ian MacGregor to run the National Coal Board — eventually won the day.

Her victory, after a year-long dispute, was a defining moment for both Thatcher and the country, paving the way for the liberalization and globalization of Britain’s economy, yet leaving a legacy of shattered communities as the mining industry was shredded.

No one in their right mind would wish for repetition, of such a bitterly divisive dispute. Yet, when I see leaders of the British Medical Association talk of being “excited” at the prospect of going out on strike again, it is hard not to wonder if we need a politician with the tenacity of Thatcher to tackle today’s most powerful union and help salvage public services.

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For almost a century, the prevailing political view has been to buy off this self-serving union, rather than risk a battle with our widely-admired physicians, regardless of the costly consequences for taxpayers and any corrosive impact for patients. So, extra cash gets pumped repeatedly into health service coffers, only for much of it to end up flowing into the pockets of doctors. Yet with their productivity falling, NHS dissatisfaction rising and health projected to soak up a spiraling share of national wealth — an additional 1% of Gross Domestic Product each decade — this is simply unsustainable.

Thankfully, Westminster is shedding the strange delusion that our NHS is envied across the planet. But the latest 10-year plan, filled with familiar ideas, and talk of tackling bureaucracy by Health and Social Care Minister Wes Streeting are simply not enough for a struggling health service that — in the words of its new boss Sir Jim Mackey — views patients as an “inconvenience”. If we are to have any hope of saving the health service, we need politicians with the bottle to stand up to the arrogant and selfish doctors’ union.

It was Dr Ross Nieuwoudt, co-chair of the BMA’s resident doctors’ committee, who said so shamelessly that “the vast majority” of his 55,000 members “are excited to go again”, anticipating another wave of possible prolonged walkouts. Let us bear in mind these bolshie medics have taken industrial action 11 times over the past three years, leading to about 1.5m cancelled appointments in the chronically overloaded National Health Service before they won a bumper pay deal last year. It was worth 22.3% over two years, thanks to an incoming Labour government. Their actions cost the country £3bn, according to the NHS Confederation. Yet, now they are holding another ballot — closing on 7 July — over their latest pay demands, which are a 29% wage rise.

Nieuwoudt, a surgical trainee from Merseyside, is the joint leader of the rebranded junior doctors part of the BMA, which has been seized by a campaign group called DoctorsVote. These are Scargill’s true successors, despite their white coats, stethoscopes and suits. The medic hastily corrected himself after an outcry over his statement, insisting that he meant “excited as in energized — not excited as in looking forward to it”. Yet, his slip was revelatory. The full-time basic pay for a resident doctor hits £54,300 this year. The latest government offer — equating to a 5.4% rise — is the highest in the public sector. Even Nieuwoudt — who styles himself a “pay restoration enthusiast” on social media — admitted this was “generous” in a radio interview, before insisting that “it needs to be more generous”. But still these activists cannot wait to get out of their wards and back on the barricades.

These militant young doctors want a fresh mandate for what one is terming “terrible disruption”, based on dodgy claims that cherry-pick the data and inflation metrics. The BMA is also holding an “indicative ballot” of senior doctors in a dispute on NHS consultants, the top grade of doctors who reportedly earn an average £145,000 a year. The union wants this to rise more than one-third over the next three years — and if not, they might join residents on the picket lines (when not padding out their pay with private work in a sector thriving from patients frustrated by long NHS waiting lists).

The BMA, of course, insists it is driven by the desire to protect patients. Yet, do not be fooled: this body has always been ruthlessly focused on protecting the interests of its members — to the extent that it even fought the home secretary to stop 500 Jewish doctors fleeing the Nazis in 1938 from coming to Britain, resulting in only 50 of them being able to find safety in this country. Then it opposed the creation of the NHS that it now claims to defend so doggedly in a fight that a prominent historian waspishly pointed out lasted longer than the Second World War. Labour’s Health Minister Aneurin Bevan — accused by one leading BMA figure of setting Britain on the path towards National Socialism — loathed doctors’ leaders, viewing them as “politically poisonous”, but infamously said he had to “stuff their mouths with gold” to win support. Sadly, this approach has been adopted repeatedly by his successors.

The first significant action by consultants in the NHS was a four month work-to-rule in 1975 in defense of private work, then junior doctors walked out later that year to protect “on-call” and overtime rates. Ministers backed down both times. After Tony Blair’s government ramped up health spending, one BMA negotiator of a notorious 2004 contract for general practitioners boasted that he had led their salaries to soar 60% over three years. Dropping out-of-hours cover in return for a small cut was seen, he said, as “a bit of a laugh” — although this reform lies behind the overcrowded A&E wards and has even led to a rise in avoidable emergency hospital admissions for children. “It’s right we make our GPs the best paid in Europe,” said the Prime Minister, when put on the spot over soaring salaries.

The Tories endured a BMA strike in defense of gold-plated pensions in 2012, then a lengthy contract dispute four years later with junior doctors, whose leaders piously intoned to the public that their wave of strikes was about “safety, not pay”. Leaked WhatsApp messages, however, later revealed that their “only real red line” was over weekend payments while exposing a desire to draw out their action to tie up health bosses “in knots for the next 16-18 months”. Publicly, they said the tussle could be resolved if the government would only negotiate — yet privately, their top official said the “best solution” would be for ministers to impose a deal on them. And the chair of the junior doctors committee urged colleagues to participate in “rubbish” mediation talks “to play the political game of always looking reasonable”.

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When you hear hard-pressed doctors complaining today about staff shortages, it is worth remembering also that the BMA resisted the expansion of training places for many years, arguing against “the overproduction of doctors with limited career opportunities” and demanding a ban on opening new medical schools. This stance was backed by a vote at its 2008 conference after impassioned warnings about a glut of doctors lowering standards, which would be “wrong and immoral and a waste of taxpayers’ and students’ money”, in the words of one GP representative. Since that debate, the number of full-time equivalent NHS workers has surged by at least 30%, propped up by heavy recruiting from abroad with international staff now comprising more than one-third of NHS doctors.

When the historian Rudolf Klein reflected on the institution earlier this century, he concluded that “keeping the doctors happy — that’s the story of the NHS.” Now even a Labour government accepts this system is “broken” and the public is losing faith shown by record levels of dissatisfaction. And yet will simply pour in more and more money.

No modern health service is immune to serious problems. And Labour’s instincts are right: to drag the NHS belatedly into the digital era; shift care from hospitals to community services, focus more on prevention and empower patients. But we have heard this several times before over the past two decades. Meanwhile, spending on the voracious NHS keeps on rising faster than economic growth. It accounts for about four in every 10 pounds of the daily state spending budget and is constantly prioritized over all other public services — even defense of the realm at this time of rising threat from hostile nations. And the National Audit Office predicts NHS staffing needs to increase by at least two-thirds more over the next 12 years.

Health soaks up more than double its share of public spending at the turn of the century and roughly four times more than when I was born in the Sixties. Yet, the services have often become shambolic, waiting lists are still appalling and fatal safety scandals keep emerging from maternity through to mental health services. Almost everyone has anecdotes about delayed or dire treatment, despite the best efforts of so many caring, dedicated and skilled staff. But the response of the BMA — persistently exploiting public trust in their profession while bleating about protecting the interests of patients — is to threaten yet more strikes to hoover up more cash for its members. Just as when Scargill badly misled the miners, these militant medics need to be taken down by a bold political leader for the wellbeing of our nation.

Hygiene theatre is mostly gone now, but the habit of policing others’ choices has proven too hard to quit, and now one of its preferred targets is alcohol. This has been in the offing for some time: the temperance movement, which had struggled to shed the air of puritanism surrounding it since the repeal of prohibition in America, has refashioned itself in recent years through an emphasis on health. The first rumblings of alcohol hysteria could be detected in the relish of the abstemious when it turned out resveratrol, an antioxidant found in red wine, might not be the elixir of life it was once touted as. Then there was the clawing-back of guidelines for moderate drinking: in 2023, for example, Canada dropped its so-called “low-risk threshold” from 10 drinks per week for women and 15 for men to two or fewer for either sex.

More recently, the progressive press has jumped on the anti-alcohol dogpile, with headlines calculated to horrify. “There is No Such Thing as a Safe Level of Alcohol Consumption,” The Guardian warns us, while The New York Times, now a surrogate parent for those who stopped talking to their own parents because they voted for Trump or refused to tack a land acknowledgment onto the end of the Thanksgiving dinner prayers, chides readers virtually every day with articles like “Even a Little Alcohol Can Harm Your Health,” “Alcohol Carries New Risks in Middle Age,” and the condescending “Is That Drink Really Worth it to You?”

And worldwide, health authorities have responded. In 2026, Ireland will become the first EU country to place warning labels on alcoholic beverages. In 2024, the World Health Organization published its “Global Alcohol Action Plan” a masterpiece of bureaucratic jargon that employs the stock aims of “empowering people and communities”, “ending poverty”, and “achieving gender inequality” to encourage member states to monitor their citizens’ alcohol use, engage in anti-drinking campaigns, and ultimately reduce consumption by 20% by 2030. Finally, this past January, the US Surgeon General issued an alarmist report entitled “Alcohol and Cancer Risk”. I will not contest the Surgeon General’s findings, though they fail to include alcohol’s possible protective effects against kidney cancer, non-Hodgkin’s lymphoma, dementia, and other diseases. What I will not accept is their significance. In America, it appears, alcohol “contributes” to 100,000 cancer diagnoses and 20,000 cancer deaths each year. Putting aside that the nature of such a contribution is indeterminable — and that confounding factors, which there are in virtually every case, should be a motive for caution, rather than conclusiveness — this means that alcohol is deemed to be a factor in 5% of cancer diagnoses and 3% of cancer deaths per year. These deaths constitute .006% of all deaths in the United States — significantly lower than mortality due to influenza or unintentional falls.

The report goes on to state that alcohol is the third leading cause of preventable cancers, after smoking and obesity. But smoking is the only one of these where the link is clear-cut: around 14% of smokers will develop lung cancer, with the number higher for men than for women. For everything else, it’s a guessing game, because the factors are too difficult to disentangle: if an obese drug user who binges on processed food comes down with cancer of the colon, who is to say whether one or all of these, or none, caused those first cells to mutate?

Of course, cancer isn’t the only thing you can die of, and a mere month before the Surgeon General’s doomsaying appeared, the National Academies of Sciences, Medicine, and Engineering released its own report on moderate alcohol consumption and health outcomes, the findings of which reconfirmed two things: first, that moderate drinking is associated with a lower risk of heart attack and stroke, and second, that compared with abstinence, it also correlates with a lower risk of mortality. This last datum in particular is a source of consternation to the new temperance advocates, who have tied themselves into all sorts of interesting knots to explain it away. Most entertaining of these is the “sick quitter” theory which suggests that the pool of hale teetotallers is befouled by the wrecks of ex-drinkers who gave up the bottle too late, and remain ravaged by their years of sin; if only their numbers could be excluded, the appearance of any health benefits of alcohol would vanish.

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This hypothesis is nonsense, and has been shown to be nonsense in repeated studies of lifetime abstainers; likewise, the faddish notion that moderate drinkers owe their health to their generally better socio-economic standing is not borne out by statistical data. Whence, then, the moral panic?

A hint, paradoxically, lies in the near absence of heavy drinking from these discussions. Because an alcoholic is an addict, and over the past several years, the addict has been configured as a powerless object of pity and solidarity, the alcoholic lies beyond censure; his “disease” is the likely product of trauma, and following the precepts of “harm reduction”, he must be coddled until he chooses to get better. The moderate drinker, on the other hand, is a being self-possessed, one who consciously takes a drink or two or five in full awareness of the minuscule danger, because he is enjoying himself, and would like to enjoy himself more. Contemporary progressive dogma is fundamentally anti-responsibility, placing the blame for social ills anywhere but on the subject; and the calculated risk-taker is a constant and exasperating reminder that maybe all that is bullshit, and that accepting the consequences for one’s possibly unwise actions is a basic criterion for participating in society. Moreover, as the editorializing classes have fallen for a “standpoint epistemology” according to which one’s measure of illness or trauma determined how much of a right one has to speak, the mere fact of self-composure has acquired the illiberal stink of “privilege”.

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By Tomiwa Owolade

I would put down the bottle if what I were offered in return were worthwhile, but I fear the antidote is worse than the poison. I am aware of drinking’s association with violence, sexual assault, deaths on the road, liver disease, and a host of other problems; this is what makes it a vice, though unlike the slow-motion disaster of legalized marijuana, at least it’s one we have lots of practice in handling. The harms of not drinking are harder to track, but that doesn’t mean they’re not there, and their consequences are ominous for our societies. In a 2010 study, Charles Holahan, a psychologist of the University of Austin, found associations between abstinence and an enormous suite of problems: obesity, depression, avoidance coping, poor social engagement, lack of support from friends, significantly decreased likelihood of marriage. He concluded: “All of these factors that were associated with abstention significantly predicted mortality.”

Why harp on these benefits, though? The social neurosis surrounding alcohol is no more concerned with health than Covid vaccine-shaming was five years ago (I say this as a believer in vaccines, but one who feels intransigence was a moral and policy failure). And even if we take others’ alleged concern for our bodies at face value, what is health, and what is the point of it? To quote Nietzsche, “In order to determine even what health involves for your body, what matters is your purpose, your horizon, your powers, your impulses, your errors and in particular the ideals and phantasms of your soul.” Life in itself is not an unalloyed good; it is only worthwhile to the extent that it is lived; and much of what people mistake to be health is preparation for a life they never get around to starting. “Is it not,” the Swiss novelist Hermann Burger wrote about his own weakness, tobacco, “far worse, more frustrating, to have to renounce life’s most sublime pleasure hundreds of thousands of times over than to pay for decades of wishes granted with a narrowing of the vessels in old age?” Quite so, I’d say, and if you’ll excuse me, I must step away to pour myself a glass.

Which is what evolutionary psychologist William Costello did, posting before-and-after photos of the singer Olly Murs, either side of a “12-week gym transformation”. In picture one, Murs has visible muscles but is a little on the chunky side — a classic “dad bod”, in the thirsty language of the internet. In picture two, he’s straight-up ripped, body fat stripped away and every muscle on show — a lean, honed Adonis at the pinnacle of his physical development.

And yet: almost four times as many women chose the “before” over the “after”. But nearly twice as many men chose the “after” over the “before”, and a lot of them seemed as baffled by the “feminine soul” as Freud ever was. The moment Costello’s post went mega-viral was when another user screen-grabbed the results and shared the image with the caption, “why are women lying about this? like what’s the actual cause?”

In other words: even when several women tell you outright what they want, some men simply can’t believe it. Women must be being dishonest, said aggrieved men in the replies — or if not that, then they must be deceived by lighting or repulsed by after-Olly’s tiny shorts or anything, anything rather than being authentically more attracted to a body that doesn’t look like you could break a nail on it.

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The gods of the discourse are capricious, but the gods of the discourse must be served. Did I ever think I would have an opinion on the sex appeal of Murs, arguably the most inoffensive man in pop? I did not, and yet I nevertheless have an opinion: the before is hotter. “Before” looks solid. “Before” looks like he could pick up a few heavy things without fainting. “Before” looks like someone you could hang out and eat pizza with. “After” looks like someone whose only concern is when it’s time to eat his next egg white omelette.

A ripped physique is for sure impressive, if only because of the obsessive effort it takes to achieve it. But obsessive is not the same as attractive. Competitive bodybuilders alternate “cuts” (fat-loss programs) with “bulks” (which involve taking on extra calories to build mass), meticulously timing the cycle to ensure that they hit the stage at the point of optimum body composition. In fact, it’s impossible to cut indefinitely: at some point, if you keep losing weight, you’ll start losing a noticeable amount of muscle.

Achieving the perfect look for flexing is too brutally restrictive to do for very long. As Murs’ wife Amelia (herself not exactly a slouch in the fitness stakes) commented on his Instagram: “So proud of you… does this mean we get to eat the same dinners again now?!” Which is funny and sweet, but also points to part of the problem with the super-lean male body from the female point of view: any man who attains it isn’t going to have much attention left over for you after he’s given his all to meal prep. Women, on the whole, are looking for relationship material, and relationship material has time for you.

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A woman doesn’t need to know anything about the quest for macros to know what she likes, though. All she has to know is that a man with a reasonable proportion of body fat — not obese, but with a little in reserve — looks healthy, at ease in himself and capable. The evolutionary explanation might involve something about a well-fed man looking like a reliable provider. Maybe part of the reason after-Murs is off-putting to most women is that they can see he’s effectively starving.

The bigger questions are why men can’t take a woman at her word — and why men themselves should be so attached to a wrong opinion about what constitutes an ideal body. Now, I’m not accusing the men of lying about what they like. That would be unnecessary. But I am fascinated by the lengths men will go to in order to acquire a physique that most women find a comprehensive turnoff.

Out in the incel wilds, men discuss the mythical “Gigachad”: a man so humongously swole (and charming and confident, but mostly swole) that he’s irresistible to women. In the sexual theology of the manosphere, the Gigachad is the counterpart to the female Gigastacy — meaning he has exclusive access to the most attractive women. Young men in forums sincerely discuss how they can achieve Gigachaddom, swapping tips on achieving calorie deficit while hitting protein goals in order to achieve that elusive washboard stomach.

The longer you spend reading those forums, though, the more obvious it becomes that the primary audience these men have in mind isn’t female at all. The meticulous dissection of delts, lats and abdominals (and even more importantly, the display of delts, lats and abdominals for the purposes of feedback) is for each other. This is a subculture of men looking at men, and projecting their preferences onto women. If it wasn’t for that last part, the supposed hotbed of frustrated heterosexuality would actually look pretty gay.

Gymmaxxing, as the incels call it, is not politically neutral. It’s Right-coded — so much so that when The New York Times recently profiled streamer Hasan Piker, a socialist who also (gasp) lifts weights, the headline described him as “a progressive mind in a MAGA body”. On the face of it, this is ludicrous, not least because no one who’s seen a MAGA rally is likely to confuse it with Mr Universe. But it is true all the same that the subcultures that are most concerned with traditional masculinity are also the most concerned with the arduous maintenance of a masculine aesthetic, however much they might deny that “masculine” and “aesthetic” belong in the same sentence.

If you want to get not merely ripped but really big, it takes more than diet and exercise. Robert F. Kennedy Jr., for example, adheres to an “anti-aging” testosterone regimen that has enabled him to stay unnervingly hench into his seventies: “its most obvious effects,” wrote Nicholas Florko in The Atlantic, “look a lot like juicing.” Podcasting king Joe Rogan has similarly described taking testosterone replacement therapy, and in both cases there’s a squeamish insistence on a health alibi for an appearance intervention that is not unlike me insisting I want Botox to cure my headaches rather than to fix my wrinkles.

But because masculinity is, supposedly, natural, admitting to taking hormones can seem high stakes. Which is how the fitness influencer known as the Liver King ended up, ludicrously, pretending that his gains were all down to a “primal” diet of organ meat. Even though he had a chest like two basketballs and the tell-tale corned beef complexion of the steroid user — neither of which, it should be noted, are considered particularly desirable by women. Nonetheless, he had a dedicated following of men who bought his supplements in the hope of looking more like him.

One reason for the coyness about steroids is to protect the idea that the ripped body is the product of concerted labor. No shortcuts. To the male gaze, it’s a good thing that the ripped body looks like hard work: it suggests effort that deserves reward, in the form of female attention. Meanwhile, there’s often a distaste for the effort women have to put into hotness maintenance: according to incel lore, Gigastacys can work out, but they don’t need to. Girls aren’t meant to sweat, just to be perfect objects without trying.

Men’s taste in men has nothing to do with what women want. The masculine dream of the ultimate six-pack isn’t about getting the chicks. It’s a fantasy of marble perfection: no softness, no flab. It’s also a cope: if you can convince yourself that women will only fall for the most extreme physique, you’ve already explained away your own sexual failures. Meanwhile, women will carry on preferring the man who looks like he can both flip a tire and eat a cookie without having a panic attack. Despite what Freud thought, women really are pretty basic.

The United States needs a health secretary who will, at the minimum, cast a skeptical eye on the pharmaceutical industry, which turns enormous profits and helps ensure American health care will always be commodified. Before the pandemic, most Democrats had little problem railing against Big Pharma. They were the villains, deservedly so, of the opioid epidemic, and it was not an exaggeration to say several of the pharmaceutical behemoths, most notably Purdue Pharma, had blood on their hands.

When Covid arrived, however, the politics shifted. Republicans resisted the vaccines once President Joe Biden was in office, even though Operation Warp Speed had been a Team Trump accomplishment. Democrats defended the Covid vaccines and their manufacturers — Pfizer and Moderna, in particular — at all costs, even though the jabs did cause injuries in relatively rare instances and couldn’t stop the spread of the novel coronavirus as originally promised.

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Naturally, RFK Jr. was a Covid-vaccine skeptic. Hence he became, in the 2020s, a public enemy for many liberals.

Yet he should be listened to when it comes to one of his most cherished causes: banning pharmaceutical advertising from television. In a sane world, this would be a bipartisan cause. Few countries on Earth allow pharmaceutical companies to relentlessly market their drugs to unsuspecting consumers. Non-Americans are always shocked by what is permitted on the airwaves. Turn on the television, especially the news, for any length of time, and you will be barraged by ads for every type of malady under the Sun. Since the Nineties, drug companies have spent tens of billions on these ads.

Drug advertisements began appearing with regularity in newspapers and magazines in the Eighties, but they were mostly kept off TV by a requirement that ads naming a specific illness include the long list of side effects. In the late Nineties, the Food and Drug Administration relaxed its rules, permitting advertisers to briefly summarize the drug’s risks. The TV floodgates were thrown wide open. These days, the most aggressive campaigns are for newer medications that haven’t yet gone generic; competing brands duke it out in a packed field of similar drugs to reach patients with widespread conditions like arthritis and diabetes.

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The average American drug ad is easily parodied but plainly effective. Typically, some older adults are shown in a cheery setting with friends and family. The color palette is bright. A narrator with a warm voice speaks about health challenges that might arise. The older adults are never shown to be in pain or distress; they might be taking a jog, playing with their dog, or firing up the grill. They’re bright-eyed, maybe laughing. Towards the end of the ad, the narrator will briefly summarize the drug’s side effects. Anyone with a morbid sense of humor can enjoy the contrast, just a bit: the scene remains focused on life’s joys as the narrator informs you the drug might cause rashes, bleeding, blackouts, or suicidal thoughts (in “rare cases”, rest assured).

But we know the big business of Big Pharma is no laughing matter. The drug companies are prepared to furiously fight any sort of ban that Kennedy might attempt. They will call up their expensive lobbyists on retainer in Washington to bend rank-and-file Republicans and Democrats to their will. They will probably get to Trump, who doesn’t feel passionately about the issue.

The courts have snagged reforms in the past. Efforts to minimally restrict drug ads have repeatedly been defeated, often on First Amendment grounds. The first Trump administration tried to require that commercials mention the drug’s price, but a judge blocked the policy, saying that it lacked authority from Congress.

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Will Congress act? In theory, if Trump prioritized the ban, lawmakers could push it forward. The current Republican Party will obey Trump’s commands. The narrow majority the GOP holds in the House could be bolstered by a slew of progressive and populist Democrats who might view a fight with Big Pharma as a winning issue. Several centrist Democrats in swing districts, including Marie Gluesenkamp Perez in Washington state, campaigned on a platform that was critical of pharmaceutical companies.

There’s a coalition to be built if the Trump administration takes the issue seriously. If a critical mass of Senate Republicans back legislation, it’s not hard to imagine the most Left-wing members of the Democratic conference, including Bernie Sanders and Elizabeth Warren, supporting a ban on TV ads. Chris Murphy, a Democratic senator from Connecticut who may run for president and has swerved in a more populist direction, could be a convert, too.

But that’s the rub: Trump has never demonstrated that he is all that interested in the granular work of getting policy priorities through Congress. In the first term, he was content to let Mitch McConnell and Paul Ryan hash out a corporate tax cut and attempt — unsuccessfully — to repeal ObamaCare.

For now, Congress is focused on classic GOP priorities like tax cuts for the wealthy and gutting Medicaid, the health-care program that covers more than 70 million Americans. In addition to being cruel to the poor, a budget reconciliation package with tax and health-care cuts is likely to prove inflationary, especially when paired with tariffs. Beyond the tariffs, there’s no grander project here. The populism Trump promised isn’t being delivered — DOGE, and its wanton budget cuts, certainly aren’t it.

What conservatives don’t quite understand is that the truest owning of the libs will come through triangulation. Trump can begin to subdue Democrats by pursuing policies like a ban on TV pharmaceutical ads, forcing the Left to stand with him for something popular or oppose him and appear extremely out of touch. Trump doesn’t seem to have that kind of savvy. He’s fine to let his party scheme over Medicaid cuts.

That will not end well for the GOP. Democrats know how to campaign on health care, and taking it away from working-class people will make the 2026 midterms rather easy for the party out of power. Those political ads write themselves. They’ll be sandwiched between the 30-second spots for heart disease pills that may cause internal bleeding and murderous thoughts. In rare cases.

Cofounded by Hjalmar Nilsonne and Daniel Ek, one of the billionaire founders of Spotify, Neko now boasts various influencers posting reels of their health check, which cost £300 a pop. That hefty asking price comes with some big claims about what the firm can do: Neko claims their scans have led to “potentially life-saving” healthcare. Nor are they alone. Longevity has become an obsession for a range of tech titans. Sam Altman and Peter Thiel are just two examples here, even as other firms are springing up to imitate Neko’s model.

Fundamentally, these ideas are rooted in logical, predictable input-outcome systems which primes people to apply the same mechanistic thinking to the complexities of human biology. But the human body is more than a “complex computer”. Tech enthusiasts, driven by a relentless march of progress in processing power and engineering, can harbor a blind faith in cutting-edge medical technologies — an approach that can sometimes do more harm than good both to patients themselves and the NHS at large.

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At the heart of Neko’s platform is a full body check, aimed at seemingly healthy people, using around 70 different sensors alongside a mix of proprietary and off-the-shelf technologies. Together, they non-invasively photograph every inch of a patient’s body. To quote Ek: “The visual metaphor early on was around the airport scanner.” On their website, Neko explains that they scanned just under 3,000 people in 2023, of whom 14.1% required medical treatment. At the same time, Neko say that 1% of their patients received potentially life-saving treatment for severe conditions like cardiovascular diseases, severe metabolic diseases, and skin cancer, and that “none of these individuals was aware of their condition prior to their visit”.

These results come with the caveat that this is “not a scientific study with a control group for comparison” — but they “would like to share our outcomes for transparency and knowledge sharing”. That’s arguably fair, especially given the NHS is in such trouble at the moment. With so many people simply struggling to get through to their GPs on the phone, Neko offers results in “under an hour” and is “accompanied by substantial in-person time with a doctor”.

Yet there are problems here. For one thing, there’s an inbuilt inaccuracy risk. Some people will inevitably have what’s known as a “false positive” result: they won’t actually have the disease they were tested for. This means at least two things. First, patents risk becoming stressed unnecessarily. Second, they risk being investigated for ailments that aren’t actually there.

Even so, the “earlier is better” political mantra is a boon to those companies jumping on the early detection bandwagon. A spokesperson for Neko told UnHerd that NHS leaders, together with Health Secretary Wes Streeting, have “emphasised the importance of preventive care using modern technology to improve healthcare outcomes”. But true preventative healthcare is stopping problems before they start — not finding them early. That involves the boring but sensible stuff: eating a varied, plant-heavy diet; not smoking; not drinking excessively; being a healthy weight and doing reasonable amounts of varied exercise.

At the same time, Neko told us that the NHS provides “the most basic options, available only to individuals of specific ages and at certain intervals”. They, on the other hand, claim a comprehensive service delivered at speed. But this is to misunderstand the early detection — or screening — programs that the NHS does offer. These breast, cervical, bowel, aortic and newborn health assessments have been tested to ensure they do, on balance, more good than harm. And it’s not just about the risk of false positives. It’s also whether the tests deliver information that’s useful, rather than simply being a data dump.

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Investigate Neko’s offering and there are other worries too. That talk of sensors and non-invasive photographs is certainly reassuring — but the claims that the firm’s scans have led to “potentially life saving” healthcare are impossible to prove because they have no control group. While 1% of their patients received potentially life-saving treatment, we don’t know what would have happened without the screening, and whether any interventions really did help.

Dr Minna Johansson is a Swedish family doctor and head of the Global Center for Sustainable Healthcare. A few years ago, she was invited to meet Nilsonne and Neko’s head of research to discuss the company’s offerings. In the end, though, Dr Johansson was unimpressed. “There are recognized scientific methods for evaluation of screening — which they seem to be totally unaware of,” she tells UnHerd. “The data they are gathering is quite useless for evaluating the benefits and harms of their intervention.”

In any case, some Neko services are already available in the NHS. That includes cholesterol and blood pressure tests — even as some Neko offerings simply haven’t been shown to give health benefits. Among other things, the NHS doesn’t recommend blood count or ankle blood pressure tests for healthy people. This isn’t because the health service is tight with money: some patients were tested in randomized trials, yet the results showed no benefit. As Johansson adds, other tests have never been properly evaluated or tested, so there’s no good evidence to think they’ll save lives.

The upshot? That people who do go to Neko may be falsely reassured that certain behaviors — too much alcohol; too little exercise — aren’t adversely affecting them. As Johansson puts it: “Based on the best available evidence, I would say that it is more likely that this is a waste of money and time: and there is an obvious risk that the individuals buying this intervention will be harmed through overdiagnosis and overtreatment.”

Undeterred, Neko Health is seeking to expand their user base. To quote their website: “Build upon your data. Every year.” Given three quarters of their customers apparently book a repeat test, this approach does seem successful, even as Ek has claimed his scheme is ultimately philanthropic. “I would be super happy if this turned out to make me no money, but we actually solved real issues in the world for real people.”

Perhaps. But turning testing into a rolling investment is catnip to companies looking for long-term gain. Certainly, other firms are entering the fray beyond Neko Health. Numan, a digital health company, offers a “fear nothing blood test” with big billboard-style adverts. They claim it’s an “accurate, science-based snapshot” of what’s happening inside your body. Finger-prick home tests assess liver enzymes, vitamin D and thyroid function.

Last year, however, Numan was censored by the Advertising Standards Authority for promising that their test was “free if we don’t find anything”. But as the ASA stated: “At least 90% of people who had used the Fear Nothing Blood Test had a result for at least one biomarker outside of the ‘normal’ range. We considered that this was a very high proportion of people whose test result indicated that they likely had something medically wrong with them. There was no information in the ad to inform consumers that false positives could occur or that their test results could be inaccurate.”

“From a statistical perspective,” explains David Spiegelhalter, emeritus professor of statistics at Cambridge University, “it is essentially inevitable that an apparently ‘positive’ result will be found if enough tests are done, just by chance alone. Investigating such a ‘false discovery’ can only lead to unnecessary anxiety and expense.” At the same time, ASA has also challenged Numan’s subscription model — claiming that people weren’t aware they were signing up to repeat tests.

As advocates of health screening always say, people have a right to obtain whatever information they wish about their own bodies. But companies selling these tests should tell the full story of their limitations. For not only do these firms fail to inform people adequately about what they’re signing up for, they also risk causing needless anxiety — and clog up the NHS when worried patients go to their doctors. This isn’t merely a hypothetical danger: one 2023 survey found that 90% of responding GPs had patients who visited them to discuss the results of private screening tests. The NHS is essentially left to pick up the pieces once the private sector has profited, leaving those who really do have valid concerns at the back of a lengthening queue.

Obviously, Neko Health claims this isn’t their model. They say, rather, that their aim is to alleviate strain on the NHS, suggesting that patients will see a doctor during their visit to the clinic. The physician is there to explain results, answer questions and arrange any further tests “at no extra cost” to either the patient or the NHS But, tellingly, Neko will then “refer you back to your GP with our findings and recommendations”.

As the NHS grapples with immense pressures, the likes of Neko Health and Numan purportedly step in to fill the gap. The result? Longer waiting times, diminished resources, and a growing sense of inequity in healthcare access. It’s a troubling paradox: as our public health system falters, the private sector thrives, and we all bear the brunt of its consequences.

The defendant, picked up in a routine traffic stop, denied being the man who’d carried out an inside-job fraud at the shop where he’d worked some years earlier. His name, ID and credit cards matched, and apart from a little weight gain and a new hairdo, he looked exactly like the two available photos of the criminal. A defence “facial mapping” expert pointed out several differences, but our own expert explained them away and supported the identification. Forceful cross-examination of the defence expert led him to concede that he might be wrong. But a last-minute double-check by the police unearthed — finally — one of the fraudster’s former colleagues. His probity beyond question, he was brought to court to say whether he recognised the man in the dock. A guileless “no”, followed by an unfakeably perplexed chuckle when it was suggested it might be the man he used to work with, confirmed the defendant’s innocence. (The two might well have been cousins sharing an identity, but that’s another story.)

It immediately became blindingly obvious to me that the photos of the two men were not the same person at all. You could tell at a glance! But when you are given a theory, and you run with it, it takes something big to bring about that paradigm shift.

In the case of the nurse Lucy Letby, a theory that she was a murderer was alighted upon by one of the ward’s consultant paediatricians very early on — after only a very few of the unexplained deaths or collapses that ended up on her indictment — and the theory was based almost entirely on her having been on shift at the relevant times. There can be little doubt that there was not, at that stage, enough evidence for murder to be anything other than a remote possibility. So either it was a very lucky guess, or this theory was later taken up by others in a way that led to inaccurate expert medical opinion, the misleading presentation of evidence, and a terrible miscarriage of justice.

Following her conviction in August 2023, for murdering seven babies and trying to kill six others, a 13,000-word piece in The New Yorker told a compelling story of her likely innocence. More recently, and once the reporting restrictions were lifted after her conviction in early July in a retrial for the attempted murder of one of the babies on which the jury could not agree, long pro-defence pieces have appeared in The Guardian, Telegraph, Independent and Private Eye. Also recently published — withheld pending the outcome of the retrial — is the written judgement of the Court of Appeal, who refused her application for leave to appeal.

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An appeal first goes to a single judge, who makes a decision on the papers whether to let you argue it at a hearing. In Letby’s case, that judge was Sir Robin Spencer, who turned her application down. Coincidentally — or perhaps not — Spencer was the barrister who led the prosecution of Sally Clark in 1999, who was wrongly convicted of killing two of her young children. That notorious miscarriage of justice, as well as others from the same era, such as Angela Cannings and Donna Anthony, was based on flawed statistical evidence about cot death from the since-discredited and disgraced paediatrician Sir Roy Meadow.

“Unknown unknowns” back then included the possibility of a genetic factor that could explain multiple cot deaths in the same family. It was nearly 20 years before a good candidate was discovered. A growing collection of lawyers, doctors and statisticians believe that something similar — flawed statistics and paediatric misdiagnosis without due respect for unknown unknowns — may have occurred in Letby’s case.

If the first Court of Appeal judge turns you down, you can try again at an oral hearing in front of three others. Letby was again unsuccessful. Their written judgement is long, detailed and illuminating. But it will not, I suspect, relieve much anxiety about a possible miscarriage of justice.

The main issue in the original trial, and indeed the retrial, was whether the deaths and other “events” were deliberately caused. Letby’s biggest problem here was the two allegations of attempted murder by insulin — Babies F and L, committed some eight months apart. Blood test results showed high insulin accompanied by low levels of a chemical called c-peptide. When the pancreas produces insulin, it produces similar levels of c-peptide. Therefore, the Crown said, the insulin was not produced in the body. It was, in other words, artificial. Therefore, it was an attempt to kill.

The inference to foul play with these two babies is arguably much stronger than it is with the more numerous diagnoses of air embolism, which was a more subjective opinion, more dependent on the statistically questionable “shift-pattern” evidence. The two guilty verdicts on the insulin counts were the first the jury returned — the next not coming for three days — and were two of only three unanimous convictions in the trial.

The Court of Appeal records that “the integrity of the blood samples and reliability of the biochemical testing was challenged by [defence KC] Mr Myers. However, in her evidence at trial, the applicant admitted that both babies had been poisoned by insulin, but denied that she was the poisoner.” The Crown made much of this “admission”, but the point is seriously unfair.

Letby was being pushed quite hard to swallow an inference which she was in no position to accept or deny. Her evidence was that she did not poison them — simple as that. So her opinion of the validity of the blood samples and the inferences to be drawn from them is neither here nor there.

This is a common practice by prosecutors, easy to lapse into in the heat of the moment. I’ve done it myself. “So it’s all just a big coincidence is it? Or have these two complainants put their heads together?” — that sort of thing. You’re trying to make a little speech and put the defendant on the back foot, in the course of questioning them about matters within their knowledge — which is what you should confine yourself to. But a defendant’s answers to such questions are not a sound basis for treating a prosecution inference as agreed by the defence. If the reliability of a blood sample is not agreed, or an inference not accepted, there the matter should rest. Her barrister explicitly did not concede the accuracy of the results in his speech to the jury, much less the inferences to be drawn.

And it seems there may be good reason not to accept their validity. The Guardian has reported serious concerns about the results from senior experts in the field. The Telegraph quotes guidance from the relevant lab saying that its tests are “not suitable” where the introduction of artificial insulin is suspected. And The New Yorker piece quotes the Crown’s expert as saying that there was a third insulin case, with similar blood results, not attributed to Letby. The samples cannot be tested again as they were destroyed soon after they were taken — because the babies’ blood sugar levels recovered and there was no suspicion of wrongdoing at the time.

But even without these post-conviction queries, if this were the only evidence, and these the only allegations, I would hope no jury would convict a nurse for attempted murder on that basis. The timing and detail of the insulin results meant that the Crown had to say that not only must Letby have poisoned the feeding bags she herself put up, but also must have poisoned one or more other bags in the store cupboard so that they would unwittingly be administered by other nurses after she had left. (The bags themselves, of course, are long gone.) Would you feel sure a random nurse tried to kill two babies eight months apart, or would you think this might be an instance of why the lab says its tests are “not suitable” for proving the presence of artificial insulin? But of course, this was not the only evidence against her.

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There are also Letby’s online searches for bereaved families, and the collection of medical notes found at her home relating to some of the events she was charged with. Neither of these, I feel, are anything like as bad as they look: they both stand against a background of a much larger number of non-suspicious searches and medical notes.

But for many observers, and perhaps for the jury, the “confession” note is persuasive. For criminal lawyers, less so. That’s because false confessions are surprisingly common. So much so, that a law was enacted to prohibit a confession being given in evidence unless the prosecution can prove beyond reasonable doubt that it was not obtained by oppression or as a result of anything “said or done” that was likely to render a confession unreliable.

How could any nurse subjected to a long investigation into whether they have been murdering babies find the process anything but oppressive? If the case against her can be proved beyond reasonable doubt, one might think it could — and even should — be proved without the mixed inculpatory-exculpatory scrawls of a woman on the brink.

Almost all of the rest of the convictions — that is, all seven murders and three of the alleged attempts — involved the deliberate injection of air, leading to air embolism. One ground of Letby’s appeal impugned the prosecution experts’ diagnosis-by-exclusion — i.e. “we don’t know what else it could be, so it is likely to be air embolism” — as well as their diagnosis on the basis of various kinds of unusual skin discolouration that were observed. The 1989 research paper relied on by the Crown’s experts, Pulmonary Vascular Air Embolism in the Newborn, is very short, and says relatively little about skin discolouration other than that, in about 10% of the 50 or so cases they reviewed, “migrating pallor” in the skin was observed — which, it was not disputed, may be caused by other things.

The Court of Appeal was not impressed by this complaint, or by fresh evidence from the surviving author of the 1989 paper in which he criticised the use to which his research had been put in the Letby case. The experts were entitled to use skin discolouration as supportive of the diagnosis, the court said, as being “consistent with” embolism; the fresh evidence did not undermine that; and the lack of any other plausible explanation is significant.

“Consistent with” does a lot of heavy lifting for the Crown in criminal trials. A piece of evidence only helps to prove something if — and to the extent that — there is a difference between the probability of finding the evidence if the hypothesis (e.g. guilt, or air embolism) is true, and the probability of finding it if it is false. More precisely, it is the ratio between these two that determines the strength of the evidence in either direction. That, in a nutshell, is Bayes’s theorem. So, if you can say no more than that a piece of evidence is “consistent with” the hypothesis, but it is also “consistent with” its negation, and you can’t say how much more “consistent” it is with one rather than the other, then the evidence does not assist you either way. For example, if a prosecutor says “the fact you were wearing gloves makes you more likely to be guilty of this robbery”, that evidence is in fact worthless if it’s winter time and everyone is wearing gloves: wearing gloves is “consistent with” both guilt and innocence, to the same degree.

It seems, though, that the experts used skin discolouration as more than merely “consistent with” air embolism. They used it to prove, to some extent, that diagnosis. Which they are entitled to do, if it is a justifiable professional opinion, but it does point to a fundamental danger with expert evidence: the difficulty a jury has in getting behind the curtain and judging what weight to give it.

One way of achieving this is to look at whether the experts have been wrong before. In the case of the lead expert in Letby’s case, Dr Evans, the defence discovered halfway through the trial that he had been utterly excoriated in a ruling by a Court of Appeal judge in a different case. “No effort to provide a balanced opinion… No attempt made to engage with the powerful contradictory indicators… The report has the hallmarks of an exercise ‘working out an explanation’ that exculpates the applicants… tendentious and partisan expressions of opinion that are outside [his] professional competence.” That level of criticism from a senior judge is not made lightly: they know it can be career-ending. And if the Crown had known of it in advance, I suspect they would have looked for a different expert.

Now, this was on one view a gift to the defence: they could now undermine Dr Evans’s credibility by cross-examining him on it in front of the jury. True, his conclusions in the Letby trial were supported by other experts who had checked his work, but the defence argued that those experts were merely rubber-stamping his opinions. The jury may have had a difficult task in assessing what weight to give the criticisms of Evans’s previous work — one with somewhat binary options: disregard his evidence, or believe it. Ultimately, the Court of Appeal upheld the trial judge’s rejection of the defence’s application to exclude his evidence. It might not have been an easy decision for the trial judge, or the Court of Appeal, and although it may have been the correct decision, I cannot imagine any lawyer would claim the situation overall was entirely satisfactory.

Zooming out, the big question remains: without knowing of the police investigation and the suspicion of foul-play, and the fact that one nurse was on duty for many or all of the incidents under review, would any expert have diagnosed air embolism by the deliberate injection of air, in any of those cases? Certainly none of the pathologists did at the time.

In his recent Private Eye piece, Dr Phil Hammond gives a startling statistic: in a review of more than 1,000 cases of infant death in south-east London, “the cause of mortality was unexplained for about half of the newborns who had died unexpectedly, even after post-mortem examinations”.

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So, the shift-pattern evidence — i.e. the fact that Letby was on duty for so many unexplained deaths and collapses — does seem to have been central to the case against her. And statisticians are questioning its probative power. Even leaving aside the issue of deaths and other negative events that occurred when Letby was not on duty, coincidences of that scale occur — just as someone will win the lottery each week, at odds of 14 million to one.

Also very unusual is the fact that Dr Evans “pitched” his services to the police, when he heard about the investigation in the media. This is not the way experts are normally selected. The defence argued it indicated pro-prosecution bias. The Court of Appeal disagreed.

And then there’s the fact that in the last few weeks Dr Evans has commented publicly on the defence not calling their own expert, who was advising them throughout the trial. Indeed, that expert, Dr Hall, has himself gone on record saying that he “does not know” why he was not called. And the same question was posed by the Court of Appeal, somewhat pointedly: without having called their own expert, can the defence really complain if the jury agree with the Crown’s?

It’s an entirely valid question. But I would be slow to assume the worst. One reason the defence might have chosen not to call Dr Hall (and I am speculating here) is if they felt they had so thoroughly undermined Dr Evans that they were better off leaving it at that. That would be a big tactical call, but covering your own back is not always consistent with protecting your client’s interests.

So, for example: if your own expert would contradict much, but not all, of the Crown’s expert’s conclusions, and you believe the credibility of the Crown’s expert has been totally destroyed, you might judge it prudent not to put your own expert in the witness box. Avoiding the potential for future criticism and hindsight regret by putting your client in what you believe will be a worse position — by calling your own expert — is not a boss move. This is all speculation, but I guarantee that careful thought went into the decision not to call Dr Hall. None of this, though, would mean the conviction is safe.

There is evidence against Letby. And the fact that it’s “circumstantial” is not a valid criticism: circumstantial evidence can be, and often is, utterly overwhelming. But this is where comparison with the Sally Clark case really comes in. The famous statistical error in that trial was that the expert Professor Roy Meadow wrongly treated two putative cot deaths as probabilistically independent. But arguably the more important point is that while the probability of “coincidence” might indeed have been very low, so too is the probability of a mother murdering her children. In Letby’s case, the chance that a randomly selected nurse is a baby killer is vanishingly small. As Carl Sagan put it, paraphrasing the French mathematician Laplace, extraordinary claims require extraordinary evidence.

Defence lawyers often say to juries that their clients start off innocent: the fact that they are in the dock is no evidence at all. But this is not quite right. If the probability of guilt is zero, no amount of evidence — that is, no Bayesian likelihood ratios, no matter how high or how numerous — will alter that chance. Rather, a defendant’s prior probability of guilt — that is, before any evidence has been called — is just very, very small. But not all crimes are equally common. A randomly selected member of the public is much more likely to have stolen a bike — given the number of bikes that get stolen — than a randomly selected nurse is to be a serial killer of her patients. But there isn’t much room for these fundamental concepts to be explored and explained to a jury.

There has been some commentary to the effect that those protesting Letby’s innocence should pipe down, that they are behaving irresponsibly. But miscarriages of justice do occur, and the Court of Appeal sometimes gets things wrong.

The only route for Letby now would be a referral back to the Court of Appeal by the Criminal Cases Review Commission, which would require substantial new evidence of one sort or another. The process is not quick, and the Commission do not refer many cases. But I would not be surprised if one day it happens. I hope it does. If Letby has been wrongly convicted, it would be one of the worst miscarriages of justice we have ever seen. If she is guilty, well, true verdicts, like true scientific theories, are only strengthened by rigorous testing and challenge.

***

This article was first published on 24 July 2024.

Over the last two decades, it has become increasingly clear that plastic is everywhere. While the material is largely resistant to decomposition, it does degrade and shed small fragments, known as microplastics, which vary in size from millimetres down to microns and nanometres. These are now part of the fabric of our physical world. They have found their way into fresh Antarctic snow, and are accumulating in the deepest regions of the ocean. They are present up and down marine food-chains, and in agricultural soil. In Florida, plastic accounts for more than 1% of the body weight of some hatchling sea turtles.

The alleged microplastic discoveries extend deep into our own bodies as well, in a morbid list of nouns: lungs, heart, liver, intestines, blood, semen, penises, testes, placenta, breast milk. Most recently, their presence has been reported in the olfactory bulb of the brain. And the build-up of plastic is only going to grow. We produce more than 400 million metric tonnes of it every year, and that is predicted to increase by 70% by 2040. Plastics are now used in an enormous range of products — in clothes and carpets, paint and pipes, buildings and roads, tea bags and cigarette filters. Very little is recycled: less than 5% in the United States, which is by some margin the biggest consumer of plastic on a per-person basis. In any case, it would be more accurate to say down-cycled, since most discarded plastic can only be reconstituted in lower-grade forms. According to a widely cited estimate, the equivalent of a truckload of plastic waste enters the ocean every minute.

If some of this will end up in our bodily tissues, the question, naturally, is how harmful it is. The answer is that we aren’t sure. Various pathologies caused by plastic ingestion have been observed in wild animals, such as the scarring of sea birds’ digestive tracts. Plastic shreds can also act as vectors for toxic, hormone-disrupting chemicals such as Phthalates and Bisphenol A, which are used in the fabrication process. Lab studies have linked microplastics to a range of nasty-sounding effects, but the extent to which these are occurring inside the body is still unclear. Microplastics may help to explain falling sperm counts, neurodegenerative diseases and rising cancer rates in young people — but then again, they may not.

For the time being, then, microplastics are as much a cultural phenomenon as a medical one. With so much uncertainty surrounding their effects, they tell us more about the anxieties that lurk in our minds than the health of our bodies. In fact, they tell us something important about our relationship with the modern world itself.

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Plastic has a claim to be one of the great human achievements of the past century. In 1941, two British chemists anticipated the coming age of “Plastic Man”, who would live in a world where “man, like a magician, makes what he wants for almost every need”. In the following decades, as scientists learned to arrange hydrogen and carbon atoms in long chains of molecules, known as polymers, they gradually made this vision a reality. For the first time, human beings could make materials with properties of their choosing, whether firm or malleable, wearable or tearable, waterproof, heatproof or indeed bulletproof.

As consumer culture flourished in the Sixties, plastic was marketed as fun, colourful and disposable, signifying a miraculous affluence after decades of depression and austerity. Researchers found many useful applications for plastic too, discovering, most notably, that polyethylene packaging could extend the shelf life of fresh food. Lightweight, mouldable, durable and affordable: this combination of properties, unique to plastic, has made it indispensable to all kinds of products we use on a daily basis.

But if plastic marked the ultimate triumph of human beings as artificers — allowing man to “make what he wants for every need” — then this is also, today, what has given it a sinister quality. Throughout the modern era, the development of increasingly complex, artificial societies has produced an undercurrent of reverence for the purely natural, the “unspoilt”. Even as we enjoy the products of science and technology, we designate certain spaces as natural, and seek to protect them from the corrupting forces of modernity. These natural domains include not just wild and bucolic places — places like that Scottish beach, for instance — but also the human body, childhood, and vestiges of traditional culture. Ironically, while capitalism is broadly understood to endanger these sacred domains, it also encourages us to worship them, with its health foods and organic cosmetics, its tourist industries and escapist entertainment.

If we know one thing about plastic, it’s that it is unnatural. And so, even before an awareness of microplastics gave “Plastic Man” a terrible new meaning, the burgeoning prevalence of plastic things had become a source of anxiety. Writing in the Atlantic some years ago, Jamie Passaro described the struggle that parents face in choosing products for their children. The villain of the piece is her daughter’s favourite doll, which Passaro took an instant dislike to. “Everything about her plastic body seemed artificial,” she wrote, “Her skin was a peachy shade like a spray tan. Her painted-on blue eyes seemed startlingly wide, like someone slipped her an energy drink… Her body was too hard to bend, though her arms and legs and neck could swivel all the way around.” In the appropriate context, plastic is reassuringly clean and sterile; but when it invades a natural realm, such as the innocence of a child, it can suddenly appear garishly fake, even obscene.

And therein lies the peculiar horror of microplastics. These invisible particles, spreading like an infectious disease, render everything vulnerable to our unhealthy, synthetic culture. They do not simply pollute; they contaminate. Reporting on the subject, even in dry factual newsprint, pulses with an almost lurid revulsion as it relates how another precinct of nature, whether inside us or around us, has been violated by plastic. As Mark O’Connell has observed, microplastics cross the political divide as few other issues do, haunting progressives with a new phase of ecological destruction, and conservatives with a chemical threat to fertility and masculinity. Yet these are just different expressions of the same modern neurosis about the contamination of the natural.

Such fears are not necessarily misguided — microplastic pollution may turn out to be as disastrous as the pessimists suspect — but they do suggest a failure to comprehend the artificiality which pervades the modern environment, for better and for worse. Our distinctions between natural and unnatural, though sometimes useful, are usually inconsistent and arbitrary, based on aesthetic preferences more than anything. Thus Passaro found out that her daughter’s doll might be made of PVC, in which case it really could be dangerous; yet she was surprised to learn that the more “natural” toy she bought as a substitute, a Swedish-designed cloth baby, was also plastic in its polyester form.

Plastics are made using petrochemical by-products from the fossil fuel industry, but so too are the pharmaceutical substances that keep us healthy, and the fertilisers that grow our food. Many of those crops also require chemical pesticides, just as our water requires chlorine to be drinkable. Alternatives to plastic, such as paper, glass and cotton, often use more resources, produce more carbon emissions, and create their own forms of pollution. Asbestos, lead and mercury turned out to be toxic; but so did smoking tobacco and cooking with firewood and crop residues. Hormonal interference is widespread in the form of birth control. Tiny metallic particles, small enough to enter the bloodstream, waft through the London Underground in much the same way as microplastics.

To live in the modern world is to be a deeply artificial creature, a monstrous hybrid of biological processes, synthetic chemicals and industrial pollutants. It has been decades since any significant number of people on the planet have lived otherwise, and those who come closest tend to be extremely poor. Microplastics simply underline the totality of this condition; however fastidiously you try to carve out a more natural existence, however far you run, you will still be at risk of inhaling and ingesting substances designed in laboratories, used to fabricate shopping bags and Coke bottles.

And this will, presumably, be the case for many generations. Next month, in South Korea, the United Nations will discuss a treaty to reduce global plastic production. But even if this comes to fruition — unlikely, since it lacks Chinese support — the plastic we have already made, and continue making, will still be with us. So we will learn to live with this plague, not because we should, but because we have no choice. No doubt it is precisely to cope with such strange circumstances that we cling to our simplistic ideals about natural places and natural bodies.

What starts out as casual snacking and “comfort” eating, often as learnt behaviour from childhood, develops into the sort of physical and mental obsession more commonly associated with drug abuse. Junk food companies, like their peers in gambling or social media, are well schooled in the art of getting people hooked on “food” that has little or no nutritional value. Rather, it’s developed, created, marketed and sold with the sole purpose of feeding the habits of the weak, the poor, the vulnerable. 

And if this leads to a country of personal disasters, of wretched lives and early deaths, our junk food obsession is rapidly becoming a thoroughgoing national emergency. With the NHS already creaking under the pressures of an ageing population, and our yearning for biscuits showing no sign of stopping, we risk destroying our national healthcare. Yet if reform is urgently needed, the government seems unwilling to act decisively, instead preferring dubious drugs and hopeless appeals to morality. 

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Britain’s eating habits are shocking, something that’s clear enough from the numbers. According to one recent study, after all, seven of the top 10 global food manufacturers made over two thirds of their food and drink sales in Britain from selling junk. According to The Times, meanwhile, these same firms are responsible for over 90% of Britain’s online advertising, spent on chocolate and chips and ice cream. The target of all this activity, I hardly need to add, is children. In 2022, to give one example, the biggest companies spent £55 million on online ads for products linked with youth obesity.

Nearly a quarter of English children aged 10-11 years are now obese. And if this is a disturbingly recent phenomenon — when Harold Macmillan was prime minister, fewer than one in ten 11-year-olds were overweight — the consequences here go way beyond being mocked in the playground. Obesity, after all, is now the second biggest preventable cause of cancer, itself a disease that one in two Britons will face during their lives.

Shamefully, the UK is now the fattest country in Western Europe. The British Heart Foundation says that since the early 1990s, the proportion of obese people in Britain has almost doubled. Today, almost 30% of adults are obese, or classed as having a body mass index (BMI) of more than 30. That’s the equivalent of over 15 million adults, even as 64% have a BMI over the recommended threshold of 25. In particular deprived corners of the country, the situation is even worse. In Kingston upon Hull, for instance, four in 10 people have a BMI above 40. 

The pressure that obesity puts on our overburdened healthcare system can’t be overstated. In England and Scotland, it is now a bigger killer than smoking. Thanks to its links to cancer and heart attacks, it accounts for one in every 10 deaths. And it’s not just in the numbers. As an emergency doctor myself, I see the damage wrought by food companies each and every day. I see dental infections, and abscesses, and DIY medical interventions, where patients have sometimes removed their own teeth with pliers as they cannot afford dental care.

I’ve seen 35 stone patients in peri-arrest — just about to have a heart attack and die outside of hospital. Any obese patient needs very aggressive cardiorespiratory resuscitation, and that takes valuable time. Without access to the full range of A&E equipment only a minimum of life-saving treatment can be administered in any pre-hospital environment. In other words, if you’re obese and have a heart attack at home, at work or in the street you’re as good as dead before someone like me gets to see you.

British obesity, however, is more than just a matter of physical health. On the contrary, it crushes the spirit just as surely as it bolsters the waistline. It’s not uncommon for hospitals to receive patients who’ve effectively become prisoners in their own homes, with paramedics forced to extract them using specialised cutting equipment. In one case, firefighters had to remove the gable of a semi-detached house to get a patient out. Such extremes are, of course, the thin edge of a very thick wedge. What’s more common, if just as troubling, is the age of the obese patients I see. Very few are old. Why? Because they die young, before they see their grandchildren grow up. 

As that reference to cutting equipment implies, moreover, Year on year, the NHS has to budget for additional kit, redesigned workspaces and even specialised lifting equipment to deal with the increasing number of obese patients. From extra-wide bariatric stretchers, to specially modified ambulances designed for patients who literally can’t fit in standard models, this added burden has prodded NHS obesity costs to £6.5 billion a year, even as Wes Streeting has said the true figure could be almost double. For context, the direct cost of obesity to the NHS 20 years ago was a mere £500 million. And beyond the pounds and pence, I’ve seen the disruption obesity causes with my own eyes. In fact, I’ve treated way more people who’ve had heart attacks from eating rubbish than from people taking cocaine or heroin. While it’s the “war on drugs” that gets the headlines maybe what we really need is a war on junk food to tackle our ever-expanding waistlines.

Given the desperate blend of wasted lives and wasted cash, it’s unsurprising that politicians have long sought a solution to our obesity epidemic. Back in 2021, the Conservative government announced a plan to ban all junk food advertising on TV before the 9pm watershed, all in an attempt to reduce young people’s exposure to sugary, salty and fatty foods. Yet despite upward obesity trends at the time, the Tories pushed back the plan to give the food industry “more time to prepare”. The Labour government now says a ban on junk food adverts being shown on television before 9pm will come into force on 1 October 2025. It says the watershed on junk food advertising will also be enforced, alongside a total ban on paid-for online adverts, both as a way of targeting childhood obesity. 

Considering past failures, and the immense financial heft of Britain’s food companies, I’ll believe it when I see it. Nor should we hold much hope for miracles cures in a needle. For while the Department for Health has recently made much of  weight-loss drug Mounjaro  — including partnering with pharma giant Lilly to run a trial in Greater Manchester — it only fights symptoms not causes. 

As NHS England medical director Professor Sir Stephen Powis warned recently, weight-loss drugs are not a “holy grail” for curing the nation’s obesity ills. If Saxenda and Wegovy doubtless help with weight loss, making patients feel fuller and suppressing appetite, administration can only happen via injection. And if that makes long-term treatment difficult, they’re also only effective as long as the patient uses them. Stop taking them and the fat comes back, alongside the physical and mental health problems associated with weight gain. 

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Quite aside from the predatory nature of a Ferrero or a Mondelez, meanwhile, I just don’t think we should put the onus on those millions of Britons struggling with obesity due to congenital conditions, or hormones, incapacitation or the side effects of life-saving drugs. And even for those without medical excuses, for those who could just eat less and exercise more, it’s clear that the big food manufacturers are waging a cynical war against public health for profit — and they’re winning.

What, then, is the solution? Especially given the current state of the NHS, and a obesity-induced healthcare crisis that shows no sign of stopping, the Treasury would do far better dip into the Chancellor’s extra £50 billion and finally tackle the problem at source. 

For starters, the Government needs to go beyond prohibiting when and where unhealthy foods are advertised and marketed and refocus and clamp down on how big brands from fast food outlets to high street supermarket chains use algorithmic techniques, seductive imagery and loss leaders to get consumers hooked on junk food. If sugary, salty, fatty and carbohydrate-rich products are harming more people than smoking then why don’t we marginalise the branding of these silent killers the way we do tobacco instead of fetishising them?

If the NHS is to benefit from Reeve’s budget windfall, it should be invested in the people with the skills and creativity to roll out an anti-obesity, pro-nutrition national programme.

No one wants to see a “fat tax” that punishes people for the odd slice of cake or a cheeseburger. But we also don’t want a two-tier food landscape in which the rich or “educated” stay thin while those who are struggling get fat. Rather than stigmatising the unemployed, as Wes Streeting did recently, the Government must instead bite into the profit margins that make the junk food industry so strong. They’re the ones profiting from the misery of millions of overweight Britons, so why not tax them for the privilege? Of course, they’ll simply pass the cost on to the consumer but if this dampens the public’s appetite for junk food, so be it. Perhaps then we can finally begin to cut down waistlines — and squeeze the junk food pushers down to size too.

The first is that, last year, I was in a catastrophic rock-climbing accident in which I broke my neck. The result is that I am now tetraplegic, one of the most severe disabilities it is possible to acquire. Some highlights include having no sensation, or motor control, from around my nipples down. That doesn’t just mean I will have to use a wheelchair for the rest of my life; it also means I am doubly incontinent. Instead of peeing out of my penis into a toilet, my urine drains directly out of my guts into a plastic bag strapped to my leg. Not only am I liable to shit myself without warning; I have no control over when I do or don’t go. This means every morning I am treated to the delights of “manual evacuation”, where a trained care worker sticks suppositories up my arse, before fingering me until I defecate. While still in bed.

I need them to do this because tetraplegia means that I have lost around 95% of the use of my hands. Just like I also need somebody to wash me, dress me, and cook for me — none of which I can do for myself anymore. (I am writing this using voice dictation software.) On top of that, my broken neck means I am at risk of a unique medical condition called autonomic dysreflexia, which basically means that my body is liable to begin a deadly feedback loop, which if untreated culminates in agonising pain, strokes and death. For these reasons, I now require 24-hour care. In fact, this list only scratches the surface — but you get the idea. It is not exactly how I planned to spend my 30s.

The second thing you need to know about me is that I was born and raised in Southport. Both my parents still live there, in the house where I grew up. Many of my friends also still live there, though thankfully none of their families were victims in last week’s horrendous events.

These two things ought to have nothing in common with each other. And until last Monday, they didn’t. What changed this was finding out that the far-Right activists who have been causing havoc across the UK for the past week were planning to bring their “protests” close to my home. And not just my original home of Southport, which they’d already desecrated on the ludicrous pretext of “avenging” the awful stabbings that took place there. But my current home of Walthamstow, in London. And incredibly, not just my borough — but literally my street, urging their followers to “mask up” at 8pm on Wednesday outside the Waltham Forest Immigration Bureau, which I can practically see from my bedroom window.

Now, this generates some quite serious practical safety problems. Not for me personally, because I can just sit safely inside my flat, away from the idiots. The problem is for my care team. By and large, the person who looks after me in the day swaps over with somebody else at 8pm. Then at 9pm, a second person arrives to assist with the rigmarole of putting me to bed. Thus, three people are faced with the prospect of negotiating an EDL “protest” that may well have turned into a race riot. This would be bad enough, but gets considerably worse when you factor in that one of them is Nigerian, and two of them are Pakistani.

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In a way, this is just a practical problem. As it will not be safe for them to be on the street outside my flat given the kinds of people who are going to be around, we need to work out some different arrangements in terms of who comes and goes, and at what times. To some extent, this is just a logistical pain. Much worse than that is the shame I feel in having to look them in the eye and discuss the fact that white English people (like me) are threatening to have a riot on the street outside, because of a hatred for people like them.

Let’s unpack that.

On the one hand, my carers turn up every day to do things like wipe my arse, drain my piss, wash my genitals, dress me, feed me, put me back to bed for scrubbing when I’ve shit myself, and so on. On top of that, they also have to deal with me. The truth is I would be lying if I said I had come to terms with how I must live now. I am riddled with depression and anxiety, and while most days I manage to keep a lid on it, some days I just don’t. I live in a permanent state of frustration, which means I’m often just rude (which I then hate myself for). At my worst, I have near-psychotic breakdowns. Like last week, when I started hitting myself in the head as hard as I could and begging the staff to kill me, promising to give them the contents of my ISA in exchange. In other words, caring for me is no picnic.

And yet I’ve never once heard them complain, or get frustrated with me, or show me anything other than patience and kindness. And it is not like they are doing this for great monetary reward. They are employed not by the NHS, but by a private care agency that gets its funding through the NHS. I don’t know exactly what that means in terms of staff wages, mostly because I’m too embarrassed to ask. But we all know it’s not going to be the stuff of envy.

Nor is it some strange coincidence that my care staff are immigrants from much poorer countries. This is just the norm, as I’ve come to learn over the past year. When it comes to basic care work — i.e. the stuff that nurses are too qualified to sensibly be assigned to do, but which absolutely needs to be done to stop people dying, to keep them clean, to ensure they eat, and so on — the fact is that English people just won’t do it in anything like sufficient numbers to meet the demands of the indigenous population. The only people willing to do this shit work, for crap pay, are those who come from countries so poor, with economic prospects so bad, that moving to the UK seems worth it. And now that they are here, the self-appointed “defenders” of England tell them that they are not wanted, and threaten them with violence.

After my accident, I spent the first eight months in different hospitals. As an estimate, I would say that 85% of the people involved in my care — from top surgeons all the way through to cleaners and kitchen staff — were non-white. To some extent, this was skewed by the fact that I spent most of my time in London. And quite a few of those people were second or third-generation immigrants (although that is offset by the fact that a lot of the white staff were Eastern Europeans). For four months after that, I had to live in a residential nursing home while independent living arrangements could be secured for me. One of the care staff there was referred to as “the English girl”. Because she was, literally, the only one.

So, when I hear “patriots” bemoaning immigration, while claiming to love the NHS, I roll my eyes. Perhaps they could try breaking their necks, and seeing what I’ve seen. I think they might change their minds. It is not just the NHS that would collapse if the EDL got its way; the entirety of social care in this country would disintegrate overnight.

In many ways, it is a strange irony that an explosion of racial tensions should emanate from my hometown, of all places. My memories of growing up there, nearly 20 years ago, are of it being basically an Anglo-Saxon ghetto. I think there was one black person in my high school. The only Asian was my mate Pricey. I remember hearing that there was a synagogue somewhere, but I didn’t meet a Jewish person until I went to university. Clearly, things must have changed to some extent: last week, I was genuinely surprised to learn that Southport even has a mosque. But still, of all the places in Britain where a second-generation Rwandan immigrant born in Cardiff might perpetrate an act of unspeakable horror, Southport would have seemed one of the most unlikely candidates, at least before tragedy struck. At any rate, trying to invoke Southport, of all places, as the emblem of anti-immigration sentiment, will be patently ridiculous to anybody who’s ever actually been there.

But those are facts, and as we know in this age of social media lies, encouraged by vile opportunists like Nigel Farage, the facts don’t matter anymore. So, forget about the facts, I want to say something different to the yobs planning to “protest” on my street this week. On behalf of Southport, on behalf of my carers, on behalf of myself, and on behalf of all decent Britons: will you please just fuck off?

None of this was particularly shocking. It was hardly the first time a mentally ill patient had attacked another on our watch; nor was the trigger of his psychosis anything but expected.

More surprising (and troubling), however, was the scene I witnessed when I returned to work on Monday morning: the patient was still there, standing in my ward, cursing staff and patients alike. When I asked one of the nurses why nobody had staged an intervention, she explained that the psychiatry team were still assessing his condition, and whether he should be sectioned. And as a result, he had spent two and a half days on the ward causing mayhem.

Eventually, the police carted off the young man to be processed through the criminal justice system. But we’re under no illusion that this will cure him. No doubt he’ll return to us soon: yet another reminder that Britain’s A&E departments are reaping the whirlwind of a disintegrated heath, social care and psychiatric system that lacks joined-up thinking, let alone joined-up action.

Only the week before, I was confronted with the case of an 86-year-old woman who presented with a fracture following a fall at home. Despite her injuries, and being shaken up by the accident, she was as bright as a button. But as her octogenarian husband has dementia, and she is his primary carer, due to safeguarding issues he had to accompany her in the same ambulance to A&E —  only to find that there was no room in the emergency department for either of them. They were both left in limbo in a corridor for hours while multiple members of staff and assorted agencies tried to figure out what to do with them. Eventually, they were wheeled into another corridor. Out of sight, and out of mind.

Both cases are typical of people forced to survive on society’s fringes. Whether it’s through deep-seated mental health issues or a debilitating condition such as Alzheimer’s, if you find yourself in a crisis with nowhere else to turn, chances are you’ll wind up in A&E — along with the hundreds of other people. The patients I see often don’t have the money to pay for a carer or book into a hotel for a few nights, or family they can lean on in times of need. They have no one, except for us.

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For the most part, these people have paid into a system through progressive taxation and National Health contributions — just like the rest of us. But do they get value for money? Or do they end up on a trolley in a crowded corridor until they die from neglect? This is, after all, exactly what happened to 39-year-old Inga Rublite, who was found unconscious, lying under her coat, slumped in a waiting room at the Queen’s Medical Centre (QMC) in Nottingham in January. She died days later of a brain aneurysm.

As Britain’s new health secretary, and as someone who has experienced this A&E anarchy first-hand, one would expect Wes Streeting to make fixing it a priority. In 2021, after being admitted to the A&E department at his local hospital, the King George in Essex, with a kidney stone, a scan revealed a cancerous growth on the same kidney, which was soon removed. “That A&E found my kidney cancer and our NHS saved my life,” he reiterated a few weeks before this year’s election. “Now I’m determined to save our NHS.”

But will he? Put to one side yesterday’s announcement that Labour might scrap the Conservatives’ plan to build or expand 40 NHS hospitals by 2030, how is Streeting faring?

Along with Queen’s Hospital, Romford — which, as the MP for Ilford North, is also on Streeting’s local patch — the King George is run by Barking, Havering, Redbridge University Hospitals Trust (BHRUT). In May, it came out of “financial special measures” after failing to pay suppliers on time, though it recently declared an “internal critical incident” due to an evaporation of bed spaces. Only last week, the trust came under fire for seeing a fivefold increase in patient complaints; a few days earlier, a BBC news crew filmed 17 patients from Queen’s being treated on beds in corridors, a situation the emergency department’s director of nursing called “customary practice”.

Perhaps understandably, BHRUT is seeking £35 million from the Government for an A&E rebuild. As the trust’s chief executive, Matthew Trainer says: “The A&E at Queen’s was built for 300 people a day. In March, the average daily attendance was more than 600.”

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Now, given Streeting’s local connection to the trust, as well as his very slender electoral majority, I wouldn’t be surprised if he finds the cash for the BHRUT. But will other nearby A&Es be so lucky? There are, after all, at least six major hospitals in the Essex and northeast London catchment area surrounding his seat, all of which have high levels of deprivation, demographic change and patient acuity — a combustible mix when it comes to accessing health and social care resources. Just yesterday, it was reported that the BHRUT had the worst A&E waiting times in the UK, with a third of patients having to wait more than 12 hours.

None of this is to say that Streeting doesn’t feel passionately about the NHS, or that doctors aren’t rooting for him. Following a succession of careerist Tory health ministers, many of my colleagues feel reassured that we finally have a health secretary who seems willing to listen to our concerns. But even so, Streeting has a mammoth task ahead of him.

Indeed, look at where the money has been spent in recent months, and it becomes clear that this isn’t a question of competence or commitment — but of whether, given its profligacy, the NHS can be saved at all. A number of integrated care systems have been ordered to hire cost-cutting management consultants, with immediate effect, due to concerns over finances, while earlier this year, NHS England awarded £40 million to a consultancy firm to advise on “strategic and productivity matters”.

Both these developments might seem perfectly reasonable, especially since roughly three-quarters of England’s 42 integrated care systems have been unable to set balanced budgets for 2024-25. But we shouldn’t forget that these proposals are being administered by the same NHS England that has repeatedly thrown money at the very same problem — only to watch it go to waste.

Last year, in an effort to improve patient care and data efficiency, NHS England handed a staggering £330 million IT contract — the biggest in its history — to Palantir, an American spy-tech company. Palantir’s connections to the CIA and Ministry of Defence sparked concerns among campaigners about data privacy, but less discussed was the financial risk. Few senior doctors have forgotten the National Programme for IT in the NHS, which was launched in 2002 and supposed to improve services and patient care. It would have been the biggest non-military IT system in the world — but was eventually abandoned after costing more than £10 billion of taxpayer money. (The initial projection was £2.3 billion over three years.)

And yet, debates over the state of the NHS — and A&E in particular — are suffused with collective amnesia, with few willing to say that the honest thing: that the best Streeting can hope for is that Labour is able to secure a second term, beyond which point its reforms might actually take effect. But as things stand, Britain’s A&E departments embody everything that is wrong within the healthcare system, from social care to psychiatric support.

True, Streeting has taken the radical step of effectively dumping the Care Quality Commission, one of New Labour’s last innovations, which was long overdue. On the wards, it’s generally accepted that, as a regulator, it’s been hopeless. Several hospitals haven’t been inspected for years, including one which was last reviewed a decade ago.

But simply shutting down an ineffective regulator and hiring expensive consultants to tell us what we already know isn’t “reform”. It’s not even a sticking plaster. Every week, I see patients presenting with medical conditions ordinarily not seen in this hemisphere or century because they’re not being treated until it’s almost too late. They are the broken Britons of broken Britain — and I’m no longer convinced we’ll be able to save them.

The defendant, picked up in a routine traffic stop, denied being the man who’d carried out an inside-job fraud at the shop where he’d worked some years earlier. His name, ID and credit cards matched, and apart from a little weight gain and a new hairdo, he looked exactly like the two available photos of the criminal. A defence “facial mapping” expert pointed out several differences, but our own expert explained them away and supported the identification. Forceful cross-examination of the defence expert led him to concede that he might be wrong. But a last-minute double-check by the police unearthed — finally — one of the fraudster’s former colleagues. His probity beyond question, he was brought to court to say whether he recognised the man in the dock. A guileless “no”, followed by an unfakeably perplexed chuckle when it was suggested it might be the man he used to work with, confirmed the defendant’s innocence. (The two might well have been cousins sharing an identity, but that’s another story.)

It immediately became blindingly obvious to me that the photos of the two men were not the same person at all. You could tell at a glance! But when you are given a theory, and you run with it, it takes something big to bring about that paradigm shift.

In the case of the nurse Lucy Letby, a theory that she was a murderer was alighted upon by one of the ward’s consultant paediatricians very early on — after only a very few of the unexplained deaths or collapses that ended up on her indictment — and the theory was based almost entirely on her having been on shift at the relevant times. There can be little doubt that there was not, at that stage, enough evidence for murder to be anything other than a remote possibility. So either it was a very lucky guess, or this theory was later taken up by others in a way that led to inaccurate expert medical opinion, the misleading presentation of evidence, and a terrible miscarriage of justice.

Following her conviction last August, for murdering seven babies and trying to kill six others, a 13,000-word piece in The New Yorker told a compelling story of her likely innocence. More recently, and once the reporting restrictions were lifted after her conviction three weeks ago in a retrial for the attempted murder of one of the babies on which the jury could not agree, long pro-defence pieces have appeared in The Guardian, Telegraph, Independent and Private Eye. Also recently published — withheld pending the outcome of the retrial — is the written judgement of the Court of Appeal, who refused her application for leave to appeal.

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An appeal first goes to a single judge, who makes a decision on the papers whether to let you argue it at a hearing. In Letby’s case, that judge was Sir Robin Spencer, who turned her application down. Coincidentally — or perhaps not — Spencer was the barrister who led the prosecution of Sally Clark in 1999, who was wrongly convicted of killing two of her young children. That notorious miscarriage of justice, as well as others from the same era, such as Angela Cannings and Donna Anthony, was based on flawed statistical evidence about cot death from the since-discredited and disgraced paediatrician Sir Roy Meadow.

“Unknown unknowns” back then included the possibility of a genetic factor that could explain multiple cot deaths in the same family. It was nearly 20 years before a good candidate was discovered. A growing collection of lawyers, doctors and statisticians believe that something similar — flawed statistics and paediatric misdiagnosis without due respect for unknown unknowns — may have occurred in Letby’s case.

If the first Court of Appeal judge turns you down, you can try again at an oral hearing in front of three others. Letby was again unsuccessful. Their written judgement is long, detailed and illuminating. But it will not, I suspect, relieve much anxiety about a possible miscarriage of justice.

The main issue in the original trial, and indeed the retrial, was whether the deaths and other “events” were deliberately caused. Letby’s biggest problem here was the two allegations of attempted murder by insulin — Babies F and L, committed some eight months apart. Blood test results showed high insulin accompanied by low levels of a chemical called c-peptide. When the pancreas produces insulin, it produces similar levels of c-peptide. Therefore, the Crown said, the insulin was not produced in the body. It was, in other words, artificial. Therefore, it was an attempt to kill.

The inference to foul play with these two babies is arguably much stronger than it is with the more numerous diagnoses of air embolism, which was a more subjective opinion, more dependent on the statistically questionable “shift-pattern” evidence. The two guilty verdicts on the insulin counts were the first the jury returned — the next not coming for three days — and were two of only three unanimous convictions in the trial.

The Court of Appeal records that “the integrity of the blood samples and reliability of the biochemical testing was challenged by [defence KC] Mr Myers. However, in her evidence at trial, the applicant admitted that both babies had been poisoned by insulin, but denied that she was the poisoner.” The Crown made much of this “admission”, but the point is seriously unfair.

Letby was being pushed quite hard to swallow an inference which she was in no position to accept or deny. Her evidence was that she did not poison them — simple as that. So her opinion of the validity of the blood samples and the inferences to be drawn from them is neither here nor there.

This is a common practice by prosecutors, easy to lapse into in the heat of the moment. I’ve done it myself. “So it’s all just a big coincidence is it? Or have these two complainants put their heads together?” — that sort of thing. You’re trying to make a little speech and put the defendant on the back foot, in the course of questioning them about matters within their knowledge — which is what you should confine yourself to. But a defendant’s answers to such questions are not a sound basis for treating a prosecution inference as agreed by the defence. If the reliability of a blood sample is not agreed, or an inference not accepted, there the matter should rest. Her barrister explicitly did not concede the accuracy of the results in his speech to the jury, much less the inferences to be drawn.

And it seems there may be good reason not to accept their validity. The Guardian has reported serious concerns about the results from senior experts in the field. The Telegraph quotes guidance from the relevant lab saying that its tests are “not suitable” where the introduction of artificial insulin is suspected. And The New Yorker piece quotes the Crown’s expert as saying that there was a third insulin case, with similar blood results, not attributed to Letby. The samples cannot be tested again as they were destroyed soon after they were taken — because the babies’ blood sugar levels recovered and there was no suspicion of wrongdoing at the time.

But even without these post-conviction queries, if this were the only evidence, and these the only allegations, I would hope no jury would convict a nurse for attempted murder on that basis. The timing and detail of the insulin results meant that the Crown had to say that not only must Letby have poisoned the feeding bags she herself put up, but also must have poisoned one or more other bags in the store cupboard so that they would unwittingly be administered by other nurses after she had left. (The bags themselves, of course, are long gone.) Would you feel sure a random nurse tried to kill two babies eight months apart, or would you think this might be an instance of why the lab says its tests are “not suitable” for proving the presence of artificial insulin? But of course, this was not the only evidence against her.

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There are also Letby’s online searches for bereaved families, and the collection of medical notes found at her home relating to some of the events she was charged with. Neither of these, I feel, are anything like as bad as they look: they both stand against a background of a much larger number of non-suspicious searches and medical notes.

But for many observers, and perhaps for the jury, the “confession” note is persuasive. For criminal lawyers, less so. That’s because false confessions are surprisingly common. So much so, that a law was enacted to prohibit a confession being given in evidence unless the prosecution can prove beyond reasonable doubt that it was not obtained by oppression or as a result of anything “said or done” that was likely to render a confession unreliable.

How could any nurse subjected to a long investigation into whether they have been murdering babies find the process anything but oppressive? If the case against her can be proved beyond reasonable doubt, one might think it could — and even should — be proved without the mixed inculpatory-exculpatory scrawls of a woman on the brink.

Almost all of the rest of the convictions — that is, all seven murders and three of the alleged attempts — involved the deliberate injection of air, leading to air embolism. One ground of Letby’s appeal impugned the prosecution experts’ diagnosis-by-exclusion — i.e. “we don’t know what else it could be, so it is likely to be air embolism” — as well as their diagnosis on the basis of various kinds of unusual skin discolouration that were observed. The 1989 research paper relied on by the Crown’s experts, Pulmonary Vascular Air Embolism in the Newborn, is very short, and says relatively little about skin discolouration other than that, in about 10% of the 50 or so cases they reviewed, “migrating pallor” in the skin was observed — which, it was not disputed, may be caused by other things.

The Court of Appeal was not impressed by this complaint, or by fresh evidence from the surviving author of the 1989 paper in which he criticised the use to which his research had been put in the Letby case. The experts were entitled to use skin discolouration as supportive of the diagnosis, the court said, as being “consistent with” embolism; the fresh evidence did not undermine that; and the lack of any other plausible explanation is significant.

“Consistent with” does a lot of heavy lifting for the Crown in criminal trials. A piece of evidence only helps to prove something if — and to the extent that — there is a difference between the probability of finding the evidence if the hypothesis (e.g. guilt, or air embolism) is true, and the probability of finding it if it is false. More precisely, it is the ratio between these two that determines the strength of the evidence in either direction. That, in a nutshell, is Bayes’s theorem. So, if you can say no more than that a piece of evidence is “consistent with” the hypothesis, but it is also “consistent with” its negation, and you can’t say how much more “consistent” it is with one rather than the other, then the evidence does not assist you either way. For example, if a prosecutor says “the fact you were wearing gloves makes you more likely to be guilty of this robbery”, that evidence is in fact worthless if it’s winter time and everyone is wearing gloves: wearing gloves is “consistent with” both guilt and innocence, to the same degree.

It seems, though, that the experts used skin discolouration as more than merely “consistent with” air embolism. They used it to prove, to some extent, that diagnosis. Which they are entitled to do, if it is a justifiable professional opinion, but it does point to a fundamental danger with expert evidence: the difficulty a jury has in getting behind the curtain and judging what weight to give it.

One way of achieving this is to look at whether the experts have been wrong before. In the case of the lead expert in Letby’s case, Dr Evans, the defence discovered halfway through the trial that he had been utterly excoriated in a ruling by a Court of Appeal judge in a different case. “No effort to provide a balanced opinion… No attempt made to engage with the powerful contradictory indicators… The report has the hallmarks of an exercise ‘working out an explanation’ that exculpates the applicants… tendentious and partisan expressions of opinion that are outside [his] professional competence.” That level of criticism from a senior judge is not made lightly: they know it can be career-ending. And if the Crown had known of it in advance, I suspect they would have looked for a different expert.

Now, this was on one view a gift to the defence: they could now undermine Dr Evans’s credibility by cross-examining him on it in front of the jury. True, his conclusions in the Letby trial were supported by other experts who had checked his work, but the defence argued that those experts were merely rubber-stamping his opinions. The jury may have had a difficult task in assessing what weight to give the criticisms of Evans’s previous work — one with somewhat binary options: disregard his evidence, or believe it. Ultimately, the Court of Appeal upheld the trial judge’s rejection of the defence’s application to exclude his evidence. It might not have been an easy decision for the trial judge, or the Court of Appeal, and although it may have been the correct decision, I cannot imagine any lawyer would claim the situation overall was entirely satisfactory.

Zooming out, the big question remains: without knowing of the police investigation and the suspicion of foul-play, and the fact that one nurse was on duty for many or all of the incidents under review, would any expert have diagnosed air embolism by the deliberate injection of air, in any of those cases? Certainly none of the pathologists did at the time.

In his recent Private Eye piece, Dr Phil Hammond gives a startling statistic: in a review of more than 1,000 cases of infant death in south-east London, “the cause of mortality was unexplained for about half of the newborns who had died unexpectedly, even after post-mortem examinations”.

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So, the shift-pattern evidence — i.e. the fact that Letby was on duty for so many unexplained deaths and collapses — does seem to have been central to the case against her. And statisticians are questioning its probative power. Even leaving aside the issue of deaths and other negative events that occurred when Letby was not on duty, coincidences of that scale occur — just as someone will win the lottery each week, at odds of 14 million to one.

Also very unusual is the fact that Dr Evans “pitched” his services to the police, when he heard about the investigation in the media. This is not the way experts are normally selected. The defence argued it indicated pro-prosecution bias. The Court of Appeal disagreed.

And then there’s the fact that in the last few weeks Dr Evans has commented publicly on the defence not calling their own expert, who was advising them throughout the trial. Indeed, that expert, Dr Hall, has himself gone on record saying that he “does not know” why he was not called. And the same question was posed by the Court of Appeal, somewhat pointedly: without having called their own expert, can the defence really complain if the jury agree with the Crown’s?

It’s an entirely valid question. But I would be slow to assume the worst. One reason the defence might have chosen not to call Dr Hall (and I am speculating here) is if they felt they had so thoroughly undermined Dr Evans that they were better off leaving it at that. That would be a big tactical call, but covering your own back is not always consistent with protecting your client’s interests.

So, for example: if your own expert would contradict much, but not all, of the Crown’s expert’s conclusions, and you believe the credibility of the Crown’s expert has been totally destroyed, you might judge it prudent not to put your own expert in the witness box. Avoiding the potential for future criticism and hindsight regret by putting your client in what you believe will be a worse position — by calling your own expert — is not a boss move. This is all speculation, but I guarantee that careful thought went into the decision not to call Dr Hall. None of this, though, would mean the conviction is safe.

There is evidence against Letby. And the fact that it’s “circumstantial” is not a valid criticism: circumstantial evidence can be, and often is, utterly overwhelming. But this is where comparison with the Sally Clark case really comes in. The famous statistical error in that trial was that the expert Professor Roy Meadow wrongly treated two putative cot deaths as probabilistically independent. But arguably the more important point is that while the probability of “coincidence” might indeed have been very low, so too is the probability of a mother murdering her children. In Letby’s case, the chance that a randomly selected nurse is a baby killer is vanishingly small. As Carl Sagan put it, paraphrasing the French mathematician Laplace, extraordinary claims require extraordinary evidence.

Defence lawyers often say to juries that their clients start off innocent: the fact that they are in the dock is no evidence at all. But this is not quite right. If the probability of guilt is zero, no amount of evidence — that is, no Bayesian likelihood ratios, no matter how high or how numerous — will alter that chance. Rather, a defendant’s prior probability of guilt — that is, before any evidence has been called — is just very, very small. But not all crimes are equally common. A randomly selected member of the public is much more likely to have stolen a bike — given the number of bikes that get stolen — than a randomly selected nurse is to be a serial killer of her patients. But there isn’t much room for these fundamental concepts to be explored and explained to a jury.

There has been some commentary to the effect that those protesting Letby’s innocence should pipe down, that they are behaving irresponsibly. But miscarriages of justice do occur, and the Court of Appeal sometimes gets things wrong.

The only route for Letby now would be a referral back to the Court of Appeal by the Criminal Cases Review Commission, which would require substantial new evidence of one sort or another. The process is not quick, and the Commission do not refer many cases. But I would not be surprised if one day it happens. I hope it does. If Letby has been wrongly convicted, it would be one of the worst miscarriages of justice we have ever seen. If she is guilty, well, true verdicts, like true scientific theories, are only strengthened by rigorous testing and challenge.

Two years ago, I wrote here that the NHS was at breaking point. That point has now been breached. Every day in my own A&E department, I see colleagues — support staff, nurses, doctors, senior managers — in tears. In many respects, it’s encouraging: at least they still care. It’s when they stop crying that I know another person has given up on the system.

The bottlenecks are there for all to see: at one end of the funnel, thanks to breakdowns in primary healthcare provision, too many people access our overwhelmed emergency services. You’re now more likely to see an ambulance queuing outside a hospital than on your street. Inside, meanwhile, would-be patients are forced to wait in bloated emergency rooms, slumped on the floor. That’s because the other end of the funnel is clogged up, too. Bed blocking means patients are stuck in a holding pattern further up the system. Unless these conditions are resolved, a seamless transition from home to ambulance to A&E to a specialist ward is a pipe dream. No one can move forward; no one can move on.

Watching Channel 4’s Undercover A&E earlier this week, what left me slack-jawed was the surprise, rather than disgust, that a consultant displayed when he learned that a patient presenting with a suspected stroke had not been properly examined after being left in a waiting room for 24 hours. If you’re a consultant with an acute specialty, in a leadership role, and you’re not aware of such problems on your watch, then you’re part of the problem.

Especially when none of these horrors is anything new. In 2018, the Government placed Shrewsbury and Telford Hospital NHS Trust into “special measures” following concerns about “several challenges where patient care could be at risk”. These challenges included governance, urgent and maternity care and, revealingly, whistleblowing.

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How did the Conservative government choose to remedy this? By serving up five different health secretaries since the start of 2018, one of whom, Steve Barclay, served two separate terms in office. Not a single one has been able to manage, reform or revitalise the NHS in a manner they can present to the country as a vote-winning achievement. As Dan Poulter, the former Tory MP for Central Suffolk and North Ipswich, said after defecting to Labour ahead of the election: “I found it increasingly difficult to look my NHS colleagues in the eye, my patients in the eye, and my constituents in the eye with good conscience.”

And yet, while the case against the Tories is damning — years of neglect, underfunding and contempt — I’m far from convinced that Labour can do any better, or is interested in trying. Shadow health secretary Wes Streeting sounds like he’s got it in for doctors already. “You can’t just keep on pouring ever-increasing amounts of money into a leaky bucket,” he said recently. “It’s not right to keep on asking people on low-to-middle incomes to pay high taxes when they’re struggling… and it’s not right that they don’t get much for the money they are putting in.” As far as my colleagues and I are concerned, his message wasn’t hard to glean: NHS doctors are lazy and overpaid. And it seems few in the party are willing to correct him.

Since refusing to back Streeting’s call for private sector intervention, Dr Rosena Allin-Khan, former shadow mental health minister, has been M.I.A. regarding Labour’s health policy. Elsewhere, at least 30 doctors of assorted political hues are standing as candidates next Thursday. Not that you’d know it. Since the election was called, there has hardly been any discussion about the “national treasure” that is the NHS; they’d rather bury the subject until afterwards for fear of being unable to deliver on manifesto promises. Every party’s pledges to boost NHS spending seem fanciful at best, while it remains unclear how these promised funds will be allocated to each department. But such detail doesn’t seem important, especially when you can — as Labour does — simply promise to “cut NHS waiting times” and “double the number of cancer scanners”.

It’s not my business to advise or suggest who to vote for, not least because, when it comes to sorting out the NHS, it will inevitably be a pyrrhic victory. But assuming the polls are right, and some force majeure doesn’t intervene, my fear is that, come the morning of 5 July, Mr Streeting will be my boss, empowered by a “supermajority” that will compel him to do… well, not very much.

Junior doctors will press on with their industrial action; the clogged emergency departments will continue to overflow; social care will continue to be ignored; and the private hospitals will carry on cherry-picking uncomplicated patients and leaving under-resourced inner-city hospitals to pick up the slack. To his credit, Keir Starmer has repeatedly made clear that the NHS is not for sale — but who, let’s be honest, would want to buy it?

Opened in 1989, and closed following a litany of scandals last year, GIDS — the UK’s only specialist service designed to help children questioning their gender and/or identifying as transgender — drew on just one, since widely critiqued, study to underpin its practice. This, despite the fact that it has treated roughly 2,000 young people with hormone blockers and in some cases cross-sex hormones.

“The Dutch Protocol” describes a three-step treatment pathway for children with gender-related distress or incongruence. It starts at the brink of puberty with puberty blockers to prevent the development of secondary sex characteristics, is followed by cross-sex hormones that help to feminise or masculinise appearance, and then concludes with genital and/or breast surgeries in adulthood. The Dutch reported that, after puberty suppression alone, their cohort of 70 young people experienced a reduction in behavioural and emotional problems, decreased symptoms of depression and a significant improvement in functioning. Despite choosing to make medical treatments available to younger children from 2014 anyway, GIDS were not able to replicate the Dutch findings — a fact they didn’t share with the world until 2021.

Given the increasing polarity among professionals on the matter, Dr Hilary Cass, a former President of the Royal College of Paediatrics and Child Health, was employed by the NHS to conduct a review of the published evidence on the use of puberty blockers and cross-sex hormones in children and young people with gender dysphoria. In March 2021, she concluded that they had not been able to find evidence “strong enough to form the basis of a policy position”. It was clear then, at least to those paying attention, that the evidence needed to justify the existing clinical practice in Gids did not exist. And yet, it wasn’t until last month that the NHS announced it would no longer be offering puberty blockers to young people in England and Wales.

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Today, as Cass finally publishes the results of her wide-ranging review, the reason seems obvious: her 388-page report concludes that, for most young people, up to the age of 25, “a medical pathway will not be the best way to manage their gender-related distress”. Commenting further on the lack of evidence, she states that not only is there no way for a clinician to accurately determine who will continue to identify as trans for life and who won’t, but that the fundamental rationale for using puberty blockers in the first place “remains unclear”. She speaks of the need to balance medical innovation with the potential “creep of unproven approaches into clinical practice” and calls for the use of “standard evidence-based” interventions instead.

Cass also makes it clear that the factors influencing gender-related distress might be as much social as psychological or biological, with a particular focus on the new cohort of adolescent girls who now make up the majority of gender clinic patients. Instead, she suggests, we need to draw on bio-psycho-social thinking to ensure that future child patients receive the safe and effective care they deserve.

The motivation behind this isn’t hard to glean. The sociological “broken windows” theory hypothesises that, once something becomes damaged just a little, it sends a message that the thing is no longer of value at all, and leads to further vandalism. At heart, the Cass Report is an attempt to prevent this from happening: it punctuates a process that, left unchallenged, might have led to further extraordinary practices creeping into other areas of psychology or medicine.

For those of us working in the field of gender, the influence of social media on adolescent mental health, in multiple and complex ways, has been undeniable. What gets less attention is the impact on us, the adults and professionals. After all, we are just as vulnerable to social influence, including misinformation. One of the factors that has led to the increased demand for medical interventions from gender-distressed young people are the ideas, widely shared on social media platforms as facts, that the medical pathway is not only safe but effective, even life-saving, for all.

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Despite the absence of face validity or the long-term data needed for such certainty, some have claimed that regret rates for the surgeries many Gids patients received during early adulthood are lower than for knee surgeries. Yet, as the Cass Report highlights, some of the “facts” shared online are not certainties but myths. Sadly, for example, some young people do later experience profound regret — a reality that Cass acknowledges in her recommendation that “NHS England should ensure there is provision for people considering detransition”.

Yet rather than accept Cass’s rational, evidenced conclusions, a number of professionals and institutions will no doubt continue to argue with certainty that access to medical interventions is both a necessity and a human right. They already call for their colleagues to join them in becoming “practitioner-activists”. Others openly describe their motivation to pursue the medical approach Cass wishes to end as being “based on how passionate we are about the work”. Passion can be a good thing, of course, when aligned to evidence and fact. But when passion becomes untethered to these, or worse tethered to misinformation, it risks transporting us into a troublesome arena. Such an approach has already led to serious lapses in best practice and governance, particularly in relation to the use of puberty blockers for children. The question now is: will such extraordinary practices be able to continue post-Cass?

This is where a sense of concern starts to creep in. For while NHS England has refocused on the need for evidence-based interventions in recent years, some practitioners have already made clear their resistance to this. Last year, we heard that the endocrinologist responsible for prescribing to Gids patients had questioned whether the Cass Review was necessary in the first place. Leaders in the field of clinical psychology have also challenged the need for the review, and splits in the UK’s two psychology associations have been apparent for a while now, with one publicly criticising Cass. Remarkably, as today’s report discloses, the NHS’s adult gender clinics have also set themselves up in opposition to evidence and research, by refusing to participate in the Cass Review’s centrepiece longitudinal research study — an attempt, albeit retrospective, to follow into adulthood the 10,000 young people who’ve been through GIDS’s doors.

In an attempt to explain away such behaviour, some have sympathetically described GIDS as a “justice project”. Yet, in her interim report, published in February 2022, Cass made clear that the implications of GIDS’s approach were far more serious than this: its clinical approach, she wrote, had “not been subjected to some of the usual control measures that are typically applied when new or innovative treatments are introduced”. Just over two years later, she ends her final report by remarking that, while GIDS clinicians were “passionate and wholly committed to their care, [they] had developed a fundamentally different philosophy and approach compared to other paediatric and mental health services”. This deviation from best practice was, in other words, an injustice, and resulted in one group of children receiving less robust standards of care than others.

To mitigate this, Cass invites a return to the ordinary, and an embrace of the scientific method. And this requires sensitivity: after all, understanding why gender-distressed and non-conforming people might have been reluctant to trust ordinary science, medicine and psychology/psychiatry should also be part of the post-mortem to come. Medical approaches and institutions haven’t always been a safe place for them. Sadly, this is not the first time that gender non-conforming people have been considered so different as to require extraordinary treatment. Perhaps Cass’s recommendation to offer regular treatments to our distressed, but still ordinary, children and young people is where the true justice will begin.

Ryan acknowledges that his decision to pay £25,000 for a surgery that was pioneered to help soldiers recover from battlefield injuries might seem irrational. Now in his late 20s, he worked extra shifts as a waiter and freelance writer to help finance the operation. “A normal person would think you were crazy,” he says. “But I was at breaking point. If you lived in my head for the last five years, you’d understand.”

Despite having an outwardly confident exterior, Ryan’s height-related insecurity began at around the age of 16 while he was still at college and started to notice that younger friends were outgrowing him. “I remember feeling significantly smaller than my classmates, as if I was underdeveloped. There was a sense that I didn’t matter as much as the others and that there was that something missing.”

Although he was never bullied, Ryan found the long-term cumulative effect of occasional height-related digs corrosive enough to lead from low self-esteem to anxiety and depression. “You realise that there’s something about you that’s outside the standard deviation of people that you’d meet — and then you realise you can’t do anything to fix it. It was definitely a contributing factor to a lot of the mental-health difficulties I had during my late teens and early 20s. It sort of consumes you.” Even close friends had little sense of the extent of his despair.

Ryan remembers reading that cosmetic limb-lengthening surgery had been pioneered in the United States. But at a prohibitive cost of around £125,000, it was too remote a prospect to ever entertain seriously. And then he became aware that, by outsourcing post-operative care and physical therapy to a non-clinical setting in hotels, providers in Turkey were offering several versions of the same procedure at more affordable rates.

At around £45,000, the most expensive package there replicates the higher-tech version of operation available in the States. By implanting an extendable nail in the bone cavity, and then using magnetic sensors to lengthen it by remote control, it does away with the need for a bulky metal external fixator while also speeding up recovery and reducing the likelihood of infection, nerve damage, blood clots or the possibility of the bones not properly fusing.

However, younger patients on more limited budgets like Ryan, tend to opt for the lower-tech Lengthening Over Nail (LON) method that costs between £25,000 and £33,000 Unfortunately, LON does requires require the bulky external fixator, which is wrapped around the leg externally and attached to the bone through the skin with pins, making scarring and infections more likely. What’s more, LON patients are required to lengthen their limbs themselves, by manually twisting a key in the metal fixator on four excruciating occasions throughout the day.

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By the time Ryan was ready to outline what the LON procedure would entail to his girlfriend, he had sunk further into his depression. Although she was initially horrified at the idea, she came around when she realised that the risks of doing nothing outweighed those from the surgery itself. Therapy had been repeatedly tried and had failed to remove Ryan’s crippling insecurity.

“She could see that I was at breaking point and that I’d already made my mind up, so she supported me throughout the process,” he says. After undergoing surgery 18 months ago, Ryan remained in hospital for five days on a cocktail of strong painkillers, morphine, antibiotics and blood thinners before being transferred to the hotel.

Today, Ryan claims he was one of the lucky ones because he always found the pain manageable; he remembers mind-numbing boredom being the biggest challenge. Robert, also from the UK, is there now and has not been so fortunate. When I spoke to him, he was halfway through the three-month lengthening process and still in very obvious discomfort. On the rare occasions that the pain subsides, Robert, an IT developer in his late 30s, can work remotely. “The pain is constantly there so I’m using painkillers. It stops you from doing anything like reading or watching films, but I sometimes manage to do some work on the laptop.”

Relentlessly, every six hours without fail, Robert turns the key in the external fixator that lengthens the legs by 0.25 mm. Invariably, the pain intensifies 10 minutes later as the muscles, and nerves stretch to accommodate the adjustment. ‘’It’s a serious procedure and being trapped in a hotel with such limited movement is obviously a very unusual situation.”

When I ask him why he’s putting himself through this, Robert cites a lack of confidence and a general sense of never quite being able to live life to the full. “Being taller has always been at the back of my mind — a sort of secret wish. You do feel as if you’ve missed out on certain things. And of course women desire taller men compared to themselves.”

By the time he returns to the UK in around six weeks, Robert is hoping for 8cm of growth (from 167cm to 175cm). While he still needs a wheelchair to get around, by then he should be able to manage on crutches — although a full recovery will probably take nine months. He has no plans to broadcast where he’s been, but if close friends expressly ask him where he’s been or notice the change in his appearance, he plans to confide in them if they promise to be discreet.

Back in Istanbul, Makbulijana Haruni, the patient welfare coordinator at the Iwannabetaller clinic, remains inundated with dozens of enquiries about limb-lengthening each week. She explains that most requests are rooted in the desire to project more confidence, power and status at work. “We see a lot of businessmen who say I’m in a senior position and need to lead teams of people but with this height I’m not able to do this,” she says. People believe that if they are taller, they will be heard more or more likely to be considered for promotions because they’re taken more seriously.”

As a patient welfare coordinator, Haruni comes as part of the package. The clinic has the capacity to operate on 80 patients each year and Haruni works with her team to screen out patients with body dysmorphia — a serious mental-health condition where sufferers obsess over flaws in their appearance. She acknowledges that patients with body dysmorphia can be treated more effectively by therapy and antidepressants; surgery would be futile. Patients have to pass a pre-surgical psychological assessment to be eligible for the operation.

However, according to Haruni, not all of their competitors are quite so scrupulous. You only have to type limb-lengthening surgery into a search engine to see the proliferation of the procedure with clinics popping up in health tourist hotspots Mexico, India and even Iran. It’s an entirely unregulated global market where orthopaedic surgeons promise simple surgical solutions to complex problems with far too much gusto and entrepreneurial flair.

“Around the world, orthopaedic surgeons have clearly realised that they can make a lot of money in this way,” Haruni says, before adding that the hype is clearly fuelling unrealistic expectations. She increasingly has to reason with patients demanding growth of more than 6-8cm from the procedure, even though that escalates the risks of potentially life-changing complications.

But what is driving such international demand? When the American sociologist Saul Feldman popularised the term “heightism” in the Seventies, he identified an insidious unconscious bias that’s hiding in plain sight. “American society is a society with a heightism premise: to be tall is to be good and to be short is to be stigmatised,” he wrote. And to combat the last socially acceptable form of discrimination, he called for a “sociology of stature”. Over the past half century, researchers have been amassing an imposing body of research, with international studies showing that being tall correlates not just with enhanced educational outcomes, social mobility, romantic success, and acquisition of leadership positions, but a better quality of life in general.

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Elsewhere, anthropological studies across cultures consistently show that taller stature is linked to increased social status. Although the reason why is unclear, there is a lot of evidence to support the interpersonal dominance theory — that we’re more likely to defer to the judgement of taller people because they are more likely to win a physical confrontation. When, for instance, the journalist Malcolm Gladwell was researching how we unconsciously form erroneous first impressions for his book Blink, he found that 58% of the CEOs of Fortune 500 companies were above 6 feet even though only 14% of men in the general population were that tall.

Does this mean that heightism is hardwired into our consciousness as an insidious prejudice? Taken in the aggregate, the evidence for the existence of the so-called “height premium” is certainly compelling, to the extent that limb-lengthening surgery starts to seem like the extreme end of the cosmetic-procedure continuum: how different is it to transhumanist endeavours such anti-ageing biotech or biohacking?

Viewed in this way, Turkey’s nascent limb-lengthening industry feels like an unnerving glimpse into that biomedical brave new world where status itself is a marketable commodity. A tummy tuck or nose job might give you confidence and change the way you feel about yourself, but it can’t re-engineer the invisible power dynamics in every room that have been crafted by millions of years of evolution in the way a “height transplant” can.

Eighteen months on from his surgery, and three inches taller, Ryan has transitioned from just below average height to just above, and is perhaps uniquely placed to comment on these new power dynamics. “I just feel that I’m a default person now with my own attributes who can no longer be as easily dismissed,” he says. “It forces people to engage with me for who I really am.”

Neurobiologists there have discovered that a specially designed “deep neural network”— that is, an AI presumably devoid of the misogynist prejudices of ordinary mortals — can reliably sort brains into male and female categories based on the detection of “hotspot” activity patterns. Worse, it seems that the AI can also use these differences to reliably predict different cognitive performances in men and women on certain tasks, suggesting that functional brain variations have behavioural implications. Though it’s a bit early to say, perhaps we can now look forward to a more harmonious future, where a woman can be proudly unapologetic for her inability to reverse park, and a man gets to blame his brain for repeated failures to notice that his wife is crying. Meanwhile, for the many thinkers who have staked their professional identities to the non-existence of two kinds of brain, now might seem like a good time to move some eggs into a different career basket.

Indeed, some feminist researchers already appear to have got that memo, with their provocative stances becoming noticeably more diluted as the years pass and new evidence for the opposition’s case stacks up. Back in 2019, British neurobiologist Professor Gina Rippon — author of the brashly-titled The Gendered Brain: The new neuroscience that shatters the myth of the female brain — felt confident enough to dismiss the idea that there were any systematic brain differences based on “sex alone” as “neurofoolishness’. Furthermore, she said, any limited differences that did exist between men’s and women’s brains were “much more a function of experiences”, and a result of contingent exposure to “our gendered world”, than the predictable result of background chromosomes and hormones.

Yet this week, we encountered Rippon in the Telegraph, responding to the Stanford findings in an apparently more conciliatory vein: wondering whether it might be that “almost all brain–shaping factors are dynamically entangled products of both sex and gender influences”; and whether perhaps, with the new research, we are “looking at what should be called sex/gender differences” rather than “sex differences” or “gender differences”. Given widespread acknowledgement of the importance of social environment for brain development, and also of the existence of neuroplasticity — including by all those who insist that underlying biological factors make a systematic difference to some of what human brains are, and what they can do — it is unclear which of Rippon’s opponents would disagree with her. As is often the case, what started life as two spicily hot contrasting takes have ended up occupying so much shared territory that it’s no longer clear what exactly is being argued about.

In retrospect, for researchers to rule out systematic brain differences largely caused by biological factors in a sexually dimorphic species like ours — and, even more boldly, before adequate technology had been developed to spot them — was always going to pose a reputational risk; a bit like 16th-century astronomers pronouncing themselves absolutely positive there are no further planets in the solar system just before telescopes are invented. What could explain such apparent recklessness? Partly to blame must have been the fear that modern scientific confirmation of the existence of such differences would be used against women in the long run.

As with progressive arguments about reality generally, sometimes the most pressing task is not to establish what is true or false, but rather to lure people away from accurate apprehension of a socially dangerous idea. And it’s not clear that dire predictions in this respect are wrong. Although now a cliché, it’s still true that, throughout history, a raft of excuses for female ill-treatment and subjugation have been predicated on claims about their supposedly more inferior brains. In many countries, the already parlous state of women’s equality would surely be propped up by any scientific-looking discovery of non-negotiable cognitive and behavioural variations from the male norm. Equally though, in countries like the UK where feminised skills like verbal reasoning and emotional intelligence are increasingly demanded in the jobs market, it could be that the discovery would end hurting men’s life chances more.

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Whatever problems might result in either direction, these would be compounded by general statistical illiteracy and an inability not to hear a claim that there are certain patterns across a huge population as an invitation to draw the same conclusions about each and every member. And then there’s also an apparent temptation to start treating some sex-typical behavioural patterns, averaged across a general population with many exceptions, as representing a kind of template definitive of the “male brain” or the “female brain” itself — which can even be lifted from its original genetic context and attributed to individuals of the opposite sex, should their individual qualitative characteristics seem to fit the bill. Bizarrely, given his intellectual background, this appears to be the approach adopted by former mathematical physicist Eric Weinstein, who in a widely circulated clip this week claimed that “there are people with male brains in female bodies, and conversely”, arguing that society should be more compassionate towards them.

Of course, many of us by now are very familiar with the general gambit of adjusting claims about reality to fit better with perceived moral commitments. For its basic form is also present in the progressive doctrine that self-identified transwomen should indeed be classified as women, because it would be very harmful for them if people said otherwise. Indeed, there is an increasingly popular narrative amongst anti-feminist commentators such as Matt Walsh that the current transactivist derangement still gripping many institutions started with feminism. In most ways this is diabolically unfair, especially since radical feminists were at the forefront of fighting transactivist ideas years before Walsh cottoned on. But it’s true that certain feminist academics wrote the playbook for wishful thinking about reality. Time and again in scholarly writing, you encounter the bizarre thought that if an idea has consequences that are helpful to women, that must be a point in favour of its truth; and if unhelpful, it’s a point against.

This isn’t just the more benign claim that some inconvenient truths can safely be ignored. There are lots of facts in the world it would be pointless or detrimental to pursue. It’s not even a deliberate fake-it-til-you-make-it strategy, self-consciously pretending to others that something is true because a widespread commitment to the existence of that thing would better fit some group’s interests. Rather, it’s the mad idea that the anticipated social undesirability of something being widely believed to be true can be recycled into a positive epistemic reason as to why that thing couldn’t actually be true in the first place.

For instance: there can’t be consistent sex differences favouring mathematical reasoning abilities in males, on average, because if there were, this would keep talented females out of STEM subjects. (Argue away about the differences by all means, but don’t pretend this is a good reason to think there aren’t any.) Or: women must be understood as a socially defined “gender” and not as a biologically defined sex, because if women were a biologically defined sex, unscrupulous men would treat their biology as destiny, and oppress them on that basis. The latter argument appears in feminist writing from at least the Seventies onwards, and is still being regurgitated by philosophy professors with a supposedly advanced grasp on logic to this day.

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Quite apart from the fact you are likely to end up spouting gibberish if you proceed in this way, there are other pitfalls too. One is that, since your assumed noble aim is to avoid harm to others by reasoning as you do, you are more likely to start uncharitably misrepresenting intellectual opponents in a particular factual dispute as if their primary aim must be to commit harm — when of course it need not be at all. This partly explains not just the unjust accusations of “transphobia” so easily launched at sex realists, but also the weirdly spikey feminist mentions of neurofoolishness and the like in the context of brain research.

And relatedly, since you have now lost touch with reliable truth and evidence-seeking methodologies at least some of the time, you are more likely to have to resort to histrionic misdirection in arguments with your opponents: not just unfair ad hominems, but also objections that they have not read or understood “the literature” or paid suitable deference to elders in the field; accusations of mansplaining when they quite reasonably argue back; complaints that you are too exhausted to carry out the emotional labour of “educating” them all over again; and so on. Again, such manoeuvres are by now a well-known staple of reality-denying transactivism, but arguably, reality-denying versions of feminism got there first. Ironically, such guilt-tripping, heartstring-pulling rhetorical devices are still sometimes employed by self-proclaimed feminists, partly in the service of insisting that women could not possibly be more emotional or irrational than men by nature. And I hate to be the bearer of bad news, but it does not come across as particularly convincing.

Recent weeks have brought us two new and impressive examples of this genre. A New Yorker long read about the project of growing a near-identical breast milk substitute from human mammary cells relates the touching tale of Leila Strickland, a cell biologist at Stanford whose personal struggles with breastfeeding led to the formation of her company Biomilq. And within the pages of the Financial Times, we encountered Nicole Shanahan, ex-wife of Google co-founder Sergey Brin and CEO of an intellectual property software company in Silicon Valley. At the age of 31, Shanahan was having difficulties harvesting her eggs in order to freeze them for a future conception — the updated version of “was trying to have a baby but couldn’t”.

In a description that would sound impossibly neurotic were it not being uttered about someone with massive personal wealth, readers are told that she “was haunted by the fear that her life was being shaped by an organ that had been ageing before she was born” (namely, her ovaries). Attending a gathering in the home of a “Hollywood power couple” in 2017 and listening to a talk about the project of scientifically increasing human longevity, she idly swipes open her fertility tracking app and has “a moment of powerful insight”: why is nobody working on “reproductive longevity”? Or, in other words, how can we stop ovaries ageing so fast?

Several years later, and post-divorce from the Google bloke after an alleged (but denied) tryst with Elon Musk, the entrepreneur is still bankrolling academic research into this question on an epic scale. One study she funds is apparently looking at the potential of immunosuppressant drugs currently licensed for organ-transplant patients to delay menopause — if nothing else, a pleasingly symmetrical companion to the prescription of terrifying-sounding off-label drugs to delay puberty at the other end of things.

For some, it will be quite hard to get behind the supposed drama and nobility of Shanahan’s quest — to see her as we are implicitly encouraged to do, as a kind of brave pioneer or astronaut, wandering about in a mostly unknown realm — because this requires us to act like we don’t already know the answers to the questions she asks so urgently. As listed by the FT, these include: “Why are the ovaries one of the first organs to age? Why does the quantity and quality of eggs fall so dramatically? Why do humans go through menopause when so many animals do not?”

The truth is that evolution and natural selection have quite straightforward explanations; in fact, from that perspective, a much more puzzling question is why human females don’t die immediately after menopause, as so many other animals do. But then you realise that Shanahan and her researchers are totally uninterested in any answer that might position the female body as part of the natural world. When they ask “why…?”, all they really want to know is what mechanisms and environments immediately cause the limited shelf-life of human ovaries, so that they can then try to fiddle about with the process.

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A different reporting trope in this area is to observe that if such-and-such reproductive problem was happening to men, modern medicine would have dealt with it already. True to form, in the story about Strickland’s ambitions for breast milk substitute, a food scientist is quoted as saying that, thanks to “middle-aged white men”, there has been little medical interest in lactation historically. In the story about Shanahan, meanwhile, we’re told that “while men were finding myriad ways to lengthen their own lives, barely anyone was researching how to slow ageing ovaries”.

Such clichés fit well with the feminist complaint that, due to sexism, the particularities of a woman’s body have been under-researched historically and are still poorly understood, relatively speaking. It is, of course, a fair objection — yet perhaps we should be careful what we wish for.

For the middle-aged men (and women) are now most definitely coming for the female physiognomy, and many of them have dollar and pound signs in their eyes. As such, it would be naïve to think these people have thought through all the consequences of whatever they are trying to sell us. Though Shanahan stresses that her own interest is not commercial, one Bloomberg article late last year estimated that the market for ovarian longevity drugs could reach $44 billion within the next decade. Similarly, a separate report from late last year suggested that “the global infant-formula market” is expected to be valued at “over $100 billion by 2032”.

It’s not hard to anticipate the appeal of such products, should they ever get off the ground properly. Nearly every new mother knows the hell of poor latching, mastitis and cracked nipples, and in my experience is keen to tell everyone else about it: I know I was. To a pregnant or would-be pregnant woman faced with such horror stories, having access to a near-identical breast milk substitute that you could pay for, should it all go wrong, might seem like a blessing. And to the woman not ready to face any of that terribly visceral stuff, but who still assumes they will want to get knocked up at some point, the existence of drugs apparently minimising the luck of the gestational draw in later years might seem a good thing too. In both cases, one assumes, there is a sense of prudentially shoring yourself up against the vicissitudes of biology; of running from capricious Mother Nature into the soothingly reliable arms of the market instead.

This flight from the perceived contingency of biology is obviously behind much of the appeal of so-called technological advances in fertility and reproduction: from the construction of artificial wombs to laser-assisted egg-hatching to AI’s predictive role in embryo selection and beyond. Viewed by prospective buyers, such developments would seem to raise your individual chances in the lottery of healthy baby-making; and who, you might think, could argue with that? A similar rationale makes a surrogacy arrangement desirable to some — except that in this case, another woman’s body now counts as a bit of the technological kit to be carefully tested first and then enhanced through suitable diet and exercise, in order to maximise the success of your aim.

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Indeed, in her mostly absurd book Full Surrogacy Now, author Sophie Lewis argues for widespread surrogacy as the norm for reproduction, partly on the grounds of what she calls “the tragedy of worldly contingency”: the fact, for instance, that “[s]ometimes people can’t become mothers; sometimes mothers die; sometimes they don’t love their babies; sometimes they abort them, abuse them, abandon them, divorce their co-parent or even kill”.

This isn’t so much an aversion to biological luck as a rejection of the very existence of all luck in human projects, full stop. The underlying message seems to be that if an action or process can go wrong in any way, it therefore needs to be improved. And it might be easy to reject such thoughts as adolescent wailing about life’s unfairness, except that a similar motive seems to lie behind technological innovations these days that has ostensibly little to do with mediating biology. Viewed from one perspective, for instance, the appeal of a retreat into VR for some looks like an attempt to cut down the random haphazardness from real life. Why go visit a mountain when you can sit in your living room, experiencing a wraparound panorama of the same thing on your new Apple Vision Pro glasses? Choose what you see and hear, and what you don’t; surround yourself, in the words of the Apple Vision marketing team, in a “beautiful environment”, making your screen “feel 100 feet wide”.

But of course, you can’t get rid of radical contingency in this life, no matter what you do — all you can do is choose your preferred rollercoaster. Apple Vision Pro glasses will eventually malfunction. Selecting a surrogate still means you are at the mercy of what happens to her body, to the eventual baby, and to the human relationships involved afterwards. You can try to mitigate the unreliability of your breast milk by buying a substitute, but you can’t control the supply chain or the price point. And drugs can only help you play reproductive roulette for that bit longer. The problem is not technical, it’s existential — and there’s nothing a biotech start-up could ever produce that would solve it.

Pity the poor Guardian-reader; now faced, alongside all his other heavy psychological burdens, with the prospect of health anxiety spiralling in an uncontrollable loop, recursively feeding off his last set of worries about worries about worries until he keels over from sheer mental exhaustion. And the rest of the newspapers’ health pages this week won’t have helped much. Even as an early test for Alzheimer’s was being greeted with much fanfare, it was also emphasised that the latest drugs are still relatively powerless to reduce the disease’s terrible ravages once diagnosed: bad news for anyone who tends to panic when they lose their reading glasses or forget a word. And there were also unpleasant tidings for fans of ZOE, the wildly popular private programme designed to improve digestive health. One Times report this week suggested that ZOE’s focus on gut health is distracting people from more pressing problems like high blood pressure and cholesterol. Ironically, it also suggested that engagement with the programme is likely to increase health anxiety — bad news indeed for nervous ZOE users who subscribe to both the Times and Guardian.

As it happens, someone in my house has been a ZOE user for the past few weeks, so I’ve had an inside view of the process, as it were. And I can certainly see how it might encourage neurosis. For two weeks, you stick a needle in your arm and temporarily turn yourself into a cyborg, able to check your blood sugar at any point in the day by waving your smartphone somewhere near your armpit. Meanwhile, in a move perhaps secretly designed to revive the fortunes of the Royal Mail now that we’ve all stopped writing letters to one another, you are also instructed to send your faecal matter off in the post. Back comes a chart arraying your personal gut bacteria types, each cosily personified by use of a familiar first name. “Jesse”, “Bethan”, “Polly”, “Somesh” and “Priya” are good bacteria, while among the bad bacteria, there seems a strangely high preponderance of Scandinavian and Eastern European names, including “Sven”, “Slawek” and “Lars”. The goal is to decolonise your gut, quite literally. It’s not hard to imagine that perfectionist types, already susceptible to taking purity metaphors too far in their personal lives, will become obsessed.

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I speak of all this relatively empathically, as a former member of the hypochondriac community. Though free from it now, at earlier times in my life health anxiety has been a torment, made no less unbearable by the knowledge that I was very probably imagining things. My first perceived encounter with the grim reaper was at university, when — sitting trembling in a doctor’s surgery I’d hastily found in the yellow pages — I stammered out my tragic tale to a bored looking medic. About two months earlier, I reported, I’d found a worrying lump on one side of my neck. Later, about two days before the present appointment, I’d discovered another symmetrical lump on the other side. The doctor reached forward and prodded the lumps. “These?” he asked. I nodded solemnly.  A diagnosis was issued: “They are bones holding up your skull.” The relief was intense, as was my embarrassed resolution never to get into such a ridiculous state again. But both were ultimately short-lived.

It’s easy to laugh at hypochondriacs — I do, at my past self — and, if you are one, it’s easy to blame yourself, too. For me, shame was a crucial component of the distress, which lent to an agonising stand-off where I couldn’t bring myself to see a doctor to put an end to the worrying, at least momentarily, for fear of medical disapproval or even ridicule that would come with reassurance. And, actually, the real story is how widespread and debilitating health anxiety is these days, though sufferers are often too ashamed to talk about it; and how newspapers and even the medical profession itself contribute to feeding the beast to bank the clicks.

On one hand, there is the ludicrous boom-or-bust pattern of health reporting. First comes the hope: pouncing with great fanfare on some new piece of research or technology, emphasising its promise to improve some dreaded physical outcome (Ozempic, anyone?). Then, sooner or later, the more sceptical debunkers arrive, suggesting that the original breakthrough was not all it was cracked up to be. Most of us lack the expertise to assess either claim, optimistic or pessimistic, and so are at the mercy of whatever our individual psyches would have us believe. But the more (dis)information that circulates about the relation of behavioural choices to health, or about the range of diagnostic tests or prophylactics newly available, the more everyday decisions can seem freighted with potentially devastating consequences, and the heavier the guilty responsibility if you get things “wrong”.

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And then there is the media’s approach to hypochondria itself; an approach apparently also shared by many doctors. This, as already indicated, is effectively to pathologise the problem as a psychological disorder that, if possible, should be managed or treated — whether through CBT, antidepressants, being “kind to yourself’, or better educating yourself about differential diagnosis, as one Telegraph article suggests. It’s not that these are all bad ideas, necessarily, but more that the initial medicalised framing of the issue hinders rather than helps. The report about ZOE this week exemplifies the paradox: telling us all to worry more, not less, about things like cholesterol and blood pressure, but equally not to worry too much about any of it, as that too would be unhealthy. But while many of us can respond all too readily to a medical cue to be vigilant about something in particular, we cannot mentally stand down on command so easily. Speaking as a person with well-established hypochondriac tendencies, where these get framed as a form of health disorder, the mere existence of them becomes yet one more problem to haunt your thoughts.

And it’s not just the media’s fault, nor even the internet’s generally. In GPs’ waiting rooms around the country, campaign posters exhort you to stay on the alert for even small physical changes, and to alert a doctor as soon as any sinister ones appear — while also failing to say how to distinguish sinister from benign. The general aim of public-health campaigns seems to be not just to scare people, but also to moralise vaguely about non-compliance. Conscientious or suggestible types can easily start feeling as though it is an ethical duty to do regular breast scans, mole checks, and other close bodily readings, and that you have somehow failed if you don’t. I have no doubt, in this time of lengthening waiting lists, that surgeries are full of people with concerns that otherwise would not have occurred to them, had they not been artificially prompted. People with real illnesses are the main losers.

You haven’t failed morally if you miss something terrible, though. I’m not exactly sure what contributed to my own emergence from body-checking hell, but properly accepting that serious illness would never be my “fault”, no matter what the circumstances or lifestyle choices supposedly behind it, was definitely one aspect. Facing the inevitability of death was another; and stopping reading The Guardian, probably a third. I now steer clear of health reporting generally, knowing that, by its very nature, it can only ever increase confusion and not alleviate it. And in general, I try not to think about health anxiety as a medical problem at all, rather viewing it as a relatively normal by-product of strong attachment to life, with all of its known unknowns. When it comes to worrying about worrying about illnesses, probably the last person you should trust is a health professional.

A righteous scourge where progress is concerned. He fell foul of feminists in the Eighties on account of a book about gender that championed the old-fashioned way of doing sex. Traditional sex roles as a bulwark against undiluted consumer culture or some such gender complementarian red-herring. He was greeted at the college campus in Marburg where he was teaching at the time by a mob brandishing a giant papier-mâché phallus. His reputation never recovered. Up until then, he’d been something of a fixture in academic circles. A Roman Catholic priest-cum-anarchic theorist. A bit of a celebrity, even. An ascetic who never really called anywhere home. His final years of transitory earthly existence he spent refusing to treat a large, painful growth emanating from his neck. Reputedly self-medicated by puffing on opium instead.

The corruption of the best is the worst, a Latin Maxim he frequently cited. Illich was at war with the systematisation of charity. The systematisation of everything, in fact. His most famous book — Deschooling Society — is a denunciation of compulsory education, of the “specialised torpor” it can’t help but induce. “Giving” in the Christian sense should not always have to be broken down into rules. This was the essential message embedded in the parable of the Good Samaritan. You answered the call of a specific suffering. As in antiquity, you should not be bound by place or people, but free to love at will. With the institutionalisation of the Christian message, with its ascension to power, the inclination to force the hand of kindness took hold. The mystery was sucked right out of it, and with it went so much of the power and the glory. The church became the forerunner of the law-abiding modern state, the modern state whose incessant social engineering Illich heaps scorn upon from behind a wall of medieval scholarship.

However, it is a later Illich book, in which he turned the same line of attack onto modern medicine, that I find most provocatively stimulating in a 21st-century context. Written in the Seventies, Limits to Medicine — Medical Nemesis: The Expropriation of Health (catchy title) constitutes one of several blistering critiques of modernity and post-industrial alienation Illich produced in his heyday. The gist of it is that the more we lather ourselves in technology, the more of our autonomy we inevitably sacrifice, and the more technology we need just to get by in turn. Instead of enhancing nature, we attempt to step beyond it. A self-replenishing negative feedback loop ensues. The result: Nemesis, the envy of the gods. “Unbounded material progress has become everyman’s goal. Industrial hubris has destroyed the mythical framework of limits to irrational fantasies, has made technical answers to mad dreams seem rational…” I wonder what he might have made of Dignitas?

For Illich, anguish is a part of health, and the inner resources we acquire putting up with it are more precious than decent blood pressure, than the odd bit of surgery. They are fundamental to the building of community. What he calls the “art of suffering” is paramount. In all pain there is a question mark, he claims. To smother it out entirely is to prioritise one aspect of healing — treatment — at the cost of atrophying all of our cultural and spiritual strengths when dealing with agony. Pain-killing gone too far renders us little more than spectators of our own decay. If we don’t bother trying to turn suffering into meaning, we are left ever more dependent on “the machine”.

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The book is broken up into three sections. Beginning with clinical iatrogenesis, when pain and death are a direct result of medical procedure — most obviously, when myopic surgeons do things like amputate the wrong limb, and more obliquely through drug side-effects or antibiotic resistance. Here you’ll lumber into a swamp of footnotes, and far too many Seventies-born statistics, some of which have aged badly. For a start, treatment for cardiovascular disease has come a long way in the last 50 years. You can argue that medical practice sponsors a morbid society by inculcating slovenly lifestyles, but credit where it’s due, I’d far rather suffer this illness today than in 1973.

The sections covering social and cultural iatrogenesis in turn tackle what becomes of society when health policies reinforce an industrial organisation that encourages ill-health. He’s not wrong when he declares that the more energy invested in medicine as a commodity, the greater the delusion that society has a supply of health locked away somewhere. I’ve lived my entire life under this delusion, and will no doubt continue to do so. In fact I’m a prime candidate for an Illichian makeover. I’m depressive, over-ambitious, obsessive-compulsive, an addict and a complete neurotic. I’ve leapt under the knife at every available opportunity. Five times in all. As an adult I’ve had the tonsils out, despite being told it was non-essential. I’ve had two painless, totally benign lumps removed from my neck. Most recently I had a node sliced off of my right vocal cord. I’m the kind of person that starts hammering Solpadine Max the moment I get a sniffle. I expect industrial medicine to sort it, whatever it is, and in no time at all. No self-healing capacity whatsoever.

Illich claims that the negative function of money is the devaluation of that which cannot be bought and sold. The more we dismantle any natural ability to cope, the more we shroud ourselves in pseudo-divine scientist mystification. Obvious enough statements. What’s more interesting is Illich’s attempts to reach behind this dilemma. In his opinion, blaming Big Pharma for the abuse of proscribed chemicals is tantamount to blaming the mafia for the abuse of street drugs. Short-sighted and pointless. When the market for consumer goods reaches a critical level, civilisation convinces itself that the human condition can be remodelled without limit: this is his real gripe, what he considers the root of the problem. When we hit a brick wall, the same thing that birthed the problem is reached for. This cycle of over-consumption he sums up as a kind of compulsive nostalgia, a desperate hankering for yesterday’s progress. In a world unfit for human habitation, Illich’s notion of the “patient” becomes an accomplice to the lie that his failings are biological, as opposed to systemic.

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The lofty Catholic material really starts to sing once you get into old age and death in part three: cultural iatrogenesis. “From Stockholm to Wichita the towers of the medical centre impress upon the landscape the promise of a conspicuous final embrace…” Illich is very much in favour of old people being given a corner to die in at the family gaff as opposed to subjecting them to invasive and repeated medical procedures, and instead of outsourcing terminal decline to the old folks’ homes and the hospice. A cruel inversion here he points out: to die at home now is the preserve of the rich. Yet, the more wealth the country from which you hail globally has, the more likely the man in the street is to wind up surrounded by strangers in the closing chapter of his life.

From what I’ve seen, death in the mountains of Kabyle, where half of my family live, looks like more fun than death in working-class England. The intergenerational support network provided by the more “primitive” society is something most of us no doubt miss, subconsciously but bitterly. Have we shunned death? Illich certainly believes so. For us, death is crisis, instead of something to which we relate every step of the way, instead of that which informs and enriches our ability to fully live. Keep it out of sight. It spoils the utopian fantasy that everything is manageable, if we just hurl enough cold rationality at it. Shrouding it in an air of “crisis” justifies near limitless ineffectiveness where science is concerned, our replacement for religion. An excess of futile treatments in the dying embers being symbolic of this. As far as Illich is concerned, at the moment of demise, the insured are paying for participation in their own funeral rites and little more: “in an insidious way the doctor provides each citizen at the last hour with an encounter with society’s deadening dream of infinite power”.

In his antipathy for the industrial world, a lot of the time he goes way too far. He appears drunk on his own ideological fervour. On a botched suicide he writes: “I know of a woman who tried, unsuccessfully, to kill herself. She was brought to the hospital in a coma, with a bullet lodged in her spine. Using heroic measures the surgeon kept her alive, and he considers her case a success; he no longer has to worry about her ever attempting suicide again.” I like a bit of hardcore cynicism, it’s refreshing in a world which seems sworn to naïveté, but isn’t this beyond harsh where the medical practice in question is concerned? He’s not into birth control — I don’t agree but I can look past that, he’s a man of the cloth after all, it’s kind of to be expected — but what good does this statement do anybody? At one point he even appears to call for the scapegoating of doctors as a plausible solution to the overextension of medicine into human civilisation. That to me just sounds like sour grapes.

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You’ll often run into this problem reading Illich. Any remedy shy of some kind of Marxism-tinged, back-to-basics, Catholic revolution-cum-devolution is only furthering the grief, only enabling the torment of the species further. He attacks welfare as only deepening the problem, for instance. Unless people are downing tools entirely, they’re not doing enough. They’re complicit in their own damnation. I like the fiery tone, the austere biblical voice, but come on, let’s be pragmatic about this. At the end of the day, who’s going to remove your appendix, your uncle Abdul? Your gran?

That being said, prescribed medication is still the third highest cause of death globally. Some of this stuff has aged badly, but aspects of the underlying philosophical argument he hammers home are perhaps even more valuable today than at the time of writing. Overly radical yes, but Illich is also something of a seer. He’s maybe not your man for a solution, but through the prism of his very specific and expansive learning we can look at the mess of our current state of affairs with fresh clarity.

Now he has pivoted back to his true passion, gut health, and taken many of his followers with him. Endorsed by celebrities such as Davina McCall and Carrie Johnson, the new version of the ZOE app promises a personalised nutrition plan and comes with a glucose blood monitor usually used by diabetics. It is proving hugely popular, with over 100,000 subscribers paying up to £600 in their first year — and a further 300,000 on the waiting list. 

It boasts all the hallmarks of a scientific endeavour, with endorsements by world-leading experts and numerous studies. But how convincing are its claims?

Deborah Cohen, a medically qualified TV, print and radio reporter, and Margaret McCartney, a GP, undertook a forensic investigation for UnHerd and found that ZOE’s scientific foundations aren’t as strong as they would have you think…

Read on to learn about:

1. ZOE and the influencers
2. Why Tim Spector created ZOE
3. Does ZOE think you are healthy?
4. Why ZOE wants your data
5. What does your gut tell ZOE?
6. How scientific is ZOE? 

***

1. ZOE and the influencers

“I gave up after a month.” Gail, 49, is talking about her experience of using the ZOE app — the heavily promoted personalised nutrition plan that, we’re told, will help us understand our bodies and make us more healthy. “It certainly didn’t change my food compulsion — if anything, it made me feel worse.”

Take a look at ZOE’s lavish series of adverts, or the rapturous response to the app on social media, and you would be forgiven for thinking that Gail is an anomaly. TikTok, Facebook and Instagram are filled with celebrities, ZOE “members” and influencers sharing their positive experiences and inviting you to join the club.

One is Carrie Johnson, who recently shared her welcome email on Instagram, another is Davina McCall, one of the faces of ZOE’s marketing campaign. She claims she is now “living her best life”, telling prospective consumers (and her 1.7 million Instagram followers) that the knowledge provided by the technology is the “greatest gift ever”. A vocal menopause-awareness campaigner, McCall claims the gut microbiome is “completely different” in pre- and post-menopausal women.

But women only make up part of the market. Steven Bartlett, of Diary of a CEO podcast, is also an ambassador: “There’s an incredible correlation between what I’ve eaten, my blood glucose levels, and how I’m feeling,” he claims.

These three are among the 117,000 people who ZOE claims are now “members”. Another 300,000 are on the waiting list. This, despite the fact that ZOE isn’t cheap: it costs £24.99 per month (roughly £300 per year) and £299.99 for the intro kit which includes the instantly recognisable bright yellow blood glucose monitor that users display proudly.

These monitors are all part of a “personalised nutrition” plan that also measures your gut “microbiome”: the collection of “good” and potentially “bad” microorganisms in your intestines. This is assessed via stool samples which you collect in a “hammock” over the loo bowl and then post to the “lab” for testing.

After a fortnight of continuous blood sugar monitoring, combined with your gut bug measurement, you are provided with a nutritional programme — basically foods you should eat and those you should avoid. ZOE suggests that this sort of personalised approach can help with energy levels, reduce hunger, help you reach a healthy weight, feel less bloated, sleep better, and avoid chronic health issues.

But is ZOE the solution? Certainly, its stratospheric rise is a marketing triumph. But beneath the sheen of its glossy adverts and its wealth of medical testimonies, ZOE’s scientific foundations seem far from healthy…

2. Why Tim Spector created ZOE

From its inception in 2018, ZOE has relied heavily on the profile and academic credentials of co-founder Tim Spector, professor of genetic epidemiology at King’s College London. Already a familiar name in nutrition circles, he rose to prominence during the pandemic with his ZOE Covid symptom tracker app, described by The Financial Times as “arguably the world’s largest ever citizen science experiment”. With millions logging on to share their test results and symptoms, Spector’s app, boosted by £5 million of government funding, was credited with first highlighting that loss of taste and smell accompany Covid infection.

A self-described “measured risk-taker”, Spector told The FT that he moves from subject to subject “if I’m not very interested in the next step or the next stage any more”. He started out as a rheumatologist, treating joint and muscle disorders, before turning to epigenetics, the study of how behaviours and environment can affect the way your genes work. Then, he set up the UK Twins Registry, one of the richest collections of data about identical and non-identical twins in the world.

It was this work, in particular, that led to his current interest: the interplay between diet and gut health. When he was studying the genetics of obesity in twins, he noticed that their weight sometimes greatly varied — which he attributed to the fact that their gut microbes were different.

After this Eureka moment, he decided to focus his efforts on nutrition, writing several books, the most recent being Food for Life: The New Science of Eating Well (2022). And he takes his own advice seriously — eating plenty of “fermented food” such as kombucha, kefir and kimchi to help his microbiome. He also microdoses on a diabetes drug which, he claims, could have anti-ageing benefits.

According to Spector’s website, it was during one of his presentations on his microbiome research that he met his ZOE co-founders, the now-CEO Jonathan Wolf and president George Hadjigeorgiou, both of whom have backgrounds in machine learning and business. They “shared his vision of helping individuals understand their unique biology to improve their own wellbeing in an accessible way”.

After opening offices in Boston and London, they rapidly attracted $27 million in initial funding to commercialise Spector’s work. (He remains a part-time ZOE employee and company shareholder.) And in 2019, they paid for a study that seemed to confirm the key concept for ZOE’s entry point into a crowded consumer market of products that offer advice on the healthiest foods to eat.

The PREDICT1 study suggested individuals’ metabolic responses to the same foods vary remarkably, with genes only playing a small part. (More on what you can infer from it later.) At a conference in the US, Spector revealed that they had found “really surprising” variation between certain biomarker responses — including some of those used by ZOE — to standardised meals.

It was what other investors needed to hear. The combination of a personalised nutrition app coupled with machine-learning and big data proved to be alluring buzzwords for the wellness-obsessed digital world. Steven Bartlett invested more than £2 million earlier this year. ZOE, he says, is a company that represents “the future”. It is “health science, driven by big data” that doesn’t just extend “our lifespan, but more importantly our health span”. Venture capitalists and those involved in a crowdfunding exercise thought similarly. Last year, one of the CEOs valued the company at over £209 million.

Yet some are sceptical. They suggest this is just the latest iteration of Big Diet — or Big Nutrition. “This is a classic playbook. X doesn’t work; the experts are wrong; read my book and find out the truth. Then buy my product which FINALLY fixes everything,” says one critic, who did not want to be named. Interestingly, Spector himself used to be of these sceptical voices, writing cautiously in The British Medical Journal in 2018 that observational studies — such as those since published by ZOE —  are limited by the inability to measure causal relations between microbes and health traits. They can only show associations.

“The strongest level of evidence is obtained from interventional clinical studies — in particular, randomised controlled trials,” he wrote. (ZOE is yet to publish controlled trial data.) In 2019, he again suggested evidence was limited. In the same year he promoted ZOE study findings at that US nutrition conference, Spector wrote in a medical journal, that “there is a lack of long term human studies, or indeed follow-ups of short-term dietary interventions” to understand whether “diet-induced modulation of the gut microbiota endures”. Could this barrier be overcome?

3. Does Zoe think you are healthy?

On social media, it doesn’t take long to find people posting about the thrill of receiving their ZOE test results. As one user, Joel, 28, said to us: “It gives you another thing to share on Facebook or Twitter.” But how much can we actually infer about what’s going on inside our bodies?

There has long been a temptation in medical circles to assume that the more biological parameters we measure, the better. The truth, however, is that not all test results are useful. Just because something is measurable in your body, doesn’t necessarily mean that the result will yield useful information.

Dr Guess claims the app might be doing little more than recommending more fruit and veg to everyone. “They have no published data showing all this info results in personalised dietary advice,” she says. “They need to show that the dietary recommendations made by their algorithm can be replicated by other scientists. In other words, does the test give the same dietary recommendations on Wednesday as it did on Monday? This is one of the hallmarks of good science. Even more important, they need to show what they’re doing actually improves a user’s short and long-term health.”

This isn’t to say that continuous glucose monitoring isn’t useful. It is offered in the NHS, but for specific reasons — for people with diabetes. Readings can help to adjust insulin doses and improve control of potentially harmful spikes and troughs. Many people say that it has revolutionised their care. In people without diabetes, however, blood glucose is under continuous physiological control — with the pancreas regulating the release and storage of sugar in the body to keep it within normal parameters. This is the market ZOE is aiming for.

They’re not the only company making continuous glucose monitors aimed at people without diabetes. Even those in the clinical medicine arena are pivoting into this space. Indeed, The Global Wellness Institute estimates the global market segment for “healthy eating, nutrition and weight loss” is worth $946 billion a year.

The only problem is we don’t really have any evidence that these monitors do keep non-diabetic people healthy.

Dr Shivani Misra, a consultant in metabolic medicine at Imperial College London who researches continuous glucose monitoring, cautions that we don’t totally understand how to interpret measurements in healthy people. “We have no robust evidence base to suggest that those rises and falls are signalling anything untoward in the present or that they have negative consequences in the future,” she says. In fact, different devices might have different readings in response to eating the same meal.

Dr Kevin Hall investigates the regulation of body weight and metabolism for the publicly funded US National Institutes of Health, which has a programme in precision nutrition. His team has studied the use of continuous glucose monitoring in highly controlled environments — when people actually live at the lab for a month and undergo very specific diets and exercise regimens. They measured the glucose levels of one person wearing two devices. They found that sometimes one of the devices would give a very high glucose reading after a meal, and the other would give a low reading. They also analysed readings on the same device. They changed the regimens week to week — and concluded that the response to the same meal might vary as much as it did to eating a different meal in different weeks.

“Even in these very highly regimented kinds of controlled feeding studies, they don’t give rise to reproducible measures,” Dr Hall says. “It’s very likely that if that person ate a banana the next week, even if they had exactly the same previous food and did the same exercise that day, they might get a very different response.”

Unsurprisingly, the results are causing confusion. For instance, Gail says her glucose levels went up when she was exercising and her friend, who has diabetes and is used to monitoring their glucose, looked at her graph and thought it looked high. “I felt I didn’t get enough explanation about what this means or what might happen to my glucose,” Gail says. On TikTok, users also warn against the unwanted “spike”, saying they need to get a flatter line and describing their worries about their glucose dipping at night.

But this is not necessarily something to worry about: glucose going up and down is a normal bodily response. “Any time they see a slight rise or spike, people panic and it’s creating unnecessary anxiety,” Dr Misra says. “Then they think it’s wrong to eat carbohydrates — which release glucose into the blood — and there is no evidence that this is necessary or beneficial. Some tell me it’s taken over their life.”

4. Why ZOE wants your data

But what about those who do feel their energy levels drop and notice a lethargic “crash”? Joel, for example, frequently wakes up at 3am to find his glucose dipping. He was even told he was waking up because of this dip. But he’s not entirely sure what to do about it.

This isn’t entirely surprising. While symptoms and how we feel are real, it can be hard to attribute cause and effect. In her clinic, Dr Misra sees people with and without diabetes who tell her they’re getting symptoms of low blood sugar, but when they’ve actually measured it, it’s within normal range. “There’s a risk everything becomes glucose-related,” Dr Misra says. “It’s human nature when you’re monitoring something you become hypervigilant about that.” This is something Dr Hall and his team also found in their studies. “I think the fascinating thing is that when people are provided with more and more information, they tend to make these correlations,” he says.

The risk is that we are creating problems for people rather than solving them, and turning healthy people into patients.

Ironically, perhaps mitigating this is the relationship between social class and health: in other words, the people most likely to be able to afford ZOE may be among the least likely to benefit from it. Because of this, Amitava Banerjee, professor of clinical data science at University College London and consultant cardiologist, says that ZOE plays into what is called the “digital divide”.

“Even when digital interventions are useful, the people who need them least are usually accessing them most, especially given the cost,” he says. “Those who are at the highest risk of health problems are often in more deprived and ethnically diverse areas, with neither the money nor the resources to use ZOE.” And even though it’s been largely tested on young healthy people of European ancestry — as the ZOE team has written in medical journals — the marketing goes beyond this cohort of people. “The results they get from studies might not be applicable to people outside that group,” Professor Bannerjee cautions.

Elsewhere, some doctors have turned to social media to complain about the increased workload the app is creating for them among a cohort known as the “worried well”. GPs have described to us how they’ve been contacted by patients concerned they have diabetes, as they think that is what their continuous glucose monitors are showing. While ZOE is just one of dozens of private companies and influencers who generate blood results capable of causing alarm and sending patients to NHS GPs, they all add pressure on appointments — especially if people didn’t get good enough information about what the test results actually mean.

5. What does your gut tell ZOE? 

Blood sugar is only a part of what ZOE tests. Other indicators as to the function of our metabolism and how we respond to food is determined by our gut microbiome. Zoe wants to harness the “potential power” of this to affect your long-term health and certain symptoms, and so takes a reading on how good your “gut bugs” are with the help of your stool sample. A diet plan to improve that is then constructed.

But not everyone is convinced there is sufficient scientific evidence to justify this approach. Dr Hall says research suggests you can change the microbiome in pretty consistent ways across individuals by changing their diet. “The complexity of the microbiome kind of belies a single readout of good versus bad. How you even come up with a single good, bad kind of criteria is mystifying to me,” he says.

Professor Tariq Iqbal, a gastroenterology consultant who runs trials into faecal microbiota transplantation in people who have bowel disorders, says that we’re only just beginning to understand to what degree levels of microbes naturally fluctuate in the gut in a healthy person over time. “At the moment, there is no reason to get your microbiome generally tested,” he says. “We don’t have good evidence about what a “normal” microbiome looks like. It’s more complicated than simply saying there are ‘bad’ and ‘good’ bacteria in the gut.”

Current research suggests that there is no “standard” microbiome composition that can be used as a baseline for health. There may also be problems with reading too much from a single sample. According to Guts UK, a digestive disease charity that works closely with the Gut Microbiome for Health Group of the British Society of Gastroenterology, the bacteria found in your stool does not necessarily tell you what microbes are in your gut. Meanwhile, the British Dietetic Association warns: “Commercial gut microbiota testing and lifestyle change programmes based on the test results cannot be advised currently as the science is not at a stage that can support testing and treatments programmes.”

Nor, Dr Guess adds, is there any robust evidence to support the claim that personalising a diet based on the gut microbiome is more effective than generic healthy eating advice for any of the claims being made. In fact, Professor Iqbal says that patients might be unnecessarily worried by what microbiome testing shows. “At the moment, we just do not have enough knowledge to safely and accurately recommend any specific interventions (such as particular changes in diet, and/or particular probiotics) to cause beneficial long-term changes to the composition of the bacteria in the gut,” Guts UK said.

ZOE, however, told us that their data showed members “who follow ZOE advice, including gut booster foods, see an improvement in their gut microbiome score” — the mix of “good” and “bad” microbes. This conclusion is drawn from a ZOE internal survey of 450 members who followed their advice for more than 12 weeks, which also showed 70% have more energy, 85% improved their gut health and others saw improvements in their menopause symptoms. This is all heavily promoted across their website.

These results haven’t been published and they declined to share it with us when we asked, so we are unable to assess what was asked or how the sample was selected. Moreover, as Dr Guess points out, “the data has not been validated or peer-reviewed”. Neither was there a control group, which would be needed to know whether it was ZOEs’ specific advice, or simply better healthy eating, that was making a difference. When we relayed this to ZOE, they agreed this meant that we could not be sure these were “clinically meaningful results” and told us they were going to be publishing a randomised controlled trial in the future.

6. How scientific is ZOE?

It is hard not to be blown away by the dizzying array of high-profile journals that feature on ZOE’s website: Nature Medicine, The BMJ, The Lancet, among others. It links to abstracts of papers published in peer-reviewed journals, which on the surface seem to provide proof of the science. At a closer look, however, not all is as it seems.

ZOE places the weight of their programmes’ claims on three main studies with the acronym PREDICT (Personalised Responses to Dietary Composition Trial). They were carried out with scientists from prestigious universities, including Stanford, Harvard and Kings’ College, London. They have not yet all been published.

The studies analyse the results of people making multiple readings about their body and food intake. This has produced a huge dataset: more than 4 million glucose readings so far, for example. These findings are then used to develop models to predict the impact of particular foods on our bodies — all valid areas of study. The researchers have searched for associations between different measurements, such as hunger and types of food eaten.

All of which sounds impressive. Until you realise that these were observational studies, which can only show associations between various data collected, and not causations, as Tim Spector himself has previously noted. For while measuring lots of variables to find patterns can be a useful research technique, it also means you increase the chances of finding coincidences — which puts you at risk of misinterpreting random variation as a meaningful difference. Poor practice in this type of study is known as “data dredging”.

Nor do they answer the key question: is there evidence that the individualised advice generated by the ZOE tests, which is the key market differentiator, does what it claims?

The answer: we don’t know. There have been no trials published exploring whether the “personalised” advice given by ZOE can result in better health outcomes compared with standard diet and lifestyle advice.

And the same holds for menopausal women, the key ZOE demographic targeted by Davina McCall. The first PREDICT study in 2022 compared data in pre, peri and postmenopausal women. According to ZOE: “Women who have been through menopause had, on average, higher blood pressure and blood sugar, a greater risk of developing cardiovascular disease in the next 10 years, worse sleep, and more body fat. Crucially, the team’s analysis found that diet and the bacterial species that were present in women’s guts were at least partially responsible for the changes.”

However, Dr David Nunan, Senior Research Fellow at the Centre for Evidence Based Medicine at the University of Oxford, is sceptical. “It’s a cross sectional [observational] study” he says, “which means that no claims of causation can be made.”

The design of the study, in other words, simply isn’t capable of telling whether any changes in the microbiome are a result of menopausal change. In fact, Dr Nunan says, “when the data for all microbiome species are compared, there is no statistical difference in pre and postmenopausal women. It’s only when you examine a subgroup of species that 8 out of 2,452 show a statistically significant difference.” Moreover, even when this happens, the study has not indicated what this means in real life. In other words, we do not know what impact this has for the ways that women metabolise food.

Yet despite these gaps, ZOE told us that they are “proud” to have recently completed their own randomised controlled trial “with a non-personalised control group versus the ZOE programme”. The full manuscript, they say, is “under preparation”.

According to its critics in the science community, however, even this trial has its design flaws. One group receives the whole ZOE package, the other receives a leaflet with US health advice. But the way it is set up, people will know exactly which group they are in, thereby rendering results less reliable. A fairer test to assess is its ZOE’s personalised algorithm that makes the difference would be for both groups to receive blood monitoring and stool analysis, and what they thought was personalised advice. The only difference should be that one group receives advice based on ZOE’s tests and algorithms, while the other receives advice that looks like it might be “personalised” but isn’t.

“You have to bear in mind when looking at these studies that they aren’t fully independent,” Professor Banerjee says. “They are marking their own homework. You need external validation and testing to reproduce the results.”

None of this is to say that paying close attention to nutrition is not important. ZOE is only one of hundreds of apps that measure our biometrics in this age of the quantified self. But while keeping abreast of our data might be interesting, are these promises of personalised advice based on sound medicine? And are they, as the website promises, scientifically proven to lead to real-world improvements?

Without this evidence, Zoe is simply collecting our data and then selling it back to us. And not only does this come at a financial cost — it could be making us less healthy.

It’s not an uncommon experience, especially today when young people feel more comfortable developing relationships online than throwing themselves into the uncertainty and unpredictability of real life. But I was also an early adopter of a nascent but now ever increasingly “important” message: these feelings you have are neither normal nor existential nor simply “growing pains”. They are a health condition, and the only way to overcome it is to seek professional help.

For the past decade, an emerging class of therapeutic entrepreneurs has consolidated this claim, warning that the problems of everyday life are simply too much for the uninitiated layperson to manage with their own resources. While recognising that deep emotional pain is part of life, there is a growing sense that even “normal” feelings require “treatment”, lest they spiral out of control.

This assumption has become most startlingly apparent on university campuses, where young people’s preference for seeking help from “informal sources” such as friends and family is frequently seen as a problem and a risk. Yet the modern education sector has always been a target for expanding professional services, as I detail in my forthcoming book. Since the Nineties, British universities have seen a rise in counselling services, with groups such AMOSSHE and HUCS lobbying heavily for growth. They swiftly joined forces with mental health charities and urged students to lead campaigns for more funding. And as concerns about student mental health grew, a wave of apps, surveillance tools, and other light-touch interventions emerged, offering solutions and even prevention.

Long before there was evidence, therapeutic entrepreneurs were certain that a widespread “mental health crisis” demanded these interventions. In 2013, with this in mind, the National Union of Students (NUS) conducted a survey in collaboration with mental health advocacy groups to push for more funding. The results must have been disappointing. Released during Mental Health Awareness Week, it claimed that “20% of students consider themselves to have a mental health problem” — a figure that combined those suspecting they had a diagnosable condition (8%), those actively seeking diagnosis (2%), and those with a confirmed diagnosis (10%). The only problem? The number was slightly lower than the general population of the same age, despite its conflations and reliance on self-selection and self-reports, known to inflate incidence.

The campaigners, however, continued undeterred. Ignoring the findings that students were at no greater (and probably lower) risk than age-matched populations, Poppy Jaman, chief executive of Mental Health First Aid England, stated that the NUS findings were “unsurprising”. It was proof, she said, that “the student community is considered high-risk for mental ill health, with exams, intense studying and living away from home for the first time all contributing factors”. Perhaps as insurance, the survey also produced the eye-catching claim that 92% of students suffered from “mental distress” — which spanned everything from “feeling unhappy/down” to “suicidal thoughts”. Put this way, it is surprising that 7% of respondents reported no “negative” emotions at all throughout their university experience (1% selected “prefer not to say”).

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Still, campaigners highlighted that their “main concern” was the proportion of students preferring their informal networks to professional ones. As one newspaper asked of a recent NUS survey: “Why don’t students seek help from their universities — and how can this be reversed?” Or as one Director for Student Experience warned: “Ultimately, if high-stress situations go unmanaged, they can sometimes develop and even lead to mental illness.” It became common to hear that, no matter how small the problem, only professional support could prevent things from spiralling out of control. And the consequences of failing to seek help could be dire: “They may start to self-medicate with drink or drugs, self-harm, or even take their own lives,” claimed one commentator.

But would they “take their own lives”? Newspapers proclaimed a “university suicide epidemic” and campaigners dangled the threat of student suicides over institutions should they fail to invest sufficiently. The evidence for this was frequently cobbled together from Further Education, Higher Education and young people as a group. However, according to ONS estimates released in 2018 and 2020, the rate at which university students commit suicide appears to be significantly lower than the general population of the same age. For young people up to the age of 24, the rate was 2.7 times higher than those in Higher Education. Headlines might have read: “Going to university significantly lowers suicide risk”.

But they didn’t. When these stats were first released, media coverage maintained mental health advocates’ framing. MailOnline ran with: “Number of university students committing suicide nearly doubles since 2000”. The Sun went for: “SUICIDE UNI SHOCK”. Other papers demanded that the student “mental health crisis” be “top priority”, citing rises between different years. Counsellors were described as working on the “frontline”.

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Yet the ONS itself had warned against such conclusions; it’s easy to produce a high rate of increase if you’re dealing with already low numbers. Indeed, a number of conclusions could be drawn depending on the year emphasised — for instance, that the rate had fallen since 2004/5 or that, in recent years, the number has fallen even more and remains low.

Despite years of encouraging young people to seek help for any problem “no matter how small”, increased help-seeking itself thus became a key indicator of the severity of the “student mental health crisis”. And here, campaigners were pushing at an open door. While the majority of students might still take their problems to their friends, they have been seeking help in greater numbers since the early 2000s. Today’s students have been taught through years of therapeutic education; trained in the virtues of constant self-surveillance, they know that as good citizens in the making, they should interpret distress as a potential “symptom” for which they should “seek help”.

These processes are greatly aided by what Nick Haslam has called “concept creep”, or the tendency for psychological concepts of harm and pathology to expand to include new and less extreme phenomena. It’s easy to see how this happens. For instance, two years after the disappointing results of the NUS survey, the organisation put out another which shed the restrictive language of “diagnosis”. Instead, it asked: “Do you believe that you have experienced problems with your mental health in the last year, regardless of whether you have been formally diagnosed?” This produced the headline-grabbing statistic that 78% of university students suffered from “mental health problems”.

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At the same time, universities became increasingly receptive to the claims of professionals who promised that they could contain risk and breathe new life into institutions already struggling with their meaning and purpose. Universities, after all, are constantly exposed to the reputational risks that might result from young people’s behaviour. To soften this threat, promises to provide ever greater levels of therapeutic and “wellbeing” support have quickly become part of the “package” sold to eager students and their parents on Open Days.

But they are also selling a way of being and a way of thinking about the self. For all that is invested in myriad new-fangled interventions, they struggle to live up to that great healer: time. The kids might not be all right, but most of them will be eventually.

To say this has become heresy. I’m not discouraging therapy and counselling and no doubt many will need professionals. But they are not helped by being queued behind so many who don’t. Twenty years ago, when I ended up seeing a university counsellor, I realised in that awkward interaction that I didn’t need a stranger, much less some diagnosis into which I could safely place all of my problems. I needed some experiences, some meaning and purpose in my life and some friends to share it with. If I had not had that realisation, I probably would have become dependent on strangers and discouraged from relying on those networks that ultimately provided my release. Today, it’s difficult to avoid the conclusion that this is precisely the point.

To feel relief, though, is surely misguided. Nurse Letby might be behind bars, but those who ignored, shielded or enabled her remain unpunished. Regardless of their motives or excuses: the public record has shown that senior executives at the Countess of Chester Hospital obfuscated attempts to stop Letby.

This is not to say they aided and abetted her. But as any lawyer will tell you, ignorance is no defence in law. On the wards, as anywhere else, those who want the benefits, privileges and status that come with the highest level of leadership must shoulder responsibility for what happens on their watch.

Following Letby’s conviction, the Northern Care Alliance NHS Trust in Greater Manchester suspended Alison Kelly, former director of nursing and quality at the Countess of Chester. The hospital’s former CEO, Tony Chambers, also faces mounting claims that he had dismissed warnings about Letby before walking away with a £1.5 million pension.

Under Kelly and Chamber’s leadership, the neonatal unit’s head consultant, Dr Stephen Brearey, who first raised concerns in June 2015 about the link between Letby and an increase in baby collapses, was ignored. Likewise, Dr Ravi Jayaram, a consultant paediatrician at the hospital, and others, were forced by hospital bosses to apologise to Letby after was “upset” by their criticisms of her.

We don’t know what Kelly and Chambers were thinking as they watched a significant rise in the number of babies suffering serious and unexpected collapses in the hospital’s neonatal unit from 2015 and 2016 — a rise that was well above the expected local average. We do know that they failed to act decisively. We also know that they both objected  to concerns raised by Breary, Jayaram and other clinicians. These “whistleblowers” were told there was “no evidence” against the nurse “other than a coincidence”.

In my experience, such negligence can be partly the result of the professional differences — and hostilities — between those from a nursing or midwifery background and doctors and senior consultants. When doctors raise concerns about nurses, the nurses’ ranks tighten. When the roles are reversed, however, doctors are far less likely to put professional favouritism first.

And this conflict particularly afflicts maternity wards. As I warned in UnHerd last year, the Care Quality Commission found that two out of five maternity units in England were providing “substandard care to mothers and babies” — a disturbing review preceded by another damning inquiry, Dr Bill Kirkup’s three-year investigation into mass failings at East Kent Hospital Trust’s maternity care. Between 2009 and 2020, he concluded, 45 babies who died under the trust’s aegis might have survived had they received “nationally recognised standards of care”.

Taken individually, these scandals and exposés are little more than horror stories, the sort of voyeuristic fodder rinsed out by newspapers before moving onto the next tragedy. Taken together, though, they are symptoms of a greater problem: our maternity service’s dysfunctional relationship between management, staffing and patients across the board. And there is something unique about this dysfunction: while the Bristol heart scandal during the Nineties revealed how a combination of ineptitude, arrogance and an old boys’ culture had contributed to dozens of babies suffering brain damage and death following cardiac operations by surgeons, today we are seeing cases, such as Letby’s, in which the “heroes” are senior consultants who come up against bloated, self-serving and intransigent management.

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Over the past days, weeks, months and years, my colleagues and I have repeatedly called for senior managers in the NHS to be more accountable. The Letby case clearly illustrates — along with the East Kent, Bristol, and Mid-Staffs scandals, the latter in which anywhere between 400 and 1,200 patients died as a result of poor care between 2005 and 2009 — there is zero jeopardy for the legions of NHS senior managers when things go wrong, and lives are needlessly lost. As Dr Breary has pointed out, a “structure akin to the General Medical Council or the Nursing and Midwifery Council” solely for NHS managers is needed to “monitor the integrity, competence, and conduct of senior NHS executives”.

But I would go further. Within its health sectors, the NHS has too many managers floating between various levels of management. This murky bureaucracy has created a culture in which weaker and weaker talent fails upwards, driving out many consultants at board level who simply can’t cope with the cumbersome ineptitude of senior management committees. Once they have ascended to management positions, people who were mediocre on the wards vent their petty grievances and exert their lack of talent by putting consultants in their place. It’s an open secret that NHS management has become a gravy train, an opportunity to put your feet up and “protect your workload”. If anything, this cynicism, laziness and inertia is as deadly as the rare cases of pure evil.

No doubt there will be those with questionable “leadership skills” who view my and colleagues’ calls for an audit of management capability — and culpability — as a witch hunt. But we’re willing to take that risk. There’s clearly something rotten at the heart of the NHS.

Here was a prominent figure dedicated to the role of science in solving global problems — even if he did display flashes of the egotism that led him to serve on the Sage advisory body during the pandemic and then quit to rush out a book lamenting other people’s failures.

“If we do revert to a lack of evidence, a lack of information — if we’re going back to the era where we’re just making policies up with no evidence behind them, the world is in a worse place. And we’re moving away from an era of sort of 20th, 21st-first century enlightenment to something darker,’ he concluded with a flourish. ‘We can’t let that happen.”

Who could argue with the need for evidence-based science and the unfettered flow of information to help make the world a better place? It was no surprise, however, Farrar chose The Guardian for his valedictory interview as he heads to Geneva for a new post as chief scientist of the World Health Organization. For this ensured there would be no challenging questions over his central — and profoundly anti-science — role in stifling debate on the pandemic origins and effectively pushing his own conspiracy, cooked up with a handful of influential colleagues, including Anthony Fauci in the US, which suggested any idea that Covid might have emerged from some kind of laboratory incident in Wuhan was crackers.

Never mind all the evidence that has emerged showing how members of a group of experts that Farrar marshalled to squash the lab-leak hypothesis harboured their own doubts over the disease emerging naturally, based on its location and unusual properties. Let alone his own initial fears on this vexatious issue — or indeed, his recently-revealed verdict on high-risk experiments on coronaviruses being carried out in low bio-security laboratories in Wuhan as “Wild West” research. Instead, his interviewer, a long-serving health reporter, dutifully told her readers that “Farrar’s position is that while it is likely to have come from animals, it is important to stay open-minded and gather evidence. Above all, we need transparency, he says.”

This is, sadly, typical of the pitiful reporting seen on this particular issue from The Guardian. Presumably this continuing failure is a legacy of the media group’s reaction to Donald Trump’s promotion of the possibility of a lab leak, a response shared with The New York Times. The Guardian, however, even allowed British scientist Peter Daszak to publish an article headlined “Ignore the conspiracy theories: scientists know Covid-19 wasn’t created in a lab” without disclosing his organisation’s financial and research links to Wuhan Institute of Virology (WIV) until forced into hasty clarification. Farrar, incidentally, promoted this risible piece on Twitter: “As always worth reading @PeterDaszak”.

Yet The Guardian was far from alone; almost all Western media failed in their duty to challenge powerful players and vested interests on the crucial issue of the pandemic origins. Patsy journalists churned out reports fed to them by prominent scientists that dismissed “conspiracy theories” about a possible lab leak, placing more faith in a brutally-repressive Chinese dictatorship than an elected US government. They kept pointing to an animal market in Wuhan as the most likely source of SARS-CoV-2, a theory dismissed even by the Chinese authorities and despite obvious flaws in this argument given earliest cases. Ultimately, much of the media ended up presenting a collective idea that there was settled consensus, sweeping aside the voices of bravely-dissenting scientists.

Farrar was at the centre of this deceptive web, spinning lines to impede unfettered debate on the origins of the biggest public health crisis for a century. Along with two of his Wellcome Trust colleagues, he joined 24 other scientists to sign a key letter in The Lancet journal sycophantically praising Chinese experts for their “rapid, open, and transparent sharing of data” and hitting out at “conspiracy theories suggesting that Covid-19 does not have a natural origin”. It was later discovered to have been covertly organised by Daszak, who had spent years working with his friend Shi Zhengli, the celebrated lead researcher into bat coronaviruses at WIV.

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Farrar also hosted a conference call on the first day of February 2020 at the behest of former presidential adviser Fauci. They were joined by Francis Collins, then head of the biggest US science funding body, and Sir Patrick Vallance, the British government’s chief scientific adviser, and at least 10 other experts. We know now that several taking part held concerns over the virus being engineered. Even after the call, Farrar admitted he was “50:50” on whether it came from a lab. Yet he oversaw the near-instant drafting by four participants and one other author of “The proximal origin of SARS-CoV-2”, another hugely-influential article published by Nature Medicine stating firmly that they “do not believe that any type of laboratory-based scenario is plausible”.

Dr Robert Redfield, an eminent virologist who led the US Centers for Disease Control and Prevention when the outbreak began in 2020, has long feared Covid resulted from a lab leak. Now his suspicions are backed by two US intelligence agencies. FBI chief Christopher Wray admitted last week they have “for quite some time now assessed that the origins of the pandemic are most likely a potential lab incident”. Yet Redfield told a congressional committee hearing into the virus’s origins this week that he was deliberately “sidelined” by the likes of Fauci and Farrar: “It was told to me that they wanted a single narrative, and that I obviously had a different point of view. Science has debate and they squashed any debate.”

Redfield’s written submission to the committee rightly argued that both theories on the origins “needed to be aggressively and thoroughly examined” — although his own view “indicates Covid-19 infections more likely were the result of an accidental lab leak than the result of a natural spillover event”. This conclusion, he explained, was “ based primarily on the biology of the virus itself, including its rapid high infectivity for human to human transmission… as well as a number of other important factors to include the unusual actions in and around Wuhan in the fall of 2019”.

Many other experts disagree. This is how science works: through the clash of ideas and rooting out of evidence to test theories. Yet Redfield told investigative journalist Paul Thacker last year that he believed Fauci and Collins used their political power in the scientific community to set the narrative and exclude dissident voices such as his own, using Farrar as “the front person”. He claimed The Lancet statement, as well as the Nature Medicine missive, “was orchestrated by Jeremy Farrar — I think under direction of Fauci and Collins, trying to nip any attempt to have an honest investigation of the pandemic’s origin”.

This is incredibly damning: these two documents were the most influential papers on the pandemic’s origins — accessed by millions, widely shared, heavily quoted and even used by social media to suppress publication of “conspiracies”. Meanwhile, Farrar pointed to the Nature Medicine statement when questioned on his belief that natural transmission was the most likely cause of the pandemic. “Jeremy’s belief is that the Nature Medicine research paper remains the most important research on the genomic epidemiology of the origins of this virus to date,’ his spokeswoman told me in June 2021.

Prior to this week’s hearing, Republicans on the committee issued a sharp memo asking why Farrar’s work on the Nature Medicine paper — which his spokeswoman confessed to me he had helped to “convene” although it now emerges he made at least one edit to toughen its tone — was uncredited by the journal. A fair question. They also quoted an email from lead author Kristian Andersen dated February 8 — eight days after that secretive conference call — to German participant Christian Drosten, which admitted “our main work over the last couple of weeks has been focused on trying to disprove any type of lab theory”.

Yet before the conference call, Anderson was “60-70%” convinced the virus came from a lab, according to Farrar’s book, alarmed by properties such as its receptor binding domain which “looked.. like a perfect key for entering human cells”, and the infamous furin cleavage site, which allows more efficient entry into human cells and is not found on similar types of coronaviruses.

Concerns have grown after it was discovered EcoHealth Alliance, the group run by Daszak that funnelled US funding to support research at WIV, sought a grant in 2018 from the US Defense Advanced Research Projects Agency proposing to insert a furin cleavage site into SARS-like bat coronaviruses to assess their ability to infect cells. The bid was declined, due to the risks. Daszak insists the collaborators have not pursued the research to his knowledge. But who knows exactly what really went on in those Wuhan labs given the stonewalling of outside inquiries? They could have continued the work with other funds for all we know.

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Let me state again with absolute clarity: we do not know the pandemic’s cause. It might have been through natural transmission. Or it might be the legacy of some kind of unfortunate laboratory incident. There is no hard proof for either theory, despite intense efforts to find an intermediate species of animal that might have “amplified” a bat virus to spill over into humans. Yet it was foolish to ignore that SARS-CoV-2 erupted 1,000 kilometres from the closest colonies of wild bats with similar coronaviruses. And in a city that was home to China’s only maximum bio-security laboratory — especially when WIV held the biggest repository of bat viruses in Asia, had known safety concerns, suddenly took its virus databases offline weeks before the pandemic emerged, and was carrying out risky gain-of-function research to boost infectivity of mutant bat viruses in humanised mice.

Whatever the origins, it seems alarmingly clear that a group of influential scientists, empowered by holding the purse strings for research, set out to deliberately stifle debate over the birth of a pandemic that has caused such devastation — often while saying that we must “follow the science” and despite their own early concerns over risky research in Wuhan and the virus’s strange properties. They pushed the toxic notion that anyone asking valid questions was inflaming conspiracy theorists and backing “implausible” ideas — and were aided by weak politicians, supine journalists and complicit science journals. Such was the influence of these funding behemoths, they set the tone across Europe. This was the real Covid conspiracy.

We can only guess why they adopted such a stance, although I suspect it was through misguided desire to protect both science and some of their own reputations having backed gain-of-function research. Regardless, their stupidity risks harming their profession through sinister efforts to crush free debate, a doctrine that lies at the root of scientific advancement. Sadly, all those journalists who failed to do their job of challenging powerful players and vested interests have also undermined my own profession again. This should provoke soul-searching, especially on the Left, over allowing partisanship to override fearless interrogation of important issues.

We can, however, now see the reason for the shameful silence in Westminster and Whitehall following the furore over former health secretary Matt Hancock’s leaked WhatsApp messages. These reveal how the Government argued behind the scenes that the outbreak’s location was “entirely coincidental” and that any discussion of a possible lab leak risked “damaging national security”. So our bureaucrats, politicians and spooks put their desire to appease a Communist dictatorship in China above the global quest to discover the truth about the pandemic origins, which might help us to prevent subsequent health disasters. No wonder my Freedom of Information requests on this issue have been stymied in both London and Edinburgh.

These inquiries still have some distance to travel, although slowly but surely the truth is emerging. “Recently released unredacted email messages make it clear that in early 2020 science funding heads Fauci, Collins and Farrar were informed by Anderson and three others that the genome sequence of Sars-Cov-2 raised the possibility that it was a laboratory product. The funding agency heads told them this threatened “great potential harm to science and international harmony”. The four scientists, following their paymasters’ lead, published a commentary in a journal falsely affirming that science ruled out the possibility of laboratory origins. “This false narrative still colours discussion, having dominated the debate for a year,” said the biosafety expert Richard Ebright, professor of chemical biology at Rutgers University.

But this begs a question: how can Farrar, having corroded the brand of one of our nation’s finest institutions and played such a role in promoting this narrative, now be handed the influential role of chief scientist at the WHO? “In this context, the appointment is a major error,” says Ebright rightly. This is another disastrous own goal by a UN body that has performed so badly in the pandemic from the earliest days. This post, arguably the most influential scientific role in the world, has been given to a figure who was at the epicentre of spinning a web of deception that stifled scientific probing of the first global pandemic for a century. It suggests that we are sliding from an era of enlightenment to something darker — and as Farrar says, we can’t let this happen.

Today, however, the rich are separating themselves in perhaps the most obvious way of all: by perfecting their bodies, rather than what they put on them. The rich are fit and the poor are fat: reams of research confirms that the prevalence of obesity decreases as income increases. In the United States, where 41% of the entire population is obese — compared with 25% in the United Kingdom — it is a rare wealthy person who is morbidly overweight (blimp-sized Illinois governor J.B. Pritzker and portly former New Jersey governor Chris Christie are outliers). Increasingly, the rich in late middle age have come to resemble Jeff Bezos and Sarah Jessica Parker: ripped to shreds and almost certainly “enhanced” with various anti-ageing drugs and techniques, ranging from steroids and growth hormones to Botox injections and liposuction. 

Into this mix comes semaglutide, an antidiabetic medication better known by its trade name Ozempic. Sold by pharmaceutical manufacturer Novo Nordisk, the drug, which reduces food intake by curbing appetite and slowing digestion, was approved by the US Food and Drug Administration to treat obesity in 2021. Since then, celebrities and fitness influencers have routinely shared before-and-after pics captioned with details of their courageous weight-loss journeys, which entailed jabbing themselves with a 1.5ml pen that contains a month’s worth of doses and costs roughly $900 without insurance.

Predictably, stories about Ozempic have proliferated in the tabloids and on social media. Some see the drug as a challenge to the celebrity movement that touts “fat acceptance”, and brought us the “slim-thick” era of curvy female superstars. They argue that Ozempic may work hand-in-hand with the return of the “heroin chic” look of the late Nineties. As interesting as it is to consider where these mixed messages might lead us — to a culture in which poor people are told it’s fabulous to be obese, while the rich get ever thinner and fitter — if this is a conspiracy, it’s not a new one. The rich have lusted after youth, beauty and fitness, in others and themselves, since time immemorial, always keeping the poor as downtrodden as possible while pacifying them with bromides about equality, liberty and fraternity. Ozempic, then, is not simply the key to thinness; those who pay for it are buying even more distance between themselves and the hoi polloi. 

In short, this appears to be yet another sign that the elite are headed toward some sort of crude transhumanist utopia, complete with gene therapy and designer-baby selection. Some may scoff that this is science fiction, but this future looms: once they’re sufficiently fine-tuned, gene editing tools will likely eradicate heart disease, muscle wasting, neurodegenerative disorders, and other conditions in embryos that are still in utero — but their price will be nothing short of staggering. Similarly expensive gene therapies will enhance the overall performance of already-healthy humans, raising ethical questions about whether these procedures should “improve” a person or merely “fix” a condition. The rich, of course, will leave those debates to the philosophers and pay upfront for the best bodies that their considerable resources can buy. Already, news stories abound of billionaires pursuing immortality, with a few commentators trying to sanitise the pursuit by arguing that the research will somehow benefit even the least of us.   

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I have first-hand experience in the big-bucks world of anti-ageing science, and I can state unequivocally that the most compelling benefits are not going to trickle down. In 2017, I worked for a transhumanist medical organisation, producing marketing content related to stem-cell therapy and other forms of anti-ageing medicine. I received several treatments myself, and while I can only speak anecdotally, they significantly relieved decades of aches and pains related to hard training. And these were one-off procedures, not the monthly “Cadillac plan”, which involved steroids, growth hormones, and Botox. Wealthy clients would walk in as untrained, middle-aged slobs and, less than a year later, boast gym-hardened physiques that might take unenhanced trainees a decade to develop. 

The organisation’s telos was the stuff of nightmares: the acquisition of a yacht to serve as a floating hospital so that various procedures that are illegal in North America could be performed in international waters; or the same-day infusion of stem cells harvested from a delivery of rich clients’ babies. Although peer-reviewed research has shown no difference between using frozen and freshly-harvested stem cells, there was marketing value in promising clients the freshest ingredients possible. It allowed for a considerable markup in the price of the procedure. It wasn’t the “these vampires want to drink baby blood” of conspiracy-nut ramblings — but it did resemble them. 

So, when I see discussions of Ozempic’s social impact, I don’t think about plus-sized singer Lizzo and skeletal commentator Ann Coulter trading barbs about the ideal female physique. That sort of chatter is all a sideshow for the general public; the rich clients doping themselves to remain forever young do not much care about how the poor and middle class choose to identify (be it fat or fit) as long as few have the money to identify as rich. Without truly high-end gene editing that might enable skeletal and organ reconfiguration — still a way off, though one never knows — the rich are limited to the basic shape and size of their natal bodies. But being able to invest tens of thousands of dollars per annum in upkeep will nevertheless produce an optimised body utterly unlike that of the poor American.

The culture of fitness influencers and body performers is downstream of this. Their bodies represent an investment that will yield riches, which can in turn be reinvested in the upkeep of those bodies. They are selling you a picture of health that doubles as a picture of wealth, often lying about just how much they spend on effective drugs. In the marketing of bodies, deception is the key to the kingdom. You might, for example, promote your Ozempic transformation on TikTok while failing to mention the $6,000 “micro-liposuction” procedure you’ve used to improve problem areas, because you’re sponsored by an online clinic that writes prescriptions for the drug. Or you might fail to mention your Ozempic and steroid use completely, touting instead a diet that is far less effective in the absence of all these chemical crutches, but tied to prepared meals and meal-replacement shakes you’re being paid to promote. 

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As a lifelong strength athlete, I have toiled in filthy gyms and basements to maintain my own physical condition. I would like to say that remaining “natural” or practising intense physical discipline offers some intrinsic reward. Unfortunately, it does not; it is a hard-to-follow path made more tortuous in my case by my stubborn unwillingness to take any effective shortcuts (even though the stem cell injections I received worked like a charm). But a resistance to emptying my wallet, and an aversion to some of the side effects from these drugs — cancerous tumours in the case of Ozempic — has hindered my route to body optimisation.

For me, glorifying the “natural” in and of itself, then, is little better than writing some trite ode to manual labour. There are loads of people, nearly all of them poor and sick, whose bodies are relatively resistant to weight loss. For them, the simplicity of the Ozempic jab — as opposed to the creation of a stomach pouch via laparoscopic gastric bypass surgery — might offer an improved quality of life in much the same way that cheaper insulin and other band-aids help ease the pains associated with sedentary, unhealthy lifestyles.

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By Oliver Bateman

But the rhetorical appeal of this medicine — that it will produce gains that will “trickle down” from the upper classes to the masses — is an old lie. Time is a thief, stealing each passing minute from us, but as money proves able to purchase ever-increasing amounts of it, it will be disproportionately hoarded by those rich people who are already proficient at squirrelling away their money. Whether by violent nature or scientific nurture, the body is merely something to be overcome. And if you’ve the money to opt for the latter, why wouldn’t you?

In the meantime, those of us doomed to remain mere humans can only watch this process unfold while the rich become superhuman. Consigned to increasingly rare “normal” bodies that are both temples and tombs, the middle class must study this journey from the sidelines, watching on as a vast array of battered, bloated and ruined bodies are left in the wake of a transhumanist train that goes in only one direction. 

While other countries continue to grow health spending as a share of GDP, in the UK it continues to decline, along with wages (nurses’ pay is now 12% lower in real terms than before the 2010 election). And in the absence of proper funding, other sources of money start to swoop in. With a budget allocation of £168.2 billion for 2022-23, the NHS is the UK government’s biggest financial burden, but also the biggest cash cow for vulture capitalists. The next biggest spenders — education (£77.1 billion) and defence (£32.1 billion) — not only have smaller tills to dip into, but also offer far less opportunity for private investment.

As the pandemic illustrated, any enterprising fool can tap up the NHS, if you know which backdoor to go through. Take Conservative peer Michelle Mone, who, along with her three adult children, reportedly received £29 million from at least £65 million in profits paid to her husband, Douglas Barrowman by PPE Medpro — a supplier the Government now alleges supplied defective gowns to the NHS.

Then there is Sarah and Richard Stoute, whose Full Support Healthcare company netted £1.8 billion in contracts for medical gowns and masks — making them the single biggest beneficiaries of NHS PPE deals, as well as the proud new owners of a £30-million Caribbean villa, a £6-million English mansion and an equestrian centre. They haven’t broken any laws — and they insist that they are not Covid profiteers. But with the British government estimating that £84.7 million of PPE bought from Full Support Healthcare remains unused, at the very least it demonstrates that private investment doesn’t guarantee efficiency.

PPE scandals aside, Big Pharma is seen as one of the NHS’s greatest predators, not least because it is associated with the sort of rapacious capitalism we identify with America. Certainly, the way that drug companies do business often leaves much to be desired. Last summer, the Competition and Markets Authority (CMA) fined Pfizer and Flynn a total of £70 million for abusing their dominant positions to overcharge the NHS for the life-saving epilepsy drug, phenytoin sodium. The previous year, the CMA handed down fines worth more than £260 million to more than 10 pharmaceutical companies following a lengthy investigation into a staggering 10,000% price hike for generic hydrocortisone tablets. Officials said that Auden Mckenzie, the drug’s sole provider for many years, “paid off would-be competitors” to stay out of the market after acquiring generic rights to the medicine. To put the ruse in perspective, pre-2008 NHS England was spending around £500,000 a year on the drug. By 2016, that figure had ballooned to over £80 million.

Several agencies work together to procure medicines, pharmaceutical products and services for acute care in the NHS, including the Commercial Medicines Unit (CMU), which is responsible for tendering, awarding and managing frameworks for licensed medicines for the regional purchasing groups. There is no suggestion that the CMU and its agencies procure medicines for the NHS with anything but integrity. But drug companies spend millions each year on partnerships with the NHS, which the British Medical Journal found was only transparent in one in five cases involving NHS trusts.

Sometimes, this lack of transparency appears to pay off. For instance, work on a Covid vaccine developed by the University of Oxford and AstraZeneca benefitted from long-term funding from UK Research and Innovation (UKRI), followed by an additional £2.6million in Rapid Response from UKRI-National Institution for Health Research (NIHR). What AstraZeneca put in the R&D budget is harder to determine, but in early 2022, two years into the pandemic, the company had recorded nearly $4 billion in Covid vaccine sales for the previous year and a record $37.4 billion in revenue.

To date, more than two billion doses of the AstraZeneca vaccine have been released in more than 170 countries. And such rapid distribution was only possible because the Cambridge-based company and other Big Pharma brands could afford to team up with the best scientists from Oxbridge, Imperial and other leading global research institutions. So, who are we to begrudge them earning a few billion in profits? Well, since then, AstraZeneca has been criticised for dropping its non-profit model, with Oxfam accusing the company of “breaking its promise” to deliver vaccines to all countries during the pandemic as the world’s poorest countries remain largely unvaccinated. But the truth is the NHS isn’t in the pharmaceuticals business, so Big Pharma has an essential, albeit controversial role to play. Like it or not, it’s an unavoidable, incontrovertible public-private relationship.

Real privatisation through the backdoor, however, is less obvious. NHS Trusts and Foundation Trusts, for instance, now offer private healthcare services. But as these private services are usually delivered in NHS facilities, despite the need for such services to identify themselves as private (through branding), most patients will see an accompanying NHS logo and draw what would seem like an obvious conclusion.

Thanks to the Government’s “elective recovery plan” as the British Medical Association (BMA) diplomatically puts it, the Government is “further embedding the independent sector into the fabric of health services delivery”. In practice, this means that more and more NHS contracts and funding are being outsourced to the private sector, rather than the government focusing policy on increasing NHS capacity. Only last year, BMA research found that public spending on independent sector providers (ISPs) is growing annually, with £13.8 billion spent in 2020-21, up to £2 billion on the previous year. In 2003-04, 0.02% of all NHS-funded elective activity was provided by the private sector. By 2020-21, it had risen to 5.2%. The privatisation back door may be just ajar at the moment, but at this rate of increase, relatively soon it’ll be swinging wide open.

From concerns about standards of care to value for money, ISPs, by their very definition, seek to turn a profit. It’s hard not to agree, then, with the BMA when it concludes that the Government’s “commitment to reducing elective waiting lists and waiting times will further accelerate the shift towards independent sector provision of routine operations, such as cataract surgery, leaving complex, and more costly operations to the NHS”. In other words, ISPs are cherry-picking relatively routine operations and procedures because they don’t have emergency care facilities or staff to deal with complex patients. And as the BMA warns: “There are fundamental concerns that the outsourcing of simple procedures will compromise both the clinical and financial viability of NHS services, that it will consequently intensify working conditions, and increase pressure on staff”, particularly GPs.

In the meantime, the benefits for patients are often hard to discern. On the one hand, I have had people coming into A&E who have attempted dentistry on themselves, and failed miserably, because they can’t afford to visit a dentist. On the other, a close friend recently underwent a shoulder operation in a private hospital after being fast-tracked for treatment through the NHS. Describing the procedure and overnight stay as “better than most hotels I’ve ever stayed in”, the only expense my friend incurred was the cab fare home from hospital and a course of painkillers.

Meanwhile, I have colleagues who have responsibilities to the NHS but also have a hand in the private medical sector, where they carry out routine, profitable procedures and treatments, such as my friend’s shoulder op, which are effectively sold to the private sector because the NHS doesn’t have the capacity to do carry them out. One highly sought-after colleague, for instance, has an NHS waiting list that currently stands at 18 months for standard procedures. However, for approximately £5,000 plus add-ons per operation, the same work can be completed within two weeks.

To the average patient, this is a grey area of medicine that should, in truth, be black and white: either work for the NHS or work in the private sector. But for many clinicians, there’s no ethical dilemma. The system not only allows having two masters — it encourages it.