I am remaking myself, quite literally. I’m getting rid of toxic red blood cells and making clean new ones. Each week I go to an NHS clinic at my local hospital in North London, where a pair of friendly and efficient nurses (trained in the Philippines) relieve me of a pint of blood. It takes about fifteen minutes for it to pour through a needle inserted into the vein in the crook of my left elbow, into a bag balanced on a set of souped-up bathroom scales on the floor under my chair, while one of the nurses keeps a weather eye on the digital display. Then she uncouples the line and throws the bag into a big yellow bin. My job is to make more blood, for next week. I’m halfway through a ten-week cycle—ten weeks, ten pints. When I asked the specialist (trained in Pakistan) how many pints of blood I had to start with he said, rather gleefully, “eight or nine.”
I’m in my early sixties, which, my doctor tells me, is rather late for a diagnosis of hereditary hemochromatosis. The condition causes iron overload. Not everyone with the wonky gene suffers from excess iron, but if you are going to get symptoms from the buildup of iron in your joints and organs, particularly the liver, spleen, pancreas, and heart, they usually show up in men in their forties and in women in their fifties—after menopause. The main treatment for iron overload is removing blood from the body, something that happens for women naturally, until it doesn’t anymore. For years I was embarrassed to admit that I enjoyed my heavy monthly bleeding. It made me feel powerful, and now I know that that wasn’t just a weird, witchy fantasy—it really was keeping me safe.
My GP advised me that my gut symptoms, excessive fatigue, and aching joints were the result of food intolerance (“Try going gluten free,” “Try the FODMAP diet”). I owe my diagnosis to my sister Bridget, who insisted that I go back and tell him I am Irish—although actually we are part Welsh, on our father’s side. My sister is a medical scientist, and she has always suspected that our uncles—contrary to my assumption that they died in their forties of poverty, drink, and general fecklessness—succumbed to heart and liver damage caused by hemochromatosis (not helped by poverty, drink, et cetera). The condition is known as “the Celtic curse”—one in five Irish people carries one copy of the C282Y mutation in the HFE gene, and one in eighty-three, like me, has two, predisposing them to excess iron.
I’ve been immersing myself in DNA analysis and genome sequencing of Neolithic and Bronze Age skeletons. A Bronze Age, blue-eyed male, one of three buried on Rathlin Island in the North Channel, has the gene, so it was present in Ireland at least four thousand years ago, when being unable to rid your body of iron might have been an evolutionary advantage, given an iron-poor diet. There are also high numbers of people with the genetic mutation in Sweden, Norway, and Denmark, a fact that has given rise to “the Viking hypothesis.” There’s a bit of an argument among geneticists researching “founder effects” and DNA backstories over whether the mutation spread with the Vikings into Ireland or (the theory my doctor favors) the Vikings picked it up from Ireland and brought it home—via the women they captured on their raids and kept “in thrall.” Because the Irish like to get the last laugh.
How and why the gene ran amok in northwest Europe in the first place is a puzzle. My favorite hypothesis is that the Neolithic farmers who migrated north over generations from the Middle East, bringing with them techniques of domesticated cereal production and dairying, hadn’t reckoned with the weather. A milk and grain diet low in iron was all very well in the warmth and sunshine of Southern Europe, but how were people supposed to keep warm in chilly and damp conditions? Iron is crucial for thermoregulation. The gene mutation helped the Celts on the western seaboards of Europe stay warm. My condition, and all the costs of treatment by the NHS that go with it, is the fault of the Irish rain.
Hemochromatosis is thought to be the most common genetic disorder in the UK, though it is not much talked about and wasn’t on my GP’s radar. The trouble with diagnosing iron overload is that the early symptoms—exhaustion, brain fog, weakness, digestive upset, joint pain—are so common. They are pretty much the same as the symptoms of iron deficiency, among many other things, indeed the symptoms of life. And this is not a story about the failures of the NHS—rather the opposite—although when the blood tests showed high iron saturations, my GP asked me whether I had private insurance. Yes, I said, I had taken it out through my university employer a few years earlier. I had never used it. Now might be a good time, he suggested, as the wait to be seen by an NHS hematologist was eight months or more. Within a month I was seen by a private specialist, had the genetic test that revealed I carried two copies of the mutated gene, had an MRI on my liver (multiple lesions, one of which looked iffy), and got my ten venesections booked. I was due back to discuss the MRI results when my inbox pinged with a note from the insurer explaining that since the condition has a genetic cause, all coverage would cease from that moment. I wasn’t insured for my genes.
That evening I met a couple of GPs at a friend’s dinner party (one of the doctors had trained in Ireland, one in Pakistan). Given that science is slowly uncovering the genetic component of many diseases, we wondered how long it would be before insurance covers nothing at all. I now had the knowledge that my liver was damaged, and only getting more so. I was going to have to wait months for an appointment, but at least the NHS couldn’t refuse to treat me.
My condition came into being as a consequence of migration, and the NHS’s free-at-the-point-of-use treatment relies on the same process. The two MRI technicians who talked calmly to me while I was inside the tube in the hospital in Watford were trained in Malaysia; the man operating the CT scanning machine in the mobile unit in North Finchley got his skills in the Philippines; the guy shooting me in the side with a FibroScan device at my local North London hospital was trained in Indonesia. According to the General Medical Council, just under 63 percent of doctors joining the medical register in 2022 qualified overseas. Yet in June 2023 there were still 10,855 vacancies for doctors in secondary care. The pattern is similar for nurses, with nearly 24 percent of nurses and midwives trained abroad. So far in my local hospital all the older nurses I’ve met are Irish (although they likely trained in England), and everyone under forty is from the Philippines.
One day during one of my long waits in the hospital corridor I encountered a group of medical students hanging about, waiting to sit in on the clinic appointments. They all had middle-class Home Counties accents, bordering on posh, and there was an amount of bravado in their performance of cool for one another. About seven thousand doctors are trained in England each year, but they are a self-selecting group because it is expensive to study medicine. In June 2023 the Conservative MP Nadine Dorries claimed that it costs the British taxpayer half a million pounds to train a doctor, and that “when they are qualified, almost half of them from some medical schools head to Australia or NZ.”
She exaggerated. In a parliamentary debate the previous month the cost of training an individual doctor for seven years was given as £327,000, shared between the NHS and the student (who is liable for university fees and living costs for the first five years, and can access repayable loans of between £74,000 and £93,000). In his “love letter” to the health service, Free for All: Why the
NHS Is Worth Saving (2023), the GP Gavin Francis argues that the introduction of university fees has seriously dented doctors’ morale. They may have anticipated having to pay back their loans by toiling for long hours in overcrowded hospitals, but not the distrust and anger of patients, not the marketization of bureaucracy, not the crushing sense that they are giving their working lives to a broken system. Since March 2023 resident doctors have gone on strike no fewer than fourteen times, campaigning for higher pay and better conditions. One immediate cause of resentment is that, because of poor workforce planning, there is a bottleneck of newly qualified doctors. Those 10,000 vacancies are further up the chain, while recent graduates face unemployment. There are as many as 18,000 UK-trained doctors currently practicing overseas, a figure that has increased by 50 percent since 2008. Will I meet those young medical students on the wards in years to come, or will they have bailed for more dependable careers and sunnier weather?
A work by the sculptor Andy Goldsworthy has recently been exhibited in Edinburgh. Titled Red Wall (2025), it is an installation made from clay-rich earth dug from the Lowther Hills in Dumfriesshire. “This earth is a vivid red because of its high iron content,” Goldsworthy writes in the catalog. “Our blood is also red because of the iron in it. It’s a reminder that we are bound to the earth.” And in truth, I do feel earthy, a bit terra-cotta. I worry a little about setting off body scanners primed to look for metal, although the greater danger may be rust. When one doctor told me I should avoid swimming in the sea I assumed he was joking, until he explained: the marine environment is iron poor. Unlike people with normal iron levels, I would be prey to a microorganism that seeks out iron. It enters the body through any small cut or graze, where it multiplies exponentially as it gluts itself on iron and causes sepsis. It lies in wait in the ocean like a very, very tiny shark, circling for blood. One symptom of my condition may be a compulsion to make bad jokes: I’m in my element; I’m feeling sanguine about it.
I’ve been consulting William Harvey’s book On the Motion of the Heart and Blood in Animals, first published in Latin in 1628. It was Harvey (born in Kent, studied in Padua) who first theorized that the heart was a pump, circulating blood through the body in a closed system. Harvey’s circulatory system challenged the “consumption” model popularized by the second-century Galen (who started out as a surgeon to gladiators in Asia Minor and ended up in Rome as the personal physician to Marcus Aurelius). Galen argued that blood was the result of the “sanguification” of food in the liver, the engine of the body, from where it was sent out in all directions to the muscles, to get used up.
The veins and arteries carried the four humors (black bile, yellow bile, phlegm, and blood), which were also linked to the four elements (earth, fire, water, air). Disease was a matter of imbalance in the humors, and venesection and ligatures (which could be used to direct blood to a particular part of the body) were the recommended cures for pretty much everything. Harvey saw blood, not organs like the liver, as the primary force in the body, though he had no way of figuring out that red blood cells carry oxygen. But even when everyone accepted that blood circulates rather than dissipates (valves in the veins were a major clue, as was the force with which blood shoots from a cut artery), drawing blood remained popular for centuries.
It’s hard to find much support for therapeutic bloodletting nowadays. Most accounts of doctors’ zeal for the practice put it down to a lingering belief in the benefits of humoral “equilibrium” and a vague but persistent dedication to ridding the body of impure substances. It was also something to do, when physicians had few options for treatment. Bloodletting became wildly popular in late-eighteenth-century Europe, particularly France and England. The Jacobin François Broussais argued in 1808 that fevers were caused by inflammation of the organs, which could be locally treated by leeching, or more radically with the lancet. (An incidental result of the popularity of Broussais’s theory was the almost total destruction of the European leech population. France alone in 1833 imported 42 million leeches.) But in the history of nineteenth-century medicine the celebrated figures are those who were skeptical of bloodletting: Pierre Louis’s research in Paris, published in the 1820s, effectively debunked the efficacy of bloodletting in patients with pneumonia, by producing a set of comparisons of seventy-seven patients, few of whom derived any benefit. His pupil Marshall Hall (a founding member and president of the Harveian Society) brought the skepticism back to Edinburgh and London. Or we might think of Tertius Lydgate (trained in Edinburgh and Paris) going into battle with the doctors of Middlemarch, including Mr. Toller, proponent of the “heroic treatment,” whose favored procedures were bleeding, blistering, starving, and purging the unwell.
Bloodletting has not been good for literature, overall. Keats learned to be wary of the lancet as a young medical student, but that didn’t save him from the “depletion theory” embraced by his Roman physician, who in 1820 prescribed starvation and bloodletting when Keats coughed up blood. Four years later it was Byron’s turn to die of the cure when, despite his objections, he was subjected to aggressive bloodletting for the rheumatic fever he had contracted in Missolonghi. It’s tempting to wonder, what was wrong with these doctors? Were they blind, or just blinded by prejudice?
The most persuasive argument I have come across for this stubborn insistence on bleeding dying patients is the Swedish researcher Annelie Drakman’s. She has analyzed nearly nine thousand annual reports written by Swedish provincial doctors between 1820 and 1900. She argues that the “energetic support for phlebotomy” in the early nineteenth century had little to do with balancing humors, and more with maintaining flow through the body and getting rid of blockages. The big enemy was congestion; physical weakness was a sign of a sluggish system. By “breathing a vein” doctors were able to restart the body’s flow mechanically. She quotes one doctor who was called to tend to a man who had been injured in the head with an ax: the farmer had “an almost negligible pulse. Therefore, I immediately opened his veins. Once the pulse had risen and was free, I began to investigate the injury.”
Missing from these early accounts is any sense that blood should be preserved. There are no worries about loss, no concerns to maintain boundaries, no attempts to save vital energies. Within a generation Swedish doctors had rejected bloodletting en masse, and spent their time complaining that the peasants kept turning to quacks to bleed them for their ailments, or they did it to themselves. (Lots of people seemed to have felt better after bleeding, or imagined that they felt better, which is the same thing. And some people positively enjoyed it. Samuel Johnson liked it so much he got his servant to lance his veins when his doctor was absent.) Drakman speculates that the medical establishment’s sudden rejection of bloodletting as benighted and barbaric had less to do with evidenced arguments than with a new conception of the internal economy of the human body, a new sense of our bodies as organisms whose energies must be saved, not spent.
I was delighted to learn of my treatment. Short of dating a vampire, what could be better, I thought, than to experience the eighteenth century in the setting of a modern, hygienic clinic? I considered buying myself an A-line dress and one of those ceramic bowls with a piece cut away for my resting arm, so that I could practice being Marianne in Sense and Sensibility—or rather Kate Winslet. (There is no bloodletting scene in the novel, though Austen describes the practice in her letters.) Of all the conditions for which bloodletting was considered a cure for more than three thousand years, mine is one of the very few that legitimately called for it. I rejoiced in the knowledge that I would have thrived in the ancien régime along with one in eighty-three Irish people and quite a few Swedes and Danes. But it turns out that bloodletting is making a comeback—it is being touted as a therapy for all sorts of conditions, including aging itself.
My first doctor (the private one) extolled the benefits of venesection. I was lucky, he explained: after the ten venesections, I’d end up with “the blood of a thirty-year-old.” Each pint that gets thrown away into the yellow bin (the sign reads “Offensive Waste,” which slightly offends me) takes with it a bunch of hemoglobin molecules that then quickly need to be replenished, and for that the red blood cells need iron. They draw it first from the bone marrow, but as the hemoglobin is repeatedly depleted over a number of weeks and months, the bone marrow stores run out—I put this in layperson’s terms because those are the terms in which the process was explained to me. It is at that point that the red blood cells find the excess iron stored in the organs of people with iron overload (for example, the liver) and “mobilize” it for use. Simple but ingenious—and, it strikes me, not untrue to the sense of the body as a series of flows. By breathing my veins the nurses are kick-starting the flow of iron out of my congested liver—I can’t quite rid myself of an image of the phlebotomy bag as a magnet, pulling hundreds of tiny iron filings through the eye of a needle.
None of that equates to the blood of a thirty-year-old. But my doctor was adamant. “In the United States,” he said darkly, high-net-worth individuals regularly undergo venesection to reduce the risk of cancer and other diseases from oxidative stress. He painted a picture of the US as a country populated by extremely old and frail but well-off people whose organs don’t give out. He gave the example of Jimmy Carter. He warned of the traffic on Florida highways, permanently backed up with mobile phlebotomy units visiting retirement homes for the rich, to mass-bleed the residents and reduce their iron. I understood he was exaggerating for effect.
I have been unable to verify his claims, in relation either to Jimmy Carter personally, or more generally to the health regimes in retirement villages for the well heeled. But I do find an ever-lengthening list of conditions for which bloodletting may be beneficial: by reducing whole blood viscosity, iron levels, and oxidative stress, venesection can improve cardiovascular health. It’s good for edema, apparently, so Johnson (who suffered badly from dropsy, along with several other conditions) wasn’t necessarily wrong to demand it; wet cupping is believed to reduce inflammation and improve “blood flow” in patients with rheumatoid arthritis and other autoimmune diseases; phlebotomy can reduce blood pressure and aid glycemic control in metabolic syndrome; it is being trialed as a treatment for nonalcoholic fatty liver disease. And everyone knows that excess iron causes cancer. It’s one of the reasons we are told not to eat too much red meat. In 2007 an eight-year study on a cohort of half a million members of the AARP established the link between eating red and processed meat and esophageal, colorectal, liver, and lung cancers. It’s a relatively small step from regulating your intake of iron through diet to eating what you like and depleting your iron stores with a lancet.
I am not advocating the practice—just imagine the lawsuits—only pointing out that contemporary iron-related science sits surprisingly well with the idea that health requires getting rid of impurities and promoting flow in and out of the body. The notion that too much iron is the great enemy seems like it might be useful to Putin and Xi in their pursuit of immortality. But I pass on my doctor’s recommendation freely, and before someone tries to monetize it: blood donation is not only selfless; it may help you live longer, too.
NHS managers also care about flow. They too are at war with congestion in the system. Their task is to keep the stream of patients moving steadily through the organism of the NHS, from their arrival via GP or Accident and Emergency (A&E, the British term for ER) to their departure at the other end of the process, ideally by way of successful treatment in outpatient clinics or hospital beds, or alternatively through death. Blockages in the system cause backups and, eventually, overflow. A 2021 report on waiting lists for elective and cancer care by the National Audit Office—the UK’s independent public spending watchdog—uses the graphic of a bathtub to explain the problem: new referrals pour through the tap at a faster rate than the patients drain out, so the “referral to treatment” waiting list (the water in the bath) keeps increasing. There were 4.14 million outstanding referrals on the elective care waiting list when the report was written—a figure that is steadily rising. It currently stands at 7.41 million. Some of the congestion is owing to the Covid pandemic, when nonurgent services were suspended (and many sick people in need of care stayed away for fear of infection or because they thought they should), creating hundreds of thousands of “missing” patients who have now found their way back into the system. But the number of people waiting, and the length of time they’ve had to wait, was growing long before that.
Less than ten years ago a US Commonwealth Fund study ranked the NHS as the best health care system in the developed world. It scored particularly well on the “care process” (providing preventative, safe, and coordinated care) and on “equity”—the extent to which rich and poor get treated equally. It even came in third on administrative efficiency—the NHS is not particularly expensive to run, and it employs fewer managers than most large corporations. It did least well on health care outcomes (mortality and the overall health of the population), where it came in tenth, but it was still ahead of the US, which trailed at number eleven out of eleven.
The priorities of the current government’s ten-year health plan are to “speed up the drive to cut waiting times, expand community-based care and reduce health inequalities.” But when it comes to measuring any of this, the bottom line is never the policies to discourage smoking, to legislate against air pollution, or to take on the ultraprocessed food giants, the sugar industry, and the alcohol lobby. It is always appointment waiting times.
Every day there is a new media story about the failing state of the NHS. In recent weeks it’s been the latest resident doctor strike; the slashing of 18,000 administrative and managerial roles in NHS England in favor of more “frontline” staff; the impact of the H3N2 flu strain on overstretched clinics; the projected loss of foreign-born nurses because of tighter immigration rules; the government’s standoff with the pharmaceutical industry over drug pricing; and the publication of the parliamentary Public Accounts Committee’s “scathing” report on NHS England’s delivery of their 2022 plan to speed up elective care: “NHSE missed its recovery targets by significant margins. By July 2025, 22% [of] patients waited more than six weeks for diagnostic tests. This is far higher than the standard of 1%.”
Anyone who wants to be treated in the NHS knows they are in for a series of waits. There’s the initial wait for a GP appointment. Whereas a few years ago you could wait three weeks for an in-person appointment, the wait for my GP surgery now generally comes in at under two weeks, and urgent requests are dealt with within forty-eight hours. That’s for a phone appointment, which has become the norm since the “digital-first” care directive introduced a few years ago, mandating online appointment booking, and triaging and consultations by phone when possible—a disaster for the elderly, the deaf, the app-reluctant, the technologically unsavvy, and the 7 percent of households in the UK that don’t have access to the Internet, but popular with young professionals who can now talk to a doctor from home or while on the move. I recently witnessed a near fight in my GP’s office when a man in his fifties came in to make an appointment in person, only to be briskly told that he had to go home and fill in an “e-consult” form online. His aggression seemed to me to be a symptom of panic. He’d come in because no one was answering the phone. There was the receptionist in front of him. I wondered at the blithe assumption that he should be able to navigate his way through the online system, and I am willing to bet that what he did instead was go to A&E. Where he would have to wait.
In 2010, 95 percent of A&E patients were supposed to be seen within four hours. Now the target is 78 percent of patients, but last March only 61 percent made it in under time. Waits in A&E are often a prelude to “trolley waits,” which means waiting for a bed (often in a corridor, often for more than four hours) after the decision to admit has been made but before a bed has been found. Last January more than 60,000 patients (or about 11 percent of emergency admissions) waited twelve hours for a bed. There is strong evidence that the odds of post-discharge death are higher the longer a patient has waited to be seen. Some hospitals have a “call first” system, with receptionists offering booked time slots. Others post live waiting times on an app, so that people with flexible transport can choose the shortest queue. Things are looking bad right now in Forth Valley (a nine-hour wait) and in Milton Keynes (seven hours).
The best waits are the in-person waits in outpatient clinic corridors. As long as you are not frightened about your health, you have nowhere else you need to be, and you have no child or elderly relative in tow, the hospital corridors can be immensely entertaining. I am now extremely familiar with the waiting areas on the first floor at my local hospital. There are never fewer than four or five different clinics going on at the same time, and rarely are there sufficient rooms for the clinicians or enough seating for the patients who mill about, not sure where to go. Everything spills out into the corridors. It’s like watching television.
The admin staff who wheel themselves on their office chairs between mobile computer stands to share information; the nurses searching for files or the keys to the medication trolley; the translators searching for patients; the patients searching for clinics; the receptionists trying to make themselves heard above the mayhem—the atmosphere is frenetic but friendly. The maintenance guys putting out buckets to catch the rain coming through the roof; the peeling paint and the piece of wood jamming the window closed; the whiteboards covered in drooping, blue-tacked signs; the chairs held together with tape. The building needs an overhaul, but it’s not on the list of urgent repairs to be done under the New Hospital Programme, so it won’t be looked at until after 2040—priority is being given to hospitals that are crumbling because they were made of reinforced aerated concrete in the 1960s and 1970s, but even some of those projects won’t begin till 2028.
Occasionally I find myself thinking: I’m paying for this. I’m paying, through taxation, quite a lot more than I paid for private health insurance, but it is not easy to work out exactly how much more. NHS spending for 2023–2024 (the most recent year for which we have figures) was £174 billion, and NHS capital investment for the same year was £8 billion. If you divide those figures by the 58 million people living in England in mid-2024, you get a sum of £3,318 per person for the year, or around £260 a month. But if you divide them by the number of economically active people in England then the figure each tax-liable individual pays for the NHS is probably double that. Workers on immigrant visas pay an additional immigration health surcharge, currently around £1,000 a year each and £800 for each dependent. And large numbers of economically inactive people they share the hospital waiting areas with are paying nothing at all.
When dark clouds of financial selfishness threaten me, I remind myself of the occasions when I’ve received free health care in other systems, most memorably a night in the mid-1980s spent on a gurney in a corridor at Bellevue in Manhattan. Someone had put something in my drink at a bar on Avenue B, and I collapsed on the street. When the ambulance arrived the paramedics asked me about insurance, and I had none. (I was a student in my early twenties earning money by working as an agency cleaner in Brooklyn and Queens in the summers, without papers and without foresight.) At Bellevue I shared the corridor with a number of men handcuffed to prison guards and some very unwell heroin addicts. I was treated with exemplary care by the doctors, whose salaries were being paid by others, and quite possibly by some of you.
It is reassuring to me to know that despite the MRIs, CT and PET scans, FibroScans, venesections, and multiple hospital appointments, despite the multidisciplinary team meetings, the radiographers writing reports, the admin staff typing letters and receptionists arranging appointments, the acute treatment for my condition is not the biggest drain on the NHS. It’s the chronic illnesses like obesity, cardiac diseases, diseases of aging, and the mental health crisis that cost the big money. Those are what mainly account for the volume of water in the bath. The treatment I’m undergoing for iron overload will hopefully help guard against liver, colon, esophageal, and other cancers, and protect my pancreas, spleen, and heart from all that toxic metal. To that extent the venesection therapy is money saving. Of course there is a downside to this success. The very fact that now I am unlikely to die of hemochromatosis means that I will still be around to get something else. I will hopefully be prey to many of the illnesses and conditions of old age. The only truly absent patient is a dead patient. I’ll get there. I do intend to do my duty by the NHS, but ideally not yet.
I’ve been accused of Stockholm syndrome—not personally, but collectively, as one of the vast majority of UK citizens who don’t want the market to mess with the NHS. Peter Thiel, the cofounder and chairman of the data analytics company Palantir, which now has a £330 billion contract to develop data software for the NHS, believes that the service “makes people sick” and requires someone to come in and “just rip the whole thing from the ground and start over.” He blames the system’s stagnation on the public’s affection for it, but recent polls show that people are generally negative about the state of the health service overall (although they are broadly happy with their local provision). It is just that they are decisively more negative about dismantling a tax-funded system, free at the point of delivery, in favor of a system based on patient charges or social insurance, which would inevitably discriminate against what in the US are called “preexisting conditions.” They like to know they will be treated no matter what their genes might be.
Palantir’s function at the NHS—developing a new system called the Federated Data Platform (FDP)—is meant to increase the flow of information (such as bed occupancy, waiting lists, operating room availability, and patient details) between siloed data sources in order to speed up care. According to one source, hospitals using the FDP have seen a 35 percent fall in discharge waiting times and performed on average an extra 114 elective surgeries per month. But there has been a backlash against the use of Palantir’s software. Some NHS hospitals have found it inferior to their own. And there are political concerns. Earlier this year doctors with the British Medical Association (BMA) passed a motion objecting to the management of patient data using the same technology that is perfecting the “kill chain” (or “targeting cycle”) in US and Western military conflicts, honing algorithms used in predictive policing, and facilitating ICE roundups. The BMA motion states:
This partnership threatens to undermine public trust in NHS data systems, due to a lack of transparency in how the data will be stored and processed, a track record of creating discriminatory policing software in the US, and close links to a US government which shows little regard for international law.
In July Louis Mosley, the head of Palantir UK, was asked to comment on the BMA’s stance at a meeting of the parliamentary Science, Innovation and Technology Committee. “If I may be frank,” he responded,
I think that the BMA has chosen ideology over patient interest. I think our software is going to make patients’ lives better, by making their treatment quicker and more effective, and ultimately by making the healthcare system more efficient.
I was tempted to accept this as a reasonable, pragmatic position, until I looked further into Mosley’s own ideology, and in particular at a peculiar speech he gave this year at a conference organized by the Alliance for Responsible Citizenship, a group whose stated aim is “to challenge prevailing global narratives of declinism…in an age marked by economic stagnation and pessimism in the West.’’ Mosley argues that today’s technological revolution can be understood as a version of the Cromwellian revolution of the 1640s. Populist movements take advantage of shifting political and technological balances of power to overthrow the censorship regime of the “elites” (“armies of fact-checkers and experts, cadres of activists and lawyers, networks of universities, media outlets and NGOs”), just as the Levelers overthrew the old order—before they fell out disastrously with Cromwell.
Today’s Levelers are the young men staffing Elon Musk’s DOGE (Mosley gave his speech before Musk’s fall) and the online armies who challenge “the official narrative on…the origins of the Covid pandemic, or mass migration.” The age of “globalism” is over, evidenced by Brexit, the return of Donald Trump, and the rise of populist movements across Europe. Mosley appears at first to be arguing in favor of free speech, civil liberties, and Western values. He says of Palantir, “We use AI to defend the West against its enemies, and make Western governments more efficient.” But the task of “restoring our civilization” also requires policing the borders of freedom. Mosley warns that AI must not get into “the wrong hands,” which is an odd position for someone against censorship.
No doubt it is unimaginative of me, but I worry that the person in charge of data management at the NHS is against fact-checking. When Mosley condemns the postnationalist globalist elite for its censorship of alternative theories of mass migration, he is making a not-very-veiled reference to “replacement theory”—the nativist conspiracy that white populations in Europe and the United States are somehow deliberately being replaced by nonwhite immigrants and their progeny. He is careful not to tout the conspiracy himself; he associates it instead with his new model army of online information Levelers. “The data belongs to the customer,” Mosley says of Palantir’s NHS Federated Data Platform. But it is hard to feel, yes, sanguine about what might happen if the personal and intimate health data of the UK population, including all its migrants, did get into the wrong hands.
During his appearance before the parliamentary committee, MP Kit Malthouse presented Mosley with a hypothetical: “If I have a large pool of data about a set of individuals and, in a defensive or offensive capability, I wish to target particular individuals with particular characteristics, your AI would allow me to do that.” Mosley obfuscated:
Targeting is an area where, again, rather like the governance around the data, we provide an enormous amount of control and governance to the organisations that use our software for that purpose, to manage precisely the kinds of risks that you are talking about so that, through that targeting cycle, you have assurance and, at the end of it, end-to-end auditability.
As Malthouse put it, “That sounds like a yes.” Yes, the software will allow targeting of particular individuals with particular characteristics, in which case the BMA is probably right to be concerned that people will lose trust in the organization for fear of discrimination.
Suspicious journalists in the British media and online commentators have pointed out that Mosley is the grandson of Oswald Mosley, leader of the British Union of Fascists—though Mosley is no more responsible for his genes than I am. Oddly enough we may share a good proportion of them. My family name is Moxley—a name that was sometimes written Mokesley, Moaksley, or Moazley. It’s an uncommon name in the west of Ireland; a genealogist once told me that he had traced it back to a soldier who arrived in Ireland with the Cromwellian plantation of Munster, after the 1641 Rebellion, when Catholic-owned land was confiscated and given to soldiers and adventurers in return for their services. This would mean I’m descended from one of Mosley’s New Model Army soldiers, whose heirs intermarried sufficiently with the descendants of the Celts to give me two copies of the C282Y gene.
Responsible citizenship can take various forms. There’s the civil war kind—joining an evangelical, militaristic crusade in favor of upholding Western values, securing borders, and overthrowing the armies of the elite censorship regime. Personally, I’m not keen. I prefer the fact-checking kind. Take the common perception that immigrants to the UK place an excess burden on the NHS—a popular claim made by politicians from all sides in favor of welfare nationalism. Seven out of ten Britons believe that immigration places extra pressure on the NHS, and nearly a third believe that migrants use the NHS more than people born in the UK. But evidence comparing GP registrations and hospital admissions suggests the opposite: not only do immigrants work for the NHS in disproportionately high numbers and pay taxes to fund it (plus an extra health surcharge), but they are around half as likely to use the service as people born in the UK—partly because they tend to be young and healthy.
The NHS is under tremendous strain, and one of the reasons for that is the poor general health of the UK population. Waiting lists are backed up with the casualties of a malfunctioning capitalist system that generates more and more ill health, inequality, and social problems: the NHS backlog is symptomatic of a society that is not well. It is also testament to the fact that, despite all the features of privatization, marketization, and outsourcing that have been introduced into the NHS over the past thirty years, the system still functions for the benefit of all. The postwar welfare state and progressive taxation in the UK reduced the country’s vast disparities of wealth and led to a significant decrease in social inequality. The NHS is the one element of that social contract that has not yet been destroyed, and that is why, despite its flaws, we want to keep it.
English (US) · 