番茄社区

I started my column at 番茄社区 in 2018, and -- with the exception of an 18-month hiatus -- I have been posting essays almost weekly. The essays have been well-received and have generated a great deal of discourse. Some posts are read by more than 100,000 people throughout the world.

So, it was surprising when a colleague recently asked me a question that caught me off guard. (The dialogue below is not verbatim.)

Colleague: How much are you getting paid to write these essays every week?

Me: Nothing. 番茄社区 provides a wonderful platform. But they don't pay me. I do not even have a contract or any written agreement with the publisher.

Colleague: You are kidding me! You are giving your work away for free?

Me: Yes. What is wrong with that?

Colleague: When you have something to say and have an enormous following, you should not be giving your thoughts away for free. You are missing an unbelievable opportunity to make a great deal of money.

Me: You are being silly. People give their opinions away for free on Twitter all the time. I do not have a Twitter account. I post my thoughts and work on 番茄社区.

Colleague: You cannot monetize tweets that are limited to 240 characters. Tweets are not very informational and are often quite emotional. But you are writing whole essays that are very well written and researched. Your opinions are valued, and thousands of people want to read what you write.

Me: So, what are you recommending exactly?

Colleague: Have you heard of Substack?

Me: Yes, it is an online platform that supports subscription newsletters. It allows writers to send digital newsletters directly to subscribers.

Colleague: Substack makes money through rather than advertisements. It was founded only a few years ago, but Substack already has more than a . Many people who have something to say and who have large followings can make a substantial amount of money on the platform.

Me: It sounds like a site for politicians and journalists, rather than physicians.

Colleague: You are wrong. Eric Topol, who built an enormous following on Twitter, just joined Substack as a "." And many other physicians write for Substack. In fact, some of the most popular Substack writers are physicians using the platform to spread disinformation about COVID-19 and promoting strong anti-vaccine messages.

Me: I have heard that the content on Substack is not moderated. Many people who have been kicked off Twitter or Facebook have moved to Substack. Robert Malone, MD, and Alex Berenson are a couple examples.

Colleague: Yes, and they are making millions of dollars a year by selling their thoughts to subscribers on Substack. Being a physician who spreads disinformation about COVID-19 is very profitable.

Yes. It is very profitable.

According to Sheera Frenkel, the New York Times and citing the nonprofit Center for Countering Digital Hate, physician Joseph Mercola, DO, heads the list of the 12 people who are responsible for two-thirds of all anti-vaccine messaging on social media. Kolina Koltai, PhD, a researcher at the University of Washington, refers to him as the "pioneer of the anti-vaccine movement." Apparently, Mercola has labeled the COVID-19 vaccines as "medical fraud" and claims the shots "alter your genetic coding, turning you into a viral protein factory that has no off-switch."

In addition, Mercola has advocated for unproven treatments for COVID-19, and has promoted his own products for other diseases. Before the pandemic, in 2005, 2006, and 2011, the Mercola and his company that they were making illegal claims for their products' ability to detect, prevent, and treat disease.

Mercola began his anti-vaccine messaging on Facebook, where he has nearly 2 million followers. He has more than 360,000 followers on Twitter, but is banned from YouTube. In May 2021, he removed many of his own Facebook posts to evade the social network's crackdown on anti-vaccine content. But of course, on Facebook and Twitter, he was sharing his thoughts for free.

To monetize his writings, Mercola established himself as a writer for Substack, where he enjoyed the platform's hands-off approach. And more importantly, he could charge subscribers for reading his work. Interestingly, on Substack, he publishes articles that he personally regards as being too controversial even for his own website. Apparently he a range of absurd cures for COVID-19 on his website in May 2021; he later deleted them, but then published the same content on Substack.

Why would he do that? Outlandish statements and preposterous claims drive subscriptions. If subscribers pay $5 a month and a physician has 100,000 subscribers, that generates $6 million annually. Even with the platform taking 10% of subscriber fees, the writer still walks away with $5.4 million per year.

Do physicians spreading COVID-19 disinformation really make that much?

According to The Guardian, they do make that much, and they can make more than that. As Elise Thomas writes, on the list of the most popular Substack subscribers, Mercola is . Another controversial figure in COVID-19 messaging is Berenson, who is listed as number 6. In fact, many of those who have the largest subscriber base on Substack are COVID-19 controversy or disinformation. The Center for Countering Digital Hate estimates that certain physicians and individuals routinely publishing false or misleading information about COVID-19 pull in at least $2.5 million a year, but the figure could be as high as . (Writers who sign up with Substack substantial monetary advances.)

Yet, Substack defends its business model. In a recent statement, the : "As we face growing pressure to censor content published on Substack that to some seems dubious or objectionable, our answer remains the same: we make decisions based on principles not PR, we will defend free expression, and we will stick to our hands-off approach to content moderation..." To be precise, Substack's guidelines prohibit content "that promotes harmful or illegal activities," but they any specific ban on publishing false information.

I want to be clear: there are thousands of physicians who work very hard and provide essential or valued services and information, and for their diligent work, they can deservedly make a great deal of money. Certainly, no one would begrudge anyone for being richly rewarded if they provide invaluable guidance or treatments with the potential to improve the lives of patients.

But would some medical practitioners really commit fraudulent acts to make vast sums of money?

Physicians engaged in have earned tens of millions of dollars. Two nurses allegedly collected $1.5 million by issuing fake COVID-19 vaccine cards. So, the answer is a resounding yes: medical practitioners will commit crimes to earn enormous amounts of money.

But spreading medical disinformation is not a crime. And if some governmental authority were to make it a crime, it would be impossible to enforce. It has always been difficult to distinguish "facts" from .

In trying to identify the publication of disinformation, many would be tempted to apply the standard proposed in 1964 by Supreme Court Justice Potter Stewart to define the publication of obscenity ("I know it when I see it"). But defining "false information" can be extremely difficult. In fact, many people do not realize that "misinformation" and "disinformation" are not the same. , "misinformation" is incorrect or misleading information unintentionally presented as fact, whereas "disinformation" is deliberately deceptive. So how can you tell if the purveyor of false information (1) is ill-informed; (2) truly believes something that is demonstrably false; or (3) intends to deceive their readers for an ulterior motive?

Despite the challenge of parsing out these motives, several journalists have been severely critical of Substack and have called on the platform to "police" the content on its site. As noted above, Substack is not interested in doing anything against its own strategic interests. Yet, it seems likely that those who are critical of the platform are hoping to create sufficient negative publicity so as to discourage reputable writers from publishing their work on Substack.

But the purpose of this essay is not to question what Substack is doing or to criticize the platform. This article is not about writers who use the platform to express their views, however useful or unpopular. It is about how certain physicians who intentionally seek to spread disinformation about COVID-19 use Substack in order to monetize their followers.

Many of my colleagues wonder what could possibly motivate a physician to promote false information about vaccines that work and about drugs that do not work. What reason could they possibly have to mislead the public?

Now, perhaps, we do not need to wonder anymore.

Do we have a name for the intentional and harmful exploitation of others for reasons that are entirely related to making large sums of money? Some would equate that with capitalism. But it is not capitalism -- it is crass opportunism. And sadly, throughout the civilized world -- regardless of whether one lives in a capitalistic or socialistic economic system -- it is entirely legal.

Milton Packer, MD, is currently distinguished scholar in cardiovascular science at Baylor University Medical Center at Dallas and visiting professor at Imperial College in London. Packer is an internationally recognized clinical investigator who has made many seminal contributions to the field of heart failure, both in understanding its mechanisms and defining its rational management. His work has spanned more than 40 years and has established the cornerstone of the current modern treatments for heart failure, including ACE inhibitors, beta-blockers, angiotensin neprilysin inhibitors, and SGLT2 inhibitors. He has authored nearly 600 peer-reviewed publications and has been the overall principal investigator for 20 large-scale international trials of novel interventions in heart failure.

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