Sunday, December 09, 2018

Mission-Hostile Hospital Management: Quieter, but Still Pernicious After All These Years

Hospitals exist to take care of sick people, with the goal of making them better.  Hospitals employ and work with health care professionals, again who are sworn to put taking care of patients ahead of all other concerns.

However, since we founded Health Care Renewal, we have noted striking examples of hospital leaders threatening their hospitals' fundamental mission and/or health care professionals' core values, which we dubbed mission-hostile management.  We also saw mission-hostile management affecting the broader health care industry, particularly pharmaceutical and device companies.  Most recently, the most striking examples of mission-hostile health care related management appearing in the press have come from the Trump administration.

While journalists attention is focused on Trump et al, and coverage of other topics fades, bad management of hospitals has received less attention.  However, the problem has not vanished, nor become less important.  So here is my round-up of cases of mission-hostile hospital management from the recent past.

Hospitals Offering Better Care to Wealthier Patients

Hospitlas generally proclaim that they endeavor to care for all patients, regardless of their personal characteristics, or worthiness for care  Yet we have seen non-profit hospitals offering better care to those who can pay more.  

Preferential Treatment for Wealthy Foreign Nationals Seeking Organ Transplants 

A story from November, 2017 in ProPublica documented how some US hospitals seem to give preferential treatment to wealthy people coming from overseas specifically for organ transplants.  

Little known to the public, or to sick patients and their families, organs donated domestically are sometimes given to patients flying in from other countries, who often pay a premium. Some hospitals even seek out foreign patients in need of a transplant. A Saudi Arabian company, Ansaq Medical Co., whose stated aim is to 'facilitate the procedures and mechanisms of ‘medical tourism,’' said it signed an agreement with Ochsner Medical Center in New Orleans in 2015.

In particular,

Foreign patients generally are not entitled to the same discounts as those with private insurance or Medicare, the federal insurance program for seniors and the disabled. In 2015, for instance, the average sticker price for a liver transplant at NewYork-Presbyterian was $371,203, but the average payment for patients in Medicare was less than one-third of that, $112,469, according to data from the Centers for Medicare and Medicaid Services, which runs Medicare. In the case of Saudi Arabia, its embassy in Washington often guarantees payment for patients.

This is actually not a new pheonomenon. 

There have been scandals in the past about foreigners and organ transplants. In 2005, a liver transplant center in Los Angeles shut its doors after disclosing that its team had taken a liver that should have gone to a patient at another hospital and instead had implanted it in a Saudi national. The hospital said its staff members falsified documents to cover up the incident.

The University of California, Los Angeles, came under fire in 2008 for performing liver transplants on a powerful Japanese gang boss and other men linked to Japanese gangs, and then receiving donations afterward from at least two of the men. The hospital and its surgeon said they do not make moral judgments about patients.

We discussed the case of the Yakuza transplants most recently here.

Note that while foreign nationals seem to end up on the same waiting lists that US citizens may be on, the operation of these medical tourism programs implies that they are virtually guaranteed an organ, while US citizens are not. The preferential treatment of the medical tourists does not seem to stem from compassion, but rather from the larger fees they are willing to pay. 

Discouraging Organ Transplants for Patients Unable to Afford Expensive Anti-Rejection Drugs and Other After Care

A story from December, 2018 from Kaiser Health News published in the New York Times, suggested that most organ transplant centers will not take care of patients until they can show their ability to pay, usually to pay the "sticker prices." One case made public in November, 2018, brought this issue to light

Hedda Martin, 60, of Grand Rapids, was informed that she was not a candidate for a heart transplant because of her finances. It recommended 'a fund-raising effort of $10,000.'

The Times reporters found that this was not unusual.

Two years ago, Mr. Mannion, of Oxford, Conn., learned he needed a double-lung transplant after contracting idiopathic pulmonary fibrosis, a progressive, fatal disease. From the start, hospital officials told him to set aside $30,000 in a separate bank account to cover the costs.

Mr. Mannion, 59, who received his new lungs in May 2017, reflected: 'Here you are, you need a heart — that’s a tough road for any person,' he said. 'And then for that person to have to be a fund-raiser?'

Ms. Martin’s case incited outrage over a transplant system that links access to a lifesaving treatment to finances. But requiring proof of payment for organ transplants and postoperative care is common, transplant experts say.

'It happens every day,' said Arthur Caplan, a bioethicist at the New York University Langone Medical Center. 'You get what I call a ‘wallet biopsy.’'

Virtually all of the nation’s more than 250 transplant centers, which refer patients to a single national registry, require patients to verify how they will cover bills that can total $400,000 for a kidney transplant or $1.3 million for a heart, plus monthly costs that average $2,500 for anti-rejection drugs that must be taken for life, Dr. Caplan said.

Note again that the 'sticker prices' quoted above are much higher than those paid by US government health insurance programs, so this insistence on having enough money or coverage available to pay the sticker prices appears to discriminate against poorer patients who may not have the most deluxe insurance coverage.  Futhermore, it is likely that the actual costs to do the transplant and provide follow-up care are lower than the discounted prices, suggesting that the hospital are putting their revenue ahead of the mission to provide care to patients according to the patients' needs.

Expensive Concierge Care at Non-Profit Academic Medical Centers

We have previously discussed cases of non-profit academic hospitals offering deluxe services to patients able to pay hefty fees, despite their idealistic mission statements about serving the whole coummunity.  In March, 2018, the Michigan Daily discussed the latest version of such care offered by Michigan Medicine,

Michigan Medicine at the University of Michigan is currently launching Victors Care, a concierge medical care model aiming to deliver tailored health care access to a limited number of patients. These patients will receive specialized, convenient and optimized care with purchase of an annual membership fee to cover primary care services without copays or deductibles.

A number of faculty members took exception to this program in a letter addressed to top Michigan Medicine executives,

grievances listed in the faculty letter include: being unaware in the content of the Victors Care program invitation letter, video and website; discriminating against the underserved; promotional materials suggesting Victors Care patients will 'receive preferential treatment at Michigan Medicine based on ability to pay'; implication that if receiving Victors Care is quality care, receiving care from traditional primary care physicians is not quality; and a concern that Victors Care promotional materials and website recommend care that is not evidence based.

'We ask that the institution stop recruiting our patients to this program and advertising it as providing much better care than all the rest of our primary care clinics, the letter reads. 'Victors Care purports to offer ‘better’ health care to those with enough money to pay a large access fee. The University of Michigan is a public institution and our commitment is to serve the public, not a private few.'

The letter also includes direct quotations from Michigan Medicine faculty, one of which notes: 'This reinforces UM as an elitist institution catering to the wealthy.'
Note that Michigan Medicine is a creature of the University of Michigan, a non-profit, state-supported institution, although I cannot determine whether legally Michigan Medicine is a government entity, a non-profit corporation, or something else.  The mission statement on the organizational website is:

We advance health to serve Michigan and the world

It says nothing about providing better service to wealthier patients 

Hospital Spending Priorities Put Patients and Health Profesionals Last

Increasing Market Dominance Rather than Improving Affordability of Health Care

The problem was described in a February, 2018, NBC News article, entitled with the question:"Hospitals made $21B on Wall Street last year, but are patients seeing those profits?"

Some medical economists say that nonprofit hospitals are using lucrative Wall Street portfolios to fatten their bottom lines rather than lower what patients pay for health care.

'The tenor and the responsibility of hospital CEOs has now changed over time,' said Gerard Anderson, a professor of health policy, management and international health at the Johns Hopkins University Bloomberg School of Public Health. 'They focus on the bottom line and … they get performance ratings based on profitability,' he said.

In particular, the article suggested rather than using investment earnings to lower costs to patients,

Hospitals have an incentive to reinvest Wall Street income into growing their networks in order to compete. 'To acquire hospitals you need to have money. If you want to be the biggest hospital system in your community you have to have a lot of money,' Anderson said.

But bigger hospital networks don’t necessarily mean better, or cheaper, health care for patients.

Luxury Hotel Like Accoutrements Rather than Direct Patient Care Services

Furthermore, while the patients may literally see the results of lavish hospital spending, much of that spending has scant relationship to patient care. An  article in the Spectator, March, 2018, described the lavish ways many big non-profit academic medical centers spend their money.

The Emperor Nero would have felt at home in our hospitals.

At St. Vincent’s Hospital in Worcester, Massachusetts, visitors immediately encounter a waterfall, trees, massive rocks, and a pathway for hospital-goers interested in a stroll all located underneath a glass atrium. The massive indoor nature preserve of sorts appears about half the size of a football field. It provides peace and tranquility in a place in need of such comforts.


IU Health in Indianapolis boasts a monorail-like People Mover that shuttles patients, families, employees, and anybody else who cares to ride between hospitals for free. Cedars-Sinai in Los Angeles offers deluxe maternity suites featuring such perks as access to a 'personal doula,' 'soft colors and recessed lighting to offer a soothing environment for laboring women,' and an 'in-room refrigerator stocked with complimentary chilled juices and bottled water.' Even hospitals labeled 'struggling' struggle to avoid lavish spending. The New York Post reported in 2016 that Brooklyn’s SUNY Downstate Medical Center paid consultants $83,000 for such frills as 'pricey rooms at the Carlyle Hotel on the Upper East Side, a booze-infused ‘team dinner’ at the Docks Oyster Bar in Midtown, and sticker-shock limo bills.'

True to the publication's ideology, the article blamed the spending on the government.  Obviously, though, it was hospital managers who made the spending decisions.

Hospital Board Members Meet in Cayman Islands While Budget for Employee Benefits Threatened

Hospital managers, even in hospitals meant to serve the poor, like to use the hospital budget for lavish perks.  For example, according to a report from Newsday from March, 2018, Nassau University Medical Center, is a "safety net" hospital which

treats low-income people, receives state aid even though Nassau County ended its subsidy several years ago. However, the county is liable for more than $242 million in hospital long-term debt if NHCC defaults.

Its finances have been challenged:

hospital finances continue to be tight as NuHealth faces tens of millions of dollars in liabilities for accrued employee time, health care and pensions.

'This is a cash cow without the cash,' [Chairman of the Board George] Tsunis said. 'We have a very perilous position here.'

Yet until then, hospital management continued

the practice of sending three hospital officials to the Cayman Islands for a week during Thanksgiving and a week in February to discuss the health care corporation’s offshore self-insurance facility, Tsunis said.

Like other hospitals, NuHealth set up a limited liability company called NHCC LTD in the Cayman Islands for tax purposes to self-insure for malpractice and general liability claims. The hospital’s chief executive officer, chief financial officer and chief operating officer are the company board members. To maintain the Cayman location, company officials must meet at least once a year outside the United States.

The hospital usually sent all three board members to the Cayman Islands twice a year, Tsunis said.

Now the hospital will send two people once a year to a meeting at an airport hotel ... in Canada.

So even when the bottom line was threatened, Caribbean jaunts for board members continued, apparently until they were caught 

Eliminating Faculty Retention Bonuses to Pay for Legal Liability Due to Alleged Mismanagement

While hospital managers may get lavish perks, when expenses go up they do not shrink from cutting the pay of their employees, even their most well-trained medical professionals.  For example, in January, 2018, McClatchey reported (here via the Charlotte Observer) that the University of New Mexico suspended its retention bonuses for anesthesia faculty because of the settlement it had to pay for a suit brought by 'a former dismissed problem resident.' However,

The woman said in the wrongful termination lawsuit filed in 2011 that she was raped in June 2009 by a post-doctoral fellow and anesthesiologist at the university. Afraid she’d face repercussions, she waited until September to report it to department higher-ups, the lawsuit said.

The lawsuit said officials 'discouraged' her from reporting the alleged assault to law enforcement officials to avoid damaging the school’s reputation.

The suit accused the university of failing to conduct an investigation into the allegations and of eventually terminating the resident, violating state laws, in 2011. The case was thrown out in 2013 but reinstated on appeal in 2015. UNM’s attorneys agreed to settle for an undisclosed amount in November, according to the NM Political Report.

So the suit alleged considerable bad management, as well as bad behavior by one anesthesia trainee,  but the money to settle it had to come out of senior physicians' compensation, not management's pockets.

Hospitals Threatening Health Care Professionals who Call for Patient Care Improvements that Might Cost Money

Hospitals depend on health care professionals to actually take care of patients. Health professionals swear to put patients and patient care first, while hospital managers have no such professional values, unless they are also health professionals.  Yet hospital managers have been known to threaten health professionals who dare differ with them on matters pertaining to patient care, particularly professionals who call for changes that would cost more money.

In Medscape, from October, 2017, Dr John Mandrola described the plight of employed physicians who dare protest actions by their hospitals' managers:

The need to keep one's job decreases a worker's candor. Seniority offers little protection. Look at what happened to an esteemed surgeon who spoke out on double-booking in the OR. Hospital leaders fired him.

The irony of the employed-clinician model is that many embraced it for job security but have ended up feeling more vulnerable than before. And feeling vulnerable means making less noise. The danger is obvious: Clinicians become clock-punching workers rather than leaders; bad policies persist; outlier doctors continue working unabated, and low morale becomes the new normal.

In November, 2018, the New York Daily News reported a graphic example of a hospital CEO threatening to fire a nurse who complained about staffing levels:

Brooklyn Hospital CEO Gary Terrinoni, along with several other executives and department heads, were updating the nursing staff about the hospital's future a month ago when Terrinoni launched into what sources described as a nasty screed.

'Are you all tired?' Terrinoni mockingly asked the nurses, according to a letter distributed by the New York State Nurses Association.

When no one offered a response, Terrinoni singled out one veteran RN, who at first politely tried to deflect his question. After more prodding, she answered that the biggest problem they faced was understaffed shifts.

'That's what I'm talking about! Look at your attitude!' Terrinoni allegedly erupted. 'Then you don't need to be here. Go find another job!

When the 13-year Brooklyn Hospital vet noted she had more than a decade on the job, Terrinoni only grew more agitated, the union said.

'I don't care if you've been here ten years or 30 years,' he allegedly said. 'You can leave if you don't like it here.'


Recently we have seen many examples of mission-hostile management by political appointees to health care related leadership positions in the Trump administration.

However, while the political conflagration in Washington, DC has pulled journalists away from the health care beat, we continue to see examples of bad, and particularly mission-hostile management of non-profit hospitals that threatens care of vulnerable patients. Such management tends to prioritize hospital revenues, and the financial self-interest of management over patient care.

Some recent examples of related posts included one from 2017 in which we discussed a New York hospital CEO who seemed to put revenue generation in support of his own very generous paycheck ahead of quality of care and patient safety (look here).  Also, the revered Mayo Clinic seemed to let patients with more remunerative commercial insurance coverage get attention before poor patients who have only government insurance, despite its stated mission "providing the best care to every patient" (look here).

Mission-hostile management in hospitals, pharmaceutical companies, or government agencies seems to have been enabled by several factors. 

Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations' work.  Managerialism has become an ascendant value in health care over the last 30 years.  The majority of hospital CEOs are now management trained, but lacking in experience and training inmedicine, direct health care, biomedical science, or public health.  And managerialism is now ascendant in the US government.  Our president, and many of his top-level appointees, are former business managers without political experience or government experience.  

The rise of the manager-leader occurred at a time when management schools increasingly preach the dogma that maximizing shareholder value, usually equivalent to maximizing short-term revenue, should be the first, if not the only goal of all managers (look here).  A recent article on the miseducation of Sheryl Sandberg, Facebook's chief operating officer, asserted that

Harvard Business School, like much of the M.B.A. universe in which Sandberg was reared, has always cared less about moral leadership than career advancement and financial performance.

The article recounted a recollection of a case discussion which included Jeff Skilling, the now disgraced former CEO of Enron

in which the students were debating what the C.E.O. should do if he discovered that his company was producing a product that could be potentially fatal to consumers. 'I’d keep making and selling the product,' he recalled Skilling saying. 'My job as a businessman is to be a profit center and to maximize return to the shareholders. It’s the government’s job to step in if a product is dangerous.' Several students nodded in agreement, recalled LeBoutillier. 'Neither Jeff nor the others seemed to care about the potential effects of their cavalier attitude. . . . At H.B.S. . . . you were then, and still are, considered soft or a wuss if you dwell on morality or scruples.'
Boards of directors or trustees, which are now often dominated by managers, are inclined to financially reward organizational managers for increasing revenue.  Hospital boards rarely are so interested in improving patient care or public health.  So the result is mission-hostile management, which is very bad for patients' and the public's health

As I have said before,  true health care reform would put in place leadership that understands the health care context, upholds health care professionals' values, and puts patients' and the public's health ahead of extraneous, particularly short-term financial concerns. We need health care governance that holds health care leaders accountable, and ensures their transparency, integrity and honesty.

But this sort of reform would challenge the interests of managers who are getting very rich off the current system.  And these days, such reform would also challenge the interests of many people in top positions in the US government.  So I am afraid the US may end up going far down this final common pathway before enough people manifest enough strength to make real changes.

Sunday, December 02, 2018

The Perils of CEO Worship - What Happens When the Leader Becomes Demented?

Introduction: the Cult of the CEO

Although the US and most developed countries are nominally democratic, many of us seem to be again yearning for a man on a white horse, and in the current era, the horse ridden is corporate.
On Health Care Renewal, we having been talking about this pheonomenon for a long time. We have written about it in terms of the messianic (or visionary, or charistmatic) CEO, CEO disease, and the imperial CEO.

These concerns are diffusing into the broader media.  For example, from the introduction to a revent Vox article entitled "The Problem with CEO Worship"

Society has always had heroes, be those of war or art or politics. But entrepreneurs are particularly suited for our current moment, in which success in business is our primary marker of achievement. Business acumen doesn’t just get you money anymore; it can make you the most powerful man in the world.

The signs of CEO worship are everywhere: unprecedented venture capital funding for founders, media overemphasis on company leaders, and to use the most extreme and obvious example, the election of Donald Trump.

That article noted that CEO worship may overestimate the importance of leaders; create "secular fundamentalists" out of individuals; perpetuate destructive neoliberal ideologies; encourage CEOs to make worse decisions; and be bad for business

Those are not the only consequences.  CEO worship makes it possible for a progressively impaired leader to go unconstrained. Unfortunately, we may be seeing the ultimate example of this in the US.

Incoherent Verbal Utterances

Even before he was elected, we noted that Donald Trump sometimes was completely incoherent when describing his health policy ideas.  In early 2016 we raised questions about Donald Trump's cognition.  At that time, a conservative columnist labelled as "word salad" Trump's attempts to sketch a position on health care, specifically the "mandate" provision of the Affordable Care Act (ACA).  We found other examples of his utterances on health care policy that could be characterized as gibberish.  This one was short, if not sweet

I want to keep pre-existing conditions. I think we need it. I think it’s a modern age. And I think we have to have it.

How could anyone understand this while listening in real time? A close reading suggests that maybe this was meant to suggest that some people ought to have  insurance coverage for pre-existing conditions. However, Trump seemed to befuddled by that concept.  Furthermore,  note that pre-existing conditions are not desireable, so that one would not want to "keep" them, nor can one choose not to.  To what the word "it" in the second sentence and again in the fourth refers is unclear.  The third sentence seems to be a complete non sequitur. 

We found additional examples of incoherent verbal responses about health care in 2017, and early 2018.  In the last six months, things have only gotten worse.  Examples of verbal incoherence have multiplied, although most were not related to health care. 

In July, 2018, MediaIte reported Trump's incoherent comments at a political rally,

I have broken more Elton John records, he seems to have a lot of records. And I, by the way, I don’t have a musical instrument. I don’t have a guitar or an organ. No organ. Elton has an organ. And lots of other people helping. No we’ve broken a lot of records. We’ve broken virtually every record. Because you know, look I only need this space. They need much more room. For basketball, for hockey and all of the sports, they need a lot of room. We don’t need it. We have people in that space. So we break all of these records. Really we do it without like, the musical instruments. This is the only musical: the mouth. And hopefully the brain attached to the mouth. Right? The brain, more important than the mouth, is the brain. The brain is much more important.

Perhaps this was meant to suggest that the president drew a larger crowd to an arena than did Elton John.  However, note the non-sequiturs: from "Elton has an organ" to "lots of other people helping" to "we've broken a lot of records," "They need much more room, for basketball, for hockey..." Who are the people helping whom are they helping, and to do what? What records were broken by whom, and how is this relevant to Elton John, etc.  To whom does they refer, and why do they need a lot of room? Etc, Etc.  Again, in real time this would have made no sense at all

In September, 2018, CNBC reported that speaking at a meeting about preparations for Hurricane Florence, Trump said

This is going to be a very large one ... It's tremendously big and tremendously wet. Tremendous amounts of water

Maybe he meant to say this will be a very large hurricane, bringing a tremendous amount of rain.  However, he seemed to be unable to convey the concept of rain.

In September, 2017, the Hill had reported that Trump had defended difficulties in providing relief for Puerto Rico after Hurricane Maria thus,

This is an island, surrounded by water. Big water. Ocean water

Again, to be charitable, he seemed to handle the concept of an island in a vast ocean as would a three-year old.

Media articles also suggested that normal people cannot follow or understand what Trump says in real time.  For example,  on November 8, 2018, a Bloomberg op-ed said this about a recent Trump news conference,

In fact, the president was difficult to follow because he simply doesn’t make any sense half the time.

More specifically,

Trump was asked one specific question about health care, and good luck to anyone who tries to figure out what his answer meant. He pretty clearly has just as little idea what he’s talking about on most major policy issues as he did when he first started running for president. On Jamal Khashoggi, waivers on Iranian sanctions, North Korea and Russia, he either ducked the questions with non sequiturs or just babbled.

On November 11, 2018, an article in Slate noted that Trump confused Baltic states with Balkan states in a way that could have foreign policy repercussions,

When President Donald Trump met with Dalia Grybauskaitė of Lithuania, Kersti Kaljulaid of Estonia and Raimonds Vējonis of Latvia earlier this year, he started with a criticism. At the White House in April, Trump opened by chastising the Baltic leaders for starting the war in the 1990s that ended with the breakup of the former Yugoslavia. The Baltic leaders were apparently very confused and it took them 'a moment' to realize that the commander in chief was confusing Baltic states with the Balkans

this case is particularly notable considering Melania Trump is originally from the Balkans. The first lady was born in Slovenia, which gained independence in 1991 at the start of the Balkan wars. As Le Monde wrote, Trump remained 'apparently uneducated in the matter by his wife, Melania, originally from the former Yugoslavia.'

This suggests at best that at times Trump may be unable to distinguish words that sound vaguely alike but have quite different meanings. 

A November 28, 2018, Vox summary article about Trump's recent interview with the Washington Post provided this quote from Trump about economics,

And I’m not blaming anybody, but I’m just telling you I think that the Fed is way off-base with what they’re doing, number one. Number two, a positive note, we’re doing very well on trade, we’re doing very well — our companies are very strong. Don’t forget we’re still up from when I came in 38 percent or something. You know, it’s a tremendous — it’s not like we’re up — and we’re much stronger. And we’re much more liquid. And the banks are now much more liquid during my tenure. And I’m not doing – I’m not playing by the same rules as Obama. Obama had zero interest to worry about; we’re paying interest, a lot of interest. He wasn’t paying down — we’re talking about $50 billion lots of different times, paying down and knocking out liquidity. Well, Obama didn’t do that. And just so you understand, I’m playing a normalization economy whereas he’s playing a free economy. It’s easy to make money when you’re paying no interest. It’s easy to make money when you’re not doing any pay-downs, so you can’t — and despite that, the numbers we have are phenomenal numbers.

The author of the article stated,

I have basically no idea what Trump is talking about here, and I’m pretty sure he doesn’t either.

On repeated close reading, I still do not have any idea what Trump meant.  I would add the following questions:  38 percent of what? Who is much more liquid, and how is liquid defined?  Who is paying a lot of interest? What does "paying down and knocking out liquidity" mean? What is a "normalization economy?"  Note that this was coming from someone who claims to be a brilliant business manager.

Furthermore, consider what Trumps aid about the climate,

And when you’re talking about an atmosphere, oceans are very small. And it blows over and it sails over. I mean, we take thousands of tons of garbage off our beaches all the time that comes over from Asia. It just flows right down the Pacific, it flows, and we say where does this come from. And it takes many people to start off with.

Oceans are "small?" What "blows over and sails over?" Over what? What "flows?" What "takes many people?"

In 2017, StatNews published an article describing how 

STAT reviewed decades of Trump’s on-air interviews and compared them to Q&A sessions since his inauguration. 

To summarize the conclusions.

The differences are striking and unmistakable.

Research has shown that changes in speaking style can result from cognitive decline. STAT therefore asked experts in neurolinguistics and cognitive assessment, as well as psychologists and psychiatrists, to compare Trump’s speech from decades ago to that in 2017; they all agreed there had been a deterioration, and some said it could reflect changes in the health of Trump’s brain.

In 2018, Trump's verbal communications at times are even more garbled.  Parts of the passages above suggest the word salad produced by somebody with fluent aphasia versus the nonsensical responses produced by patients suffering from acute delusional states. That Trump is capable of producing this sort of word salad at times, without realizing he is making no sense, suggests the intermittent symptoms seen early in progressive dementia.  

Lack of Insight About Cognition

Furthermore, Trump appears to lack insight about his difficulties commicating.  

In July, 2018, after the NATO conference,  Politico reported, that Trump seemed to have no insight about why much of what he says appears unbelievable to others.  The article noted
leaders who spent the first 18 months of Trump’s presidency thinking there might be a method to his chaos creation — and struggling to discern what it might be — now seem to have concluded that it’s just chaos, and that Trump himself may not understand what he’s doing.

More specifically, European officials commented on what Trump was saying:

A senior NATO official said leaders had concluded that they simply could not rely on anything Trump said.

'You know the way he speaks, you cannot take him literally,' the official said.

Another EU official echoed the point. 'He speaks a language that doesn’t match with diplomacy,' the second official said. 'We were used to the Brits, who speak a more frank diplomatic language, but this is another thing.'

These officials again seemed to be stating that Trump's verbiage can be completely incoherent, albeit they were doing so diplomatically.  After the conference, however, when confronted with a question about the inconsistency of his remarks,

When a Croatian journalist confronted Trump about his inconsistencies, the president flatly denied there were any, and he repeated a defense of his own sanity that he had made when previously questioned about his fitness for the presidency.

'We understand your message, but some people ask themselves, will you be tweeting differently once you board the Air Force One?' the reporter said.

Trump, speaking at his news conference before leaving the summit, replied: 'No, that's other people that do that. I don’t. I’m very consistent. I’m a very stable genius.'

Not to belabor the point, but the examples noted above suggest neither consistency nor stability.  And true geniuses almost never boast about their intellect.

In September, 2018, The Hill reported an interview with Trump in which he said his personal health and management style were reasons that Republicans might do better than expected in the 2018 elections,

'You know, I took that test when I got my last physical, and the doctor said that’s one of the highest scores we’ve ever seen,' Trump said. 'I did that not because I wanted but I did it, I was always good at testing.'

He continued: 'But if there’s anything great about me it’s stability, and I’m a good manager. Always been a good manager, but you know, I have a vision,'

Note that above Trump was presumably referring to the screening test for dementia he took during his official physical examination.  High scores on the test are common, and do not signify great intelligence, just the probable absence of dementia.

In addition, this interpretation assumes that the test was administered in an unbiased way.  However,  there are reasons to question whether Trump's physical was unbiased.  In retrospect, we now know that soon after taking the test, Trump nominated the physician who administered it to be Secretary of Veterans Affairs.  Later the physician withdrew his name after allegations of his questionable personal behavior appeared (look here).  

At least Trump's boast about having "a vision" does correspond to the language often used by public relations spokespeople to justify their CEOs' lack of accountability and high compensation (look here)

Similarly, in the Vox summary of the November, 2018, Washington Post interview (see above for link), Trump stated
a lot of people like myself - we have very high levels of intelligence

Finally, a November 18, 2018 article in MediaIte described this interchange between Trump and interviewer Chris Wallace on Fox News, starting with his response to a question about how he makes decisions

'I don’t think about them,' Trump replied. 'I don’t think about, you know, how I make them....'

However, he responded to a question about Federal Reserve policy

They're making a mistake because I have a gut, and my gut tells me more sometimes than anybody else's brain can ever tell me

This suggests that Trump has lost insight into his own thinking. 

External Observers Suggested Trump Is Cogitively Impaired

In August, Vanity Fair reported:

More than ever, Trump is acting by feeling and instinct.  'Trump is nuts,' said one former West Wing official. 'This time really feels different.' Deputy Chief of Staff Bill Shine has privately expressed concern, a source said, telling a friend that Trump’s emotional state is 'very tender.' Even Jared Kushner and Ivanka Trump are unsettled that Trump is so gleefully acting on his most self-destructive impulses as his legal peril grows.

In September, 2018, Newsweek reported two instances in which apparent Trump insiders sought psychiatric or medical help for Trump's perceived cognitive problems

[Dr] Lee told Salon that two Trump administration officials approached her after the book was published to express their concern about the president’s mental health, saying he was 'scaring' them because he was 'unraveling.'

In comments to Newsweek over email, Lee said 'it appeared that the officials (if they were officials at all) were at least frequently in [Trump’s] presence.

She continued, 'They were definitely calling from within the White House, which I confirmed by calling back their number. However, I did not ask about their rank. There was no reason for me to doubt they were high-ranking enough to have regular access to the president.'

Lee also said that a 'person [who] was a friend of his entire family, since his childhood” had also been in touch with her at the same time in October 2017, as people in the White House were “stating concern about the president (this was an observation from afar).'

Also in September, 2018, a Politico review of the new book by Robert Woodward based on numerous White House interviews suggested that Trump's inner circle called him a "dope," "idiot," or "moron."


Donald Trump is the chief executive officer of arguably the most powerful country in the world.  Starting during his campaign for the US presidency, we noted that his utterances about health care were at times so incoherent as to suggest cognitive dysfunction.  In the two years since then, especially in the last six months, he has increasingly been noted to be verbally incoherent or confused, has seemed to lack insight about these episodes, and has been observed by close allies and associates to be cognitively impaired.

However, there have ben few, at best, public attempts to link these suggestions of cognitive impairment together, nor to discuss their implications.  The most recent of those that I have found was in January, 2018 (look here and here).  Yet the problems appear to have been getting worse since then.  

While patients with worsening cognitve impairment deserve accurate diagnosis, compassionate care, and access to what few effective, safe treatments may be available for their condition, they obviously should not be in a position to make consequential decisions.  They certainly should not be in charge of large organizations, particularly powerful countries with nuclear weapons.

Yet President Trump's apparent cognitive decline remains anechoic.

For this we may blame CEO worship, which we have too often seen in health care. We have seen many health care leaders praised for their brilliance and paid royally despite leadership resulting in financial distress, threats to the organizations' health care missions, poor patient care, unethical behavior, or even crime. Yet health care CEOs, like other corporate CEOs, and like politicians are just people, sometimes smart, but almost never brilliant.  Promoting them as messianic to bewitch key constituencies, justify the remuneration of other top managers, and the hiring of more public relations flacks is likely to lead to the sort of organizational disasters and system-wide dysfunction we discuss on Health Care Renewal.  The rise of the falsely messianic leader may allow the entry of the most dangerous false messiahs, the psychopathic ones.  (We discussed the likelihood that some health care leaders are actually psychopaths here.)

We must get quickly past our worship of CEOs.  We may not long survive in a world where leaders of nuclear armed nations have no cognitive clothes.

Sunday, November 18, 2018

From Russia with Money - Harvard Medical School Accepts $200 Million from Russian Emigre with Ties to Russian Oligarchs and Putin, and Who Is Under Investigation for US Election Meddling

On Health Care Renewal we have frequently written about individual and institutional conflicts of interest.  The landmark but often ignored 2009 report by the Institute of Medicine on Conflicts of Interest in Medical Education, Research and Practice defined institutional conflicts of interest as arising when

an institution's own financial interests or those of its senior officials pose risks of undue influence on decisions involving the institution's primary interests.

We have written about institutional COIs affecting academic medical institutions, medical societies and patient advocacy organizations.  Typically, the COIs arise from industry (that is, usually pharmaceutical, biotechnology medical device, and sometimes health insurance corporate funding) that might be seen as influencing the institution's decisions about medical care, health care policy, teaching and/or research.  For example, most recently we wrote about systematic research on institutional conflicts of interests affecting patient advocacy organizations, and on organizations writing clinical practice guidelines

But now things are different.

We present a big case of what looks like an entirely new, and very troubling variation on an institutional conflict of interest.

A "Transformative" Gift to Harvard Medical School

On November 8, 2018, Felice Freyer, writing in the Boston Globe, documented a huge new gift to Harvard Medical School.

Harvard Medical School has received a $200 million donation — the largest in its history — to support research into fundamental questions about human illness and health.

The pledge, from the Blavatnik Family Foundation, will enable the school to hire researchers, add to its advanced technology, and a build an 'incubator' in the Longwood area to help bring research findings to market.

The gift is so large that Harvard will rename many of the school's components after Blavatnik.

Harvard Medical School is keeping its name for now. But a large portion of the school will be renamed. The 10 academic departments in science and social science — as distinguished from the affiliated hospitals where postgraduate training takes place — will be called the Blavatnik Institute at Harvard Medical School.
Per the Harvard's in-house publication, the Gazette,

Announcing the donation, Harvard President Larry Bacow described it as an 'unprecedented act of generosity and support,' and thanked Blavatnik for his faith that HMS — and the region’s broader life sciences community — can make dreams of dramatic progress in human health become reality.

'It’s one thing to dream for oneself, for one’s family and friends, even for one’s community. It’s another thing to dream for all people, to dream for a future in which more lives are improved and saved through the creation and application of knowledge through science,' Bacow said.

HMS Dean George Q. Daley called the donation 'a transformative opportunity' for the School and said it will enable a new generation of scholars and scientists to emulate those who made key discoveries in every area from organ transplants to polio vaccines to gene therapy.

The Gazette described the donor, Len Blavatnik, thus

The foundation is led by Blavatnik, who graduated from Harvard Business School (HBS) with an M.B.A. in 1989, founded Access Industries, and became one of Britain’s wealthiest men.

What could possibly go wrong?

The Russian Connection

Actually, while he may currently operate out of Britain, Blavatnik came from Russia.  Per the Globe,

Blavatnik made his fortune in aluminum, oil, and gas after the fall of the Soviet Union and in 2011 bought the Warner Music Group. His philanthropy has sometimes raised eyebrows because of his alleged connections to Russian oligarchs.

His connections to these (other) oligarchs should raise some eyebrows, and concerns. 

The Access-Alfa Renova Consortium, Alleged Russian Sponsored Harassment of BP, and FSB Active Measures

Blavatnik's recent generous donations to Oxford sparked protests, and provided documentation of some relevant issues. Per the Globe

When Oxford University in England named a school of government after Blavatnik in 2015, some 20 critics wrote to chide the school for 'selling its reputation and prestige to [Russian President Vladimir] Putin’s associates,'

Their letter, published in the Guardian in 2015, stated that Blavatnik belongs

to a consortium of Russian billionaires called Access-Alfa-Renova (AAR). The consortium has long been accused of being behind a campaign of state-sponsored harassment against BP. In 2008-09 dozens of British and other western managers were forced out of Russia. As part of this campaign, Vladimir Putin’s FSB intelligence agency fabricated a case against two Oxford graduates. According to evidence from its jailed owner Sergei Bobylyov, Alfa-Bank oligarchs also raided a retail company called Sunrise.

The spy case and the attack on Sunrise involved the participation of Russian officials who are listed as gross human rights violators by the US Treasury in line with the Sergei Magnitsky Rule of Law Accountability Act of 2012.

These corporate abuses took place in Russia with active official support. There was a backdrop of state-sponsored propaganda. Russian state media broadcast libellous assertions against western and Russian citizens. AAR went on to make billions from a highly controversial deal with Rosneft.

The letter writers asserted

Oxford University apparently failed to investigate these facts, AAR’s track record from the beginning, and its close ties with the Kremlin.

A 2015 Guardian article described the background of the letter's signatories, including

Pavel Litvinov, one of eight people who in 1968 protested on Red Square against Moscow’s invasion of Czechoslovakia. He was exiled for five years to Siberia. Another is Vladimir Bukovsky, jailed by the KGB. Bukovsky, who lives in Cambridge, exposed the Kremlin’s use of psychiatric treatment against dissidents.

Others include former Oxford academics and graduates, members of Russia’s democratic opposition and human rights activists. One is Vladimir Milov, a colleague and friend of Boris Nemtsov, the opposition leader shot dead in February outside the Kremlin. The letter was organised by Ilya Zaslavskiy, a TNK-BP employee and Oxford graduate who ran Moscow’s Oxford alumni association.

In 2008 Putin’s FSB spy agency arrested Zaslavskiy and his brother Alexander in Moscow and accused them of being 'western agents'. Russian state TV claimed the FSB had exposed a major spy ring. The case against them was 'fabricated', the letter says.

Despite their credentials suggesting that the letter writers knew whereof they spoke, Oxford apparently has not done any further investigation.   However, per the Globe again, 

Last year, after Blavatnik donated $1 million to Donald Trump’s inauguration committee, an Oxford professor quit in protest, the Guardian reported.

In fact, according to contemporaneous (2017) coverage in the Guardian, Professor Bo Rothstein

a specialist on corruption, called the donation 'incomprehensible and irresponsible' in his resignation letter.

The academic subsequently told the Guardian he had received hundreds of messages of support about his decision, adding: 'I’m not going to be the Blavatnik chair of government and public policy because I’m not going to give legitimacy and credibility to this person. $1m is a sizeable amount of money. In my book by donating to the inauguration of Donald Trump you are supporting Donald Trump.'

The 2017 Guardian article expanded on the allegations made by the 2015 letter writers

Access began making investments in Russia after the fall of communism as the energy and aluminium groups of the former Soviet Union were broken up. Eventually Blavatnik combined assets with Viktor Vekselberg and Mikhail Fridman to form AAR. Their partnership with BP ended in acrimony.

In 2008, Bob Dudley, then the chief executive of TNK-BP and now the boss of BP, left Moscow after what the British company described as an 'orchestrated campaign of harassment'. Armed police also raised TNK-BPs office and more than 100 BP managers had to leave Russia after the authorities refused to renew their visas.

US diplomats alleged that at least one individual in AAR, German Khan, was involved in a state-sponsored campaign against BP to try to force them out of Russia. However, AAR and lawyers for Blavatnik have denied any involvement, including that of Khan, in a plot against BP.

In the end, both BP and AAR were bought out of the venture by state-backed Russian energy company Rosneft. The $55bn (£42bn) deal in 2013 handed the oligarchs, including Blavatnik, $28bn. It was signed off at a meeting with Putin.

The cash from the sale of TNK-BP pushed him to the top spot of the Sunday Times rich list in 2015. By this stage Access had already diversified beyond Russia and the energy sector.

However, note that the 2017 Guardian article's addendum included

Sir Leonard Blavatnik’s lawyers have informed the Guardian that the term 'oligarch' in his view does not apply to him. [But] The Guardian editor-in-chief disagrees.

So to recap, Blavatnik made a lot of money from aluminum, gas and oil in Russia after the collapse of the USSR.  He banded together with other very rich Russians in a consortium, AAR, that was accused by multiple people of dirty tricks meant to drive the UK oil firm BP from the Russian market.  There were allegations that this trickery involved Russian state agencies, and was likely to have been condoned by Putin.  The people behind AAR eventually netted a lot of money from the resulting buyout of their firms and of BP, a deal that apparently did involve Putin. 

Blavatnik's Changing Pattern of Political Contributions Raise Question about Foreign Influence on the US Election

While giving a lot of money to various educational and cultural institutions, Blavatnik was giving modest amounts of money to politicians. 

However, his pattern of political giving apparently changed greatly upon Trump's advent on the scene.  A May, 2018, Dallas News op-ed article by Professor Ruth May of the University of Dallas on Russian oligarchs' affinity for Trump's campaign stated,
Data from the Federal Election Commission show that Blavatnik's campaign contributions dating back to 2009-10 were fairly balanced across party lines and relatively modest for a billionaire. During that season he contributed $53,400. His contributions increased to $135,552 in 2011-12 and to $273,600 in 2013-14, still bipartisan.

In 2015-16, everything changed. Blavatnik's political contributions soared and made a hard right turn as he pumped $6.35 million into GOP political action committees, with millions of dollars going to top Republican leaders including Sens. Mitch McConnell, Marco Rubio and Lindsey Graham.

In 2017, donations continued, with $41,000 going to both Republican and Democrat candidates, along with $1 million to McConnell's Senate Leadership Fund.

A Vice News article April 2018, provided more detail,

according to the Wall Street Journal, Blavatnik gave $12,700 in April 2017 to a Republican National Committee fund that was used to help pay for the team of private attorneys representing Trump in the probe of Russian interference in the 2016 election. He’d given the RNC legal fund $100,000 in 2016, the Journal said.

The problem is that, as stated by Represenative Adam Schiff (D-CA), likely now incoming chair of the House Intelligence Committee,

'Unless the contributions were directed by a foreigner, they would be legal, but could still be of interest to investigators examining allegations of Russian influence on the 2016 campaign. Obviously, if there were those that had associations with the Kremlin that were contributing, that would be of keen concern.'

Under federal law, foreigner nationals are barred from contributing directly or indirectly to political campaigns in local, state and federal elections.

Note that according to an April, 2018, Mother Jones article, the 

the question of possible illegal foreign donations from Russia is also under scrutiny by the FBI and the Federal Election Commission. 

Apparently because of these allegations that Blavatnik was helping to channel Russian money to influence the 2016 election, per the Globe

Although no wrongdoing has been alleged, ABC News reported in the spring that special counsel Robert Mueller is looking into Blavatnik’s donation to the inauguration as part of an inquiry into foreign financial support for Trump.
So to recap, Blavatnik became a dual UK-US citizen, and for quite a while made political donations in a style similar to that of many rich businesspeople at the time, giving amounts to both parties, presumably to enhance access whoever was in power.  However, when Trump became a presidential candidate, Blavatnik began making much bigger donations, and only to Republicans and Trump-related causes.  Then he gave a million dollars to Trump's inagural.  Given the known scheme  by Russia to meddle in the US election to benefit Trump (see the 2018 Senate committee report as discussed here), this raised suspicions that Blavatnik, was helping to also influence the election on Russia's behalf. 

Blavatnik's Sanctioned Associates

Moreover, perhaps Mueller is also interested in Blavatnik's ties to other Putin-linked oligarchs.  A profile in Forbes from October, 2018, stated

Blavatnik still retains a few Russian assets. He and Vekselberg, along with [Oleg] Deripaska, are key investors in Rusal, one of the world’s largest aluminum producers.

Note that

His former business partners are now facing U.S. sanctions. They include Viktor Vekselberg (net worth: $13.1 billion) and Oleg Deripaska (net worth: $3.3 billion), two of seven Russian oligarchs that the U.S. Treasury and State departments identified in the April sanctions. Allegations made against the sanctioned oligarchs include interference with the 2016 presidential elections and financially profiting from a Russian government that engages in 'destabilizing activities.'
To recap, Blavatnik has ongoing business relationships with other oligarchs who have been sanctioned for meddling in the 2016 US election.

Blavatnik's Former Lobbyists Spin Through the Revolving Door into the Trump Administration

Furthermore, the April, 2018, Vice News article documented apparent ongoing ties between Blavatnik operators and the Trump administration.

Two senior Trump administration officials were once registered as lobbyists for an investment company controlled by a Soviet-born industrialist who made billions doing business with newly sanctioned Russian oligarchs.

Makan Delrahim is now the assistant attorney general for the Antitrust Division in the Department of Justice, after rising from his original appointment as deputy White House counsel and deputy assistant to the president. David Bernhardt is the No. 2 official in Trump’s Department of the Interior.

Both men registered as lobbyists in 2011 and 2012 for Access Industries, a holding company controlled by billionaire Leonard Blavatnik, according to public filings reviewed by VICE News. And though they are far from the only D.C. lobbyists to get plum jobs in the Trump administration, the connection to Blavatnik, long in business with billionaire associates of Russian President Vladimir Putin, reveals yet another link between Russia and senior Trump officials.

The article noted,

As of the fourth quarter of 2017, the lobbying firm that Delrahim and Bernhardt worked for was still on Access Industries’ payroll, according to public records. Bernhardt told the Senate during his confirmation hearing that despite filing the paperwork, he never actually did any lobbying for Blavatnik’s firm.

Delrahim, may have been in a particularly fraught position,

Both wound up on the Trump transition team. One, Makan Delrahim is now the assistant attorney general for the Antitrust Division in the Department of Justice, after rising from his original appointment as deputy White House counsel and deputy assistant to the president. David Bernhardt is the No. 2 official in Trump’s Department of the Interior.

The problem is while

Neither Delharim nor Bernhardt, who registered to lobby for Blavatnik and Access Industries in the past, currently has a job with direct oversight of issues related to the Russian economy or the Russia probe.... Delharim might have been involved when he was in the White House counsel's office, a position he left in September for the DOJ.

Richard Painter, former White House ethics lawyer under President George W. Bush, said that in his view, Delrahim would have needed to recuse himself from any work at the White House involving the investigation into Russia’s role in the 2016 election due to his previous work for Access Industries.

'I think that if I were in the White House Counsel’s Office, I’d say, ‘This guy needs to stay away from the entire Russia thing,'' Painter told VICE News.
To recap, former lobbyists for Blavatnik's firm served on the Trump transition team, and then were appointed to responsible federal offices, suggesting at the least, conflicts of interest.

Harvard Officials See No Evil

Nonetheless, Harvard officials had nothing but praise for Len Blavatnik, their generous donor.  Per the Globe,

[Lawrence S] Bacow, Harvard’s president, stood by the donor, calling him a 'distinguished alumnus' and 'somebody that we know very well.'

'We’re very comfortable with who Len is,' Bacow said. 'Len is well-known to the medical community here at Harvard and has been very supportive of science at Harvard and elsewhere. . . . He’s also somebody who is intensely curious, who believes in the power of science to improve the human condition, and he also believes in backing really talented young scientists.'

Were they totally unaware of all the accusations against, suspicions of, and likely investigations of their very wealthy donor?  Or did they just not want to look this very generous gift horse in the mouth? 

Not With a Bang,...

As noted above, there were vigorous protests of Blavatnik's much smaller gift to Oxford in 2015, and then in 2017 after Blavatnik's million dollar gift to the Trump inaugural was announced.  Yet so far, there has been little media discussion, and no protest of Blavatnik's "transformative" gift to Harvard, and the naming of a good chunk of the Harvard Medical School in his honor.

Blavatnik's story seems to be anechoic so far.  It has gotten little public coverage.  A Bloomberg article and a tiny AP story made no mention of Russia, oligarchs, Putin, etc.  Not surprisingly, coverage by Harvard's public relations did not bother either, (see the Harvard Gazette as above, and Harvard Magazine.) The only media coverage beyond the Boston Globe that said anything about the questionable aspects of Blavatnik's background was by the Harvard Crimson and WBUR.   

Summary and Discussion

Len Blavatnik  has been accused of acting in association with other Russian oligarchs, and with the Putin regime's FSB to use unethical means to push UK oil interests out of Russia.  Blavatnik has been accused of helping Russia to influence the 2016 US elections.  Some of Blavatnik's business associates have already been sanctioned by the US government for election meddling and profiting from "destabilizing activities."  And Special Counsel Mueller and other federal authorities are apparently in the midst of investigating Mr Blavatnik.

So Blavatnik's huge gift to Harvard Medical School seems likely to generate a new version of an institutional conflict of interest.  Consider a typical insitutional COI: a medical school getting a big donation from a pharmaceutical corporate foundation.  The concern in that case might be that the people running the school would be unduly inclined to support research that might boost the company's products, or support teaching that would again favor its products, or favor pharmaceutical therapy over other approaches.  Perhaps the students and professionals at that school might feel they are supposed to help hype the company's products, or avoid criticizing them.  All that would be highly concerning.

However, in the current case the issue is not how the school, its officials, its faculty, its health professionals and/or its students would favor Mr Blavatnik's corporate products and avoid criticizing them.  It is that they all are being pushed to cozy up to an oligarch, and thus might be pushed to favor the authoritarian government to which Mr Blavatnik appears tied, its anti-democratic practices, its corruption, and its apparent attempts to meddle in US elections, undermine US democracy, and support a particular candidate who may be beholden to it.

The protesters at Oxford in 2015 wrote
We insist that the university should stop selling its reputation and prestige to Putin’s associates.

Now Harvard University and its medical school appear to be "selling its reputation and prestige to Putin's associates."  This endangers Harvard, and the rest of us. Yet no on at Harvard appears to be protesting.  The silence is deafening.

Wednesday, November 07, 2018

Pharmaceutical and Other Health Care Corporations Funnel Dark Money to Republicans to Defeat "Leftward" Democratic Candidates - Partisanship Trumps Social Responsibility

Introduction - Health Care Corporations Profess Social Responsibility

As we noted recently, large health corporations, which must deal with patients, health professionals, and government regulators, usually profess their social resonsibility.  For example,

Biotechnology firm Genentech, now a subsidiary of giant Swiss biotechnology and pharmaceutical company Roche, has an elaborate web page about how the company seeks to do good.  Some quotes:

we’re passionate about applying our skills, time and resources to positively impact the patients we serve, the scientific community and the places where we live and work.


We approach giving back the same way we approach discovering medicines: we start by looking for the root cause of a problem and then we explore how we can contribute to a solution.

And particularly

We believe that the best work happens when everyone has a voice.

Similarly, giant American pharmaceutical company Eli Lilly espouses these core values

Three long established core values guide Lilly in all that we do:

Integrity: We conduct our business consistent with all applicable laws and are honest in our dealings with customers, employees, shareholders, partners, suppliers, competitors and the community.

Excellence: We pursue pharmaceutical innovation, provide high quality products and strive to deliver superior business results.

Respect for People: We maintain an environment built on mutual respect, openness and individual integrity. Respect for people includes our concern for all people who touch or are touched by our company: customers, employees, shareholders, partners, suppliers and communities.

Of course, in the policy arena, large health care corporations also tend to advocate for policies that are to their financial advantage.  Furthermore, top executives of large corporations have been known to donate to political candidates who favor their policy positions, although they used to consciously spread their donations out to all parties and many candidates to avoid any appearance of partisanship, while making themselves visible to whomever might be in power.

However, as the current US political chaos leads to more journalistic investigation, there is increasing evidence that large health care corporations have been secretly backing policy positions that do not correspond to their high-minded public statements about corporate social resonsibility, and are becoming quite political, even partisan in the process.  They do so through the use of dark money

Pharmaceutical Companies, Other Health Care Companies - and a Tobacco Company - Join Effort to Attack Left-Wing Politicians

On November 5, 2018, Lee Fang wrote about how big corporations, including big health care corporations, enthusiastically financially supported a dark money operation that specifically targeted "progressive" or "socialist" candidates:

Republican operatives and representatives from America’s largest business groups — alarmed at a wave of upset electoral victories by Alexandria Ocasio-Cortez and other avowed democratic socialist candidates — have been plotting to stem the tide of left-wing Democrats sweeping the country.

Andrew Wynne, an official at the Republican State Leadership Committee, spoke to business lobby leaders in July, encouraging them not to ignore the latest trends within the Democratic Party. He called for Republicans’ allies to enact a unified plan to defeat progressives in this week’s midterm elections.

'Recent elections have proven the leftward shift,' said Wynne. 'An anti-free market, anti-business ideology has taken over the Democratic Party, particularly this year during the primaries.'

Wynne was particularly exercised about the primary victory by Democrat Alexandia Ocasio-Cortez:

'Alexandria Ocasio-Cortez captured the energy of these voters to win a congressional nomination in New York, defeating the incumbent who many thought could be the next Democratic speaker of the House,' Wynne continued.

He noted that the defeated incumbent in the Ocasio-Cortez race, Rep. Joe Crowley, a moderate Democrat and former chair of the business-friendly New Democrat Coalition, 'was someone who the business community could have a conversation with on the Democratic side.' On the other hand, Wynne warned, Ocasio-Cortez would not be so receptive to business lobbyists.

Of course, these sentiments coming from a Republican operative are not surprising.  What was surprising was how Mr Wynne wanted to fund efforts to comabt these supposedly left-wing politicians.

Officials from the Republican State Leadership Committee, which assists Republicans in capturing power on the state level, explained during the call that they expected to raise $45 million in direct contributions and $5 million to $7 million through an allied dark money group for election campaigns this fall.

The group is organized under the IRS’s 527 rules and operates in a manner similar to Super PACs: It can raise and spend unlimited amounts from individuals and corporations. The latest disclosures suggest the group is well on track to bring in significant corporate support for electing Republican state officials.

Koch Industries, Crown Cork & Seal, Genentech Inc., ExxonMobil, NextEra Energy, Range Resources, Eli Lilly and Co., Marathon Petroleum, Reynolds American, (a tobacco company which is a subsidiary of British American Tobacco), Boeing, General Motors, and Astellas Pharma are among the companies that have already provided at least $100,000 to the committee.

Many of those companies are from industries that have long contributed to GOP causes, including resource extraction, financial services, tobacco, retail, for-profit education firms, and private health care interests.

Furthermore, the Republican State Leadership Committee has been collecting money from other dark money organizations which in turn are funded in part by health care companies:

Several of the largest donors to the Republican State Leadership Committee are themselves dark money groups. The Judicial Crisis Network, a 501(c) nonprofit that does not disclose its donors, has given $1.5 million to the group. The ABC Free Enterprise Fund, a dark money affiliate of a lobbying group that represents non-union construction companies, gave $100,000.

The U.S. Chamber of Commerce has given $1.7 million to the committee. The chamber, notably, does not disclose its donors but has been financed in the past by Goldman Sachs and Dow Chemical, among other major American and foreign companies.

We recently discussed the health care industry contributions to the US Chamber of Commerce, which came from PhRMA, Pharmaceutical Research and Manufacturers of America, the pharma trade association, and from specific companies, including contributions of at least $100K from: Aetna, Abbott Laboratories, AbbeVie, Amgen, Anthem, Celgene, Cigna, CVS, Eli Lilly, Express Scripts, Johnson & Johnson, Merck, Mylan, Procter & Gamble, and UnitedHealth.

So a lot of big health care companies, most of whom profess their devotion to the greater community and social responsibility, have been funneling considerable money as quietly as possible into an effort to thwart one particular group of politicians, that is, candidates from the leftish wing of the Democratic party.

So much for Genetech's claim:

We believe that the best work happens when everyone has a voice.

Or for Lilly's claim:

Respect for people includes our concern for all people who touch or are touched by our company: customers, employees, shareholders, partners, suppliers and communities.
Discussion and Summary

This is now the fifth time we have discussed the role of dark money in health care.

- In 2012 we discussed a case of "dark money" being used to conceal sources of support for particular health policy and political positions.

- Earlier this year,  we discussed the case of huge pharmacy chain CVS,which proclaims its "social responsibility," and its policy of only making charitable contributions to improve "health and healthcare nationwide."  Yet CVS was donating to America First Policies, a supposed non-profit group devoted to promoting the partisan agenda of President Trump, including "repealing and replacing Obamacare," and immigration policies such as building the "wall" and deporting  "illegal immigrants." (Note that these CVS dark money contributions were separate from those discussed above.)

- In September, we discussed how the pharmaceutical trade organization, PhRMA, and some large drug companies donated money to a dark money organization to combat a state initiative to limit pharmaceutical prices, but also to the American Action Network (see above) to "repeal and replace" the Affordable Care Act (ACA, "Obamacare") despite their previous support for and then current neutrality on the ACA.

- In October, we discussed how many health care corporations were donating to dark money groups, predominantly groups, like the US Chamber of Commerce, devoted to distinctly right-wing causes, almost all lately related to the Republican party and in sympathy with the Donald Trump regime.

Health care corporations recent and current funding of dark money groups seems to openly conflict with the corporations' promises of social responsibility.  The slanting of these efforts towards one end of the political spectrum, one party, and now the current president suggest that these corporations may have partisan agendas.

Note that without the various ongoing investigative efforts mainly inspired by the actions of the Trump administration, we would have little idea that this was going on.

May such investigations continue and intensify.  Maybe the recent elections, which gave the opposition to the Republican party and Trump control of the US House of Representatives, will lead to more such investigations.

Furthermore, the increasing knowledge of these corporate actions raises a big question: cui bono? who benefits?

It is obvious why a pharmaceutical company, for example, might want to defeat legislation that would lower its prices.

It is not obvious why it would want to consistenly support actions by one party, or by people at one end of the political spectrum, even if some such people seem "anti-business."  After all, for years big corporations and their executives openly gave money to both US parties and their candidates, apparently in the belief that this would at least allow more visibility for the corporations' priorities no matter who was in power.

Now, the most obvious theory is that the new practice of secret donations only in right-wing, Republican, and/or pro-Trump directions, which must be orchestrated by top corporate management, and which are not disclosed to employees or smaller corporate shareholders, are likely made to support the top managers' self interest more than the broad priorities of the corporations and their various constitutencies.

Thus not only is more investigation needed, at the very least, "public" corporations ought to fully disclose all donations made to outside groups with political agendas.  This should be demanded by at least the corporations' employees and shareholders, but also by patients, health care professionals, and the public at large.

Meanwhile we are left with the suspicion that top health care corporate management is increasingly merging with the current administration in one giant corporatist entity which is not in the interests of health care, much less government by the people, of the people, and for the people.

Friday, November 02, 2018

Nonsense-Based Health Care - in the Service of Political Ideology and Sectarian Beliefs

As an advocate for evidence-based medicine, I am used to disagreeing with officials at US government health agencies on the finer points of evidence and its interpretation.  However, it's 2018, and things are very different.  Now the current regime, and those who back it, have produced a rising tide of outright nonsensical assertions about medicine and health care used seemingly in service of  ideological or sectarian gain.

So let me list some cases, starting with the most recent, and working backwards in time.

Fox News Pundit Said Asylum Seekers Are Infected with Smallpox

This week, as discussed on Vox was:

the statement on Fox News — by an ex-ICE agent — that the migrant caravan of 4,000 men, women, and children mainly from Central America is going to bring smallpox to America.

'They are coming in with diseases such as smallpox, leprosy, and TB that are going to infect our people in the United States,' the former agent, David Ward, said this week.

This is just ridiculous nonsense.  As the Vox article stated,

There is no smallpox in circulation anymore. That’s been true since 1980, when a major global vaccine effort wiped the virus from the planet.


The risk of leprosy — now called Hansen’s disease — being imported from Latin America is similarly remote. And while some foreign-born people do have higher rates of TB, the Centers for Disease Control and Prevention (CDC) screens for TB in people moving to the US.

In case anyone is not convinced, see the CDC page on smallpox (which so far has escaped rewriting by any political appointees, apparently.)

Why would Fox News put this silliness on the air?  The Vox article suggested:

This particular kind of xenophobic fear-mongering, which Donald Trump spread as a presidential candidate, is now surfacing again as we approach the midterms, in an apparent ploy to rile up the conservative base.
So this is medical and epidemiological nonsense purely in service of short-term political gain.

Department of Health and Human Services (DHHS) Suggests Erasing Gender Dysphoria and Denying the Existence of Intersex and Ambiguous Genitalia

In October, 2018, per the New York Times,

The Trump administration is considering narrowly defining gender as a biological, immutable condition determined by genitalia at birth,

In particular, the Department of Health and Human Services (DHHS),

argued in its memo that key government agencies needed to adopt an explicit and uniform definition of gender as determined 'on a biological basis that is clear, grounded in science, objective and administrable.' The agency’s proposed definition would define sex as either male or female, unchangeable, and determined by the genitals that a person is born with, according to a draft reviewed by The Times. Any dispute about one’s sex would have to be clarified using genetic testing.

'Sex means a person’s status as male or female based on immutable biological traits identifiable by or before birth,' the department proposed in the memo, which was drafted and has been circulating since last spring. 'The sex listed on a person’s birth certificate, as originally issued, shall constitute definitive proof of a person’s sex unless rebutted by reliable genetic evidence.'

If carried out, this policy, again coming from the lead US government health care and public health agency, would deny the existence of gender dysphoria.  Per the Washington Post,

In 2013, the American Psychiatric Association’s diagnostic bible adopted 'gender dysphoria' to describe the symptoms and distress experienced by transgender people, eliminating the older designation of 'gender identity disorder.' This change in the Diagnostic and Statistical Manual marked a turning point in the treatment of people who felt they were in the wrong body, and a growing recognition that such feelings were not a mental illness.

The discussion of gender dysphoria on the APA website is here.

There are two other big problems with the proposed DHHS definition of gender.  First, it seems to deny the existence of intersex disorders.  These are defined (via Medline) as

a group of conditions where there is a discrepancy between the external genitals and the internal genitals (the testes and ovaries).

These include four categories:
46, XX intersex
46, XY intersex
True gonadal intersex
Complex or undetermined intersex
Second, the DHHS proposed policy seems to deny that fact that some babies are born with ambiguous genitalia.  The Mayo Clinic summary of this condition states,

Ambiguous genitalia is a rare condition in which an infant's external genitals don't appear to be clearly either male or female. In a baby with ambiguous genitalia, the genitals may be incompletely developed or the baby may have characteristics of both sexes. The external sex organs may not match the internal sex organs or genetic sex.

Ambiguous genitalia isn't a disease, it's a disorder of sex development. Usually, ambiguous genitalia is obvious at or shortly after birth, and it can be very distressing for families.

Although these conditions in toto are not common, they are not rare. I would assume the pseudo-experts in charge of the DHHS policy actually know nothing about the biology of sex and gender. But their idea of dichotomizing a person into male or female based on genitalia which may appear ambiguous, or may not correspond to either the person's chromosonal make-up, internal anatomy, or endocrine environment does not make any sense.

As an aside, the WaPo article noted,

At HHS, the issue is being driven by Roger Severino, the agency’s director of civil rights, who has long been critical of the Obama administration’s expansion of transgender rights.

The NY Times article noted that

Mr. Severino, while serving as the head of the DeVos Center for Religion and Civil Society at the Heritage Foundation, was among the conservatives who blanched at the Obama administration’s expansion of sex to include gender identity, which he called 'radical gender ideology.'

In a post on people in health care or public health leadership positions in the Trump regime who are without any qualifications in biomedical science, health care, or public health, we noted that Mr Severino is a lawyer without any such qualifications.  We noted then that Mr Severino and one of his colleagues seemed bent on imposing beliefs of one particular religious group on the management of health care and public health for all citizens of the US, regardless of whether they subscribe to such beliefs.

So the definition of gender now being proposed by DHHS staff seems designed to further a particular set of religious beliefs about gender, but without any consideration of the relevant medical science, or of the interests of people who do not share those religious beliefs.

US District Cout Nominee Said Contraception Causes Cancer and Violent Deaths

In April, NPR reported on a US Senate confirmation hearing for Wendy Vitter, nominated by Trump for a US District Court seat,

Vitter sought to distance herself from a brochure she had appeared to endorse while leading a panel at a pro-life conference in 2013. The panel was called 'Abortion Hurts Women,' and the brochure promoted a variety of unsubstantiated claims linking birth control pills to breast cancer, cervical and liver cancers, and 'violent death.'

On this last point — violent death — the brochure alleged that women who take oral contraceptives prefer men with similar DNA, and that women in these partnerships have fewer sexual relations, leading to more adultery, and 'understandably ... violence.'

Note that

All of these claims have been debunked by leading medical and scientific organizations, as Democratic Sen. Mazie Hirono of Hawaii observed.

'You urged the audience to distribute the materials making these dangerous claims. ... Do you believe the claims that Dr. Lanfranchi makes that abortion causes breast cancer and that birth control causes women to be assaulted and murdered?' she asked.
The reason that Vitter backed these dubious claims was not clear.  She claimed to be "pro-life," and had worked for the Catholic Church.  One might suspect that she was interested in propagating religious beliefs about birth control, even if doing so could adversely affect the lives of people who did not share such beliefs.

Former Senator, Television Commentator  Suggested CPR as Good Treatment for Catastrophic Bleeding After Gunshot Wound

In March, the Washington Post reported that former Republican Senator Rick Santorum

suggested live on CNN that learning CPR was a better way for young people to take action in response to a mass shooting, rather than protesting gun violence and asking “someone else to solve their problem” by passing a “phony gun law.” The panel on CNN’s 'State of the Union' show was discussing the March for Our Lives, which drew upward of 800,000 people to the Mall on Saturday to demand gun-control legislation.


'How about kids, instead of looking to someone else to solve their problem, do something about maybe taking CPR classes or trying to deal with situations where there is a violent shooter and you can actually respond to that?' Santorum said.

CPR, of course, does not do a lot of good for someone who is rapidly losing his or her blood volume due to a bullet wound.  A number of physicians pointed this out, forcefully,

Heather Sher, a Florida-based radiologist who examined the gunshot wounds of at least one Parkland, Fla., shooting victim on the day of the shooting, called Santorum’s comments 'gobsmackingly uninformed.'

'CPR is not effective with catastrophic bleeding,' she said on Twitter. “Speechless! Learn CPR! Everyone should for cardiopulmonary arrest. But for gunshot wounds, a) attend stop the bleeding course by trauma surgeons or b) pass #gunreform (helpful hint: option b is the better option.)”

Jo Buyske, executive director of the American Board of Surgery, described Santorum’s comments as a 'dangerous and wrong message,' saying on Twitter, 'Mr. Santorum, CPR doesn’t work if all the blood is on the ground.'

And Rebecca Bell, a pediatric critical care doctor at the University of Vermont Medical Center, broke it down in layman’s terms:

'Here are some stats made simple for Rick Santorum,' she said on Twitter. 'Survival rate of pulseless trauma victims who get CPR at the scene: VERY, VERY LOW.'

'Survival rate of people who don’t get shot in the first place: MUCH, MUCH BETTER.'
Presumably Mr Santorum was more interested in promoting his ideological opposition to any further gun regulation than understanding the medical context of his pseudo-clinical comments.  Although it probably would do some general good for society if more people could be trained in CPR, training high school students would likely have zero effect on the outcomes of school shootings.

Republican Majorities in Kansas, Utah, Idaho Legislatures Proclaim that Pornography is a Public Health Hazard

In February, the Topeka (KS) Capital-Journal reported,

The Kansas Senate approved a nonbinding resolution Tuesday declaring proliferation of pornography a public health crisis that normalizes violence against women, corrodes interest in marriage and serves as a gateway to human trafficking.

Also in February, the Washington Post noted that in 2016 the Utah State Senate passsed, at the behest of Republican Sen Todd Weiler, a resolution that

declare[d] pornography 'a public health crisis.' That nonbinding resolution, unanimously passed by both chambers of the state legislature, warned 'this biological addiction leads to increasing themes of risky sexual behaviors, extreme degradation, violence, and child sexual abuse images and child pornography.'

In March, according to the AP, per the Spokane (WA) Spokesman,

A group of Idaho lawmakers on Friday approved a proposal declaring pornography a public health risk.

'Pornography has and does have adverse impacts on all members of society. It leads to the abuse men, women and children, destroys marriages and has impacts on young and old,' said Rep. Lance Clow, a Republican from Twin Falls who is backing the resolution. 'Families are being torn apart by this epidemic.'

The problem is that there is no good evidence that pornography has important negative effects on public health, or is an addictive disorder.  As the WaPo pointed out,

David Ley does not buy it. The Albuquerque-based clinical psychologist and author of 'The Myth of Sexual Addiction' said those who have adopted the public health framing are 'cherry-picking the research.'

He pointed out that the American Psychiatric Association’s diagnosis guide, the Diagnostic and Statistical Manual of Mental Disorders, does not include pornography addiction. And yet Utah, he noted, has numerous porn addiction treatment programs.

In an article in the latest edition of the peer-reviewed journal 'Porn Studies,' Ley argues that people who seek treatment for porn addiction actually view less erotica than average, but guilt associated with religiously based sexual values creates an internal conflict with the pleasure they get from watching it, so “they just feel worse about it.'

Furthermore, the WaPo article also suggested that the notion that pornography is a public health crisis and/or an addictive disorder comes from more religious beliefs rather than evidence about public health.

About 60 percent of Utahns and nearly 90 percent of the state’s lawmakers are members of the Church of Jesus Christ of Latter-day Saints, which has declared 'depiction, in pictures or writing, that is intended to inappropriately arouse sexual feelings' to be 'a tool of the adversary,' the descriptor Mormons often use for Satan.
Again, people are free to have these religious beliefs, but should politicians impose these beliefs on those who do not subscribe to them, in a country which supposedly bars government support of particular religions?  And should they do so at the risk of distracting from real public health problems?


Since 2016, we have seen increasing attempts to distort or ignore medical science, clinical and epidemiological research findings to support the political ideology of the ruling party and the religious beliefs of their extreme fundamentalist supporters.  As we have discussed, most recently here, the Trump regime has seen fit to put ill-informed people in positions of power in health care and public health agencies.  Some of these people have put their political and/or religious agendas ahead of the public's health.  Our examples above show a continuing inclination by the administration, its sympathizers in state governments, and its enablers in the media to distort or ignore science and research again to promote idological or religious beliefs. This promotion is likely to be at the expense of patients and people who do not share these ideological views or religious beliefs. 

These trends endanger the mission of US government health related agencies, and are hostile to the notion that health care and public health should serve all people, regardless of their religious beliefs, race, ethnicity, or sex.

Furthermore, these trends undermine fundamental principles of US government enshrined in the Constitution, including prohibiting the government from establishing a religion or preventing the free expression of any religion, and equal application of the laws and provision of due process to all people, again regardless of their religious beliefs, race, ethnicity or sex. This is obviously hugely dangerous, (and made more so by the regime's and its allies' threats to other core values of US society, to US law, and the US Constitution.)

To prevent the decline and fall of US health care, and maybe the entire US experiment in representative democracy, health care professionals, academics, patients and citizens concerned about health care will have to join up with the larger populace to defend our core values while they still have any force.