Sunday, July 14, 2019

Another Echo of the Fall of the House of AHERF: Hahnemann University Hospital to Close Its Doors, Stranding Patients, Leaving Trainees without an Educational Site, and Leaving Staff and Health Care Professionals Unemployed



Those who cannot remember the past are condemned to repeat it. [George Santayana]


The impending closure of a big teaching hospital in Philadelphia did not get much national attention, but should have.

The Closing of Hahnemann University Hospital

On June 26, 2019, the Philadelphia Inquirer reported:

Hahnemann University Hospital will close in early September, with the wind-down of services at the 496-bed facility starting immediately, hospital officials said Wednesday.

Officials representing American Academic Health System LLC, which bought Hahnemann and St. Christopher’s Hospital for Children early last year for $170 million, said the closing 'on or about Sept. 6' would be orderly.

The closure would likely have big impacts on health care and medical education in Philadelphia, and on health care professionals and other hospital workers.  The article quoted the president of the Pennsylvania Association of Satff Nurses and Allied Professionals:

Hahnemann is a safety-net hospital that for decades has provided care to an under-served community,

Oddly enough, I could not find much more in the media about projected impacts on patients.  A July 2 Philadelphia Inquirer article stated

Hahnemann University Hospital’s pending closure and immediate move to turn away critically ill emergency patients threatens a safety net that has served close to 150 emergency room patients a day — many of them poor minorities who rely on the hospital for even primary care.

Close to half of the people admitted to Hahnemann were on Medicaid and two-thirds are black or Latino, according to an Inquirer analysis of state inpatient billing data.

Also,

Hahnemann had 17,000 inpatient stays and 53,000 emergency room visits in 2017, making it the eighth-busiest E.R. in the city, according to state Department of Health statistics.


The plight of the hospital's current house staff got a bit more attention.  An Inquirer article on July 3, stated,

The impending closure of Hahnemann University Hospital is forcing about 570 residents who work at the Center City institution to find a new place to continue their training.

Also,

Hahnemann’s closure is causing 'the largest orphaning of medical residents in the history of the United States,' Drexel University said in a Philadelphia Court of Common Pleas lawsuit against Hahnemann and its corporate parents. Drexel handles the educational side of Hahnemann’s residency programs.

And then there were the other employees of the hospital to think about.  An NBC10 Philadelphia article on June 26 included,

The closure would leave around 800 union nurses, said the union, which represents around 8,500 nurses across the state.

In addition,

The nurses are among about 2,500 employees that PAHS says are employed at the medical center.
A major teaching hospital will close, abandoning many poor and vulnerable patients, orphaning 570 house-staff and leaving about 800 nurses and about 1700 other staff unemployed, and the national media take no notice?  The numbness is striking.


Reactions to the Bankruptcy of Hahnemann

Also, in my humble opinion, the reactions to the impending bankruptcy were somewhat muted even in the local media.

The media did feature some complacent reactions from local health care experts with ties to other competing hospital systems or to  for-profit hospital management who seemed confident that everything would work out.  For example, from the June 26 Inquirer article:

But with more hospital beds per capita than many urban areas, Philadelphia is better equipped to handle the impact of a closure than many places, said Stuart H. Fine, an associate professor in Temple University’s College of Public Health.

'Philadelphia is fortunate to have enough hospital beds for the city’s needs, even if Hahnemann closes,' he said. 'I’m not minimizing the impact of this closure on those patients who live right by Hahnemann, rely upon it for their care, and will have difficulty traveling to other locations.'

The article, though, failed to mention that Mr Fine, per his bio on the Temple website, is a former hospital manager with a health administration, but not a public health or medical background, viz:

After having served as a health system CEO for more than 30 years, Dr. Stuart H. Fine joined the faculty of Temple University in 2014 as Associate Professor & Director of Programs in Healthcare Management for the Fox School of Business.

A few public relations people from other local hospitals seemed pleased about getting some of Hahnemann's business, but I could find no opinions from actual public health experts.

On the other hand, there was outrage from unionized employees (look here for an account of a small public protest by union members.)

The Governor of Pennsylvania and the Mayor of Philadelphia, both Democrats, issued a statement saying

We continue to stand in solidarity with the workers, patients and community. For months, the commonwealth and city have been working aggressively to protect patient care at Hahnemann and find solutions to maintain current medical services at the hospital,

However, they did not propose very strong action

While it is clear that the hospital’s current operation is no longer financially viable, we are both committed to working with potential investors to find support for the restructuring of Hahnemann and for protecting St. Christopher’s Hospital for Children

Note that they did not seem to question the notion that any continuation of Hahnemann would have to be as a for-profit corporate entity funded by "investors."

The American Association of Medical Colleges put an informational article on its website, featuring an interview with Janis Orlowski, MD, AAMC chief health care officer. However, the article only discussed the nuts and bolts of how Hahnemann housestaff might go about trying to find new positions.  There was no hint of outrage, and nothing about anything the AAMC might do beyond that.

The only discussion about the bankruptcy beyond the Philadelphia area that I could find came from presidential candidate Sen Bernie Sanders (D-VT), who was quoted in Politco a few days after the bankruptcy announcement:

'The business model of America’s current health care system is not about healing people or providing access to medical care — it is about making as much money as possible for insurance companies, drug companies and wealthy investors,' the Democratic presidential candidate said.

'The situation in Philadelphia illustrates the entire problem: In a city with one of the highest poverty rates in the country, a major hospital serving low-income communities is on the verge of laying off 2,500 people, abandoning 500 medical residents, and closing its operations thanks to an investment firm looking to make as much money as possible in a corporate fire sale.'

The Vermont senator added that he stood in solidarity with the nurses and others who are fighting to keep the hospital 'from being destroyed by Joel Freedman and his investment firm' and reiterated his call for 'Medicare for All.'

Per the Inquirer, again, Sen Sanders is also planning a rally for July 15, and plans "to call for Philadelphia, state and federal officials to find a way to keep Hahnemann open."

A major teaching hospital will close, abandoning many poor and vulnerable patients, orphaning 570 house-staff and leaving about 800 nurses and about 1700 other staff unemployed, and there is no national outrage, particularly from health care professionals?  The learned helplessness is striking.


Finally, lacking in what reporting there has been, however, is much explanation for why a big teaching hospital is coming to such a sudden, and ignominous end, particularly, since in a sense it has all been done before.  One gets the impression of deep seated ennui.


A Very Late Echo of the Fall of the House of AHERF

There might be a reason for that.  It has all been done before.

The June 26, Inquirer article did mention, somewhat as an aside:

Hahnemann, which traces its roots to a homeopathic medical college opened in 1848, has been through a tumultuous era dating to at least 1993, when Allegheny Health, Education, and Research Foundation acquired it as part of rapid expansion that led in 1998 to what was then the nation’s largest nonprofit health-care bankruptcy.

Tenet Healthcare Corp. bought Hahnemann and eight other Allegheny hospitals in the Philadelphia region but quickly scaled back, hanging on to just Hahnemann and St. Christopher’s, which were frequently the subject of sales negotiations that failed until Freedman decided to leap across the country from his Southern California base.

The Freedman to which this refers is one Joel Freedman, president and founder of American Academic Health Systems LLC, the last for-profit firm to own the hospital.

So Hahnemann and one other hospital were already the only survivors of the eight hospitals Tenet bought in 1998?  I could find a 2017 article that stated that all other hospitals it owned in Philadelphai were either sold or closed by then.  One hospital it sold, the Graduate Hospital, was converted into a long term care facility (look here). The fate of the other six hospitals seems anechoic. 

However, the lassitude greeting the demise of the last remaining hospitals was foreshadowed by the story of Tenet's precursor in the Philadelphia "market," the Allegheny Health, Education and Research Foundation (AHERF) whose demise has been much discussed on our humble blog as a harbinger of the dysfunction that would afflict US health care.

As we noted in 2008 (and discussed most recently in 2013 here), although the AHERF bankruptcy appears to be the largest failure of a not-for-profit health care corporation in US history, its story has produced remarkably few echoes for doctors, other health care professionals, health care researchers, and health policy makers. I often use the fall of AHERF as major example in talks, at least the few talks I am allowed to give on such unpleasant subjects. Rarely have more than a few people in the audience heard of AHERF prior to my discussion of it. I only could locate one article in a medical or health care journal that discussed the case in detail, albeit incompletely since it was written before Abdelhak's guilty plea [Burns LR, Cacciamani J, Clement J, Aquino W. The fall of the house of AHERF: the Allegheny bankruptcy. Health Aff (Millwood) 2000; 19: 7-41.] I doubt the case is used for teaching in most medical or public health schools. The lack of discussion of such a significant case is a prime example of the anechoic effect.

Some of the important points of this case will sound familiar  (see also this narrative, starting on page 5):


  • AHERF, one of the largest health care systems of its day, was built by the poster-boy for health care imperial CEOs, Sherif Abdelhak.
  • Abdelhak, who started as food services purchasing manager at Allegeheny General Hospital, was repeatedly hailed as a "visionary" (in the March, 1997, ACP Observer) a "genius," and the like. His plans to create a huge integrated health care system were part of the wave of the future. Abdelhak was even invited to give the prestigious John D Cooper lecture at the annual meeting of the American Association of Medical Colleges (AAMC), which was published in Academic Medicine [Abdelhak SS. How one academic health center is successfully facing the future. Acad Med 1996; 71: 329-336.] He proclaimed that "we will need to create new forms of organization that are more flexible, more adaptive, and more agile than ever before." And he announced that "my aim as chief executive has been to unleash the creativity and productive potential of every individual and to provide an environment that encourages teamwork"
  • While Abdelhak was making these grandiose promises, he paid himself and his associates very well. For example, he received $1.2 million in the mid-1990s, more than three times the average then for a hospital system CEO. He lived in a hospital supplied mansion worth almost $900,000 in 1989. Five of AHERF's top executives were in the top 10 best paid hospital executives in Philadelphia.
  • Although Abdelhak talked of teamwork, he warned the combined faculty of the new Allegheny University of the Health Sciences (AUHS): "Don’t cross me or you will live to regret it."
  • As AHERF was hemorrhaging money, Abdelhak continued to pay himself and his cronies lavishly.
  • After the AHERF bankruptcy, which was at the time the second largest bankruptcy recorded in the US, Abdelhak was charged with numerous felonies involving receiving charitable assets. In a plea bargain, he pleaded no contest to misusing charitable funds, a misdemeanor, and was sentenced to more than 11 months in county prison.
Note that at its peak, AHERF had 14 hospital in its network.  After its bankrupcy, it transferred 8 hospitals, including Hahnemann and the Medical College of Pennsylvania teaching hospital to Tenet.  In 2003 Tenet closed MCP (look here).  Tenet is a for-profit hospital system with its own history of bad behavior (look here).  So out of a 14 hospital network ultimately only one, not Hahnemann apparently will survive.

However, few people, even in Philadelphia seem to remember that history, and therefore seem to have drawn lessons from it.  However, had they, perhaps they would have concluded, as we asserted in 2013,

The story of AHERF is not merely that of an unlucky bankruptcy. It shows what can go wrong when health care is taken over by generic managers who adapt the latest management fads, and health care decision making is ruled by marketing, public relations and propaganda instead of evidence and logic, and allows power to be concentrated in organizations run by imperial CEOs.  We did not get a chance to learn this history, so we seem bound to repeat it.

And as we asserted in 2011

Saving health care will take clear thinking and hard work by a lot of people. The "visionaries," if we let them, are likely to depart with a huge cache of money, leaving us and health care worse off. If it is just "not done" to talk about cases such as that of AHERF, and other examples of "recent unpleasantness," how will be learn not to fall for the propaganda?

Of course, it is those who benefit from the propaganda who do not want us catching on to their game.

If physicians, health professionals, health care researchers, and health policy makers do not learn the lessons of the fall of AHERF, and now the fall of one of its two surviving hospital components, they will be doomed to see its endless repetitions, throughout the land.

With apologies to the Bare Naked Ladies - "it's all been done before"










Sunday, July 07, 2019

Making the Revolving Door Great Again: Recent FDA Commissioner Dr Scott Gottlieb Joins the Pfizer Board of Directors

It has been less than six weeks since our last post on the revolving door. 



That post emphasized cases of the outgoing revolving door, that is, of people leaving leadership positions in governmental bodies which regulate health care or make health care policy, then soon obtaining jobs in the health care industry, particularly organizations which they previously regulated or were affected by the policies they made, the outgoing revolving door. Now we have another big case.

Former US Food and Drug Agency (FDA) Commissioner to Join Pfizer Board


As we discussed in May, 2019, here, Dr Scott Gottlieb, FDA Commisioner from 2017 to May, 2019,  had been no stranger to the revolving door.  Prior to assuming leadership of the FDA, he had relationships with multiple for-profit health care corporations, which drew wide notice when he was appointed to head the FDA in 2017, as we noted at that time here.  Also, Dr Gottlieb was clearly very comfortable with the pharmaceutical and biotechnology industries.  For example, in 2007-2008, we discussed many examples of Dr Gottlieb's strident promotion of the interests of these industries (look here, here, here and here).

Very quickly after leaving the FDA in 2019, Dr Gottlieb rejoined his old venture capital firm, New Enterprise Associates, as a full-time partner investing partner specializing in life sciences companies.
Then, as reported by CNBC on June 27, 2019,

Scott Gottlieb, who stepped down as Food and Drug Administration Commissioner in April, will join Pfizer’s board of directors, the company announced Thursday.

Gottlieb resigned from the FDA this spring after nearly two years at the helm.

This seemed like an even more consequential case of the outgoing revolving door, obviously, because Dr Gottlieb held an extremely important position of responsibility in health care regulation, and because he quickly moved on to hold an important position of governance in one of the world's largest pharmaceutical/ biotechnology companies.  It also occurs as the next big thing after an unrelenting stream of revolving door issues affecting health care policy and regulation in the Trump regime (look here)

An Immediate Protest by Senator Elizabeth Warren


So this time, not only did dissidents like your obedient servant mutter online, but a US Senator authored a swift rebuke.  As reported by Sheila Kaplan in the New York Times,

Senator Elizabeth Warren on Tuesday called on Dr. Scott Gottlieb, the former commissioner of the Food and Drug Administration, to resign from the board of Pfizer, saying his decision to join one of the country’s leading pharmaceutical companies 'smacks of corruption.'

Ms. Warren, who is seeking the Democratic presidential nomination, said in a public letter to Dr. Gottlieb that the revolving door between government and industry 'makes the American people rightly cynical and distrustful about whether high-level Trump administration officials are working for them, or for their future corporate employers.'

The explicit reference to "corruption" is notable.  Most people would think of cases of the outgoing revolving door as conflicts of interest.  The concern is that people in government regulatory or policy positions might bias their decision making, possibly unconsciously, to increase the likelihood of lucrative employment after the end of their government service.  Transparency International's definition of corruption is abuse of entrusted power for private gain.  The outgoing revolving door seems to make such abuse more likely, but does not mandate it.

However, as we noted here, some, including experts from the distinguished European anti-corruption group U4, think the revolving door is corruption

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.
Senator Warren now seems to agree, at least in the case of Dr Gottlieb's move to the Pfizer board.

Did Dr Gottlieb's FDA Favor Pfizer?

In fact, within days, two reports surfaced that suggested possible reasons to think that Dr Gottlieb's FDA had taken actions that would have benefited Pfizer, and hence that his appointment to its board might be corrupt.

Drop in FDA Enforcement Activities During Gottlieb's Tenure

First, Science Magazine noted considerable evidence that the FDA during the Trump and Gottlieb era had notably deregulated the pharmaceutical industry.

By several measures ... FDA’s compliance and enforcement actions have plummeted since President Donald Trump took office, Science has found.

In particular,

The agency’s 'warning letters'—a key tool for keeping dangerous or ineffective drugs and devices and tainted foods off the market—have fallen by one-third, for example. Such letters typically demand swift corrections to protect public health and safety. FDA records from Trump’s inauguration through 22 May show the agency issued 1033 warning letters, compared with 1532 for the most recent equivalent period under former President Barack Obama.

Also,

Warnings from the FDA Center for Devices and Radiological Health, which helps ensure the safety and quality of medical devices, and from some of the agency’s district offices—including Philadelphia, Florida, and New York—have dropped even more steeply, by more than two-thirds. Two district offices have not issued a warning in more than 2 years.

And,

Several other FDA actions under Trump show similar declines when measured against the end of the Obama administration. FDA inspection reports labeled 'official action indicated'—typically a trigger for warning letters or similar actions—have fallen by about half under Trump and are continuing to trend downward. Even FDA’s rare injunctions, a more forceful step than warnings to prevent sales or distribution of unsafe or otherwise illegal products, fell from 35 in the last part of the Obama administration to 26 under Trump. (During a comparable period at the start of the Obama years, FDA issued 51 injunctions.) The agency’s 'untitled letters'—for concerns that fall short of thresholds for formal warnings—also have dropped sharply under Trump.

Several experts interviewed by Science emphasized the importance of these findings.

'FDA’s power to enforce its requirements is an important part of how it achieves its public health mission,' says Patricia Zettler, a law professor at Ohio State University in Columbus and former FDA attorney. 'If FDA is not using that power, it sends a signal that violations will be tolerated.'

Dr Gottlieb defended his former agency's regulatory role, and implied, of course, that any criticisms were political:

Scott Gottlieb, Trump’s first FDA commissioner, defended his record after reviewing a summary of Science’s data. 'We were pretty aggressive,' he wrote in an email. 'I don’t think you can paint us with a political narrative—that just because we were a Republican administration, somehow we must have ratcheted down enforcement activity. We didn’t.'

However, given the magnitude of the changes found, it is reasonable to wonder if Pfizer executives noted, and approved.

Lax Regulation of a Pfizer Drug (Xeljanz)

The next day, an article in the Milwaukee Journal Sentinel by John Fauber noted what appeared to be lax enforcement specifically involving a Pfizer product.

Unlike European drug regulators, the U.S. Food and Drug Administration under Scott Gottlieb did not say doctors should stop prescribing a potentially dangerous dose of a drug made by Pfizer — a company whose board Gottlieb soon joined.

In February, when Gottlieb still was head of the FDA, a Pfizer safety trial showed that rheumatoid arthritis patients who got a higher dose of the drug Xeljanz had a 'statistically and clinically important difference' of blood clots in the lungs and deaths.

The safety trial, which was required by the FDA, did not focus on the other two conditions for which the drug is approved — ulcerative colitis and psoriatic arthritis. The trial involved patients 50 or older with at least one risk factor for cardiovascular disease.

After safety concerns were found, Pfizer immediately stopped giving the higher dose to those in the trial.

Regulators in Europe went further.

The European Medicines Agency said in May doctors must stop giving the high dose to all patients who were at higher risk for blood clots, including those with ulcerative colitis for whom the higher dose was already recommended.

The FDA did not take that action, though it warned doctors about the safety findings that were discovered in the trial.

One ethics expert interviewed by Mr Fauber raised clear concerns about corruption.

'It sounds like a reward for a job well done,' said Carl Elliot, a physician and professor of bioethics at the University of Minnesota, when told by the Milwaukee Journal Sentinel about the FDA's failure to halt prescribing of the potentially dangerous high dose of the drug.

'It sure does look suspicious.'

Dr Gottlieb, not unexpectedly, denied direct involvement in the decision.

Decisions regarding Xeljanz were made by the agency’s career professional staff without my involvement. I did not participate in any matters involving this drug while I was at FDA

However, Senator Warren's concerns about corruption were heightened:

'Unfortunately, Scott Gottlieb joining the board of Pfizer will raise these kinds of questions about FDA decisions concerning Pfizer, whether it’s this or others,' Warren said in a statement to the Journal Sentinel. 'He shouldn’t have joined Pfizer’s board.'
IMHO, concerns that under the Dr Gottlieb the FDA could have taken a lax approach to drug industry regulation, particularly in the case of Pfizer's Xeljanz, ought to be enough to launch an investigation into whether his appointment to the Pfizer board was corrupt.

Dr Gottlieb Will Now Engage in Governance of a Company with an Already Spotty Ethical Record

Dr Gottlieb's appointment to the Pfizer board shuld raise major ethical questions.

Another set of questions he ought to contemplate is how he will deal with his new responsibility for Pfizer's conduct given the company's chequered ethical record.

We have long been posting about an amazing series of ethical missteps by Pfizer leadership, evidenced by various legal settlements, regulatory sanctions, and occasional guilty pleas.    Our most recent post on the subject, in 2018, noted how Pfizer settled charges of giving kickbacks to patients through disease advocacy organization to mask the prices of its drugs.  Our over 100 posts on Pfizer can be found here.

The company's track record from 2000 to 2017 is staggering.

Since 2000, Pfizer's troubles started, according to the Philadelphia Inquirer, with the following...

- In 2002, Pfizer and subsidiaries Warner-Lambert and Parke-Davis agreed to pay $49 million to settle allegations that the company fraudulently avoided paying fully rebates owed to the state and federal governments under the national Medicaid Rebate program for the cholesterol-lowering drug Lipitor.
- In 2004, Pfizer agreed to pay $430 million to settle DOJ claims involving the off-label promotion of the epilepsy drug Neurontin by subsidiary Warner-Lambert. The promotions included flying doctors to lavish resorts and paying them hefty speakers' fees to tout the drug. The company said the activity took place years before it bought Warner-Lambert in 2000.
- In 2007, Pfizer agreed to pay $34.7 million in fines to settle Department of Justice allegations that it improperly promoted the human growth hormone product Genotropin. The drugmaker's Pharmacia & Upjohn Co. subsidiary pleaded guilty to offering a kickback to a pharmacy-benefits manager to sell more of the drug.

Thereafter,

- In 2009, Pfizer paid a $2.3 billion settlement of civil and criminal allegations and a Pfizer subsidiary entered a guilty plea to charges it violated federal law regarding its marketing of Bextra (see post here).
- Pfizer was involved in two other major cases from then to early 2010, including one in which a jury found the company guilty of violating the RICO (racketeer-influenced corrupt organization) statute (see post here).  In that year the company was listed as one of the pharmaceutical "big four" companies in terms of defrauding the government (see post here).
- In early 2011, Pfizer's Pharmacia subsidiary settled allegations that it inflated drugs costs paid by New York (see post here).
- In March, 2011, a settlement was announced in a long-running class action case which involved allegations that another Pfizer subsidiary had exposed many people to asbestos (see this story in Bloomberg).
- In October, 2011, Pfizer settled allegations that it illegally marketed bladder control drug Detrol (see this post).
- In August, 2012, Pfizer settled allegations that its subsidiaries bribed foreign (that is, with respect to the US) government officials, including government-employed doctors (see this post).
- In December, 2012, Pfizer settled federal charges that its Wyeth subsidiary deceptively marketed the proton pump inhibitor drug Protonix, using systematic efforts to deceive approved by top management, and settled charges by multiple states' Attorneys' General that it deceptively marketed Zyvox and Lyrica (see this post).
- In January, 2013, Pfizer settled Texas charges that it had misreported information to and over-billed Medicaid (see this post).
- In July, 2013, Pfizer settled charges of illegal marketing of Rapamune (see this post.)
- In April, 2014, Pfizer settled allegations of anti-trust law violations for delaying generic versions of Neurontin( see this post).
- In June, 2014, Pfizer settled another lawsuit alleging illegal marketing of Neurontin (see this post).
- In 2015, a settlement by Pfizer of a shareholders' lawsuit stemming from charges of illegal marketing was announced (see this post).
- In October, 2015, a  UK judge found that the company had threatened health care professionals for using a generic competitor (see this post).
- In February, 2016, Pfizer settled a lawsuit for $785 million for overcharging the US government for Protonix (look here).
- In August, 2016, Pfizer made a $486 million settlement of allegations it bilked shareholders by concealing research showing the harms of Celebrex (look here for this and next two items)
- In December, 2016, Pfizer fined $106M in UK for using monopoly on production of generic phenytoin to overcharge National Health Service
- In November, 2017, Pfizer made $94 million settlement of allegations of fraud to delay generic competition

That Dr Gottlieb waltzed through the revolving door to a major role in the governance of Prizer does not give me great confidence that he will be part of the solution to the company's ongoing ethics problems.

Discussion: the Swamp Gets Swampier

 President Trump came to office promising to drain the swamp.



[An alligator in the Everglades, 1963]

At least in terms of health care, Dr Gottlieb's transit through the revolving door is just the latest example of how the swamp waters are rising.  So, as we have said again and again...

Our health care system appears to be rigged to favor of leadership and management of large companies, as opposed to health professionals, and particularly as opposed to patients.  For years now we have discussed stories which include allegations of severe misbehavior by large health care companies affirmed by legal settlements, but which only involve paltry financial penalties to the companies, and almost never any negative consequences to any humans, demonstrating the impunity of health care managers and executives. Furthermore, these stories are often relatively anechoic, noted often only briefly in the media, and have inspired no real action by the US government. We have previously discussed how market fundamentalism (or neoliberalism) led to deregulation, which enabled deception, fraud, bribery, and intimidation to become standard business practices, and allowed increasing concentration of power by large corporations. Managerialism allowed the top leaders of these corporations and their insider cronies to amass increasing power and money. Everyone else, other employees, stockholders of public corporations, customers, vendors and suppliers, and the public at large lost out.   These changes led to an increasingly costly system which produced increasingly bad results for patients and the public.

We have called for years for what we sometimes term "true health care reform" to derig the system. Unfortunately, despite our hopes, perceptions of a rigged system may not always inspire honest reform. Instead, they can enable the rise of demagogues and would be dictators who promise only they can solve the problem.  Donald Trump cried out that only he could fix our problems and drain our swamps.  However, at least in terms of policing white-collar crime, particularly in health care, he seems to be letting the swamp waters rise.

Nonetheless, let us remember the need for wholesale, real health care reform that would make health care leaders accountable for what their organizations do, and would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.

Sunday, June 23, 2019

Politically Driven Public Health Disinformation - the Latest Examples: Dread Infections, Porn Causing White Male Impotence

It used to be all about the money. We had previously noted deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns, to sell health policies favoring big health care corporations.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.

Also, we had previously noted health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values. Again, most such examples seemed to be generated by leaders who put their organization's revenue, often in parallel with their own compensation ahead of patients' and the public's health.

But now, it seems to be all about religous or political ideology.  We discuss examples of disinformation in the health care and public health spheres that seems driven not by people wanting to sell products and services to make money, but by political ideology.

Rumors of Immigrants with Deadly Infectious Diseases

In 2018, we discussed nonsense about migrants supposedly infected with smallpox (look here).  In 2019, there are rumors of other deadly diseases.

[influenza hospital, Camp Funston, Kansas, 1918, for the Spanish Flu epidemic] 


Drug-Resistant Tuberculosis

In April, 2019, Rollcall and the Arizona Republic traced the course of a rumor that Central American migrants seeking US asylum were carrying drug resistant tuberculosis.   According to Rollcall, tt may have been inspired thus:

The unfounded rumor of a public health crisis in Yuma [AZ] follows several viral and misleading stories in conservative media that families seeking asylum from Central America were bringing in dangerous infections.

But the source of the particular story, according to the Republic, was that:

Yuma County Sheriff Leon Wilmot said he was told about 12 tuberculosis cases at a San Luis detention center by federal authorities in a March 23 briefing. He shared that information with Lines and said he stands by it still. 

Here "Lines" referred to one Jonathan Lines, "a former chairman of the Arizona Republican Party," according to Rollcall. He also is

a board member of the Arizona-Mexico Commission, a 501(c)4 advocacy organization chaired by Arizona Governor Doug Ducey with the aim of boosting bilateral trade, according to an aide.

So,

Lines ... lead a delegation of Republican lawmakers along the border. The group also included Republican Reps. Duncan Hunter of California, Matt Gaetz of Florida, Sean Duffy of Wisconsin, Dusty Johnson of South Dakota and Pete Stauber of Minnesota.

Also on the trip was Dr John Joyce, a member of the US House of Representatives,

13th District [of Pennsylvania] Republican, a dermatologist by trade, [who] is a staunch supporter of President Donald Trump and has echoed his calls for a border wall.

Lines had "made unsubstantiated claims about tuberculosis in a video."  Joyce posted the video made by Lines to a Facebook page, since taken down. He also made a

bogus claim that immigrants seeking refuge over the Arizona border brought drug-resistant strains of tuberculosis to the U.S.

Joyce made the false claim in a briefing with reporters during a congressional trip led by Arizona GOP Rep. Andy Biggs last week to the U.S.-Mexican border near Yuma, Ariz. The claim was then echoed in the national press.

'My concern is what about the person who wasn’t coughing and wasn’t recognized as having tuberculosis, and they didn’t come here for treatment for their disease,' Joyce said. 'They could be released in a day and a half and be sitting at a restaurant (table) beside you.'

That was all ultimately debunked.

Local public health officials quickly shot down rumors of an outbreak, clarifying that there have been zero cases of multi-drug resistant tuberculosis in the county for the last six to seven years, and further, no present cases of tuberculosis in Yuma at all.

'I can say, after confirming with the Yuma County Health District, there is no drug-resistant tuberculosis in Yuma County,' Kevin Tunell, a Yuma County spokesman told the Arizona Republic. 'Further, there are no cases of tuberculosis involving migrants in Yuma County at this time.'

Who knows, however, how much traction the original warnings about tuberculosis got, and whether those who believed them saw, or credited the attempts to debunk them?

Note here that this little disinformation campaign seem to have been politically motivated, an attempt to justify the Trump administration's claims about the dangers of migrants at the border, and the need to build a wall.  It is particularly disturbing that the disinformation got picked up beyond the shadowy recesses of the web, to be propagated by political leaders into the main stream media.

Ebola Virus

We do not have such detailed information about he track of rumors of Ebola virus infected immigrants at the southern border.  However, the Associated Press did report in June, 2019,

Texas health officials said Tuesday there are no 'suspected or confirmed cases' of Ebola in the state as social media posts have falsely suggested in the wake of immigrants arriving from Africa, including Congo, where an outbreak in has surpassed 2,000 cases.

The false claims, ranging from there is an Ebola 'outbreak' in Texas to reports of a few confirmed cases, have been circulating since April. The erroneous claims are also spreading at a time when Border Patrol officials said last week there has been a 'dramatic' rise in the number of migrants arriving at the Texas border from African countries, although they remain a small fraction of the total number of migrants apprehended.

'We do not have any suspected or confirmed cases of Ebola right now in Texas,' said Lara Anton, spokeswoman for the Texas Department of State Health Services.

The U.S. Centers for Disease Control and Prevention is also unaware of any Ebola cases nationwide, spokesman Benjamin Haynes said.

Note that propaganda accusing hated others of being infected with dread diseases is an old part of the authoritarian playbook.  In particular, from the US Holocaust Museum, the second version of the Nazi propaganda film Der Ewige Jude (The Eternal Jew)

contained notorious antisemitic sequences. These scenes compared Jews to rats that carry contagion, flood the continent, and devour precious resources.

Disinformation about disease outbreaks may make it harder to fight real disease outbreaks.  An op-ed in the New York Times by Bruce Schneier, a fellow at the Harvard Kennedy School, warned

When the next pandemic strikes, we’ll be fighting it on two fronts. The first is the one you immediately think about: understanding the disease, researching a cure and inoculating the population. The second is new, and one you might not have thought much about: fighting the deluge of rumors, misinformation and flat-out lies that will appear on the internet.

He speculated,

Misinformation can affect society’s ability to deal with a pandemic at many different levels. Right now, Ebola relief efforts in the Democratic Republic of Congo are being stymied by mistrust of health workers and government officials.

It doesn’t take much to imagine how this can lead to disaster. Jay Walker, curator of the Tedmed conferences, laid out some of the possibilities in a 2016 essay: people overwhelming and even looting pharmacies trying to get some drug that is irrelevant or nonexistent, people needlessly fleeing cities and leaving them paralyzed, health workers not showing up for work, truck drivers and other essential people being afraid to enter infected areas, official sites like CDC.gov being hacked and discredited. This kind of thing can magnify the health effects of a pandemic many times over, and in extreme cases could lead to a total societal collapse.

Pornography as a Plot to Render White Males Impotent

Sometimes you cannot make this stuff up.  We have discussed, most recently in April, 2019, here, how many US state legislators have been promulgating resolutions condemning pornography as a major public health hazard, despite the lack of clear evidence to justify this belief.  They seem to have put more emphasis on this supposed threat than on much more evidence-based public health hazards.

[Porn has been around for a long time in the US: Times Square, 1973]


We had speculated that this peculiar focus was based on sectarian religious beliefs about the evils of pornography.

Note that since April, another state legislature has gotten on board.  In May, 2019, the Arizona Republic reported,

Republican senators on Monday adopted a measure declaring pornography a public-health crisis and urging the state to 'systemically prevent exposure and addiction.'

The resolution — approved by the House in February — deems the 'societal damage of pornography…beyond the capability of the individual to address alone.'

It argues that porn can lead to human trafficking, sexual abuse, infidelity, low self-esteem and eating disorders, among other issues.

The Republican supporters of this measure did not cite any epidemiological evidence about the dnagers of porn. Their Democratic opponents suggested that the state should focus on better substantiated public health threats, such as the measles outbreak, rising suicide rates, and the opioid epidemic.

Instead, per a Republican backer of the measure:

'Billions of dollars worldwide are being made upon this industry that is poisoning the minds of our citizens,' [Sen Sylvia] Allen said, calling porn 'the root problem for many of the other problems that we're experiencing.' She said it contributes to sexual activity at young ages, sexually transmitted diseases and unplanned pregnancies.

'It has morphed into something … horrible,' she said.

Although perhaps her remarks had a religious tone, religious justification for her non-evidence-based beliefs was not apparent.


In June, 2019, the New York Times reported that the sudden emphasis on the evils of pornography may have come from not just religious fundamentalist beliefs, but political extremism from the deepest internet.  The article opened with this chilling example,

Buried in the anti-Semitic manifesto of the 19-year-old man who recently opened fire in a synagogue near San Diego is a sentence in which he blames Jews for 'causing many to fall into sin with their role in peddling pornography.'

To enlarge on this example,

some of the suspects in racist attacks and their supporters have invoked the societal ills caused by pornography in manifestos or online forums.

White nationalists, misogynistic clubs and online forums have also drawn a connection between pornography and anti-Semitism. Many of the adherents appear to be young men who blame the prevalence of pornography online for their own struggles and what they perceive as society’s decline.

'Any right-leaning dude on the internet in 2019 is at least aware of the phenomenon,' said Daniel Harper, a podcaster who tracks white nationalism online.

For example, a forum on Reddit is a support group of sorts for 440,000 members who take breaks from masturbation and porn for what they believe to be mental, physical and sexual-health reasons. The Proud Boys, a self-professed 'western chauvinist' group, encouraged a similar message.

These dark beliefs turn out to be nothing new, but perhaps are having more influence in the current era in which political extremists now seen to be welcomed into the mainstream.

The theory that Jews are trying to control the West by using porn to render white Christian men impotent has deep roots. Among its exponents are several elder statesmen of the current white nationalist movement, such as David Duke, who, in a 2016 Twitter feud posted: 'Jews dominate porn — why are ‘Christians’ ok with that?'

During the 2018 race to fill Paul D. Ryan’s Wisconsin congressional seat, long shot candidate Paul Nehlen, a self-avowed 'pro-white' advocate, was suspended from Twitter for circulating a video titled 'The Jewish Role in the Porn Industry.' He has since made other racist comments and been suspended again.

There are also hints that the extemism of white supremicist politics on this topic may not be entirely divorced from the more open condemnation of pornography by some fundamentalist religious groups.

Michael German, a former F.B.I. agent who is now a fellow at the Brennan Center for Justice at New York University, said the anti-porn rhetoric was baked into the culture of the violent white supremacist groups he investigated in the 1990s.

'In any sort of fundamentalist culture, there is a desire to control sexuality, and this one’s no different,' he said.

Discussion

There have always been snake oil salemen and quck health care practitioners.  Some years ago, proponents of evidence-based medicine (EBM) were dreaming of a world in which honest discussion based on critical thought about the best available evidence from clinical research would lead to a health care revolution.  Early on, though EBM  faced difficulties from deceptive marketing and manipulation and suppression of medical research in service of promotion of drugs, devices, and other medical goods and services.

Now EBM seems under seige by a new wave of propaganda and disinformation, not so much to sell products, but to further religious or political ideologies (for other examples, look here) , or national interests of hostile countries (look here). The health care dysfunction we now see will seem like nothing compared to the dark sort of dysfunction that could be generated by health care and public health based on sectarian beliefs, extreme political ideologies, and the interests of hostile foreign powers. The time for complacency and excuses is past.  Any health care professional who cares about our national future must get on the information barricades and fight for science and the truth in health care.   

Sunday, June 09, 2019

How to Counter Medical/ Health Care/ Public Health Disinformation

It used to be so simple.  Yes, we had to cope with deception in marketing.  Commercial sponsors of clinical research were known to manipulate the research, and even suppress research with results unfavorable to them.  Key opinion leaders spun medical education and the media.  But it was all releatively straightforward in some senses.  It was all at least mostly based on medical knowledge and clinical research.  The purposes of the spin and deception were commercial: the goal was selling more products or services.  With some digging, the conflicts of interest sometimes could be discovered.

But that was before stealth health policy advocacy morphed into propaganda and disinformation (look here).  Disinformation campaigns were everywhere, and even in one case, were supercharged by a disinformation campaign run by a hostile foreign power, apparently meant to destabilize western democracies (look here).  We are now drowning in a sea of propaganda and disinformation.

What can health care professionals do before we go under?

How Medical/ Health Care/ Public Health Disinformation Works

A May, 2019, MedPage article entitled "a prescription for treating fake health news," noted how the rise of social media enabled disinformation:

Although patients' misconceptions, lack of logic, and superstitions have complicated the work of doctors since the first doctors existed, the advent of social media has taken the problem to a new dimension.

With social media, patients can more easily find misinformation, says Dominique Brossard, PhD, chair of the University of Wisconsin-Madison Department of Life Sciences Communication. They can also share that misinformation more easily.

The articles listed a series of factors that increased the potency of disinformation spread by social media:

Lies may spread faster than the truth. Researchers at the Massachusetts Institute of Technology analyzed a set of about 126,000 news stories disseminated on Twitter from 2006 to 2017. They found that more people retweeted false information than true information. The researchers speculated that people may have passed along the fake news more readily because it was more novel and evoked more emotion.

In addition, social media enhances repitition of false messages:

The wide dissemination means that some patients may receive the same false messages repetitively. In another study, Yale researchers found that the more often people receive the same message, the more likely they are to believe it, even when the message is labeled as disputed by social media fact checkers.

Also, people attend more to the immediate source of information than its origin:

when people are evaluating the reliability of health information shared online, they care more about who shared the information than they do about the original source, according to an American Press Institute study.

The article went on to discuss how individual physicians could help individual patients understand how disinformation may dupe them.  However, this is is a retail solution to a huge wholesale problem.

What Can Health Professionals Do on Social Media to Counter Disinformation?

Note that while we know something about how medical/ health care/ public health disinformation is spread, we still know little about the cause of the plague.  Unlike the old style of deception, it is not obviously based on the self-interest of companies trying to sell products or services.  Nonetheless, we need to fight disinformation even if we do not fully understand its causes.  And we know a little bit about how that could be done. The bottom line is that health care professionals need to use the same social media that is spreading disinformation to counter it with the truth.


Two recent articles specifically encouraged physicians to get online now (even if they are uncomfortable with the brave new world of the internet.)

[We cannot pretend the internet is only for computer nerds, as it may have been at the time of the debut of this original Compaq 286 Portable, the original Microsoft DOS based "portable," actually "luggable" computer]


In June, 2019, a CNBC article profiled one physician pioneer who urged all concerned health care professionals to confront disinformation on social media.

The antidote to fake health news? According to Austin Chiang, the first chief medical social media officer at a top hospital, it’s to drown out untrustworthy content with tweets, pics and posts from medical experts that the average American can relate to.

Chiang is a Harvard-trained gastroenterologist with a side passion for social media. On Instagram, where he refers to himself as a '“GI Doctor,' he has 20,000 followers, making him one of the most influential docs

Note that,

Every few days, he’ll share a selfie or a photo of himself in scrubs along with captions about the latest research or insights from conferences he attends, or advice to patients trying to sort our real information from rumors. He’s also active on Twitter, Microsoft's LinkedIn and  Facebook (which owns Instagram).

He exhorted his fellow physicians to get involved:

'This is the biggest crisis we have right now in health care,' said Chiang. 'Everyone should be out there, but I realize I’m one of the few.'

According to Chiang, doctors have historically been reluctant to build a following on social media for a variety of reasons. They view it as a waste of time, they don’t know how, or they fear they might say the wrong thing and get in trouble with an employer. Others prefer to spend their time communicating with their peers via academic journals.

But as Chiang points out, most consumers do not pore over the latest scientific literature. So health professionals need to take the time to start connecting with them where they do spend their time — and that’s on Facebook and Instagram.

So he’s working to recruit an army of physicians, nurses, patient advocates, and other health professionals to get online.

Similarly, a June, 2019, commentary in the Lancet by social media pioneer Dr Jennifer Gunter, an obstetrician-gynecologist, who described her realization

Clearly, we needed a better medical internet. So, I decided to help fix it. I started blogging to help parents navigate the gauntlet of prematurity, but greeted with so much misinformation and disinformation about vaccines I began to think about my own field, gynaecology. What disastrous information were my patients finding online?

The answer was

There was not just misinformation and disinformation about medical care. Practical day-to-day things, not typically addressed by medicine, were especially ripe for abuse—for example, how to select menstrual pads or pubic hair grooming. And many sites contained even greater dangers, notably, exposure to anti-vaccine or other medical conspiracy theories.

We have huge gaps in medicine—in both the science and how we communicate, especially in women's health—but much of what I found when I first started my online quest and what I still find today is exploiting those deficiencies, not fixing them.

Her exhortation was:

The more I see fake medical news, the more I realise we need to use all mediums and media to tackle it. The glut of medical misinformation is real and it harms. It turns people away from vaccines, fluoride, and leads them to useless products. And don't underestimate the weight of 'it can't hurt, so why not?' advice. Whether it is useless underwear changes or forgoing all sugar, it compounds desperation when it is ineffective. And snake oil peddlers are always standing by with a confidence we evidence-based practitioners can only dream to emulate.
Everything we read and share builds the internet, so we in medicine should especially take that to heart.

But Dr Jen, as she is now widely known, also had some practical advice for health care professionals out to defend the truth on social media:

First, a very simple beginning:

How does one even try? Find good medical content and post it on Facebook, Twitter, or the social media platform that works best for you. Even in a small circle of friends and family you can make a difference. If you read something accurate, well sourced, and bias free click the like button. The more clicks the greater the chance that piece will appear favourably in an algorithm. Ignore bad pieces—social extinction is the best strategy.

 Then learn some simple rules:

Everyone should learn the following four basic rules of internet health hygiene. The first is never read the comments as ad-hominem attacks beneath the content can lead people to question the very facts that were just presented. The second is avoid sharing bad information—even in jest. We are all primed to remember the fantastical and sadly medical truths are usually stodgy. Also, sharing makes the bad content more popular algorithmically speaking. The third is don't get information from anyone selling product. Bias has an impact. And finally, steer clear of content from practitioners who are against vaccination or who recommend homeopathy.

Meanwhile, do not neglect to provide your patients with accurate information, or spreading the truth by older means:

Guiding your patients to accurate information is also important. Find good online resources and offer them as handouts or e-mail the links directly if you can do that securely. Your patients are looking online, whether they tell you or not. Offering them curated content from trusted sites, such as the National Health Service in the UK or professional medical societies, validates their search efforts and I believe it makes people more likely to share with their health-care provider what they found online.

Create content, be it quality medical research in a journal or opinion pieces for the lay press. 

For those who heed these exhortations, know that fighting disinformation will not be easy.  In particular, expect strident opposition, as discussed in a commentary in the May, 2019, BMJ by David Oliver, using examples pertaining to debating anti-vaccination fanatics:

Persuading individual parents is one thing. But trying to debate with the more determined anti-vaccination activists can be a futile endeavour, not played by the rules healthcare experts are used to.

Every scientific paper in support of the cause (whatever its quality) and every commentator sympathetic to the cause (expert or not) is selectively harvested and cited. Allegedly hidden harms and risks of vaccination are highlighted. If you’re not a genuine content expert it’s impossible to wade through each individual source to appraise it or understand its limitations. If you really are a content expert, steeped in the science and leadership of mass vaccination—or an official body, from Public Health England through to WHO or the UN—you’ll be labelled as being close to (and influenced by) the vaccine manufacturers, and the impartiality of your advice will be questioned.

Reports of outbreaks and rising infections will be dismissed: 'How many of those cases were actually verified?' The severity of the disease we’re trying to prevent will also be questioned. Measles and other preventable childhood infections can kill or bring serious long term damage and disability, but these consequences will be minimised to suit the cause. You’ll be told that not all vaccinated people mount a sustained immune response (which is precisely why we need a high uptake for herd immunity).

Don’t be surprised if your defence of mass vaccination against refuseniks leads to attacks on social media or impassioned private correspondence. If you push back, the whole cycle will start again.

The idea of children developing natural, normal immunity through exposure to infections will be romanticised. Arguments about the collective societal need to vaccinate our own children so that we don’t put other children at risk will be either ignored or represented as a callous attack on parents and dismissal of their concerns—potentially a bad look for doctors and nurses, even when acting for a greater cause. And suggestions that vaccine refusers are putting their own children at risk will be used to make those doctors look even worse.

However, while it may not be reasonable to expect to convince whoever are the people who are central to the spread of disinformation that they are wrong.  Instead, the goal should be to decrease the spread of disinformation by informing those who have not yet become cultists.

Final Exhortations

However, this is not the time for the faint-hearted.  While one may not persuade the fanatics, but have some hope that it is possible to advance the truth.   Do not forget the importance of the battle.

To quote a June, 2019, Bloomberg op-ed about the the need to challenge disinformation in the political sphere,

The culture war gets a lot of attention, in part because it’s easy both to understand and to pick a side. But it’s the epistemology war – the partisan effort to break the power of facts, knowledge and expertise, and to destroy the means of assessing them -- that will determine whether the U.S. can secure a decent society in the future.

Have courage, because:

That war is Sisyphean, with victory perpetually subject to savage reversals.

What we have to do is

roll the stone uphill day after day.

So,

Speak. Repeat. Speak again. Lace up your Marine boots and put on your Republican suit. There’s a war on.

Friday, May 31, 2019

That Old Time Revolving Door Keeps Spinning

Traditionally, the American examples we have seen of the revolving door involved people leaving leadership positions in governmental bodies which regulate health care or make health care policy then soon obtaining jobs in the health care industry, particularly organizations which they previously regulated or were affected by the policies they made, the outgoing revolving door.  These examples occurred during Democratic and Republican administrations.  However, during the Trump regime, we began to see many examples of the incoming revolving door, people coming form leadership positions in the health care industry to take government health care regulatory or policy positions that could affect their former organizations' interests (look here).



However, the old-time bipartisan outgoing revolving door keeps spinning.  Here is a collection of examples in chronologic order by the date they were made public.  Also, I found an example of the incoming revolving door at the US state level, involving Democrats, not Republicans.


From Secretary of Veterans Affairs to the Board of Armada Health

On March 12, 2019, a brief item in Modern Healthcare stated:

Former Veterans Affairs Secretary Dr. David Shulkin has joined the board of ArmadaHealth, a Maryland health data company that offers a database for patients to find physicians.

President Donald Trump fired Shulkin last year from the top post at the VA, where the former secretary also served under President Barack Obama.

I could find little further information.  Note that Dr Shulkin served in both Democratic and Republican administrations.  Note further that with the increasing push to privatize the VA, its operations may have more to do with companies like ArmadaHealth.

From US Senate to Lobbying Firm Akin Gump Strauss Hauer & Feld

On March 14, 2019, Maplight.com noted:

Months after advising the Democratic Party to abandon the idea of 'Medicare for All,' a former U.S. senator has been hired by a lobbying firm whose clients are leading the fight against changes to the nation’s health care system.

Akin Gump Strauss Hauer & Feld LLP, a Washington, D.C.-based law and lobbying firm, announced on Wednesday that former Sen. Joe Donnelly is joining the firm as a partner and will be counseling clients in the health care and financial industries.

In particular, the article stated that:

Akin Gump has lobbied for the Healthcare Leadership Council since 2016. The trade organization’s members include health insurance, pharmaceutical, and hospital interests -- industries whose profits could be threatened by a single-payer system. The firm has also lobbied for Pharmaceutical Research and Manufacturers of America (PhRMA) and the Biotechnology Innovation Organization, two powerful drug industry trade groups.

PhRMA, BIO and the Healthcare Leadership Council are members of the Partnership for America’s Healthcare Future, a coalition created last year to oppose Medicare for All, as well as any of the weaker measures offered by Democrats to provide health care coverage or insurance to more Americans.

Donnelly seemed like a pretty good candidate to lobby for thiese firms because:

He campaigned against Medicare for All, even though polling by Data for Progress and the Kaiser Family Foundation last year estimated that 55 percent of Indiana residents support a universal health insurance plan. In one Donnelly campaign ad, a narrator warned that 'socialists want to turn health care over to the government.' Donnelly replied: 'Over my dead body.'

Since his loss, Donnelly has continued to warn Democrats against pushing for a single payer health care system. 'When you talk Medicare For All … you start losing the people in my state,' he said in December. 'When we start talking about, 'Hey, we're going to work together with the insurance companies to lower premiums,' that's what connects. The talk on the coasts just doesn't get it done in the middle.'
So Donnelly's new position lobbying for industry groups that oppose single payer health insurance, which they presumably see as a threat to their revenues, could be viewed as a reward for his previous advocacy of their positions.

In that vein, the article quoted health care insurance whistleblower Wendell Potter:

a former health insurance executive who has spent a decade investigating the industry’s predatory practices, panned Donnelly’s career move.

'Sen. Donnelly kept health care reform efforts at bay his whole tenure in Congress, and on his way out he went on national news to tell Democrats that Medicare for All was dangerous,' said Potter. 'Now we see his reward: A cush lobbying gig working for the health-care industry.'

'Color me shocked,' he said.

Were Senator Donnelly to have advocated the industry position because he thought it would enhance the chances of eventually getting a lucrative industry position, that could have appeared to be an abuse of entrusted power (as a Senator, to set public policy) for private gain, that is, as corruption in the ethical, if not the legal sense.

An article in the Indianapolois Star found this response from the Republican Party:

Indiana's GOP criticized Donnelly's decision.

'While Donnelly may have moved back to Granger, he clearly can’t get enough of the swamp,' said Pete Seat, executive director of strategic communications for Indiana Republicans. 'From this day forward, consider ‘Democrat Donnelly’ retired, and ‘D.C. Lobbyist Donnelly’ deployed.'

That is a reasonable criticism, but I wonder if they would make the same criticism of similar behavior by a Republican politician?   

Meanwhile, in April, Politico briefly noted

Former Rep. Lamar Smith (R-Texas), meanwhile, who also joined Akin Gump after leaving Congress in January, reported lobbying for four clients. They include HerdX, a ranching logistics company; Otis Eastern Service, an oil-and-gas pipeline company; Pebble Limited Partnership, which is trying to develop an open-pit mine in Alaska; and Pfizer, the giant pharmaceutical company.

So this particular pathway from the Senate to this lobbying firm and then to health care industry clients is a well trodden one.

From the US  Drug Enforcement Administration to Consultant for Purdue Pharma

On March 20, 2019, NBC News reported:

A former senior U.S. Drug Enforcement Administration official who testified before Congress on the government's efforts to stop the opioid epidemic is now paid to advise one of the largest opioid manufacturers in the country, Purdue Pharma, according to people familiar with the matter.

Demetra Ashley, the former acting assistant administrator of the DEA who told a Senate committee in 2017 about the need for a 'robust regulatory program' to stop the diversion of opioids and other controlled prescription drugs, left the DEA last spring and started a consulting firm called Dashley Consulting, LLC

The arrangement inspired some critcism, for example,

'This should not be allowed,' said Dr. Andrew Kolodny, the co-director of opioid policy research at Brandeis University. 'Former DEA and FDA officials should not be allowed to take money from companies they regulated.'
The issues here seem obvious.

From Top White House Adviser to Adviser to Juul

On May 21, 2019, the Washington Post reported that Johnny "DeStefano, a counselor to the president who served as a bridge between the Republican Party and the administration, is leaving on Friday." As to his destination,

He is expected to advise a number of companies, including Juul, the e-cigarette company, while helping on the campaign, according to people familiar with his plans. Juul has significant business in front of the Food and Drug Administration

I could not find much more about this. However, as a top White  House adviser without a specific portfolio, DeStafano could have affected health care and specifically FDA policy.

From Venture Capital Firm New Enterprise Associates to Director of the US Food and Drug Administration (FDA) and Back to New Enterprise Associates

On May 22, 2019, Axios reported that

Scott Gottlieb, who recently stepped down as the head of the Food and Drug Administration, has rejoined venture capital firm New Enterprise Associates as a full-time investing partner, Axios has learned.

Context: Gottlieb had been a venture partner with NEA before President Trump tapped him to lead the FDA, where he became known for cracking down on e-cigarettes and working to battle the opioid epidemic.

Gottlieb previously spent a decade with NEA, but the new role is more substantive. He's expected to lead investments in life sciences startups and take board seats.

Again, there was little other information and no substantive commentary publicly available about Dr Gottlieb's return to his old firm.

We briefly noted the considerable public discussion about Dr Gottlieb's conflicts of interest at the time of his ascension to the FDA post here. He had multiple relationships with multiple for-profit health care corporations in the years leading up to his 2017 appointment.    I should note that we have discussed previous examples, in 2007 and 2008 (look here, here, here and here), of Dr Gottlieb's strident promotion of the interests of pharmaceutical and biotechnology companies.  After 2008, I  naively thought further discussion of this topic would be redundant. 

From Director of the National Institute of Mental Health (NIMH) to Google's Verily, to Mental Health App Developer Mindstrong, to California "Czar" for Mental Health

Last, but not least, also on May 22, 2019, StatNews reported:

Noted psychiatrist and former Verily leader Dr. Tom Insel is going to be the 'mental health czar' for the state of California, Democratic Gov. Gavin Newsom announced Tuesday.

Insel, the former National Institute of Mental Health director, will also continue his work with Mindstrong, a startup that is working on a mental health app, a company spokesperson confirmed. Insel joined the company in 2017 after leaving Verily, Google’s life sciences arm.

Insel’s new job will be to 'inform the state’s work as California builds the mental health system of tomorrow, serving people whether they are living in the community, on the streets or if they are in jails, schools or shelters,' according to a press release from the governor’s office.

In a press conference, Newsom said Insel was 'volunteering' his time as an adviser. 'I’m calling him the mental health czar in the state of California,' he said.

The article also noted that

Mindstrong, which is focused on using data on how people use their smartphone to detect trends in their mental health, already has a relationship with public officials in California. One of Mindstrong’s first large-scale rollouts was slated to happen in the state through county-level public mental health systems, STAT reported in October.

A spokesperson for Mindstrong said that Insel would recuse himself from conversations about the company, and noted that he will have 'no fiscal or regulatory authority and will have no oversight of current programs in this voluntary role.'

Note that even after such specific recusal, Dr Insel would be in a position to generally influence state policy in ways that could favor Mindstrong.  Futhermore, state officials working for a "mental health czar" would be aware of his commercial ties and might thus tend to try to favor Mindstrong to please him.  

Note also that in 2010 our late blogger, Dr Bernard Carroll, wrote a series of posts about conflicts of interest and other ethical questions about Dr Insel's tenure as director of the National Institute of Mental Health (NIMH) here, here, here, here, and here.  Also, in 2015 I noted that Dr Insel transited the revolving door from the NIMH to Google Life Sciences.  This is just another example of how people and organizations that get on our radar once for ethical and leadership lapses tend to appear again and again.

[photo of Dr Carroll]


Discussion

We have repeatedly said,  most recently in March, 2019, ...

The revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,



The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.
The ongoing parade of people transiting the revolving door once again suggests how the revolving door may enable certain of those with private vested interests to have disproportionate influence on how the government works.  The country is increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

 The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.