Thursday, May 16, 2019

From "Forced Injections" to "Sorcery," - More Examples of Partisan Ideology and Religious Sectarianism Trumping Evidence in Health Policy and Public Health

Evidence-based medicine (EBM) is about medical-decision making based on critical review of the best applicable evidence from clinical research informed by knowledge og biology and medicine, of the patient's biopsychosocial circumstances, the patient's values, and of ethics and morality.  Advocating EBM, and evidence-based health care, public health, and health policy was sometimes slow going, but at least health care professionals often seemed open to these ideas.

Now we seem to be in an alternate universe.  We have discussed the rising tide of health care and public health policy unsupported by evidence, and sometimes supported only by nonsense.  This tide seems driven by ideology, partisanship, and religious sectarianism.  Furthermore, we see more and more examples of political leaders embracing such policies apparently without any input from health or public health professionals.  We discussed several relevant cases in March, and then April, and included them in an interval summary of the "new (ab)normal in health care dysfunction" in May.

Less than 10 days later, we have accumulated enough new examples to be worth summarizing, presented in alphabetical order by state.

Arizona Republican State Legislators Push Vaccine Exemptions in the Face of a Measles Outbreak, While Decrying Pornography as a Greater Public Health Hazard

In February, 2019, Arizona state legislators were pushing to further relax requirements for and even discourage vaccination.  According to CNN,

Arizona lawmakers voted last week to advance three bills that would make it easier to get exemptions from the state's vaccine requirements, and which would require doctors to provide much more information to patients and families about potential harms that vaccines pose.

The bills cleared the House's Health and Human Services Committee on a 5-4 GOP-led, party-line vote, and head to the Rules Committee on their way to the floor.

HB 2470 adds a religious exemption to the existing law requiring vaccinations, and carries an amendment that would eliminate the requirement for parents to fill out an exemption form that informed them of potential consequences of not vaccinating their children. Those consequences can include requirements to keep children who haven't received vaccinations out of school during disease outbreaks.

HB 2471 requires medical providers to give detailed information about vaccines, including the prescription's package insert, to parents.

It was not clear that any of the legislators pushing these measures based their arguments on evidence about vaccines, the diseases they may prevent, or public health in general. Instead, for example:

the bills' sponsor, Rep. Nancy Barto ... told Capitol Media Services: 'These are not, in my view, anti-vaccine bills. They are discussions about fundamental individual rights.'

In this case, was she expousing a fundamental right of a parent to increase the likelihood that the parent's child would get an unpleasant, and dangerous disease, and to transmit such a disease to others?  Soon after, in March Arizona recorded its first case of the measles, affecting an 11 month old child.

Meanwhile, Arizona state legislators decided to worry about the public health hazards, not of the measles outbreak, but of ... pornography.  We had noted also  in March that Republican legislators were pushing the notion, unsupported by evidence, that pornography is a public health crisis.  In May, CBS reported,

A Republican-backed measure in the Arizona State Senate to formally denounce pornography as a public health crisis has passed. The resolution, which does not require the governor's signature for approval, will now go to the secretary of state to be certified. According to text of the bill, the legislation claims that pornography 'perpetuates a sexually toxic environment that damages all areas of our society.'

It goes on to claim, without any medical citation, that pornography is 'potentially biologically addictive and requires increasingly shocking material for the addiction to be satisfied' leading to 'extreme degradation.'

Again, the resolution seemed to have only Republican support. It was "Introduced by Republican Rep. Michele Udall and backed by six other Republican co-sponsors...."

While there is very good evidence that measles vaccination prevents the disease, that the disease can have serious, sometimes fatal consequences, and that measles is easily transmitted to others; and there is no good evidence that pornography is harmful, the legislators treated the latter is a more serious threat.  I saw nothing to suggest they had any personal experience in medicine, health care, or public health, or that they consulted anyone with any expertise in their areas.  Although they cited "individual rights" to support vaccine exemption, they were silent about rights to free expression that might have been affected by their crusade against pornography.  Finally, all the legislators prominently involved in these moves were from one party.  


Oregon Republican Party Derides Vaccinations as "Forced Injections"

This story comes via Vice News on May 8. In response to a bill sponsored by Oregon Democrats that would remove the "moral exemption" for vaccination,

Oregon’s Republican Party isn’t on board with this whole 'forced injections' thing — otherwise known as mandating kids get their shots against life-threatening illnesses like measles, mumps and rubella.

'Oregon Democrats were just joking about 'my body, my choice' while rammimg (sic) forced injections down every Oregon parent's throat,' the state’s official GOP account tweeted Monday night, apparently referencing the Democrats’ argument that Republicans shouldn’t interfere with a woman’s ability to access abortion.

Note that parents are making decisions about measles vaccinations, which are injections, for their children, not themselves in this context.  Although Oregon apparently has not had its own measles outbreak, there is one in neighboring Washington state.  According to Vice News, the vaccination rate in some parts of Oregon may be as low as 80%, reducing herd immunity and making the risk of an outbreak high.  Again, I could find nothing to suggest whoever in the state Republican party coined the perjorative "forced injections" had any understanding of the data about vaccine effectiveness versus adverse effects, or the severe consequences and transmissability of measles.  Finally, again this seems to be making a discussion of public health partisan.

Texas Republican State Legislators Also Advocate More Vaccine Exemptions, While One Accuses Public Health Authority of "Sorcery"

In April, the Corpus Christi, Texas, Caller-Times reported that four Texas state legislators were introducing bills to make it easier to avoid vaccination,

H.B. 3857: by Rep. Tony Tinderholt, R-Arlington, would prohibit doctors from refusing to see unvaccinated patients. Pediatricians tend not to want unvaccinated children in their waiting rooms, exposing other children and their parents to preventable deadly diseases like measles. Pediatricians are kind of funny that way. So are parents who believe in vaccination.

H.B. 1490: by Rep. Matt Krause, R-Fort Worth, would make it easier for parents to opt out of vaccinations. But perhaps of bigger concern is that it would prevent the Texas Department of State Health Services from tracking non-medical exemptions. This would make it harder to respond to outbreaks and certainly harder to predict them by identifying potential hotspots.

H.B. 4274: the 'informed consent' bill by Rep. Bill Zedler, R-Arlington, would require doctors to explain the benefits and risks in detail, including ingredients in the vaccines. That may sound like a good thing on face value. But this is technical information that is more likely to cause confusion and fear than understanding and appreciation. It's like telling someone what's in menudo first, then trying to get them to eat it.

H.B. 4418: by Rep. Jonathan Stickland, R-Bedford, would let nurses rather than only doctors sign off on vaccination exemptions.

The reporters tried to understand the rationale for these bills.  The best they could do was to write

that it appears to be a mix of political opportunism and ignorance. Suspicion of vaccinations is suspicion, period, and suspicion helps drive votes. The ignorance part is best summed by Zedler, who told the Texas Observer that concerns about measles are overblown because it's beatable 'with antibiotics and that kind of stuff.' The punchline is that antibiotics don't kill viruses and measles is a virus.

Note that we had discussed Rep Zedler's remarkably wrong headed statement that measles can be treated with antibiotics here.

The Caller also noted that

not one of these bill sponsors is a medical professional or scientist. Nor are they acting on the advice of medical professionals or scientists. If they had listened to and heeded medical advice, they would not have filed these bills.

In May, a follow to this story was a bit wilder.  The Washington Post reported on the latest antics of Rep Strickland, who introduced the fourth bill in the list above,

 A Texas state legislator unleashed a vilifying attack on a leading vaccine scientist Tuesday, accusing the doctor of 'sorcery.'

It started with a report published Monday by the Texas Department of State Health Services that noted the state recorded a 14 percent rise in parents opting out of their children’s vaccinations. It was a new statistic that alarmed Peter Hotez, professor and dean of the National School of Tropical Medicine at Baylor College of Medicine.

'We have more than 64,000 kids not getting vaccinated in the state of Texas, and that doesn’t account for the over 300,000 home-schooled kids,' Hotez said during an interview with The Washington Post.

Hotez took his concerns about the report to Twitter. And then he received an unexpected, seething personal attack from the Republican state legislator, Rep. Jonathan Stickland.

New school #vaccine exemption numbers reported yesterday by @TexasDSHS. Now >64,000 kids not vaccinated, with #Austin schools, which can no longer be considered safe for kids. All to benefit outside #antivax groups from CA NY DC monetizing the internet. Where is our leadership? pic.twitter.com/x92gIZT3m9 — Prof Peter Hotez MD PhD (@PeterHotez) May 7, 2019

'You are bought and paid for by the biggest special interest in politics,' Stickland wrote. 'Do our state a favor and mind your own business. Parental rights mean more to us than your self enriching ‘science.’'

In a tweeted response, Hotez, a pediatrician and vaccine scientist, noted to Stickland that he does not receive money from the vaccine industry; instead, his work focuses on 'neglected disease vaccines for the world’s poorest people.'

Stickland, who told The Post he is 'not anti-vaccination,' tweeted his response to Hotez.

'Make the case for your sorcery to consumers on your own dime,' the Republican, who represents an area of suburban Fort Worth, snapped back Tuesday. 'Quit using the heavy hand of government to make your business profitable through mandates and immunity.'

(Hotez is not part of a for-profit business, either as a dean at the Baylor College of Medicine or as an endowed chair at the nonprofit Texas Children’s Hospital.)

What was the rationale for Strickland's position?

'It comes down to whether the government should be mandating what’s right for us,' Strickland said. 'I side with the individual.'

So note that Rep Strickland not only apparently falsely accused Dr Hotez, a recognized public health expert, of a conflict of interest, but of "sorcery," that is, witchcraft  The latter was apparently not clearly satirical, or metaphoric.  This suggests that underlying the ideology may be some very extreme religious sectarianism.  It looks like the idea of a witch hunt is not dead.




Discussion

As we noted above, here are three more cases in which politicians in three states, all Republican, none of whom had any obvious background or expertise, in medicine, health care, or public health, pushed public health policies that were unsupported by evidence and poentially harmful.

Their rationale seemed at best ideological, based on "individual rights."  Yet while focusing on the rights of parents to not vaccinate the children, they ignored how these rights could adversely affect the children, and anyone who might be exposed to disease the children might acquire.  In the case of Arizona, they also simultaneously ignored rights of free expression while they denounced pornography.

Since all the polticial leaders involved were Republicans, and in some cases their advocacy was in the context of deriding their Democratic political opposition, it seemed that their public policy stances were also partisan.  Such ideologically based and partisan arguments should alarm health care professionals who are sworn to put the patients' and the public's health ahead of other concerns, including political ideology.

Finally, the last case, which included a state legislator accusing a physician and public health expert not only of having a conflict of interest (which he apparently did not have), but of "sorcery," their public health stances also seemed to come from religious sectarianism, at its most extreme. Such  arguments are also concerning because they seem to be an attempt to use the govenrment to promote a particular set of religious beliefs ahead of patients' and the public's health, and to impose these beliefs on people of other faiths.  This apparently contradicts the US constitutional prohibition against governmental establishment of religion.

True health care reform would require government officials to use evidence, rather than personal ideology and particularly rather than their own religious beliefs when making health care and public health policy. 

    



Monday, May 06, 2019

The New (Ab)normal in Health Care Dysfunction

Introduction: The Issues Ignored by Discusisons of Health Care Reform

After the failed attempt to "repeal and replace" the Affordable Care Act (ACA, Obamacare) in 2017, we summarized what we thought were the main issues that traditional discussions of health care reform in the US (and sometimes in other countries) did not address.Despite some protestations to the contrary (e.g., here), the US health care system has been plagued by dysfunction.  According to a recent Commonwealth Fund study, the US was ranked 11 out of 11 in health care quality, but 1 out of 11 in costs.  Traditionally, health care reform has targeted ongoing problems in the cost, accessibility and quality of health care.  The ACA notably seems to have improved access, but hardly addressed cost or quality.

Now, in 2019, these issues also seem to only be getting more so.  So a little more than two years into the Trump regime, I thought we should assess the new (ab)normal in health care dysfunction, trying as best as possible to use the framework from our 2017 summary, with examples from our blog posts.


Distortion of Health Care Regulation and Policy Making: the Rise of the Incoming Revolving Door

We had previously noted that companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement.  Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.  Up to the Trump era, nearly all those cases involved people who left government who were offered corporate positions in firms that might have been affected by regulations or policies influenced by the government agencies for which they formally worked, the outgoing revolving door.




However, in the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers.


- We noted a stealth marketer for health care corporations becoming a key Trump economic adviser (look here)

- We found numerous more examples in October, 2017, including two people from the same lobbying firm, Greenberg Traurig Alston & Bird, which that year had  "earned more than $4.4 million lobbying so far this year for health care companies and trade groups including Novartis AG, Verax Biomedical, the American Hospital Association, St. Jude Children’s Research Hospital, and Aetna....," given top Department of Health and Human Services (DHHS) positions.

- A little later that month, we noted that one of those two former lobbyists, Mr Eric D Hargan, had become acting Secretary of DHHS (look here).

- Slightly later that month, there was an even more striking example, the new (permanent) Secretary of DHHS, Mr Alex Azar, who replaced Mr Hargan, was a former top executive of pharmaceutical company Eli Lilly.

- In November, 2017, an advocate for the discredited former CEO of UnitedHealth become an Assistant Secretary of DHHS. 

-  Later in November, we found two more examples of the incoming revolving door, including a lobbyist for pharma/ biotech company Gilear becoming director of health programs for the Office of Management and the Budget (OMB) here.

- In March, 2018, we posted a long list of industry figures, including a slew of lobbyists appointed to DHHS leadership positions.

- in April, 2018, we posted the next list, of top industry executives going to major executive branch positions.  The most striking example was a vice president at CVS, formerly at Pfizer, becoming a senior advisor to the Secretary of DHHS (who is a former Eli Lilly executive) for drug price reform. Pfizer and Eli Lilly alumni in charge of drug price reform, what could possibly go wrong?

- In July, 2018, the next list included a senior advisor at again Eli Lilly appointed to head an FDA division.

- In February, 2019, the list included a person with multiple leadership positions in for-profit health insurance companies, including WellPoint, and most recently a Medicaid managed care insurance provider, appointed to lead "health care reform" for DHHS.  Again, from the insurance industry to lead health care reform, what could possibly go wrong.

- In March, 2019, we noted that the newly appointed acting director of the FDA had founded and/ or was on boards of directors of multiple biotech companies.

This was a staggering record of managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting - wait for it - big health care corporations, a staggering intensification of the problem of the revolving door, which some have already asserted should be regarded as not merely severe conflicts of interest, but of corruption.  

Distortion of Health Care Regulation and Policy Making: Stealth Policy and Advocacy Morphing into Propaganda and Disinformation, Now may be Orchestrated by a Hostile Foreign Power

We had previously noted that promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  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 to the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.  Now this information may be connected to, or even organized by a hostile foreign power  

In March, 2018, based on revelations of what appeared to be an organized disinformation effort engineered by Cambridge Analytica and associates, using large amounts of personal data liberated from Facebook, to promote the Trump campaign, we started to ask how we could address deceptive public relations, propaganda, and disinformation in health care under a regime that had so benefited from foreign based disinformation efforts?




In April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak, and possibly for some of the unsupported assertions made about measles and measles vaccinationa by government leaders (see below).  The Soviet Union, which of course then included Russia, had orchestrated a disinformation campaign about HIV in the 1980s.  Erroneous beliefs generated by this campaign persist to this day.  The USSR had a principle role in the development of disinformation and other active measures meant to destablize western democracies.

 As recently documented in the redacted version of the Mueller report, Russia launched a disinformation campaign to swing the election to its preferred candidate, Donald Trump.  The role of a hostile foreign power which had used active measures during the election also using active measures to spread disinformation about medicine and public health should not be dismissed. 


Bad Leadership and Governance: Ill-Informed Leadership Now Approaching Flagrant Ignorance While Eschewing Expertise

We have long decried leaders of big health care organizations who seemed to have little background in or knowledge of biology, medicine, health care, or public health.  Typically, these were leaders of big health care corporations, such as pharma/device/ biotech companies, health insurance companies, hospitals and hospital systems, etc who were trained in management, and thus could be called managerialists.  

However, during the Trump regime we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics.  We had not previously expected leaders of government to be personally knoweldgeable about health related topics, but traditionally they consulted with experts before making pronouncements.




Since the Trump regime began, perhaps inspired by examples from Trump himself, various political/ government leaders began to publicly say ignorant or downright stupid things about such topics.

-  For example, in September, 2017, we noted a series of examples showing some basic ignorance of health policy, including fundamental confusion about the nature of health insurance.

- In August, 2018, we noted that Trump had long been an apologist for asbestos, which is known to cause asbestosis, lung cancer, and mesothelioma, claiming that those opposing use of asbestos were associated with organized crime, while more recently Trump's EPA seemed willing to relax regulation of asbestos, at a time when Russia seemed ready to become the major US supplier of it.

Bad Leadership and Governance: From Incompetence (in the Colloquial Sense) to Cognitively Impaired or Demented Leadership

Again, previously we had discussed  ill-informed and incompetent leadership in terms of leaders who had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.

However, we began to note concerning examples suggesting that the top leader of the US executive branch, President Trump himself, could be cognitively impaired perhaps from a dementing, neurological or psychiatric disorder.


- In October, 2017, we first started cataloging pronouncements by President Trump on health care and related topics that started with a grossly cavlier attitude toward health policy (e.g., it is only about fixing somebody's back or their knee or something," and ended with word salad:

Well, I’ve — I have looked at it very, very strongly. And pretty much, we can do almost what they’re getting. I — I think he is a tremendous person. I don’t know Sen. Murray. I hear very, very good things.

I know that Lamar Alexander’s a fine man, and he is really in there to do good for the people. We can do pretty much what we have to do without, you know, the secretary has tremendous leeway in the — under the Obama plans. One of the things that they did, because they were so messed up, they had no choice but to give the secretary leeway because they knew he’d have to be — he or she would have to be changing all the time.

And we can pretty much do whatever we have to do just the way it is. So this was going to be temporary, prior to repeal and replace. We’re going to repeal and replace Obamacare.

As we were taught in medical school, word salads may be produced by patients with severe neurological or psychiatric disorders.


- In January, 2018, we discussed more examples of Trump's confused, incoherent comments on health care.

- In May, 2018, we noted attempts by Trump Organization functionaries to intimidate Trump's former personal physician, presumably to prevent him from revealing details of the president's medical history.

- In December, 2018, we cataloged Trump's counter-factual, and often severely incoherent pronouncements - basically more examples of word salad - about public health, health care and other topics, at times interspersed with claims of his high intelligence.

Health care led by people with business or legal training who are willing to get advice from health care, public health and medical specialists may be as good as it gets.  Health care led by such people who do not consult experts if worrying.  Health care led by people who report to a cognitively impaired, demented or psychotic leader is extremely worrying (as is government with such leadership.)



Bad Leadership and Governance: Mission-Hostile Management Now Driven Less by Pecuniary Considerations, More by Ideology, Partisanship, and Religious Sectarianism

We had previously noted that health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values.  The example we cited then was a hospital CEO who allegedly over-ruled medical leadership to hire a surgeon despite reports that his patients died more frequently than expected, gamed reports of clinic utilization, and associated with organized crime (look here).  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.

We also began seeing examples of how politically appointed officials of health related government agencies who had no experience or expertise in health care or related fields began to assert control over health care professionals in the agencies to facilitate the Trump regime's political agenda apparently regardless of the effects on health. Sometimes the problem seemed to carry over from the leaders' previous management, rather than medical, health care or public health experience.  For example, in February, 2018, we noted that the physician who was Secretary of the Veterans Administration was challenged by a political a political appointee who used to run a brewery.

However, we then began noting leaders who also lacked medical, health care or public health background or expertise whose agenda seemed to be overtly religious or ideological, without even a nod to patients' or the public' health.


- In April, 2018, we noted a host of appointments of people who flagrantly lacked any health care or public health related experience or expertise to leadership positions in government agencies whose agenda seemed to be overtly religious or ideological, without even a nod to patients' or the public' health. For example, a 23-year old whose only experience after college was in Trump's campaign was given a significant position in the Office of National Drug Control.

- In April, 2018, we posted another such list, including a blogger who promoted racism and conspiracy theories given the Deputy Directorship of Communications for DHHS.

- In July, 2018, we noted the appointment of a physician to a leadership position in family planning within the DHHS who cited "facts" completely unsupported by evidence to justify religiously based health care policies, e.g., using her argument that adopting a child is like a "second death" to argue that mothers should not give their children up for adoption.

- In August, 2018, we discussed  three political appointees to DHHS, none of whom had any health care or public health related experience or expertise, all of whom made pointedly political public comments after their appointments, from deriding their political opponents as "clueless" and "crazy"to alleging Hillary Clinton arranged a murder.

 - In November, 2018, we noted pronouncements about health care or public health by federal agencies under the Trump regime, right-wing politicias who back Trump, and propagandists who back Trump which were unsupported by evidence, but seemed designed to support right-wing ideology or sectarian religious belief.  These included assertions that immigrants and asylums seekers carried infectious disease, that intersex patients do not exist, that contraception causes cancer and violent death, that pornography is a major public health hazard, etc.

- In March, 2019, our list included examples of multiple leaders at the state level, all Republicans, including the Kentucky Governor asserting that zombie television shows cause mass shootings, but exposure to extreme cold does not harm schoolchildren; and numerous unsupported pronouncements by state legislators about measles, including the Texas state representative who stated antibiotics can treat measles.

- In April, 2019, we discussed another batch of bizarre statements about the measles and vaccination policy made by President Trump, again the Republican Governor of Kentucky, and various Republican state legislators.  

Again, basing health care and public health decisions primarily on money seems likely to be bad for patients' and the public's health, but basing them purely on political ideology or religious belief seems worse. In some cases, the resulting mission-hostility seems to translate into violations of the US constitution.  For example, making health care decisions based on a particular religion's beliefs could be harmful for patients or citizens who do not share these beliefs, plus violate the Constitution's guarantee of freedom of a government establishment of religion.




Bad Leadership and Governance: Mission-Hostile Management by Now Partisan Corporate Leadership  

Again, previously the mission-hostile management we noted at the corporate level seemed mainly driven by pecuniary concerns, putting corporate revenues and resulting management compensation ahead of patients' and the public's health.  However,we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients' and the public's health, and even  corporate revenues.

- In June, 2018, we first noted how a large health care corporation, the huge pharmacy chain CVS, had been secretly making contributions to an ostensibly non-profit organization which actually served solely to promote Trump regime policies, including some that seemed to subvert claims the corporation had made about social responsibilty.  The contributions themselves seemed to conflict with the corporation's charitable giving policies.

- In September, 2018, we noted that big health care corporations often make high-minded public pledges about supporting patients' and the public's health, and sometimes social responsibility, but have been found to be covertly supporting policy initiatives that seemed to subvert these goals, using "dark money."  The dark money groups they used to channel this money often had explicitly partisan leadership and direction, usually right-wing and Republican.




 - In October, 2018, we discussed important but incomplete revelations about corporate contributions to such dark money groups that mainly favored again right-wing ideology, the Republican party, and Trump and associates.

- In November, 2018, we noted that health care corporations funneled funds through dark money organizations to specifically attack designated left-wing, Democratic politicians.

- In March, 2019, we noted a Transparency International study of policies on political engagement of multinational pharmaceutical companies, all of which operate in the US.  Only one disavowed the revolving door, and only two eschewed direct corporate political contributions.

- Also, in March, 2019, we discussed a study of the personal political contributions of CEOs of large corporations.  In the 21st century, the CEOs' contributions were increasingly partisan, that is individual CEOs gave predominantly or exclusively to one party, and for the vast majority, to the Republican party.

This suggests yet another route towards government putting ideology and partisanship ahead of patients' and the public's health.


Bad Leadership and Governance: Conflicted, Corrupt Corporate Leaders Now in the Context of Flagrant Conflicts of Interest and Corruption at the Highest Levels of the US Government

We had previously discussed numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.  One would hardly expect corrupt leadership to put patients' and the public's health ahead of the leaders' ongoing enrichment.

Prior to July, 2017, we had discussed some particular cases in which Donald Trump and his family had been involved in ethically questionable activities prior to his becoming president.  However, by  August, 2017, we started to discuss the corruption at the top of the regime. 


- In January, 2018, we first discussed the accumulating evidence of pervasive corruption at the top of the US executive branch, based on articles in the media, and the launch of a website devoted to tracking such corruption.

- In July, 2018, we summarized new sources of evidence about top level government corruption.

- In October, 2018, we posted yet another update, including summarizing a new and very lengthy report about the scope of Trump and associates' conflicts of interest and corruption, which at the time required 26 pages to print. It documented multiple ongoing instances of the Trump Organization, whose biggest owner is Trump, receiving large ongoing payments from foreign governments, the US government, and state governments.  The former payments seemed to explicitly violate the "foreign emoluments clause" of the US  Constitution, which bans presidential conflicts of interst involving foreign governments, and the "domestic emoluments clause," which bans those involving the federal and state governments.

- In October, 2018, we discussed the latest advances in understanding of global corruption, via Tranparency International's global meeting, which included description of trans-national kleptocratic networks, which now seems to describe Trump and the Trump Organization.

- In April, 2019, we posted our latest discussion of pervasive high-level corruption, which referenced updates from sources mentioned earlier, plus three new sources.

Prior to the Trump regime we had criticized law enforcement for a lack of interest in vigorously prosecuting health care corruption.  We documented numerous examples of the impunity of top health care corporate executives who almost always escaped any negative personal consequences even when their organizations paid large fines for bribery, kickbacks, fraud and the like.  We often attributed this laxity to excessive sensitivity respect of the value of these corporations and their products.  However, the potential for encouraging health care (and other kinds of) corruption under a regime that is itself frankly corrupt is mind boggling.


[picture of Trump International Hotel in Washington, which is frequently patronized by foreign government officials, whose payments to Trump via the Trump Organization appear to amount to the "foreign emoluments" prohibited by the US Constitution.]

Overarching Issue: Taboos Previously Enabled by Private Organizational Behavior, Now by Government Agencies and Officials, Despite the First Amendment

When we started Health Care Renewal, such issues as suppression and manipulation of research, and health care professionals' conflicts of interests rarely appeared in the media or in medical and health care scholarly literature.  While these issues are now more often publicly discussed, most of the other topics listed above still rarely appear in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant.  For example, a survey by Transparency International showed that 43% of US resondents thought that American health care is corrupt.  It was covered by this blog, but not by any major US media outlet or medical or health care journal.  We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  As we noted above, the people who profit the most, those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.  But, if we cannot even discuss what is really wrong with health care, how are we going to fix it?

Since the beginning of the Trump administration,  we began to note more examples of government officials under Trump attempting to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control.

- In September, 2017, we noted an attempt for Trump political appointees to blockade information released from the Department of Health and Human Services (DHHS) that the regime found offensive.

- In February, 2018, we noted attempts by a consultant for the Center for Medicare and Medicaid Services (CMS), a major component of DHHS, to intimidate a health care journalist.

- In April, 2018, it became apparent that the head of CMS has directed millions in contracts to a Republican public relations firm, partly to burnish her image, and that firm had hired the consultant noted above.

- We also found attempts to squelch attempts by current or former government workers to criticize Trump and his policies.  In August, 2018, we noted Trump had White House staffers sign non-disclosure agreements, which seems to expressly violate first amendment protections of free speech and federal law.




Given how hard it was to reverse the anechoic effect in the past, how much harder will it be to open discussion of what is really wrong with health care when the power of the US government is used to censor ideas which the regime dislikes?


Discussion

For years, I thought that health care dysfunction was primarily about individuals and private organizations, including but not limited to pharmaceutical, biotechnology and device companies; hospitals and hospital systems; insurance companies, academic medical institutions; physicians and their practices; etc, etc, etc.  Consequently, I thought these individuals and organizations needed better awareness of health care dysfunction to provoke them to improve matters.  I thought of the government as being involved, but mainly because of well-intentioned, sometimes bumbling government actions and policies that often had unintended effects, and sometimes excess coziness with the health care industry.  While I knew that the government was subject to regulatory capture and various leadership problems, its role, at least in the US, seemed almost secondary.

But in the Trump era, there is a new (ab)normal.  All the trends we have seen since our last discussion of health care reform are towards tremendous government dysfunction, some of it overtly malignant, especially in terms of corruption of government leadership of unprecedented scope and at the highest levels, and overt influence of government-favored political ideology and religious beliefs on health care policy and other policies and actions.

I hope that the above attempt to summarize these new trends will urgently point health care and public health professionals, patients, and all citizens towards a much more vigorous response.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways.  We do not have much time to act.

If not now, when?

If not us, who? 



        

Wednesday, May 01, 2019

Why Are We Complicit? A Narrative for Our Era

Why are seemingly good people complicit with bad things?  In health care, we have seen seemingly good health care professionals and academics silent in the face of manipulation and suppression of clinical research; deception, attacks on free speech and the press, silencing of whistleblowersconflicts of interest; ill-informed, incompetent, self-interested leadership; and outright corruption and crime, including fraud, bribery, and extortion.

We have seen the anechoic effect, that cases of such behavior are not the subject of polite discussion.  When I saw a whistleblower being threatened (he ultimately lost his job), one colleague said I should ignore it, and keep my nose "to the grindstone."

Why?  One explanation is that ordinary people are afraid to challenge behaviors that help the rich and powerful, fear losing their jobs, fear angering others.  It seems hard to comprehend the mindset of those who are complict.

Niemoller wrote

First they came for the socialists, and I did not speak out—because I was not a socialist.




The poem ended

Then they came for me—and there was no one left to speak for me.

Today we have a new narrative about how people are sucked into complicity, in an op-ed in the New York Times by James Comey,

Amoral leaders have a way of revealing the character of those around them. Sometimes what they reveal is inspiring.

Then again,

But more often, proximity to an amoral leader reveals something depressing. I think that’s at least part of what we’ve seen with Bill Barr and Rod Rosenstein. Accomplished people lacking inner strength can’t resist the compromises necessary to survive Mr. Trump and that adds up to something they will never recover from.

It starts with your sitting silent while he lies, both in public and private, making you complicit by your silence. In meetings with him, his assertions about what 'everyone thinks' and what is 'obviously true' wash over you, unchallenged, as they did at our private dinner on Jan. 27, 2017, because he’s the president and he rarely stops talking. As a result, Mr. Trump pulls all of those present into a silent circle of assent.

Speaking rapid-fire with no spot for others to jump into the conversation, Mr. Trump makes everyone a co-conspirator to his preferred set of facts, or delusions. I have felt it — this president building with his words a web of alternative reality and busily wrapping it around all of us in the room.

I must have agreed that he had the largest inauguration crowd in history because I didn’t challenge that. Everyone must agree that he has been treated very unfairly. The web building never stops.

From the private circle of assent, it moves to public displays of personal fealty at places like cabinet meetings. While the entire world is watching, you do what everyone else around the table does — you talk about how amazing the leader is and what an honor it is to be associated with him

Next comes Mr. Trump attacking institutions and values you hold dear — things you have always said must be protected and which you criticized past leaders for not supporting strongly enough. Yet you are silent. Because, after all, what are you supposed to say? He’s the president of the United States.

You feel this happening. It bothers you, at least to some extent. But his outrageous conduct convinces you that you simply must stay, to preserve and protect the people and institutions and values you hold dear. Along with Republican members of Congress, you tell yourself you are too important for this nation to lose, especially now.

You can’t say this out loud — maybe not even to your family — but in a time of emergency, with the nation led by a deeply unethical person, this will be your contribution, your personal sacrifice for America. You are smarter than Donald Trump, and you are playing a long game for your country, so you can pull it off where lesser leaders have failed and gotten fired by tweet.

Of course, to stay, you must be seen as on his team, so you make further compromises. You use his language, praise his leadership, tout his commitment to values.

And then you are lost. He has eaten your soul. 

 Preserve your souls before it is too late.

[photo of Nuremberg trial]

Sunday, April 28, 2019

April, 2019, Update: How to Challenge Health Care Corruption Under a Corrupt Regime?

In these last few weeks, the US news has been dominated by the release of a redacted verion of the Mueller report which included extensive evidence of questionable behavior by President Trump, his campaign, and various Trump associates.  This week, an editorial in Mother Jones suggested:

The Russia scandal was never, in the main, about whether the president would be prosecuted for a crime. It was, and is, about a bigger issue: A wealthy politician who hoped to profit from pandering to a foreign autocrat put his own financial interests above those of his country, who abetted a foreign attack, and who lied about it to those he swore to serve.

There is a word for this, but it’s not collusion. It’s corruption.

The editorial suggested that journalists have not done an adequate job pursuing the underlying "rot" in the US government and the Trump administration:

And rather than laying off investigating it, as too many are suggesting now, journalism needs to back up and look at the whole thing.

It seems to be a great idea, but in fact, some journalists, scholars, bloggers, etc have been looking at corruption for a long time, including health care corruption, and corruption in the US government.  The problem, however, is that much of the discussion of corruption has been anechoic.

Background: Health Care Corruption

As we wrote in August, 2017, Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.

Also,
Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.

The report got little attention.  Health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,
However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects some other places, mainly  presumably benighted less developed countries.  At best, the corruption in developed countries that gets discussed is at low levels.  In the US, frequent examples are the "pill mills"  and various cheating of government and private insurance programs by practitioners and patients.  Lately these have gotten even more attention as they are decried as a cause of the narcotics (opioids) crisis (e.g., look here).  In contrast, the US government has been less inclined to address the activities of the leaders of the pharmaceutical companies who have pushed legal narcotics (e.g., see this post). 

However, Health Care Renewal has stressed "grand corruption," or the corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements that result in fines that small relative to their  multi-billion revenues without admitting guilt.  Almost never are top corporate managers subject to any negative consequences.

We have been posting about this for years at Health Care Renewal, while seeing little progress on this issue.

Health Care Corruption in the Context of a Corrupt Government



Instead, things now only seem to be getting worse, given the increasing evidence that the Trump administration is corrupt at the highest levels.   In January, 2018, we first raised the question about how health care corruption could be pursued under a corrupt regime.  We noted sources that summarized Trump's. the Trump family's, and the Trump administration's corruption..  These included a website, entitled "Tracking Trump's Conflicts of Interest" published by the Sunlight Foundation, and two articles published in the Washington Monthly in January, 2018. "Commander-in-Thief," categorized Mr Trump's conflicted and corrupt behavior.  A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

In July, 2018, we addressed the Trump regime's corruption again  By then, more summaries of Trump et al corruption had appeared.   In April, 2018, New York Magazine published "501 Days in Swampland," a time-line of  starting just after the 2016 presidential election. In June, 2018, ProPublica reviewed questionable spending amounting to $16.1 million since the beginning of Trump's candidacy for president at Trump properties by the US government, and by Trump's campaign, and by state and local governments. Meanwhile, Public Citizen released a report on money spent at Trump's hospitality properties.


In October, 2018, we summarized the content of the voluminous Tracking Corruption and Conflicts of Interest in the Trump Administration summary appearing in the Global Anti-Corruption Blog. The blog organized corrupt activities within the Trump administration into the following categories:

1. U.S. Government Payments to the Trump Organization

2. Use of the Power of the Presidency to Promote Trump Brands

3. U.S. Government Regulatory and Policy Decisions that Benefit Business Interests of the Trump Family and Senior Advisors

4. Private and Foreign Interests Seeking to Influence the Trump Administration Through Dealings with Trump Businesses

Not only was the report voluminous, the October version of the report requiring 26 pages to print, it suggested that many examples of corruption by Trump et al were not one-offs, but were long-term activities.  For example, every time President Trump travels to on of the properties he owns through the Trump Organization, for example, has Mar-a-Lago resort in Florida, the US government is obligated to pay Trump himself through that organization for various expenses, e.g., the Secret Service renting golf carts at Mar-a-Lago.  Each time that happens it seems to violate the "domestic emolument clause" of the US Constitution, which prohibits state or US government payments to a President for anything other than his salary.  Also, foreign governments and corporations seeking to promote specific government policies in their self-interest, similarly seeking favorable regulations, or other seeking to influence government actions in their favor are making periodic payments to the Trump Organization, such as buying accomodations or paying for events at Trump properties.  When foreign governments do so, that appears to violate the "foreign emoluments clause" of  the US Constitution, which prohibits payments by a foreign government to the US President.

Updates on the Corruption of the US Government


New Source: Bloomberg's "Tracking the Trump Team's Conflicts and Scandals"

Bloomberg produced an interactive guide, most recently updated in March, 2019, and divided into sections on individual members of the team, including Trump and his family, Trump appointees, and associates and outside advisers.

New Source: the Citizens for Responsible Ethics in Washington's Blog

CREW is a non-profit organization whose goal is "to reduce the influence of money in politics and help foster a government that is ethical and accountable."It produces a blog with very frequent posts that center on conflicts of interest and corruption affecting Trump and associates.  For example, recent posts included: "IRS Commissioner Charged with Releasing Trump Tax Returns Profits from Trump-Branded Property" and "Turkish Interest Group Event Kicks Off at Trump Hotel, with Government Sponsors."

New Source: Zach Everson's 1100 Pennsylvania Avenue

Threre are so many instances of violations of the foreign and domestic emoluments clause occurring just at the Trump Organization hotel in Washington, DC that there is now a blog and newsletter dedicated to essentially daily reporting about them.



Updates of the Global AntiCorruption Blog's "Tracking Corruption and Conflicts of Interest in the Trump Administration"

Since October, the report has been updated nearly monthly .  These updates suggest new variations on these corrupt themes, for example: November, 2018, Interior Secretary Ryan Zinke's "shady property development deal;"January, 2019, questions of illegal actions by Trump's inaugural committee;
March, 2019, possible special treatment by the Government Services Administration of the Trump Organization's flagship Trump International Hotel in Washington, DC; and April, 2019, how Trump-connected lobbyists are directing clients to book rooms at that hotel.


Updates of the Sunlight Foundation's "Tracking Trump's Conflicts of Interest"

At the same time, the Sunlight Foundation's "Tracking Trump's Conflicts of Interest" project is also frequently updated.  Note that its main webpage includes links to weekly reports about relevant issues.  For example, the most recent is " This Week in Conflicts: Redacted Mueller Report Released, Undisclosed Cash Flow from Inaugural Ball and Mueller Explains Why His Family Left Trump’s Golf Club"


Discussion

Since October, the evidence of pervasive conflicts of interest and outright corruption affecting President Trump, his family, the Trump Organization, and his administration continues to mount.  The totality of the array of unethical and probably illegal activities has become mind numbing.  To underscore what we wrote in October

So the driver of US health care corruption may now be the executive branch of government and its relationship with the Trump family and cronies, trumping even the influence of health care corporate corruption.

That corruption appears to be ongoing, getting worse not better, and is not receiving adequate notice.

In November, 2017, we noted that another report by Transparency International that showed that in an international survey of corruption perceptions, substantial minorities of US respondents thought that US corruption was increasing, and was a particular affliction of the executive and legislative branches of the national government, other government officials, and top business executives.  There was virtually no coverage of these results in the US media, just as there was virtually no coverage of a 2013 survey that showed 43% of US respondents believed that US health care was corrupt.

Similarly, despite, or perhaps because of their tremendous scale, the reports about Trump related corruption listed above have generated little discussion.  Despite the extensive and ever-increasing list of apparently corrupt acts by the Trump and cronies, grand corruption at the top of US government, with its potential to corrupt not just health care, but the entire country and society, still seems like a taboo topic.  The US news media continues to tip-toe around the topic of corruption, in health care, of top health care leaders, and in government, including the top of the US executive branch.  As long as such discussion seems taboo, how can we ever address, much less reduce the scourge of corruption?  The first step against health care corruption is to be able to say or write the words, health care corruption.

So we welcome any additional attention to health care corruption, or the larger corruption within the US government that is making health care corruption even harder to address. We thus specifically welcome Mother Jones' added emphasis on this topic.


But even if we can take that step, when the fish is rotting from the head, it makes little sense to try to clean up minor problems halfway towards the tail. Why would a corrupt regime led by a president who is actively benefiting from corruption act to reduce corruption? The only way we can now address health care corruption is to excise the corruption at the heart of our government.


Sunday, April 21, 2019

The Rise of Ideologically or Theologically Based Medicine, Public Health, and Health Policy - Recent Examples


I have long been a proponent of evidence-based medicine (EBM), and evidence-based health care, public health, and health policy.  EBM, for example, is about medical-decision making based on critical review of the best applicable evidence from clinical research informed by knowledge og biology and medicine, of the patient's biopsychosocial circumstances, the patient's values, and of ethics and morality.  We have discussed challenges to EBM based on manipulation and suppression of clinical research, often in the financial interests of those hawking particular medical products of services.

A newer challenge to evidence-based medicine, health care, public health and health policy seems not to be commercial, but ideologically or theologically based.  I noticed the following recent cases that illustrate this concern. 


Theologically Based Medicine and Public Health Promoted at the DHHS

In July, 2018, we discussed the case of Dr Diane Foley, who was appointed Deputy Assistant Secretary for Population Affairs in the US Department of Health and Humas Services (DHHS).  At the time we noted that Dr Foley publicly proclaimed that adoption of children is harmful because it is a "double death;" and teaching children about barrier contraception is harmful because it is "sexually harassing."  Dr Foley also ran an organization called Life Network, which ran so-called "crisis pregnancy centers," which ran abstinence-only sexual education programs in part based on Dr Foley's beliefs about the harms of teaching about barrier contraception.  There seems to be no good evidence about the sort of harms Dr Foley attributed to adoption or barrier contraception.


Nonetheless, on April 4, 2019, ReWire reported that the DHHS would give control of  Title X federal family planning and teen pregnancy prevention and the Office for Adolescent Health (OAH), which administers the Teen Pregnancy Prevention Program to the Office of Population Affairs, which is run by Dr Foley.  In response, Senator Patty Murray (D-WA),

the ranking Democrat on the Senate appropriations subcommittee with oversight over HHS, questioned the Trump administration’s motivations behind the plan. 'It is unclear how the reorganization will result in better policies and services for those served by these offices, including adolescents, women, low-income communities, and individuals with infectious diseases, including HIV/AIDS,' she wrote. 'In fact, it is difficult to understand how this reorganization does anything other than consolidate control at HHS headquarters and prioritize ideology over the needs of the women, teenagers, and children the affected programs serve.'

In fact, there is reason to believe that Dr Foley based her beliefs more on her ideas about theology than on a political ideology.  Life Network's website has stated (see our post linked above) 

'Through our pregnancy centers we have the opportunity to see God use the miracle of ultrasound to change and save lives,' Life Network’s website says. The first element of its mission is 'presenting the gospel of Jesus Christ.'

Thus the Trump administration seems to be consolidating power over US government family planning programs in the hands of an individual who is basing her decision making not on medical or public health evidence, but on her version of a particular type of Christian theology.

Ideologically or Theologically Based Public Health Policy about Pornography Promoted in Another State Legislature

NBC Montana reported on April 16 that Montana legislators are the latest to join the quest to label pornography a public health hazard.  

One resolution state house lawmakers are taking up in Helena would label pornography as a public health hazard in Montana.

If passed, Montana would have to address pornography through education, research and state policy.

The state would have to implement measures to prevent pornography exposure and addiction, offer recovery help, and create programs that hold broader influences accountable.

The proposed resolution included assertions that, for example, pornography causes

violence and abuse of women and children by presenting rape and abuse of women and children as harmless

and

psychological and physical distress, deviant sexual arousal, difficulty in forming or maintaining intimate relationships, and problematic or harmful sexual behaviors and addiction

and

increases sex trafficking of women, sex trafficking of children, child sexual abuse, and child pornography;

Yet as we noted in March, 2019, there is no clear evidence supporting any of these assertions.  So Montana Republican legislators join those in Arizona, and also those in Kansas, Utah, and Idaho (look here)  in pushing legislation that attacks the "public health" hazards of pornography based on no clear evidence.

The genesis of the notion that pornography is a dire public health hazard is not clear.  As we noted here, though, in Utah, at least, beliefs about pornography could come from the doctrine of the Church of Latter Day Saints, which includes:

'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.

At any rate, since the proponents of these measures all seem to be Republicans, there also is suspicion that their beliefs about pornography are ideologically-based.

Ideologically Based Beliefs About Vaccination Policy Espoused by President Trump, the Governor of Kentucky, and in Multiple State Legislatures

We recently discussed how a Russian disinformation campaign has led parents in the US and elsewhere to avoid vaccinating their children for various diseases, in turn leading to outbreaks of measles in the US and other countries. Along with this disinformation campaign, various government leaders have also espoused views about the benefits and harms of vaccination, and vaccination policy that are virtually free of evidenciary support.

In March, 2019, the Louisville Courier Journal reported on the example set by the Republican Governor of Kentucky. 

Gov. Matt Bevin said in a radio interview Tuesday that he deliberately exposed all nine of his children to chickenpox so they would catch the disease and become immune.

'Every single one of my kids had the chickenpox,' Bevin said in an interview with WKCT, a Bowling Green talk radio station. 'They got the chickenpox on purpose because we found a neighbor that had it and I went and made sure every one of my kids was exposed to it, and they got it. They had it as children. They were miserable for a few days, and they all turned out fine.'

Governor Bevin seemed to imply that chickenpox is an annoying disease, but one that does not cause severe adverse effects.  However, varicella is not innocous.  According to the CDC clinical summary, it can cause secondary bacterial skin infections in children.  Rarely in children, but more commonly in adolescents, adults, pregnant women, and people with immunocompromise, it can cause severe complications including pneumonia, sepsis, and various other secondary bacterial infections.  Varicella is highly contagious, so unvaccinated children can infect other unvaccinated people who are more susceptible to complications.

Yet Governor Bevin ignored all that.  His rationale for not vaccinating his own children and not mandating varicella vaccine for other children was conveyed in his interview.


Bevin also suggested that the government stay out of mandating vaccines. In Kentucky, varicella (chickenpox) is among vaccines mandated for all children entering kindergarten, though parents may seek religious exemptions or provide medical proof that a child has already had the disease.

'And I think, why are we forcing kids to get it?' Bevin said in the radio interview, speaking about the chickenpox vaccine. 'If you are worried about your child getting chickenpox or whatever else, vaccinate your child. ... But for some people, and for some parents, for some reason they choose otherwise. This is America. The federal government should not be forcing this upon people. They just shouldn’t.'

So his ideology that "the federal government should not be forcing this upon people" seemed to trump any risks children run because their parents choose to not vaccinate them, even just "for some reason."

The Louisville Courier Journal also interviewed "Dr. Robert Jacobson, a pediatrician and expert in vaccines and childhood diseases at the Mayo Clinic in Rochester, Minnesota,


Before vaccination was available, chickenpox killed as many as 100 adults and children a year, he said.

'I think it is taking a big risk that you don’t need to take,' Jacobson said. 'It's not just a risk your children are going to have. You're putting other people in the community at risk because of your decision.'

 Note that this is not the first time that Governor Bevin expressed beliefs about public health that were not evidence-based.  In this post, we noted that in 2018 he suggested that mass school shootings are due to exposure to television shows about zombies, and in 2019 he suggested that exposing children to severely cold weather is risk free.  So he does seem consistent in the absurdity of his public health beliefs.  Unfortunately, he is in a position to endanger the public's health according to these beliefs. 

There are other US state level political leaders who seem to rely on idology rather than evidence in making decisions about health care and public health.  On April 16, 2019, Politico reported widespread attempts by Republican state legislators to free people from requirements that they vaccinate their children,

Democrats in six states — Colorado, Arizona, New Jersey, Washington, New York and Maine — have authored or co-sponsored bills to make it harder for parents to avoid vaccinating their school-age children, and mostly faced GOP opposition. Meanwhile in West Virginia and Mississippi, states with some of the nation’s strictest vaccination laws, Republican lawmakers have introduced measures to expand vaccine exemptions, although it’s not yet clear how much traction they have.

In Washington state, which has one of the biggest measles outbreaks, a bill in the state Senate to narrow vaccine exemptions passed through the health committee without the support of a single Republican. The same thing happened in legislative committees in Colorado and Maine over the past week.

Again, the Republicans seemed to base their attempts to decrease vaccination requirements on their ideology of expanding personal choice.

many are loath to diminish the right of parental control over their children’s bodies, and yield that power to the government.

Politico provided an example of a New York state legislative leader who opposed a bill that would limit religiosu exemptions to vaccination mandates.

Andrew Raia, ranking Republican on the New York Assembly’s health committee, said he wouldn't support the bill. While not totally convinced by constituents who link their children’s autism on vaccines, and unaware of any real religious injunction against vaccination, he said, 'I’m not a religious leader, and I’m not a scientist either, so it’s my job to weigh both sides.'

I suggest that his arguments are at best evidence free, but also could have been

complicated by the fact that President Donald Trump and two of his Republican primary foes, Sen. Rand Paul (R-KY) an ophthalmologist, and Ben Carson, a neurosurgeon who is now HUD secretary, both voiced support for disproven theories linking vaccine to autism during a 2016 debate.

In fact, as reported by the (UK) Independent in 2018,

On more than 20 occasions, Mr Trump has tweeted about there being a link between vaccines and autism, something experts at the government’s leading public health institute say is not true. He also repeated the claim during a Republican primary debate, a remark that was immediately dismissed as false by the Autistic Self Advocacy Network.


Summary

Outbreaks of infectious diseases previously considered controlled now bedevil the US and other developed countries.  They seem to be caused in part by parents' resistance to vaccinating their children, despite strong evidence that the vaccines are relatively effective and have harms that exceed their benefits, both for the children vaccinated and the public health.  In turn, the resistance to vaccination seems increasingly inspired by government leaders whose actions are based on ideology, or sometimes theology.

The ideologically based arguments seem to come from some sort of a crude libertarianism that holds that parents should be free to choose not to vaccinate, more or less regardless of the effects of their decision on their children, or other people.  Such arguments should alarm health care professionals who are sworn to put the patients' and the public's health ahead of other concerns, including political ideology.

The theologically based arguments are also concerning because they seem to be an attempt to use the govenrment to promote a particular set of religious beliefs ahead of patients' and the public's health, and to impose these beliefs on people of other faiths.  This apparently contradicts the US constitutional prohibition against governmental establishment of religion.

True health care reform would require government officials to use evidence, rather than personal ideology and particularly rather than their own religious beliefs when making health care and public health policy. 



Saturday, April 13, 2019

The HIV Epidemic, and Now the Measles Outbreak: The Russian Connection

I am old enough to remember having measles as a child, a thoroughly unpleasant experience.  Some children had much unhappier results of measles than I did.  So as a parent, I was happy to see that a reasonably effective measles vaccine had practically eliminated the disease from the US and most developed countries.

However, we currently are in the midst of a measles outbreak in the US.  The current number of reported cases for the first three months of 2019 is greater than all cases reported in 2018.  (See this CDC update.)  Other so-called developed countries are also seeing more cases of measles.  Why has measles returned?  A likely cause is the number of parents with negative opinions about the vaccine is rising, and their clamor to exempt their own children is getting louder (look here for just the latest example.)

The negative opinions seem not to come from reasoned arguments based on logic and facts, but from disinformation campaigns.


Prelude: the 1980s Soviet Disinformation Campaign About HIV

How disinformation can disrupt public health is a story which seemed to have been largely forgotten until 2016.  That year, how the campaign to control HIV in the 1980s was impeded by disinformation  was brought up again after so many years by the Washington Post.  The article opened

On July 17, 1983, a small pro-Soviet Indian newspaper called the Patriot published a front-page article titled 'AIDS may invade India: Mystery disease caused by US experiments.' The story cited a letter from an anonymous but 'well-known American scientist and anthropologist' that suggested AIDS, then still a mysterious and deadly new disease, had been created by the Pentagon in a bid to develop new biological weapons.

'Now that these menacing experiments seem to have gone out of control, plans are being hatched to hastily transfer them from the U.S. to other countries, primarily developing nations where governments are pliable to Washington's pressure and persuasion,' the article read.

The Patriot's article was subsequently used as a source for an October 1985 story in the Literaturnaya Gazeta, a Soviet weekly with considerable influence at the time. The next year, it ran on the front page of a British tabloid. After that, it was picked up by an international news wire. By April 1987, it was suggested that the story had appeared in the major newspapers of more than 50 countries.

The problem? The story was patently false. 

It was a product of a deliberate Soviet disinformation campaign.  A New York Times article from 2017 amplified the specifics:

Called Operation Infektion by the East German foreign intelligence service, the 1980s disinformation campaign seeded a conspiracy theory that the virus that causes AIDS was the product of biological weapons experiments conducted by the United States. The disease disproportionately impacts gay men, and the Reagan administration’s slow response had escalated into suspicions in the gay community that the United States government was responsible for its origins.

'The K.G.B. picked up on that, and added a new twist with a specific location: Fort Detrick, Md.,' where military scientists conducted biological weapons experiments in the 1950s and 1960s, said Douglas Selvage, the project director at the Office of the Federal Commissioner for Stasi Records in Berlin.

The K.G.B. campaign began with an anonymous letter in Patriot, a small newspaper published in New Delhi that was later revealed to have received Soviet funding. It ran in July 1983, under the headline 'AIDS May Invade India: Mystery Disease Caused by U.S. Experiments' and pinned the origin of the disease to Fort Detrick.

The choice of Patriot was deliberate, said Thomas Boghardt, a military and intelligence historian who traced how the campaign unfolded. 'It had no explicit links to the Soviets and was an English-language newspaper easily accessible to a global audience.'

'The Soviets intuitively understood how the human psyche works,' Dr. Boghardt said. He said the playbook was simple but effective: Identify internal strife, point to inconsistencies and ambiguities in the news, fill them with meaning and 'repeat, repeat, repeat.'

A September 1985 memo to Bulgarian intelligence from the East German secret police served as a conduit. The disinformation campaign aimed, according to the Stasi, 'to generate, for us, a beneficial view by other countries that this disease is the result of out-of-control secret experiments by U.S. intelligence agencies and the Pentagon involving new types of biological weapons.'

A month later, the Soviet journal Literaturnaya Gazeta published a paper titled 'Panic in the West or What Is Hiding Behind the Sensation Surrounding AIDS.' It included accurate information about the disease and Fort Detrick but cited the Patriot letter to connect the dots.

The paper received international attention and its allegations were repeated around the world including in Kuwait, Finland and Peru. CBS News, black newspapers, the gay press, niche publications critical of the C.I.A. and the right-wing presidential candidate Lyndon LaRouche all promoted the conspiracy theory. (Mr. LaRouche flipped the claim on its head, accusing the Soviets of using AIDS as a weapon.)

Background on Soviet Disinformation

An earlier 2017 article in the Guardian expanded the background about Soviet use of disinformation:

Unlike misinformation, disinformation is constructed to be deliberately false, with the intention of sowing discord in enemy ranks. While there are undoubtedly historical examples, the industrialisation of disinformation emerged with the modernisation of media and mass communication. This is reflected in the etymology of the word itself, which by the advent of second world war had arisen independently in both Russian and English to characterise the spread of propaganda across Europe. Russia quickly recognised its enormous potential, and as early as 1923 the GPU (forerunner to the KGB) had established an office dedicated to it.

Disinformation fast became an integral part of Soviet intelligence, and by the birth of the KGB in the 1950s, it had become an essential component in the doctrine of 'active measures', the art of political warfare. Active measures included media manipulation, the use of front groups, counterfeiting of documents, and even assassinations when required. It was the very heart of Soviet intelligence, described by KGB Major General Oleg Kalugin as:

'... not intelligence collection, but subversion: active measures to weaken the west, to drive wedges in the western community alliances of all sorts, particularly Nato, to sow discord among allies, to weaken the United States in the eyes of the people of Europe, Asia, Africa, Latin America, and thus to prepare ground in case the war really occurs.'

Throughout the cold war, the Soviets were virtuosos in creating tensions between allies. In particular, they excelled at the use of 'black propaganda': crafting damaging material which purported to be from the other side. These attempts were nebulous and prolonged, and included Operation Neptune, a 1964 attempt to use forged documents with the intention of implying western politicians had supported the Nazis. While this was quickly exposed as a counterfeit, other ruses were more successful. Whilst dezinformatsiya was targeted chiefly at the US, it was largely ignored there until 1980, when a Soviet forgery of a presidential document claimed that the administration was supportive of apartheid. This got some traction in US media, and so appalled president Jimmy Carter that he demanded a CIA inquiry.

In fact, by the 1980s, Soviet disinformation was an old story.



Ladislav Bittman wrote in The KGB and Soviet Disinformation: an Insider's View, published in 1985 that disinformation is part of what the Soviets called

'active measures' directed by the KGB ... designed for internal demoralization and erosion of power in targe countries [p 2]

He later wrote [p 48]

Disinformation is a carefully constructed false message leaked into an opponent's communication system to deceive the decision-making elite or the public.  Disinformation can be of political, economic, miliary or even scientific nature. To succeed, every disinformation message must at least partially correspond to reality or generally accepted views....

Then he noted that each message is crafted so that [p 56]

it dissuades leaders of the target country from critical analysis of the deceptive segments.  The overall purpose is not only to deceive but to cause damage to the target.  The victim of disinformation  must be led to inflict harm upon himself, directly or indirectly - either by acting agains his own interests on the basis of spurious intformation or by remaining passive when action is needed.

These elements of disinformation now may seen as echoed in the Russian campaign to manipulate the 2016 and 2018 US elections to favor now President Donald Trump and his supporters, and in some of the UK campaign for Brexit. 


The 2015 Measles Epidemic

As the years passed, and the USSR fell, the notion of disinformation seemed to fall into the dustbbin of history.  Yet, in early 2015, before anyone thought of Donald Trump as a presidential candidate, there was a small US measles epidemic.  In February, 2015, the New York Times discussed the strange inability of some then Republican candidates for the presidency to discuss the issue clearly.

The politics of medicine, morality and free will have collided in an emotional debate over vaccines and the government’s place in requiring them, posing a challenge for Republicans who find themselves in the familiar but uncomfortable position of reconciling modern science with the skepticism of their core conservative voters.

As the latest measles outbreak raises alarm, and parents who have decided not to vaccinate their children face growing pressure to do so, the national debate is forcing the Republican Party’s 2016 presidential hopefuls to confront questions about whether it is in the public’s interest to allow parents to decide for themselves.

Gov. Chris Christie’s trade mission to London was suddenly overshadowed on Monday after he was quoted as saying that parents 'need to have some measure of choice' about vaccinating their children against measles. The New Jersey governor, who is trying to establish his credibility among conservatives as he weighs a run for the Republican nomination in 2016, later tried to temper his response.

Then,

Senator Rand Paul of Kentucky, a physician, was less equivocal, telling the conservative radio host Laura Ingraham on Monday that parents should absolutely have a say in whether to vaccinate their children for measles.

'While I think it’s a good idea to take the vaccine, I think that’s a personal decision for individuals,' he said, recalling his irritation at doctors who tried to press him to vaccinate his own children. He eventually did, he said, but spaced out the vaccinations over a period of time.

The Times article speculated that

The vaccination controversy is a twist on an old problem for the Republican Party: how to approach matters that have largely been settled among scientists but are not widely accepted by conservatives.

In fact, Mr Christie had walked into a similar controversy earlier, about Ebola:

As concern spread about an Ebola outbreak in the United States, physicians criticized Republican lawmakers — including Mr. Christie — who called for strict quarantines of people who may have been exposed to the virus. In some cases, Republicans proposed banning people who had been to the hardest-hit West African countries from entering the United States, even though public health officials warned that would only make it more difficult to stop Ebola’s spread.

It all seemed odd.  After all, a lot of conservatives up to that time cultivated an image of hard-headed realism. Why would understanding of the favorable benefit/ harm profile of the measles vaccine, or of public health measures used to combat diseases like Ebola not be accepted by conservatives?

A 2018 Study of an Internet Based Disinformation Campaign About Vaccination

In 2018, a study of the role of twitter bots and Russian trolls in online vaccine discussions appeared (Broniatowski DA et al.Weaponoized health communication: Twitter bots and Russian trolls amplify the vaccine debate. Am J Pub Health 2018; 108: 1378-1384. Link here). It was an observational study designed to compare "'bots'—accounts that automate content promotion—and 'trolls'—individuals who misrepresent their identities with the intention of promoting discord."
 
To summarize its methods:

In our first analysis, we examined whether Twitter bots and trolls tweet about vaccines more frequently than do average Twitter users. In a second analysis, we examined the relative rates with which each type of account tweeted provaccine, antivaccine, and neutral messages. Finally, in a third analysis, we identified a hashtag uniquely used by Russian trolls and used qualitative methods to describe its content.

To summarize its results:

Compared with average users, Russian trolls (χ2(1) = 102.0; P < .001), sophisticated bots (χ2(1) = 28.6; P < .001), and “content polluters” (χ2(1) = 7.0; P < .001) tweeted about vaccination at higher rates. Whereas content polluters posted more antivaccine content (χ2(1) = 11.18; P < .001), Russian trolls amplified both sides. Unidentifiable accounts were more polarized (χ2(1) = 12.1; P < .001) and antivaccine (χ2(1) = 35.9; P < .001). Analysis of the Russian troll hashtag showed that its messages were more political and divisive.

The authors' discussion of results asserted:

Russian trolls and sophisticated Twitter bots post content about vaccination at significantly higher rates than does the average user. Content from these sources gives equal attention to pro- and antivaccination arguments. This is consistent with a strategy of promoting discord across a range of controversial topics—a known tactic employed by Russian troll accounts. Such strategies may undermine the public health: normalizing these debates may lead the public to question long-standing scientific consensus regarding vaccine efficacy. Indeed, several antivaccine arguments claim to represent both sides of the debate—like the tactics used by the trolls identified in this study—while simultaneously communicating a clear gist (i.e., a bottom-line meaning).

Note that they felt these results were applicable to the 2015 measles outbreak:

We recently found that this strategy was effective for propagating news articles through social media in the context of the 2015 Disneyland measles outbreak.

So here we have at least some evidence suggesting that the Russians were mounting a modern version of a disinformation campaign focused on scientific information meant to sow discord in the US and perhaps other developed countries, and to enable its victims to harm themselves or their children by dissuading them from measles and perhaps other generally beneficial vaccination.  Probably because disinformation had largely not been the subject of polite conversation since the fall of the Soviet Union and the disappearance of the old KGB (or at least, its name), US public health authorities and politicians  had failed to critically analyze what was going on.


The 2018 study got a bit of attention, and several authors suggested some responses.  In StatNews Beier and Sullivan suggested lessons learned:

First, we’ve learned that the Russians operate from a playbook that links seemingly disparate events. In the case of both AIDS and vaccine safety, they exploited pre-existing cynicism among groups or individuals outside the mainstream, planting doubts without apparent Russian links. For vaccines, Russians exploited a controversial report in the Lancet (that was later retracted by the journal) to exacerbate skepticism of vaccine safety so more parents would decline to vaccinate their children. (To be sure, the article had already generated home-grown anti-vaccine sentiment in the U.S.)

Second, we need to pay closer attention to public health measures that generate fear among those they are intended to protect, like vaccinations for children or fluoridated water.

Third, we must pay special attention to areas in which the West is widely seen as 'winning' compared to Russia — in this case public health — making them targets for disinformation campaigns.

The authors then suggested what should be done:

The federal government must take the lead on alerting the media and the public to the risks of purposefully misleading disinformation attacks. Public officials, including President Trump, must show a greater dedication to truth and facts. Whenever a prominent public official espouses support for baseless science, it helps those trying to subvert democracy. By relying on a swamp of bogus science, Russia has exploited loving parents with false, misleading, and dangerous information.

The federal government needs to work with the tech community to develop programs and algorithms to detect threats to our vital health information infrastructure from harmful lies about public health. Once such attacks are detected, Americans must work together to erect cyberwalls to thwart them.

That seemed well-intentioned, albeit unrealistic.  In particular, why would you expect the Trump regime, which appeared to gain power with the help of Russian disinformation (look here), suddenly turn into a tough, clear-headed foe of such disinformation?

Junaid Nabi in Project Syndicate made some more global suggestions:

health officials and experts in both developed and developing countries need to understand how this online misinformation is eroding public trust in health programs. They also need to engage actively with global social media giants such as Facebook, Twitter, and Google, as well as major regional players including WeChat and Viber. This means working in tandem to create guidelines and protocols for how information of public interest can be disseminated safely.

In addition, social media companies can work with scientists to identify patterns and behaviors of spam accounts that try to disseminate false information on important public-health issues. Twitter, for example, has already started using machine-learning technology to limit activity from spam accounts, bots, and trolls.More rigorous verification of accounts, from the moment of signing up, will also be a powerful deterrent to the further expansion of automated accounts.

Again, this seems well-intentioned.  But why expect social media companies, which seemed to be making lots of money through the viral spread of both information and disinformation, to be so helpful?

Of course, none of that happened. Now we are in yet another measles outbreak, considerably bigger than the one in 2015, with no end in sight.

Discussion

Life used to be so simple.  We used to write about propaganda and disinformation used to market health care goods and services (stealth marketing campaigns), and advocate for policies favorable to private health care organizations, usually under the auspices of pharmaceutical/ biotechnology/ device companies, health insurance companies, and hospital systems  (stealth health policy advocacy and stealth lobbying).  The organization and complexity of stealth marketing, lobbying and policy advocacy campaigns have often been sufficient to characterize them as disinformation.  For example, we characterized the campaign by commercial health insurance companies to derail the Clinton administration's attempt at health reform in the 1990s, as described by Wendell Potter in his book, Deadly Spin, as just that (look here).  The tactics employed in that campaign included: use of front groups and third parties (useful idiots?); use of spies; distractions to make important issues anechoic; message discipline; and entrapment (double-think).


While these efforts were done to improve corporate bottom lines and thus enhance the income of top corporate management, at least these organizations had some interest in providing or facilitating health care.

Although I had heard about Soviet disinformation, and even thought that some of the modern techniques used by big corporations for marketing and advocacy were uncomfortably close to disinformation, I, like many others, was not particularly worried about disinformation again used as a powerful weapon by a hostile foreign power.  How naive I was.  

Now we see propaganda and disinformation in the service of hostile and authoritarian foreign states meant to disrupt more democratic governments, whatever the cost in human health and lives.  And we see at best indifference to this problem on the part of politicians who may benefit from such foreign largesse.  (The hope in the StatNews piece that President Trump would become more dedicated to truth and facts was already naive at the time of publication.)

So we may need much more energetic and muscular solutions to the propaganda and disinformation that is now rotting our already dysfunctional health care system.  We cannot complacently expect a conflicted and corrupt government executive to help us.  Health care professionals, and all people who care about health care and the public health are going to have to stop wringing our hands and actually do something.  Or measles outrbreaks will be the least of our problems.