Friday, July 31, 2020

The Remarkable Case of the CEO of the Brigham and Women's Hospital Who Renounced a Major Conflict of Interest

Introduction; a Conflict of Interest Affecting the Trial of Moderna COVID-19 Vaccine

On July 17, 2020, the Brigham and Women's Hospital, a prestigious teaching hospital in Boston, announced it would be a major center for the randomized controlled trial of Moderna's mRNA based vaccine for COVID-19.  This would be the first of several eagerly awaited major RCT's of newly developed vaccines for this dangerous pandemic.  The press release noted that the hospital would be:
a clinical research site as part of the COVID-19 Prevention Network (CoVPN), funded by the National Institutes of Health. In addition, Lindsey Baden, MD, an infectious diseases specialist at the Brigham and an expert in vaccine development for viral diseases, will serve as co-principal investigator for the study.

The press release also included this disclosure:
Dr. Betsy Nabel, the president of Brigham and Women’s Hospital, has been a member of the Moderna Therapeutics Board of Directors since 2015 and has a financial interest in the company. Since its inception, this personal relationship has been reviewed and approved in accordance with Mass General Brigham conflict of interest policy and procedure, including a recent review in connection with the Phase 3 Study, and has been disclosed to the NIH/NIAID.

Although Dr Nabel would not directly participate in the trial, Dr Baden would apparently indirectly report to her as hospital CEO even though she would simultaneously be a board member of the company whose vaccine the trial was assessing. 

Another Example of What Was Once a "New Species of Conflict of Interest"

Thus Dr Nabel appeared to have a severe conflict of interest, the latest example of what we once called "a new species of conflict of interest."

In 2006, we first noticed that leaders of academic medicine also were serving as board members of large for-profit health care corporations.  The first example we discussed was that of Marye Anne Fox, Chancellor (equivalent to president) of the University of California - San Diego, and hence the person to whom the University of California, San Diego School of Medicine and its academic medical center report. The conflict was between this position, and her service as a member of the board of directors of Boston Scientific, a medical device manufacture, and the board of directors of Pharmaceutical Product Development Inc., a contract research organization.

Later in 2006, we discussed a "new species of conflict of interest." 
Medical schools and their academic medical centers and teaching hospitals must deal with all sorts of health care companies, drug and device manufacturers, information technology venders, managed care organizations and health insurers, etc, in the course of fulfilling their patient care, teaching, and research missions. Thus, it seems that service on the board of directors of a such public for-profit health care company would generate a severe conflict for an academic health care leader, because such service entails a fiduciary duty to uphold the interests of the company and its stockholders. Such a duty ought on its face to have a much more important effect on thinking and decision making than receiving a gift, or even being paid for research or consulting services. Furthermore, the financial rewards for service on a company board, which usually include directors' fees and stock options, are comparable to the most highly paid consulting positions. What supports the interests of the company, however, may not always be good for the medical school, academic medical center or teaching hospital.

As Robert AG Monks put it, board members must "demonstrate unyielding loyalty to the company's shareholders" [Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]  (Of course, after the global financial collapse of 2008 made us sadder and a little wiser, we realized that many board members actually seem to have unyielding loyalty to their cronies among top management.).

Dr Nabel's position on the board of directors of Moderna appears to be another example of this "board-level" conflict of interest.

Dr Nabel Does the Right Thing

On July 30, in the Boston Globe, Jonathan Saltzman reported that Dr Nabel had renounced her board position:
Dr. Elizabeth Nabel, president of Brigham and Women’s Hospital, said Thursday she was resigning from the Moderna board of directors after the Globe inquired about whether her position at the Cambridge biotech company conflicted with her hospital’s leadership role in a large study of Moderna’s experimental COVID-19 vaccine.

In fact Dr Nabel made the announcement while Mr Satzman was in the final stages of writing his article.  I know this because he had interviewed me about her conflict of interest earlier in the day.  So I got to unexpectedly make a new comment:

She did the right thing, It eliminates one issue that could have led to unfounded skepticism about this trial, and this is a trial where people have to trust the results.

In fact, this is the only case I can recall in which a top leader of a academic health care institution resigned from a for-profit health care corporate board after the conflict of interest presented by board membership was publicly pointed out.

Furthermore, the Globe article noted:

After Nabel announced her resignation, the Globe asked Brigham and Women’s whether she intended to keep the $6.5 million she collected in the recent sale of her Moderna stock.

Erin McDonough, a hospital spokeswoman, said, 'Dr. Nabel is considering a number of options, including charitable contributions.'


As we had previously discussed on Health Care Renewal, board level conflicts of interest can be extremely lucrative.  A typical board member of a large health care corporation makes hundreds of thousands of dollars in salary, and can collect stock options and other financial instruments worth millions.  Such compensation is obviously  a strong incentive to continue the conflict of interest.  Yet here a board member is quitting, and at least  considering giving away millions of dollars worth of stock to nullify her conflict.  That is truly remarkable.

Perhaps in this age of a dangerous pandemic, and its continuing reckless mismanagement by the US president (for example, look here), health care leaders are thinking more about what is really important. As Mr Saltzman wrote:

Medical ethics experts said it was worrisome that the head of the Harvard-affiliated teaching hospital had a financial stake in the vaccine, particularly given that many people are already skeptical of vaccines. Recent public opinion polls show up to half of Americans are reluctant to get a COVID-19 vaccine when one is approved.

'Anti-vaxxers, critics, and kooks will use any appearance of financial conflict to undermine trust in vaccines,' said Dr. Arthur Caplan, a professor of bioethics at New York University Langone Medical Center. 'It’s just hyper-dangerous now.'


So it seems that Dr Nabel recognized the danger to the public, and to reduce it was willing to take action which would involve at least some degree of personal sacrifice.

We can only hope that others will follow her.  
 



Friday, July 24, 2020

Did the Conflicts of Interest Generated by President Trump's Ownership of the Trump Organization Cause His Enthusiasm for the Premature Reopening of the Economy, and its Deadly Results?

Introduction: Trump's Personal Incentives to Push Rapid Reopening

Back in March, 2020, we posted about the possibility that President Trump's already growing enthusiasm for "easing restrictions on movement sooner than federal public health experts recommend" was due to his personal financial interests.  By that time, the Trump Organization, in whom Trump has the largest ownership share, had closed six of its seven biggest revenue producing properties, and was likely dreading the need to refinance considerable outstanding debt.

We wrote at the time:  "This raises the strong and extremely worrisome concern that he is thinking of taking measures that may risk the lives of thousands or millions of people to preserve his wealth and personal power."

Since then, Trump became an even more enthusiastic proponent of rapid reopening.  As we discussed in April, 2020, after the curve of the coronavirus pandemic began to flatten in the first heavily affected areas in the northeast US, supposedly popular protests broke out calling for the end of onerous social distancing measures to let the economy recover.  President Trump then jumped in, calling for the "liberation" of multiple states from these  measures.

Trump wrote: 'LIBERATE MINNESOTA' and then, 'LIBERATE MICHIGAN' and then, 'LIBERATE VIRGINIA, and save your great 2nd Amendment. It is under siege!'

After that, many Trump supporters among state and local politicians jumped in to "reopen" before the virus was fully controlled in their areas.  Now, viral surges have occurred in many states, predominantly in those with such political leadership, such as Arizona, Florida, Georgia, Texas, etc.  We summarized the worsening state of the pandemic in Arizona as an example here.  Some headlines just from the last few days:

Arizona Reopened Early to Revive its Economy.  Now, its Workers and Businesses Face Even Greater Devestation

Florida Hospitals Stretched to Capacity by Acute Coronavirus Outbreak

How Politics, Inequity and Complacency Undermined Texas's Fight Against COVID-19


Yet Trump has done nothing to deter his supporters' commitment to reopening even in the face of worsening viral surges. Meanwhile, more evidence has accumulated suggesting that Trump's laxness about fighting the pandemic may be due to the financial risk that he personally facing due to the virus and the effects of measures taken to combat it.

First, the Trump Organization is clearly under increasing financial threat.  Next, the organization is taking increasingly drastic measures to temporarily fend off that threat.  Finally, these measures include its own premature reopening of properties, potentially enabling spread of the virus.

Before we review some of the specifics, keep in mind that Trump's financial dealings are extremely opaque.  Unlike other US presidents, he has never revealed any recent tax returns, nor other important details of his apparently large and complex financial picture.  Nonetheless, we have learned some important things.

Trump Organization is Increasingly Under Financial Threat

Trump Organization Closes More Properties, Cuts Costs and Lays Off Workers

On April 3, 2020, the Washington Post reported:

The Trump Organization has laid off or furloughed about 1,500 employees at hotels in the United States and Canada as the coronavirus pandemic inflicts further pain on the president’s private business.

With most of President Trump’s hotels and clubs closed amid stay-at-home orders around the world, the Trump Organization has responded by slashing costs, much like other companies in the hospitality and tourism industries. The Trump Organization has laid off or furloughed employees at hotels in New York, the District of Columbia, Miami, Chicago, Las Vegas, Vancouver and Honolulu, according to public filings and people familiar with the properties, including union officials.

Seventeen of Trump’s clubs and hotels have closed. The remainder of Trump properties are operating at a fraction of their normal capacity: hotels running with restaurants closed, golf clubs operating with clubhouses shut down, and golfers warned not to share carts or touch the flagsticks.

All told, the closed properties generated an average of $650,000 in revenue for Trump per day, according to Trump’s past financial disclosures.

The Post also noted that by then:

As of Friday, 17 of Trump’s 24 clubs and hotels around the world were closed. The latest to close was Trump’s hotel in Vancouver, Canada — which announced its closure Thursday. 

[Trump's business partner in Vancouver, Joo Kim] Tiah said that 213 workers had been laid off and 18 kept on, with 11 of those working reduced hours.

In Chicago, the Trump hotel told investors on Friday that it had made the 'heartbreaking decision to' lay off two-thirds of its staff, required the remaining staff to work on two to three days a week, and suspended 401(k) contributions for all. Even the lights had been turned down to save money. 'In an effort to conserve energy, most common areas . . . are illuminated and heated at a minimum level,' the hotel told its investors in a letter obtained by The Washington Post.
[Trump Vancouver, under construction in 2016]


The estimate total of laid off and furloughed workers would soon rise.  On June 12, 2020, the Washington Post reported:

Interviews with current and former Trump Organization employees and tenants, and emails obtained by The Washington Post, show the pandemic in particular has rattled operations at the company. With thousands of Trump’s hotel rooms empty, the company laid off or furloughed more than 2,800 employees and scoured for even the smallest savings. It eliminated flowers, chocolates and newspapers at its New York hotel and turned off lights in common areas in its Chicago hotel to save on electricity, according to letters that hotel management sent to investors.

'This was not just a step down,' Eric Danziger, the chief executive of Trump Hotels, told board members of Trump’s Chicago hotel on April 22, according to an account of his phone call obtained by The Post. 'This was a steep dive.'


Trump Organization Likely Is Losing Rental Income and Revenue from Sales of Real Estate

Revenue losses were not just from hospitality income.  The Trump Organization rents space in hotels, clubs, and other properties to businesses whose ability to pay rent was also decreased due to the virus and measures to fight it.  

On June 12, 2020, the Washington Post reported:

One of the tenants in Trump-owned buildings that is almost certainly asking to pay less is Starbucks, which wrote to its thousands of landlords May 5 asking for a year’s worth of reduced rent beginning June 1. The coffee chain rents space at Trump Tower in New York and at Trump’s D.C. hotel. In Washington, Starbucks pays Trump $14,118 per month, increasing to $15,787 a month in 2023, according to Trump Organization documents obtained by The Post.

Also,

A massive Italian restaurant had been scheduled to open later this summer on the ground floor of a Wall Street skyscraper owned by Trump. But instead, as the coronavirus spreads, Nero.lab’s Italian Food Zone will probably have to adjust its initial concept — an 18,000-square-foot food hall where diners were to share communal tables and wait in lines for gelato and espresso. 

And,

Another tenant at 40 Wall Street is Neapolitan Express, which operates pizza restaurants and food trucks in New York. The company has rented space in the building since 2015, said owner Max Crespo.

Crespo’s business has cratered — revenue dropped 27 percent in March, 55 percent in April and 90 percent in May

The Trump Organization also makes money by selling condominiums.  However, on July 20, 2020, the Chicago Sun-Times reported:

It doesn’t take so much do-re-mi to buy into Chicago’s Trump International Hotel & Tower as it once did, and that’s striking sour notes for owners in the building.

Prices have fallen so hard that, if you have a mind to, you can get a unit on the cheap, relatively speaking. Some condos that are hotel rooms in the 98-story building can be had for less than $200,000.

In particular,

sales of the residences for the first half of this year averaged $566 a square foot, down 42% from the same months two years ago and 25% from 2019.

The prices are their lowest since the Great Recession of 2008 and its attendant housing bust. The building in the best of times has cleared its benchmark of $800 a square foot but has seldom reached its aspirations of $1,000.

And the same property was already having big problems renting business space,

Lastly, there’s the tower’s retail space, which Trump has never been able to lease. He sought Michigan Avenue prices for space unlikely to draw Michigan Avenue traffic.


[Trump Tower Chicago]


Finally, Trump might have been looking forward to raising considerable revenue by selling his lease on the Trump International DC Hotel,  a flagship property,but that now looks like a non-starter.


[Interior, Trump International DC Hotel]


As reported in the Washington Post, March 31, 2020:

The commercial real estate industry has ground nearly to a halt because of coronavirus shutdowns, forcing buyers and sellers of major properties, including President Trump’s company, to put their plans on hold.

The Trump Organization, which he still owns, has had to press pause on the proposed sale of its D.C. hotel lease because of the stock market collapse as potential buyers wait for banks and investors to return to normal operations.

The company’s sales representative, Jeffrey Davis of JLL, confirmed to The Washington Post that the proposed sale of Trump’s lease to the federally owned Old Post Office Pavilion has been set aside as the industry recovers.

Note that the above references stock market collapse was due to the economic effects of the then uncontrolled pandemic.


Trump May Have Difficulties Refinancing Existing Debt


Note that our original post suggested that loans from Deutsche Bank could be a major source of stress.  By June 30, a report in Mother Jones suggested that stress from the need to finance existing debt was even bigger than it first appeared:

On financial disclosure forms, Trump has reported holding 14 loans on 12 proper­ties. At least six of those loans, representing about $479 million in debt, are due over the next four years. Some are guaranteed by Trump himself, meaning a creditor could come after his personal—not corporate—­assets if he defaults.

In particular,

Trump’s biggest creditor is Deutsche Bank, which in the late 1990s took a gamble on the real estate developer whose history of corporate bankruptcies made him untouchable by most other lenders. Although Trump and the Frankfurt-based bank pulled off several profitable deals, eventually Deutsche’s commercial lending division learned the hard way one reason why other banks considered him persona non grata: If pushed by his creditors on payments, Trump shoves back. In 2008, after he defaulted on a loan for his Chicago hotel and condo development, he filed a multibillion-­dollar suit accusing Deutsche Bank and others of contributing to the recent financial meltdown, which he blamed for his inability to repay the loan.

Nevertheless, Deutsche’s private banking division, which caters to wealthy clientele, continued to lend to Trump, giving him $125 million, spread over two loans, to finance the purchase and renovation of his Doral golf resort in 2012. Both are floating rate loans, meaning the interest rate fluctuates based on market conditions, which lending experts say usually indicates they are interest-only loans. If so, Trump probably hasn’t paid down much if any of the principal and will owe something close to the whole $125 million when the loans come due in 2023.

In 2014, Trump took out a separate floating loan from Deutsche’s private bank to bankroll the development of his luxury hotel in Washington, DC. The balance of this $170 million debt is payable in 2024. That year, Trump will also owe Deutsche between $25 million and $50 million in connection with his Chicago hotel and complex.

In addition,

Trump has received additional loans from a company named Ladder Capital, a financial firm that specializes in bundling commercial debt into mortgage-backed securities. Companies like Ladder are often lenders of last resort for people and companies that, for one reason or another, have difficulty obtaining money from traditional banks (ahem, Trump). Such firms are willing to take risky bets because they securitize the debt and pass the responsibility for it on to investors. Trump has two Ladder loans due over the next several years: a $100 million interest-only mortgage on Trump Tower and a roughly $13 million loan against Trump Plaza. The Trump Tower loan is up in September 2022.

Trump may have considerable trouble refinancing these loans:

Nancy Wallace, a real estate finance professor at University of California, Berkeley’s Haas School of Business, says the scrutiny that Deutsche Bank has faced may scare off other banks. 'I think any bank I can think of in the United States would have exactly the same response: He is toxic. Exposing yourself to that kind of oversight under the current regulatory reality, for lenders who are large enough to provide capital to him, is just a nonstarter.'


Instead,

Commercial lending experts say a firm like Ladder Capital, which relies on a more cold-blooded financial calculus, might be more amenable to lending to Trump again. But with his business taking a sharp hit to its revenues for possibly years to come due to the pandemic, Trump might not like the terms, which could be less favorable than those of his original loans.

So the Trump Organization has lost large amounts of revenue from its hospitality operations and real-estate operations while it is facing the need to soon finance considerable existing debt under unfavorable conditions.
 
Dire Measures to Fend Off Financial Threat

So it is not surprising that as the pandemic continues, the Trump Organization is taking more drastic steps to raise money, cut costs, and fend off the financial threat.


Trump Organization Sought to Defer Loan Payments and Other Financial Obligations

As first reported by the New York Times on April 2, 2020:

With some of its golf courses and hotels closed amid the economic lockdown, the Trump Organization has been exploring whether it can delay payments on some of its loans and other financial obligations, according to people familiar with the matter and documents reviewed by The New York Times.

Representatives of Mr. Trump’s company have recently spoken with Deutsche Bank, the president’s largest creditor, about the possibility of postponing payments on at least some of its loans from the bank.

And in Florida, the Trump Organization sought guidance last week from Palm Beach County about whether it expected the company to continue making monthly payments on county land that it leases for a 27-hole golf club.


A few weeks later, on April 21, 2020, the New York Times reported that since the Trump Organization would not be able to quickly sell its lease on Trump International DC Hotel, it was trying to reduce its lease payments on the property:

President Trump’s signature hotel in the nation’s capital wants a break on the terms of its lease. The landlord determining the fate of the request is Mr. Trump’s own administration.

Trump International Hotel, just a few blocks from the White House, had been a favored gathering place for lobbyists, foreign dignitaries and others hoping to score points with the president. But like most hotels, it is now nearly empty and looking to cut costs because of the coronavirus pandemic.

In recent weeks, the president’s family business has inquired about changing its lease payments, according to people familiar with the matter, which the federal government has reported amount to nearly $268,000 per month.

The Trump Organization owns and operates the luxury hotel, but it is in a federally owned building on Pennsylvania Avenue. As part of its deal to open the 263-room hotel, the company signed a 60-year lease in 2013 that requires the monthly payments to the General Services Administration.


As an aside, the article went on to mention that the Trump Organization's negotiations with Deutsche Bank, Palm Beach County, and now the GSA all generated their own conflicts of interest, eg,

The G.S.A. did not immediately respond to a request for comment, including about whether its other tenants had made similar inquiries. The White House also did not respond to a request for comment.

> Companies across the country have pleaded for relief from lenders and landlords, but the Trump Organization’s submission presents a particular predicament.

If it denies the request, the agency risks running afoul of the president, who appoints its leader; but if it accommodates the Trumps, the agency is likely to draw fire from critics.

If anything, this minimizes the issues.  Since the GSA is part of the executive branch which the president leads, he is essentially negotiating with himself, a huge conflict of interest.  Furthermore, were the GSA to reduce the lease payment, this amounts to the federal government making yet another payment to Trump.  Yet the US Constitution's "domestic emoluments clause" prohibits the President from receiving "any other Emolument [payment, thing of value] from the United States, or any one of them." (See our post on Trump's vast conflicts of interests here.)


Trump Organization Asked for Aid from European Countries for its European Properties

As Bloomberg reported on April 22, 2020:

The Trump Organization is seeking U.K. and Irish bailout money to help cover the wages for bartenders, bagpipers and other employees furloughed from its European golf properties because of the coronavirus lockdown.

These resorts were already operating at losses before the pandemic:

Trump has invested several million dollars over the past decade to buy and revamp the three resorts in Scotland and Ireland, which have continued to lose money, according to their government disclosures.  It's unclear whether Trump has financed the resorts through bank loans or the Trump Organization's cash flow.

At least one local official in Scotland, Martin Ford in Aberdeenshire, opposed the bailout:

The huge tab for this will be borne throughout the whole population through higher taxes.  If what he says about his personal wealth is true, Trump doesn't need the money, and I don't see why U.K. taxpayers of the future should be helping out.

Again, should the Trump Organization receive such a bailout from a foreign government, it would again be in violation of the US Constitution's "foreign emoluments clause," which prohibits the President from receiving "without the Consent of the Congress, accept of any present, Emolument [payment, thing of value], Office, or Title, of any kind whatever, from any King, Prince, or foreign State." (See our post on Trump's vast conflicts of interests here.)


Trump Pushing to Open Properties Quickly, Possibly Subjecting Employees and Guests to Increased Risk of COVID-19

Finally, Trump's push to increase revenue, presumably augmented by all the stresses above, may be leading to premature openings and enhancement of operations at Trump Organization properties.  As reported by the New York Times on June 23, 2020:

the reopening of Trump National Doral, the most important source of revenue for the president’s strained family business, came as new cases of the coronavirus spiked in surrounding Miami-Dade County and public health officials urged caution about resuming normal activity.

Virus cases in Florida exceeded 100,000 on Monday, with more than 3,100 deaths. About one-quarter of the cases have been in Miami-Dade County, a per capita rate twice the number statewide. On Tuesday, the county reported an average positive test rate of 12.4 percent in recent weeks. The latest single-day positive rate rose to 25.9 percent.

Nonetheless,

Poolside at President Trump’s resort near Miami, dozens of guests sunned last weekend on lounge chairs and chatted in cabanas. Golfers fanned out across multiple courses, and the hotel lobby hummed with activity for the first time in months.

Despite the local surge,

many visitors and some staff members did not wear masks — something the president himself has been reluctant to do in public.

Similarly, the Trump Organization has rushed many other properties back into operation:

With the reopening on Monday of the Trump Organization’s Ferry Point golf course in the Bronx, all of the 20 Trump properties in the United States are up and running again, at least in part; even the tasting room at the Trump Winery in Charlottesville, Va., is once again welcoming visitors.

We have discussed previously how Trump and some political leaders who support him have personally acted in ways that may have increased the spread of coronavirus. There is reason for concern that the rushed reopening and expansion of operations at Trump Organization properties may further spread the virus  Per the NY Times article:

Experts say it is possible for businesses like Trump National Doral to operate safely, but they also acknowledge that the president’s properties present a special case.

'The bottom line is, can a leader lead by example?' said Dr. Aileen Marty, an infectious disease expert with Florida International University who helped design Miami-Dade County’s safety protocols for businesses. “That’s what needs to happen at every type of business — wear a mask, practice hygiene, social distance.”

When the president recently visited his golf club in Bedminster, N.J., while in the area to speak at the West Point graduation ceremony, temperature checks were required, but only when he was on the property, a person familiar with the situation said. There is no requirement that golfers or guests at Bedminster wear masks, and almost no one has done so, other than food service employees, the person said.

Discussion

There is mounting evidence that the rapid reopening of parts of the US has led to a big surge in COVID-19 infections, and now we are seeing the resulting surge in hospitalizations, severe illness, and deaths.  Many hospitals in the affected areas, chiefly in the southern US among states led by governors who are political supporters of Trump, are under increasing strain.  At least one rural county in Texas is now triaging admissions, that is, barring admission for coronavirus by patients judged to have poor chances of survival (look here).  Such emergency triage has rarely been necessary lately in the country that spends more than any other per capita on health care.
 
President Trump was clearly an effective  cheerleader for rapid reopening (look here).  Some have suggested he did so because of his strong focus on the economy, and distress that stay at home orders, lock-downs, and forced business closings led to recession.  Less charitably, others thought that he was worried that the economic decline undermined his major political accomplishment, a previously growing economyh.  An even worse reason for pushing premature reopening, however, would be conflicts of interest, Trump's concern for his own personal fortune.  Yet there certainly is now a lot of circumstantial evidence that supports that theory.

There certainly is voluminous evidence of Trump's and the Trump family's conflicts of interest and  corruption during his presidency (look here).  There are many possible ways that they have compromised Trump's decisions, making them more responsive to his personal and family interests than those of the country he was sworn to protect and defend.  Now there is reason to suspect his conflicts may have led to a rising toll of disease, morbidity and mortality.

Yet up to now, protests of his conflicts of interest and corruption have been feeble, while the country has been distracted by each new surprise from a presidency run like a reality television show.  How much longer can the country survive our lack of focus on how we are threatened? 

Sunday, July 12, 2020

How Can We Fight the Coronavirus Pandemic Under Political Leaders Who Enable the Spread of the Virus?

The Trump administration has written the book about how not to prepare for a pandemic, and how to mismanage the response once one occurs.  We have previously posted about how President Trump and his administration have hindered pandemic management in the US and around the world.  We have noted the President's support for such counter-productive policies as allowing vulnerable elderly people to fly, keeping passengers cooped up on cruise ships in which the virus was spreading, and reducing testing for the virus (in March).

Furthermore, early on we noted  instances in which the President personally promoted events at which viral spread was enabled: the CPAC conference, a large indoor event, some of whose attendees later tested positive; and a meeting at Mar-a-Lago that included officials from Brazil, some of whom later tested positive (again, in March).  Later, in May, Trump visited a factory which makes N95 masks but insisted on not wearing a mask himself, and several of his top officials, including the Secretary of Health and Human Services, followed his (bad) example and also eschewed masks.

A few such episodes could have been written off as merely particularly horrendous bungles.  However, the pattern is now so well established that it appears Trump and his followers are systematically trying to increase the spread of the virus. We have now cataloged numerous instances in which they seemed to do so. In some, there was evidence that such actions actually enabled viral spread.  I will list them by category, and within categories, chronologically.

President Trump Acting Personally to Enable Viral Spread

Trump Avoids Masks but not Close Personal Contact at Public Events

Public health experts, and the US Centers for Disease Control and Prevention (CDC) under Trump have suggested social distancing, avoiding close contact with others, and wearing masks as key measures all people can undertake to decrease viral spread.

Trump, instead has frequently sought close personal contact with others and has conspicuously avoided wearing a mask.  For example, Trump continued to shake hands with supporters, including some elderly (in Florida, March 11).  Trump continued to show up at events without a mask, usually accompanies by other administration officials who also were maskless: in Phoenix, at a mask factory, (May 5) apparently in violation of the company's policy (per the Washington Post); at another mask factory in Pennsylvanis (May 14); in the Rose Garden, accompanied by Secretary of DHHS Azar and Secretary of Defense Esper (May 15); and in a Ford manufacturing plant, violating company policy and state law (May 21).



By decreasing the number of people wearing masks and preventing social distancing at these events, Trump made it more likely that there would be virus transmission there.


While Trump Avoids Masks and Social Distancing at the White House, His Staffers Increasingly Test Positive

Similarly, Trump has deliberately tried to reduce the use of masks and social distancing in the White House and generally in his personal vicinity.  Again, this increased the likelihood of virus transmission.  On May 4, 2020, Yahoo News reported:

As the country copes with the coronavirus pandemic, millions of Americans are following social distancing guidelines from the White House coronavirus task force to slow the spread of the infection: staying 6 feet away from other people, avoiding large gatherings and wearing masks or cloth face coverings.

But inside the White House, many of these rules are not being observed. There are regularly large events with unmasked attendees in close quarters — including inside the Oval Office, where some people have been allowed to enter without wearing masks or taking tests for the virus.

Although some people have their temperatures checked,

Not everyone who goes inside the Oval Office, the president’s inner sanctum and one of the most secure spaces in the West Wing, is being tested. For both governors’ visits, a pack of pool reporters and cameramen were brought in. Though their temperatures were rechecked before they entered Trump’s office, the press pool, which stood feet away from the president, the governors and staff, were not given tests. And in the crowded confines of Oval Office press scrums, while Trump sits apart from most of the crowds, the 6-foot distancing rule is not observed, with reporters and top officials packed close together.

Another report by the Washington Post on May 8, 2020, emphasized that the lax approach at the White House was at the behest of Trump:

Several security officials with executive branch experience said in interviews Friday that the White House has taken a lax and risky approach that, in their view, reflected Trump’s consistent efforts to minimize the threat from the virus.

So,

Like Trump, most of his aides, including Pence and White House Chief of Staff Mark Meadows, have not worn face masks, and the president has huddled with guests at the White House for photo-ops that undermine the efforts at social distancing that do take place, such as seats placed more than six feet apart.

'This is a show of bravado. This is a show of ‘I got this. I’m in control,’ ' said one former security official familiar with White House security planning during past administrations.

'He’s tried to minimize this threat from day one. It’s the only way he can laugh in the face of this disease,' said this person, who like others spoke on the condition of anonymity to frankly address sensitive security matters.

Multiple anecdotes suggest that the White House is a permissive environment for transmission.  Various staffers have tested positive for coronavirus, suggesting that lax policies driven by Trump's aversion to masks were enabling spread.  First, on May 7, CNN reported:

A member of the US Navy who serves as one of President Donald Trump's personal valets has tested positive for coronavirus, CNN learned Thursday, raising concerns about the President's possible exposure to the virus.

The valets are members of an elite military unit dedicated to the White House and often work very close to the President and first family. Trump was upset when he was informed Wednesday that the valet had tested positive, a source told CNN, and the President was subsequently tested again by the White House physician.

The next day, Politico reported:

Katie Miller, a spokesperson for Vice President Mike Pence, has tested positive for coronavirus, according to two people with knowledge of Miller's diagnosis.

Miller's positive diagnosis for Covid-19 puts the potential threat of the infection squarely into the president’s inner circle. Miller serves as the vice president’s top spokesperson, traveling with him frequently and attending meetings by his side. She is also married to another top White House aide and senior adviser, Stephen Miller, who writes the majority of Trump’s speeches and spends copious amounts of time around the president, Jared Kushner and Ivanka Trump.

And on July 3, 2020, the New York Times reported:

Kimberly Guilfoyle, the girlfriend of President Trump’s eldest son and a top fund-raising official for the Trump re-election campaign, tested positive for the coronavirus on Friday before a Fourth of July event at Mount Rushmore, a person familiar with her condition said.

Ms. Guilfoyle traveled to South Dakota with Mr. Trump’s son Donald Trump Jr., in anticipation of attending a huge fireworks display where the president was set to speak.

So it is likely that despite some extraordinary measures to prevent infection in the White House, such as multiple temperature checks and copious use of rapid (but perhaps not very sensitive) tests for coronavirus, the President's insistence on avoiding masks and social distancing is allowing spread of the virus, even to staffers very close to the President.

Trump Scoffs at New Jersey Quarantine Regulations

As reported by NBC on June 24, 2020:

The White House said Wednesday that President Donald Trump will not change his plan to travel to New Jersey this weekend despite a new order by the governor requiring visitors who have been in states with high numbers of coronavirus cases to quarantine for 14 days.

'The president of the United States is not a civilian,' White House spokesman Judd Deere said when asked about Trump’s compliance with the quarantine order given his travel Tuesday to Arizona, which has seen a rise in the rate of its COVID-19 cases.

Again, Trump demonstrated his intentional disregard of standard, lawful public health measures meant to reduce the spread of coronavirus.


Trump's Tulsa Campaign Rally: No Masks or Social Distancing, Multiple Infections Documented

So far, the most vivid and elaborate demonstration of Trump's push to make the US safer for the coronavirus was provided by his campaign rally in  Tulsa, Oklahoma on June 20.  That location was one in which coronavirus cases were already climbing.  The rally went on despite Trump's and its organizers' apparent awareness of the dangers of it leading to worsening spread of the virus.

First, note that the campaign required that attendees sign a waiver to protect Trump and the organizers from liability.  As reported by CNN on June 12, 2020:

Attendees of President Donald Trump's upcoming rally in Tulsa, Oklahoma, must agree not to sue the campaign if they contract coronavirus.

Rallygoers are asked to RSVP to gain admission to the event and by registering, they must agree to a disclaimer that states they acknowledge the 'inherent risk of exposure to COVID-19 exists in any public place where people are present.'

'By attending the Rally, you and any guests voluntarily assume all risks related to exposure to COVID-19 and agree not to hold Donald J. Trump for President, Inc.; BOK Center; ASM Global; or any of their affiliates, directors, officers, employees, agents, contractors, or volunteers liable for any illness or injury,' the disclaimer reads.

The disclaimer proclaims that Trump and rally organizers were very aware that their event would likely lead to particular risk of spreading coronavirus.

Furthermore, local health authorities warned them about the risk, per Tulsa World on June 13, 2020:

Expressing concerns about COVID-19’s increasing spread, the Tulsa City-County Health Department’s director said he wishes the campaign rally for President Donald Trump at the BOK Center on June 20 would be pushed back to a later date.

In an interview with the Tulsa World on Saturday, Dr. Bruce Dart said Tulsa is seeing a 'significant increase in our case trends' that makes a large gathering like the rally dangerous for not only attendees, but the president himself.

Local health care professionals also added their warnings, as reported by Public Radio Tulsa on June 16, 2020:

Calling it a matter of public health, not politics, hundreds of health care providers have signed their names on a letter to Tulsa Mayor G.T. Bynum, calling on him to prevent President Trump's campaign rally planned for the BOK Center on Saturday.

'As our city and state COVID-19 numbers climb at a rate previously unseen, it is unthinkable that this is seen as a logical choice," reads the letter, dated June 14th and authored by Dr. Jabraan Pasha of the University of Oklahoma Medical Center in Tulsa. 'It has the potential to shake our cities [sic] infrastructure and stress our healthcare systems. It will undoubtedly cost lives.'

In case that was not enough, top public health experts on the President's own coronavirus task force also warned against the rally. As reported by NBC News on June 19, 2020:

Leading members of the coronavirus task force warned White House officials about the health risks of holding large-scale indoor campaign rallies and advised against such mass gatherings, according to two people familiar with the discussions.

Dr. Anthony Fauci, the nation's top infectious disease expert, and task force response coordinator Dr. Deborah Birx both vocalized concerns internally in the last week about the safety of holding a rally on Saturday with as many as 19,000 people in an enclosed arena in Tulsa, Oklahoma.

Their dismissal was blase:

But President Donald Trump and his campaign advisers are proceeding with the event, which is expected to draw tens of thousands inside and outside the venue who will neither be socially distant nor required to wear face coverings. They claim attendees 'assume a personal risk' and 'that is part of life.'

Again, this response indicates that the President and associates were well aware that what they were doing would likely spread the virus.

Yet there was one final warning before the event.  As CNN reported on the day of the rally, June 20, 2020:

Six staffers working on President Donald Trump's rally in Tulsa, Oklahoma, have tested positive for coronavirus, the Trump campaign said Saturday.

Nevertheless, the show would go on, but not before one extra effort by the Trump campaign to make sure there would be no social distancing at the event. As we found out in retrospect on June 27, 2020 via the Washington Post

In the hours before President Trump’s rally in Tulsa, his campaign directed the removal of thousands of 'Do Not Sit Here, Please!' stickers from seats in the arena that were intended to establish social distance between rallygoers, according to video and photos obtained by The Washington Post and a person familiar with the event.

The removal contradicted instructions from the management of the BOK Center, the 19,000-seat arena in downtown Tulsa where Trump held his rally on June 20.

The effects of the rally were discovered very quickly.  First two members of Trump's campaign team tested positive for coronavirus after the rally (CNBC, June 22, 2020).  Then it was the Secret Service's turn, per the Washington Post on June 24, 2020:

Dozens of Secret Service officers and agents who were on site for President Trump’s rally in Tulsa last week were ordered to self-quarantine after two of their colleagues tested positive for the novel coronavirus

The agents originally testing positive were part of the six staffers who tested positive listed above. How many other Secret Service agents may have been infected is not clear.

A Secret Service spokeswoman declined to comment on how many of its employees have tested positive or were quarantined, but said the Tulsa event has not affected the agency’s ability to do its job.

A few days later, a prominent Trump supporter who attended the rally fell ill, as reported by Politico on July 2, 2020:

Former presidential candidate Herman Cain announced on Thursday that he has been hospitalized with Covid-19, almost two weeks after attending President Donald Trump’s rally in Tulsa, Okla.

Cain was diagnosed with coronavirus on June 29, nine days after the president's rally, and his symptoms worsened and required hospitalization on July 1, according to a statement from his Twitter account.

'He spent the past night in a hospital and as of today, Thursday July 2, he is resting comfortably in an Atlanta-area hospital,' the statement read, adding that Cain did not need a respirator. 'There is no way of knowing for sure how or where Mr. Cain contracted the coronavirus.'

Cain, briefly a frontrunner in the 2012 GOP presidential primary, tweeted a picture on June 20 of himself and others at Trump’s indoor rally.

“Here’s just a few of the #BlackVoicesForTrump at tonight’s rally! Having a fantastic time!” the caption read. No one in the picture was wearing a mask.

Finally, the director of the Tulsa Public Health Department concluded that the rally likely made an important contribution to the surge of cases overall in Tulsa.  As reported by AP on July 8, 2020:

President Donald Trump’s campaign rally in Tulsa in late June that drew thousands of participants and large protests 'likely contributed' to a dramatic surge in new coronavirus cases, Tulsa City-County Health Department Director Dr. Bruce Dart said Wednesday.

Tulsa County reported 261 confirmed new cases on Monday, a one-day record high, and another 206 cases on Tuesday. By comparison, during the week before the June 20 Trump rally, there were 76 cases on Monday and 96 on Tuesday.

Although the health department’s policy is to not publicly identify individual settings where people may have contracted the virus, Dart said those large gatherings 'more than likely' contributed to the spike.

'In the past few days, we’ve seen almost 500 new cases, and we had several large events just over two weeks ago, so I guess we just connect the dots,' Dart said.

So despite multiple warnings from public health experts and health care professionals, Trump and his campaign held a intentionally maskless and socially compacted rally quickly followed by the spread of infection to staffers, at least one of his prominent supporters, and apparently a large but unknown number of the population of the city in which the rally was held.  Since then, Trump et al have held two large maskless and socially compacted events, one in an urban area with already a large surge in COVID-19, although it is too early to tally their effects.


The Trump Administration and Family

Ivanka Trump's Travels

Per the NY Times, April 16:

Ms. Trump herself has not followed the federal guidelines advising against discretionary travel, leaving Washington for another one of her family’s homes, even as she has publicly thanked people for self-quarantining.

In particular,

Ms. Trump and her husband, Jared Kushner, who is also a senior White House adviser, traveled with their three children to the Trump National Golf Club Bedminster in New Jersey

On Their Own, Top Administration Officials Avoid Masks and Have Others Take Them Off

Even when the President Trump is not present, his top officials have taken it upon themselves to prevent the use of masks and social distancing.  On May 8, 2020, the Washington Post reported that Defense Secretary Esper and Veterans Affairs Secretary Wilkie stood with several very elderly, and hence vulnerable to coronavirus, World War II veterans sans masks. On May 11, the Intercept reported that Vice President Pence attended an event without a mask, and that business executives in attendance were required to remove their own masks.  This occurred right after Pence was exposed to Katie Miller (see above), so soon after Pence entered quarantine.

How ICE Spread the Virus

Days ago, on July 10, 2020, the New York Times reported:

Even as lockdowns and other measures have been taken around the world to prevent the spread of the coronavirus, ICE has continued to detain people, move them from state to state and deport them.

An investigation by The New York Times in collaboration with The Marshall Project reveals how unsafe conditions and scattershot testing helped turn ICE into a domestic and global spreader of the virus — and how pressure from the Trump administration led countries to take in sick deportees.

The scope of the problem appears large:

So far, ICE has confirmed at least 3,000 coronavirus-positive detainees in its detention centers, though testing has been limited.

And,

So far, the governments of 11 countries have confirmed that deportees returned home with Covid-19.

So members of Trump's administration and family have also undermined public health measures meant to prevent the spread of the coronavirus, likely enabling infection in some affected people.

Trump Supporters in the US Congress

Trump's political supporters in the US Congress, and in state houses and legislatures have also enthusiastically followed his lead, promoting a maskless and not socially distanced life, despite increasing evidence that their efforts are leading to more people infected with coronavirus.

Republican Members of Congress Refuse Masks and Social Distancing

Republican members of the US House of Representatives have repeatedly refused to wear masks during their official duties while indoors and when close to other people.  On April 23, 2020, the NY Post reported:

Republican members of Congress were noticeably reluctant to wear masks on the House floor Thursday, sparking a sharp debate with Democrats, who readily accepted the federal guidance.

As lawmakers gathered for a morning debate on creating a coronavirus stimulus oversight committee, the GOP side of the chamber largely left their mouths and noses uncovered

The leadership provided the bad example, provoking mockery of masks as a pandemic prevention measure:

Minority Leader Kevin McCarthy (R-Calif.) and Minority Whip Steve Scalise (R-La.) arrived on the House floor without masks, as did many GOP peers.

'Nice mask!' a colleague told Scalise.

'Thanks! I wear it for Halloween, too!' the second-ranking Republican said, laughing uproariously.

Those who did not wear masks included Reps. Jack Bergman (R-Mich.), Andy Biggs (R-Ariz.), James Comer (R-Ky.), Louie Gohmert (R-Texas), Brett Guthrie (R-Ky.), Jody Hice (R-Ga.), David Kustoff (R-Tenn.), Michael McCaul (R-Texas), Tom McClintock (R-Calif.), Cathy McMorris Rodgers (R-Wash.) and Chip Roy (R-Texas).

Despite continuing exhortations from public health experts about wearing masks, House Republicans remained defiant.  As reported on May 28, 2020 by CNN:

A contingent of House Republicans continues to defy the recommendations of public health experts and Congress' top physician to wear face coverings to limit the spread of Covid-19, refusing to wear them on the floor of the chamber, in the hallways of the Capitol or when chatting with aides and colleagues -- even when they're unable to maintain a social distance.

Some of those anti-mask Republicans seem to have acquired coronavirus infections, suggesting that their deliberate avoidance of masks and social distancing has enabled the spread of the virus, even to those who advocated such defiance of public health orthodoxy.  As reported by USAToday on June 15, 2020:

South Carolina Republican Rep. Tom Rice announced Monday that he and his family contracted COVID-19, becoming the latest member of Congress to contract the deadly disease that has infected about 2.15 million Americans.

Rice, in a Facebook post to his constituents, said he and his family contracted the disease last week and were recovering. He joins seven other members of Congress who tested positive for the disease or who were diagnosed with a presumed case. But his case comes months after his colleagues' and comes as states push to reopen businesses and their economies.

And the defiance continues.  CNN reported on June 26, following up on a Congressman listed above whose state now experiencing a major surge in infections:

Texas Republican Rep. Louie Gohmert spends ample time on the House floor not wearing a mask, often talking with aides and lawmakers at length while not maintaining a social distance.

Asked why not, the 66-year-old Gohmert had an explanation that defied the science and the recommendations of leading public health experts.

'I don't have the coronavirus, turns out as of yesterday I've never had it. But if I get it, you'll never see me without a mask,' the conservative Texan told CNN Friday.

Told that health experts say that people who don't have symptoms may be carrying the virus and can unknowingly spread it to others, Gohmert responded: 'But I keep being tested and I don't have it. So I'm not afraid of you, but if I get it I'll wear a mask.'

Leading Republican Member of Congress to Hold Fundraising Event in Florida During Huge Virus Surge

I found one other example of a well known Congressman who seemed intent on holding an event that could risk further virus spread in a state already experiencing a major surge.  On July 7, 2020,Axios reported

House Minority Whip Steve Scalise’s PAC is inviting lobbyists to attend a four-day 'Summer Meeting' at Disney World's Polynesian Village in Florida, all but daring donors to swallow their concern about coronavirus and contribute $10,000 to his leadership PAC.

Why it matters: Scalise appears to be the first House lawmakers to host an in-person destination fundraiser since the severity of pandemic became clear. The invite for the 'Summer Meeting' for the Scalise Leadership Fund, obtained by Axios, makes no mention of COVID-19.


Trump Supporters in State Governments

Maskless Governors Went To Restaurants

Early on in the pandemic, despite evidence that crowded restaurants provided an ideal environment for virus propagation, one governor who supports Trump made a point of showing up in restaurants.

March 16, 2020, via the Independent:

[Republican] Oklahoma governor Kevin Stitt, has declared a state of emergency in response to the coronavirus outbreak just a day after he was slammed for tweeting a picture of his family at a crowded restaurant.

Two months later, two others made the restaurant scene, sometimes encouraged by Vice President Pence.

May 14, 2020, via the Arizona Republic

[Republican Governor Doug] Ducey’s office posted photos on social media of the governor stopping for lunch at Pita Jungle in Phoenix with a bipartisan group of legislators.

The get together was a show of support for the restaurant industry as eateries reopened dine-in service this week as the governor pulled back state restrictions in place because of the COVID-19 pandemic.

None of the politicians were wearing masks in the pictures. Restaurant staff appeared to be wearing masks.

The state’s own guidance for restaurants says eateries should develop standards for employees to wear masks around customers and coworkers.

May 20, 2020, via ABC News:

Vice President Mike Pence did something Wednesday that most Americans haven’t done in many weeks amid the coronavirus pandemic: He sat down for lunch at a burger joint.

The vice president held a photo op at Beth’s Burger Bar in Florida along with GOP Gov. Ron DeSantis to highlight efforts to allow restaurants in the state to begin reopening for limited, in-person service.


But,

Neither the vice president, nor Steele, nor DeSantis, or many others nearby, wore masks.

May 22, 2020 via the Atlanta Eater:

Photos posted to social media by WSB reporter Richard Elliott, AJC photojournalist John Spink, and AJC reporter Tamar Hallerman show Gov. Kemp and Vice President Pence speaking to the owners, staff, and diners at Star Cafe, and lunching on pulled pork and meatloaf paired with sweet tea.

But,

Despite the governor urging the public to face wear masks and to social distance during the ongoing COVID-19 health crisis, neither Gov. Kemp or the vice president — or most of their entourage — entered the restaurant wearing a mask or when conversing with people before dining, and social distancing seemed to be on the back-burner.

Note that since then Oklahoma, Florida, and Georgia have all experienced big coronavirus surges.


Pennsylvania Legislators Concealed COVID-19 Infection Acquired by One of Their Own

On May 28, 2020, the Washington Post reported:

Democratic state legislators in Pennsylvania accused their Republican counterparts Wednesday of keeping a GOP lawmaker’s positive coronavirus diagnosis under wraps for days, arguing the lack of transparency may have increased their risk of contracting the potentially deadly infection.

Republican state Rep. Andrew Lewis released a statement Wednesday revealing he received his positive test result on May 20 — a jarring announcement that rattled House Democrats who said they had no idea he had been sick or other GOP members had been told to self-quarantine due to possible exposure.

Lewis, whose last appearance at the state Capitol was on May 14, said he immediately went into isolation after testing positive and informed House officials about his condition.

In particular,

state Democrats were appalled that their Republican colleagues did not promptly inform them of Lewis’s positive test result or the subsequent self-quarantines of other GOP members, instead allowing them to potentially risk exposure by continuing to participate in person in voting sessions and House committee meetings. Several Democrats said Wednesday they only became aware of Lewis’s diagnosis from the media.

The connection between intentional behavior by the state legislators and their colleagues initially unknowing assumption of increased risk is clear.

After Refusing Masks and Social Distancing, Mississippi Legislators Acquiring Coronavirus Infections

On July 10, 2020, AP reported:

Packed elevators and crowded committee rooms. Legislators sitting shoulder-to-shoulder on the House and Senate floor. People standing close to each other and talking, sometimes leaning in to whisper, without a mask in sight.

Those were common scenes at the Mississippi Capitol in June — a month that saw a historic vote to remove the Confederate emblem from the state flag — and now at least 26 lawmakers have been diagnosed with the coronavirus in the biggest known outbreak in any state legislature in the nation.

That works out to about 1 in 7 Mississippi legislators.

Among those testing positive in the heavily Republican body are the GOP presiding officers, House Speaker Philip Gunn and Lt. Gov. Delbert Hosemann.

Again, there is a plausible connection between lack of masks and social distancing, and then rise in infections.  Note again that Mississippi has been also undergoing a major coronavirus surge.

Summary


We have thus seen an extensive array of examples in which President Trump, his administration, and his political supporters in the US Congress, state houses and state legislatures have deliberately undermined standard public health measures meant to reduce the spread of the coronavirus and better control the pandemic.  There are examples in which their defiance at least was temporally related to specific or general increases in infection.  These examples occurred before and during the latest and now most severe surge of the pandemic.  The examples occurred despite many, many warnings and cautions by public health and health care professionals, and protests by political opponents.

How can we explain this apparently perverse behavior?  Given its duration despite warnings and pushbacks, it is hard to attribute it to lack of knowledge, miscommunication, or error.  One can never dismiss the possibility of grotesque stupidity.

However, at this point, I cannot dismiss the likelihood of malevolence.  As Jurecic and Wittes postulated in the Atlantic back in March,

As the former Justice Department official Carrie Cordero declared on Twitter: 'To invert a @benjaminwittes formulation, the Trump administration #COVID19 response might be characterized as incompetence exacerbated by malevolence.'

It is an inversion in more ways than one. In the original formulation of the phrase—malevolence tempered by incompetence—the incompetence not only comes second, but it mitigates the malevolence. In Cordero’s rather apt reformulation, by contrast, the incompetence comes first, and the malevolence doesn’t mitigate it. It makes things worse.

So,

[Addressing] the malevolence. President Trump’s statements since the virus first appeared in the United States have been wholly untouched by concern for anything except blame avoidance.

Furthermore,

He barely bothers to express concern about public health, choosing instead to wax indignant about how the virus is affecting his public image. This has led to some scenes that might have been bleakly funny if not for the many lives at stake.


And as Greg Sargent wrote in the Washington Post on July 8,2020:

Not clueless and hapless.  Malevolent.

Once we dispense with the idea that Trump remains 'in denial,' we’re left with a few interpretations. The most charitable is that Trump continues to have principled disagreements with experts over these matters, but there are zero indications he has any substantively grounded views on them of any kind.

A far less charitable interpretation is that he’s merely indifferent to the catastrophic consequences that are resulting from these failures — and will continue to do so — and that he’s prioritizing nakedly self-interested political calculations over any such concerns.

Finally,

Central to getting this right is dispensing with the idea that Trump is a hapless, clueless actor rather than a deliberate and malevolent one.

If he is right, only then will be come up with a real solution for a malevolent and now life-threatening regime.

Thursday, July 02, 2020

Parlous Times—so Why Is My Dander Down?

Yes, these are parlous times, my friends, with all sorts of threat levels bouncing up and down and up again to all sorts of new heights. I've personally felt almost paralytic, in this present "Dander" series, about repeating the latest outrages from Trump-land and Corona-land.  (Lather. Rinse. Repeat.) What is there new to say? The outrages are all there, still, but with a single, over-arching theme.

To quote the great philosopher, Frankie Valli, "It's a sign!!!" The sign: a new system of governance run by a cabal of family and cronies, no inspectors-general in sight, and a whole lot of unconfirmed "acting" secretaries, under-secretaries, under-under-secretaries and under-under-under secretaries.

I've written about this syndrome in HCRenewal before, mainly in connection with the Veterans Administration. Look it up right here in HCRenewal (e.g. see here). It's a systemic neurological disorder we could call MS: Mar-a-Lago Syndrome. In this disorder the federal government is paralyzed not by the Deep State, but a pernicious Deep Nonstate of golf buddies, far-right pundits and other self-dealing defilers of democracy.

Oh, where are the mere managerialists we used to go after in HCRenewal? We do miss them so! Lather. Rinse. Repeat.

Anyway, we're in the summer of 2020 and lives have been lost. The system stays awash in waste and cronyism. But I just couldn't muster writing more about it: what was new? It's all MS and the thousand flushes of oppositional, know-nothing populist careerism that go along with it. All courtesy of a motley crew of hackers, sadly gullible flat-earthers and one particular political party busy pushing itself and the rest of us off the deep end. All exploiting the hell out of each other. Only one, the US Senate's leadership, has an internally-valid long-term goal—the judiciary—that purports to make the exercise worthwhile. Everybody else can just bump along in their miserable gerrymandered "corporations are people" lives, liking it and lumping it.

And yet: along the way, something strange seems to be happening. It's true that, yoked together and spurring on their steeds, our four horsemen of the apocalypse—America's flawed democracy, its corrupt GOP, the pandemic and its exposed systemic racism—just stay on the rampage. But look underneath all this, in health care and just maybe in the larger society, there are young hopeful shoots, sprouting somehow in the mud below. And that is something new and worth writing about.

So just now, oddly enough the dander's down. (Provisionally. Check in again in, oh, four to five months.)

Some years ago Dr. Poses, this blog's venerable editor, already pointed out how HCRenewal's message has begun to "go mainstream." Now and again, he points out further new examples.

Maybe this mainstreaming of the message—health care independence and integrity—somehow relates to a couple of major shifts in the medium, or mediums, that carry the message. The first, social networks, have worked in part to the detriment of good government. But they also enable ground-up protest in a new communications ecosystem.

Another part of this ecosystem, less evident to lay people and leaders but potentially a potent force, is the advent of a new and more independent-minded generation of science and medicine journal editors, with their accompanying editorial boards. Here we find some more of the tender young shoots, exemplifying the change that genuinely seems afoot. Let me cite three recent examples.

  • The Annals of Internal Medicine has gone from strength to strength in recent years. Under its current editor, Christine Laine, the first woman to hold that post, Annals now boasts its highest-ever impact factor [C. Laine MD, personal communication]. That's an impact in general medicine, the nation's largest specialty, boasting over a million page views per month.

    The current number of Annals, for mid-June 2020, offers an article entitled "a cautionary tale," describing last year's "orphaning" of the entire house staff of Hahnemann University Hospital. Both the content and the very fact of the publication of this article are noteworthy. The article that follows, in its title, asks "is it time to more fully address teaching religion and spirituality in medicine?" (answer: "truly caring").


    But stick for the moment with the Hahnemann debacle. The article, written by three former Drexel University College of Medicine (DUCOM) faculty members who're now spread to the four winds, probes the "diametrically opposed goals of hospital owners and educational leaders" that led to an enormously disruptive hospital closure on the verge of a pandemic, a tsunami that orphaned nearly 600 trainees and that faculty quite simply "found hard to believe."

    Those of who were around in the 1990s didn't find it so hard to believe. The authors allude to the prehistory of the Hahnemann bankruptcy in the earlier one endured by Allegheny, or "AHERF" in the late 1990s. They don't insist on the earlier one prefiguring the later one, "the largest orphaning event" in medical history, in any causal or direct fashion. But I'd argue precisely that: at the least, it made it much more likely.

    The reason, simply, a circumstance to which to their credit the authors point, was the original sin of the deal that bailed out a medical school (pre-bankruptcy MCP-Hahnemann, post-bankruptcy Drexel) and a group of hospitals (originally Tenet Healthcare). That original sin was a quarter-century earlier when the Philadelphians did a deal-that-was-never-gonna-work with Tenet Healthcare, a for-profit based west of the Mississippi. The original sin fast-fowards a quarter-century to the present authors noting that at the critical moment in 2019, "Drexel and Hahnemann released separate talking points for P[rogram] D[irector]s, but these documents contained discordant information." But the discord started in 1995 and never stopped. Graduate Medical Education run by frenemies.

    The American system of GME, like the US Constitution, contains any number of these ill fated compromises. When this happens, only a few norms serve as guardrails against disaster: in this case, the manner in which hospitals—recall that Tenet was a for profit system, and one for which both education and research are distinctively secondary—control the medical education dollars coming to them from Medicare reimbursements. "Discordant information": how can you lose?

    The departure of hundreds of residents, with all its displacement of both faculty and trainees, and with all its emotional turmoil, hardly seems like something that would cheer one up. And on its face, it's not. One can hardly overestimate the pain these authors and their colleagues went through. But what strikes me is the fact that this whole crummy system is no longer anechoic: that those within it are out there on the hustings, stating the lessons learned, trying to create the antibodies that might protect against future such occurrences. And Annals gladly published this excellent exposition-cum-cautionary tale.
  • In the same week that I received this number of Annals, I received the 25 June 2020 number of The New England Journal of Medicine. NEJM, also a super-high-impact journal, changed editorship—just a few months before the onset of the pandemic— much more recently than Annals. One waited to see whether it, too would be, shall we say, feminized. (Be clear: in this case "feminization" is for me an uncomfortable shorthand for what I dearly hope my commentators below will suggest a better word, and more or less an unmitigated good.)

    I grew up in a tradition of ritualistic CPCs—clinicopathologic conferences—in my own medical school and in key journals such as NEJM. A case would be presented of a patient who had to die. They had to die because the autopsy findings would be tortuously predicted by the academic physician as the solution to a diagnostic dilemma. This would be followed by a learned exposition of the histology and gross pathology of the disease that furnished the answer to the puzzle. Sometimes the clinician even got it wrong. The pathologist of course was always right, He—it was virtually always a he—always got the last word.

    But what the CPC model did was to reify the classic post-Laennec medical model of equating medical decision making to its laboratory-based problem-solving narrative. This began to change a bit beginning in the Journal's post-Ingelfinger and post-Relman eras, where editors began to stress correlations of clinical findings with those of the new molecular biology and immunochemistry. Now the patient didn't even have to always die! But the classic medical model, even then, was preserved. Riddle me a riddle: bench science, properly coupled with bedside wisdom, will provide the answer.

    Imagine my surprise then to find the CPC of a few weeks ago, entitled "a girl with severe psychological distress after family separation," focused on "trauma-informed care" in which the clinical outcome was not "a post-mortem examination was performed" or "a diagnostic procedure and laboratory study were performed." Here "a diagnosis and management decisions were made" and both clinical and patholgocial diagnoses were "post-traumatic stress disorder."

    The graphic is that of a cartoon pediatrician with an immigrant child, blowing bubbles together.

    Make no mistake: this is both a scientific and literary breakthrough, and a political statement. It is enormously heartening to view such a sea change in one of our most august journals. It tell us that a new, younger leadership in academic medicine is stepping up to address the socioeconomic problems that are now—far more than whether or not SARS-CoV-2 does or does not interact with ACE inhibitor agents—threatening health care in the more dire existential fashion.

    Can we extrapolate from these straws-in-the-wind? Is medicine becoming less anechoic and able to counter the threats against it? I know of no other recent precedent, but there's one from classical antiquity: the very bedrock of our medicine today, the Hippocratic tradition. In his magisterial 1995 work Hippocrates in an Age of Pagans and Christians, Owsei Temkin of Johns Hopkins showed how the classical traditions of independent medicine were able to persevere even in a later era in which they were threatened by religious authority. It was a close call then and it's a close call now: viz., the decision by a mere five to four, just a few days ago, preserving the physician's right without hindrance to provide services to a pregnant woman.

    Sometimes it comes down to one vote. And, granted, it ain't over until it's over: in November, voters in the United States will, in momentous fashion, decide the future direction not just of their own people but of the healthcare they're going to get going forward.
  • What's going on here? In truly extraordinary circumstances, leaders in medicine seem to be not abandoning the scientific model, but expanding it to incorporate insights and perspectives drawn from ethics and the social sciences, including economics. (The Allegheny-Hahnemann case is a classic example of business-economics-gone-wrong through failures of basic socioeconomic analysis.) Even in the non-clinical literature, if you take even a cursory look, you can find these tender young sprouts of freedom.

    The journal Cell, in a number published last month, began with an editorial entitled "Science has a racism problem," stating that "We are the editors of a science journal, committed to publishing and disseminating exciting work across the biological sciences. We are 13 scientists. Not one of us is Black." Cell also boats an editor of recent vintage (2018).

    But what followed was even more astounding. Amidst articles discussing matters such as how "Epitope pools detect CD4+ and CD8+ T cells," in the very next number of the journal, Duke neuroscientist and MD-PhD Kafui Dzirasa provides his account of how "[f]or Black scientists, the sorrow is also personal." This article has been widely reprinted and sent out to many thousands of physicians who practice in domains as far away from cell biology as orthopedics. It is worth quoting in extenso, and speaks for itself.

I am a medical doctor and a scientist; the first African American awarded a PhD in neuroscience at Duke University. I have led a National Institutes of Health-funded research lab for almost a decade, and I was awarded the Society for Neuroscience Young Investigator Prize in 2019. I am an American Association for the Advancement of Science Alan I. Leshner Public Engagement Fellow, and I have hosted TEDMED three times. I am a scholar, teacher, mentor, speaker, and mental health advocate. I have served on national commissions, I have advanced federal policy, and I have even held court with a president of the United States. I have published in Cell scientific journals, and as a peer reviewer, I have worked to advance the scientific rigor of my colleagues. Yet, most days, I am unseen and unknown. As I watched a knee slowly, mercilessly, and inhumanly extinguish yet another black life, I was overwhelmed by anger and sorrow, and at this very moment, I am terrified to run on the trail near my home. I am a black academic in America.

That these three examples of medical communication all point to inherent problems in American medicine, no doubt in world medicine as well, is daunting in one sense. But in another it is undaunting. It shows us how far we have left to go. By looking in the mirror and recognizing that they share the challenges of the larger society, medicine and science have at least a fighting chance of transcending them—and in doing so, regain their independence. The manner in which these authors have taken the knee, and in doing so stood very, very tall, shows us a path of speaking truth to power. In doing so, and in our anticipation of their being heard, they give us hope.

Sunday, June 28, 2020

Do Cry for Those in Arizona: What Happens When Politicians Disregard Health Care and Public Health Professionals During a Pandemic

Introduction: Health Care Professionals Vilified After They Caution Against Premature Reopening During the Pandemic

As we discussed in April, 2020, after the curve of the coronavirus pandemic began to flatten in the first heavily affected areas in the northeast US, supposedly popular protests, broke out calling for the end of onerous social distancing measures, ostensibly to let the economy recover.  President Trump then jumped in, calling for the "liberation" of multiple states from these  measures.

Trump wrote: 'LIBERATE MINNESOTA' and then, 'LIBERATE MICHIGAN' and then, 'LIBERATE VIRGINIA, and save your great 2nd Amendment. It is under siege!'

As these protests multiplied, health care professionals responded by staging counter-protests to warn people about the danger of premature "reopening."  For their pains, they were often vilified.  In particular, we noted that one brave ICU nurse silently stood at the capitol of Arizona.

'She would spend the next few hours standing silent, her facial expressions partly hidden behind her medical mask. Her body standing rigid in surgical scrubs.'

For that, she was insulted, scorned and generally screamed at by flag-waving protesters, some of whom carried signs about an overblown crisis and a 'pretend-demic'.

The state Republican chairwoman even accused her of one of the "actors playing parts."

In that and a later post we noted how these "reopening" protests were egged on by right-wing politicians, including President Trump himself; infiltrated by extreme right-wing groups, including armed militias; accompanied by threats of death and violence to counter-protesters and anyone preaching restraint; and organized and funded by right-wing political organizations, often allied with Trump, and often funded by plutocrats.  It was unclear whether more than a small minority of the protesters were truly concerned about the economic costs of delaying reopening.  Rather, they seemed mainly about pushing a political agenda which had little to do with public health or health care.

Was this any way to make health care and public health policy?  Nonetheless, these protests, which were orders of magnitude smaller than those which later broke out after the death of George Floyd, and pressure from Trump et al seemed to induce Republican state leaders to reopen early and quickly.

Now the health care professionals' warning are shown to be valid.  Consider the case of Arizona.

Health Care Professionals Inundated as Coronavirus Surges

As documented by the Washington Post on June 25, 2020:

Arizona has emerged as an epicenter of the early summer coronavirus crisis as the outbreak has expanded, flaring across new parts of the country and, notably, infecting more young people.

Maricopa County, which includes Phoenix, is recording as many as 2,000 cases a day, 'eclipsing the New York City boroughs even on their worst days,' warned a Wednesday brief by disease trackers at Children’s Hospital of Philadelphia, which observed, 'Arizona has lost control of the epidemic.'

This came after Arizona became the poster child for early and quick reopening. "The state’s cases began rising dramatically about May 25, 10 days after Ducey allowed the state’s stay-at-home order to expire...." said a local public health expert.

The Republican Governor seemed to be reacting directly to Trump's push to "liberate" states:

Trump, who was urging governors to jump-start their economies, was coming to Arizona to tour a Honeywell plant and to convene a discussion about issues facing Native Americans.

The day before the president’s visit, Ducey announced plans to accelerate the reopening of his state’s economy, lifting restrictions on salons and barbershops and allowing restaurants to resume dine-in service. A chart displaying the number of new cases, which did not show the 14-day decline recommended by White House guidelines, 'really doesn’t tell you much,' Ducey said at his May 4 news conference.

In the Washington Post's summary:

At critical junctures, blunders by top officials undermined faith in the data purportedly driving decision-making, according to experts monitoring Arizona’s response. And when forbearance was most required, as the state began to reopen despite continued community transmission, an abrupt and uniform approach — without transparent benchmarks or latitude for stricken areas to hold back — led large parts of the public to believe the pandemic was over.

Stories coming out of Arizona are starting to resemble those that came out of New York at its peak of pandemic induced misery.  On June 24, 2020, the Arizona Republic published a vivid anecdote of yet another person who scoffed at the virus, and then became ill.

Jimmy Flores, 30, met up with his close friends at the bars in Scottsdale on a Saturday night in June.

'This bar was super packed. I was kind of concerned because I was like, man, everyone's tight, they have limited cups. Some people were sharing drinks, it was weird,' said Flores, who also shared drinks with his friends at a bar in north Scottsdale that night.

He ended up hospitalized for over a week. He "was discharged home Monday, but breathing is still a challenge and he is taking multiple medications."  He started posting about his case on Facebook, but his friends thought he was being "political."  Now he says, "I really care about people not going through this and that they have to take this seriously because it really hurts."



[Old Town, Scottsdale in happier times]


And the New York Times published an op-ed on June 26, 2020 from an emergency department physician sadly mirroring the tales of despair coming out of New York only a few months ago. 

Patients are evaluated, stabilized and admitted to an inpatient medical team. But many admitted patients remain in the emergency department, 'boarding' while awaiting transfer to the hospital wards because there are no more intensive-care beds available in the hospital or there is insufficient staff to care for them in the beds that are available.

Because of that, far fewer emergency department beds are available for people with non-Covid-19 health conditions and medical emergencies. So sick people wait for an emergency department bed to become available. The surge in cases night after night shows no sign of slowing and it is terrifying.

The media has reported how few hospital beds are available in the state. But even if we had enough beds, it wouldn’t matter if our staff wasn’t physically and emotionally well enough to attend to the people occupying those beds. Many hospital systems have chosen to furlough staff and tighten belts even as health care teams were beginning to feel the psychological strain of the pandemic. Physicians are a small part of our clinical care teams. We are profoundly limited in what we can do without the support of nurses, paramedics, emergency and intensive-care technicians, respiratory therapists, radiology technicians, environmental services workers, social workers, case managers, unit coordinators, clinical pharmacists and others.

Health care workers are exhausted. Staffing shortages and increasing fatigue are the new normal for emergency departments, intensive-care units and Covid-19 units, and across hospital wards. Staffing levels are being set with an emphasis on 'productivity' as determined by financial calculations rather than clinical severity or the complex needs of our patients and the community we serve.

Finally,

Emergency medical and critical-care team members are canaries in the coal mine. When we are understaffed and overworked, when there is no staff to triage patients, when more and more patients are piling up at the emergency department door, the system breaks down, then people break down. You can borrow ventilators (until you can’t) and make more personal protective equipment (we hope). You cannot magically produce more nurses, respiratory therapists, physicians or other professionals.

And things are getting worse every single day.  The Arizona Republic reported June 28, 2020:

Arizona cases of COVID-19, the disease caused by the new coronavirus, increased by more than 3,850 cases on Sunday — the highest number of cases in a single day, according to data released by the Arizona Department of Health Services.

Arizona's total identified cases rose to 73,908 on Sunday with 1,588 known deaths, according to the most recent state figures. That's an increase of 3,857 confirmed cases, or 5.5%, since Saturday.

Inpatients with suspected or confirmed COVID-19 and ventilator and ICU bed use again hit record highs Saturday, while emergency department visits dropped from Thursday's record of 1,249, according to the daily report from the Arizona Department of Health Services.

As of Saturday, 85% of current inpatient beds and 87% of ICU beds were in use for COVID-19 and other patients.

But it did not have to happen.  Had Arizona's political leadership paid attention to the message of one brave ICU nurse back in April, or numerous messages from other health care and public health professionals, had they resisted President Trump's constant exhortations that the economy comes first, and that coronavirus is not a big problem, the pandemic would likely have been better controlled in Arizona, and elsewhere, than is actually the case.

 So do cry for those in Arizona.

Summary


Traditionally, political leaders have trusted health policy experts, and health care and public health professionals to help them make health policy.  In the past, political leaders listened to such experts and professionals when planning for epidemics and pandemics, and addressing new health and public health emergencies.

However, in our new (ab)normal, many political leaders follow the lead of the current president, Donald Trump, and his party.  They seem unworried that the president has a record of peddling lies and disinformation (look here), and has a record of conflicts of interest and corruption goes far beyond any conceivable precedent (look here). They accept Trump's multiple assurances that the coronavirus pandemic is either a hoax, or "fake news," or inconsequential, or fading away (look here).  They shrug when Trump scoffs at public health measures meant to slow viral spread, such as face masks (look here).  They put extreme politics, ideology, and sectarianism (look here) ahead of science, logic, and the warnings of experts.

So, health care professionals trying to uphold their mission to put patients' and the public's health first have stumbled into a political conflict far beyond anything we have seen in our lifetimes.  Upholding the mission is proving to be difficult, unpleasant, and now dangerous.  The danger is not just from the virus, but from our fellow humans putting their politics and ideology ahead of all else.  That does not make the mission any less important.  Innocent lives are still hanging in the balance.

We could retreat in fear from the powerful opposition we have stirred up.  That would allow complete politicization of the management of the coronavirus pandemic, doubtless leading to even more disease and death (and ironically, even worse economic disruption).  Retreating would betray our patients and make a mockery of our mission.  Or we could persist.  What will it be?

"And if not now, when?"

ADDENDUM (30 June, 2020) - This was re-posted by the Naked Capitalism blog here.