Threats to Democracy Round Up - Selected Topics, Late May, 2023

Influence of Hostile Foreign Powers

We have previously posted lots of words about the anechoic effect: the lack of echoes produced by seemingly important stories about health care dysfunction.  It seemed as if such stories were taboo, presumably because even discussing them was seen as a threat to the rich and powerful who increasingly run health care.  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 as we discussed here, the major issues we discussed prior to 2015 gave way to a new normal with the advent of Trump as a presidential candidate and the MAGA movement as a major force in US politics.  In that 2020 discussion, we noted how the Trump administration acted 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 (look here).

Now it appears that the most striking example of the anechoic effect involves discussion of the underlying causes of the anti-democratic turn in the US that threatens the system that permits public discussion, and the possibility of reforming health care dysfunction among other issues.  We continue to see bits of evidence made public about how democracy is threatened by the influence of hostile foreign powers, especially Russia, on US politics, especially elections.  Yet the evidence produces few echoes.

Here are some of the more striking bits of evidence that appeared in just the last two weeks about Russia's malign influence on US democracy.

Russia's Malign Strategy and Tactics

-The April 2023 Indictment for Russian Election Interference and Threats to U.S. Democracy "The Kremlin’s Strategy: Exploiting far left and far right fringes; Exploiting the racial divide; Going local"
https://www.justsecurity.org/86424/the-april-2023-indictment-for-russian-election-interference-and-threats-to-u-s-democracy/

Racism as a National Security Threat "the one big thru-line from the Cold War to today in terms of the  most exploitable vulnerability Russia can weaponize against us:  America’s racial divisions"
https://open.substack.com/pub/asharangappa/p/class-15-racism-as-a-national-security

Evidence of widespread Russian election meddling in other countries: "Kemal Kilicdaroglu, main challenger of Turkish President Tayyip Erdogan,  said ... his party has concrete evidence of Russia's  responsibility for the release of 'deep fake' online content"
https://www.reuters.com/world/middle-east/erdogan-rival-says-has-evidence-russias-online-campaign-ahead-turkey-vote-2023-05-12/

Linkages of Trump and Supporters to Russia

 US Trumpists are increasingly part of a new global fascist axis: "far-right populism of Hungary’s prime minister is helping to inspire  U.S. Republicans' agenda for 2024, a game plan that targets  immigration, LGBTQ rights and... the war in Ukraine"
https://www.axios.com/2023/05/08/gop-hungary-connection-shaping-2024-campaign

Reminder that Trump "is Putin's puppet": He was "repeatedly asked by CNN host Kaitlan Collins if he backed Ukraine in its 15-month conflict with Vladimir Putin’s forces, and repeatedly dodged the question"
https://www.independent.co.uk/news/world/americas/us-politics/putin-ukraine-war-trump-cnn-b2336935.html

Follow the money: Trump Media got financing from Paxum Bank, which "promoted itself...as a way for video streamers of adult content  to coordinate financial transactions across international borders" and is owned by a sketchy Russian businessman
https://www.washingtonpost.com/technology/2023/05/13/trump-truth-social-loan-questions/

[Another Trump-Russia connection?] FBI agents raid condo unit owned by Russians at Trump Towers in Sunny Isles
https://www.miamiherald.com/news/local/article275358451.html

The FBI raided a condo in Trump Tower III in Sunny Isles Beach, FL because its "owner was being arrested... on  charges of illegally selling airplane parts to Russian airline  companies"  
https://www.yahoo.com/lifestyle/days-mysterious-fbi-raid-russians-225454222.html

Putting another Russian asset in the WH: In call to ReAwaken America rally, Trump said he would give Michael Flynn a WH position.  Flynn "entered, then withdrew, a guilty plea of making false statements to the F.B.I" and hung out with Putin in Russia
https://www.thedailybeast.com/trumps-call-in-to-michael-flynns-far-right-roadshow-is-red-meat-for-christian-nationalists

Reminder: "next to Putin at the head table, in the seat of honor, was an American.  Retired Lt. Gen. Michael Flynn, who would later become Donald Trump's  national security adviser"
https://www.nbcnews.com/news/world/guess-who-came-dinner-flynn-putin-n742696

Trump and Supporters' Techniques to Downplay their Connections to Russia: The Durham Investigation 

It was supposed to show how the investigation of Trump/Russia was a witch hunt.  It didn't

Not with a bang.... Trump fans hyped the Durham investigation. Trump fans will likely keep spinning it, but it "delivered underwhelming results... securing a guilty plea from a little-known FBI employee [and] ...losing ...2 criminal cases"
https://apnews.com/article/durham-trump-russia-probe-7e84f94ca9cf7905cbc5eddc108575b3

"Durham’s...report revealed little substantial new information  about the inquiry...failed to  produce the kinds of blockbuster revelations... that...Trump  and his allies suggested Mr. Durham would uncover"
https://www.nytimes.com/2023/05/15/us/politics/trump-russia-investigation-durham.html

"Durham...scolded the F.B.I. but failed to... uncover a politically motivated 'deep state' conspiracy.... charged no  high-level F.B.I. or intelligence official with a crime and acknowledged...Clinton’s 2016 presidential campaign did  nothing prosecutable"
https://www.nytimes.com/2023/05/17/us/politics/durham-report-trump-russia.html

Despite the failure of the Durham investigation to find any important misconduct much less "deep state" politicization of the Trump-Russia investigation, to Trump fans it  "was Watergate times 10, or 100"
https://www.nytimes.com/2023/05/16/us/politics/durham-report-conservative-reaction.html

Russia, Trump and the 2016 election "Russia tried to swing the 2016 election to Trump; FBI had reason to investigate a tip suggesting Trump campaign involvement; Trump campaign welcomed help from Russia:  ‘Steele dossier’ proved to be a red herring"  
https://www.washingtonpost.com/politics/2023/05/17/truth-about-russia-trump-2016-election/

Russian Propaganda and Disinformation

"hate crimes in America are often influenced by online chatter that's  increasingly linked to Russian sites or pro-Russian narratives on more  obscure parts of the internet. The Kremlin doesn't seem to mind"  
https://www.axios.com/2023/05/09/american-extremists-russian-sites-shootings

Conflicts of Interest, Corruption, Crime

Since 2015, we have asked (here) how the US (and the world) can possibly reduce health care corruption, a major cause of global health care dysfunction, under a thoroughly conflicted and corrupt Trump administration.  Since the end of that administration, Trump has campaigned to be president again.  Meanwhile, the evidence of his and his supporters' conflicts of interest, corruption, and criminality continue to grow.  Recent examples include:

Trump's Conflicts, Crimes, and Corruption

Jury finds Trump liable for sexual abuse, awards accuser $5M [When real, reasonable people get to review Trump's conduct while free of his intimidation and bluster they may tend to do so harshly]
https://www.sfgate.com/news/article/jury-to-start-deliberations-in-suit-accusing-18087335.php

"Trump admitted more directly than before on Wednesday that he knowingly  removed government records from the White House and claimed that he was  allowed to take anything he wanted with him as personal records" Confessing to a crime?  
https://www.nytimes.com/2023/05/11/us/politics/trump-documents-white-house.html

He just can't help himself: in his CNN Town Hall appearance, Trump appeared to defame E Jean Carroll again, just days after she won a lawsuit against him for his previous defamation
https://www.nytimes.com/2023/05/11/nyregion/e-jean-carroll-trump-defamation.html

[Even more accusations of sexual misconduct by Trump, even involving his own White House staff] Top aides reveal Trump’s alleged inappropriate conduct towards female staffers
https://www.independent.co.uk/news/world/americas/us-politics/donald-trump-white-house-aides-abuse-b2337881.html

Attacking the rule of law, eve obstruction of justice? - Trump fan politicians go after prosecutors who are investigating or otherwise legally pursuing Trump, including Manhattan DA Bragg, Special Counsel Smith, Fulton County GA DA Willis
https://www.theguardian.com/us-news/2023/may/17/donald-trump-republican-allies-prosecutors-investigations

There is apparently evidence that Trump knew he was committing a crime by walking off with classified presidential records despite his later claims that doing so was legal
https://www.independent.co.uk/news/world/americas/us-politics/trump-mar-a-lago-classified-documents-evidence-b2342010.html

The Conflicts, Crimes and Corruption of Trumpist and/or Far Right Politicians

[Noticing this glaring conflict of interest] Judge to order Wisconsin Elections Commission to reconsider fake elector complaint without the commissioner who joined the scheme
https://www.jsonline.com/story/news/politics/2023/05/08/wisconsin-elections-commission-must-reconsider-fake-elector-case/70195092007/

Are they all sleazy or criminal? Republican "Rep. Bryan Slaton resigned from the Texas House on Monday after an investigation determined that he had an inappropriate sexual relationship with a 19-year-old woman on his staff"  
https://www.chron.com/politics/article/bryan-slaton-pressure-resign-texas-house-18086307.php

TX rep Slaton "proposed banning children from attending drag shows to supposedly shield them from being groomed... resigned after he was found to have engaged in inappopriate sexual  conduct with a 19-year-old intern" Fake morality of the culture warriors
https://www.theguardian.com/us-news/2023/may/09/republican-drag-shows-danger-for-kids-resigns-misconduct-intern

[Again, are they all crooks?] Rep Santos [(R-NY) is accused of using illicit campaign contributions for personal expenses "indictment accusing him of wire fraud, money laundering,  stealing public funds and lying in federal disclosure forms"
https://www.nytimes.com/live/2023/05/10/nyregion/george-santos-charges-news/santos-had-been-under-investigation-for-his-campaign-finances-and-other-activities

Rep George Santos confesses to theft in Brazil to avoid prosecution
https://www.washingtonpost.com/world/2023/05/11/george-santos-brazil-case-theft/

Follow the money: "conservative operatives using sophisticated robocalls raised  millions of dollars from donors using pro-police and pro-veteran  messages....  nearly all the  money went to pay the firms making the calls and the operatives  themselves"
https://www.nytimes.com/interactive/2023/05/14/us/politics/scam-robocalls-donations-policing-veterans.html

[And now reports of sexual misconduct by Trump's lawyer Giuliani] Rudy Giuliani accused of sexual harassment by ex-employee
https://www.bbc.com/news/world-us-canada-65606131

[Are they all thugs, if not crooks?- Louisiana] GOP Rep Clay Higgins filmed shoving activist who questioned Lauren Boebert’s divorce
https://www.independent.co.uk/news/world/americas/us-politics/clay-higgins-shoved-activist-laren-boebert-b2341682.html

Propaganda, Disinformation, Deception

We used to write about propaganda and disinformation used to promote health care goods and services (stealth marketing campaigns), and advocate for policies favorable to private health care organizations (stealth health policy advocacy and stealth lobbying).  Some stealth marketing, lobbying and policy advocacy campaigns encompass not just propaganda, but disinformation.  For example, consider the health insurance company campaign to derail the Clinton administration's attempt at health reform as described by Wendell Potter in Deadly Spin (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).

But back in the day, the notion of propaganda and disinformation as a real threat to health care, much less our democratic process and society as a whole, was pretty radical.  That was then.  By 2019 we were writing about a  a new (ab)normal that includes propaganda and disinformation in the service of hostile authoritarian foreign states meant to disrupt more democratic governments, whatever the cost in human health and lives.

 It is important to better understand the techniques of the propagandists and disinformationists, so:

Propagandists' and Disinformationists' Toolbox

Reflexive control "Using the name scholars have given to this area of research to  frame the debate baits Rufo’s opponents into arguing about what CRT is and isn’t, which... keeps the exact three words he wants (and  their attendant connotations) in circulation"  
https://open.substack.com/pub/asharangappa/p/erasing-memory

"How can we really engage in these conversations, when the tension is  there before you even pick up the book and open the topic?" [It's hard to  have a rational argument when fanatics are screaming at you]
https://www.axios.com/2023/05/04/us-history-test-results-civics-covid

The Flood the Zone with BS Technique:
[The old-time fast talking snake oil salesman in the internet age] Donald Trump steamrolls CNN’s town hall [It's easier to lie than to rebut a lie.  If someone lies very quickly, you can't respond in real time]
https://www.washingtonpost.com/opinions/2023/05/10/cnn-trump-town-hall-lies/

'"You can’t keep saying that all night long'....[so one]  can rebut him, correct him, interrupt him and otherwise battle with him  over every point, but that’s no match for ceaseless mendacity....'We don’t have time to fact-check every lie'"
https://www.washingtonpost.com/opinions/2023/05/10/cnn-trump-town-hall-lies/

It's the old Steve Bannon (and Russian) tactic: flood the zone with BS. "CNN hasn’t figured this thing out, and it’s a good bet its competitors have no better ideas" It's clear society needs a better solution to the flood the zone tactic.
https://www.washingtonpost.com/opinions/2023/05/10/cnn-trump-town-hall-lies/

"fear is weaponized even more than hate by leaders who seek to spark violence. Hate is often part of the equation...but fear is  almost always the key ingredient when people feel they must lash out to  defend themselves.
https://www.nytimes.com/2023/05/06/opinion/fear-speech-social-media.html

Ways to Combat Propaganda and Disinformation

Ending false equivalence in choice of editorial voices: "will the  newspaper raise the bar for those local or syndicated [supposedly conservative] voices — i.e.,  requiring the commentary to actually engage in a truthful semblance of a  given issue?
https://www.sltrib.com/opinion/commentary/2023/05/08/commentary-will-we-see-honest/

How the media can cover Trump better this time "Focus on 'the stakes' of the 2024 election, not 'the odds'; Explain Trump’s probable agenda;  Don’t make getting access to Republican politicians or projecting 'neutrality and 'objectivity' a main goal"
https://www.washingtonpost.com/opinions/2023/05/09/trump-2024-cnn-town-hall-media-coverage/

Christian Nationalism Threatens Health Care Professionals, Medicine, Health Care, and Public Health

Much of the "culture war" is about attacking particular patient groups (eg, transgender patients, women seeking abortions, needing birth control or care for such conditions as ectopic pregnancy and miscarriage) and the health care professionals who care for them, or about attacking public health professionals (eg, those involved in pandemic policy) or creating phony public health problems, eg, pornography.

Furthermore, while these attacks are often framed in a biomedical, health care or public health context, the motivation behind them seems to come from extreme sectarianism, particularly Christian nationalism.

Leaked data on right-wing physicians group shows its support of extreme sectarian religious beliefs, recruiting "doctors and medical school students seen as holding Christian views," returning US to a time when "evangelical Christian beliefs" were favored
https://www.wired.com/story/american-college-pediatricians-google-drive-leak/

The state's near-total abortion ban is forcing providers to leave the state "she had to tell a patient that her  pregnancy had a significant fetal abnormality.... her hands were tied. She  couldn’t offer any more care- they had to go elsewhere"
https://www.huffpost.com/entry/idaho-abortion-ban-crisis_n_6446c837e4b011a819c2f792

[Attempting intimidation for taking care of patients] Texas AG Ken Paxton probing Austin children’s hospital [but] "It’s not clear what law Paxton believes Dell Children’s has broken;  Texas does not currently have age limits on gender-affirming care"
https://www.texastribune.org/2023/05/05/ken-paxton-trans-care-investigation-dell-childrens/

Fearing legal repercussions, doctors in Texas say they are risking grave patient harm to comply with new abortion restrictions [abortion bans'  adverse effects:  Extreme sectarian based medicine hurts patients]  
https://www.newyorker.com/news/dispatch/in-the-post-roe-era-letting-pregnant-patients-get-sicker-by-design

Reminder that movement against abortion imposes extreme sectarian religious beliefs on those of other faiths: "Jewish law dating back to the Torah has established that abortion is not murder."
https://www.charlotteobserver.com/opinion/article275261916.html

Confluence of far-right politics and health care nonsense: After DeSantis' coup, New College will host Dr Scott Atlas as commencement speaker. He was a  member of the Trump administration who promoted herd immunity as solution to COVID
https://www.tampabay.com/news/education/2023/05/09/new-college-picks-trump-covid-adviser-scott-atlas-commencement-speaker/

[How sectarianism and superstition creeps into public health] Ladapo's wife who "studied traditional naturopathy, plant and herbal medicine, and shamanism" convinced Ladapo to go to  counseling that that caused him to believe he was following "God’s plan"  
https://www.orlandosentinel.com/2023/05/13/joseph-ladapo-says-anti-vaccine-crusade-was-gods-plan-it-cost-him-his-peers-trust-2/

[More threats to health care] Abortion Clinics Are Dealing with More Arson, Stalking, and Anthrax Threats Now-  Abortion providers feared they’d see an increase in harassment and threats if Roe v Wade was overturned. They were right.
https://www.vice.com/en/article/v7bday/rise-in-abortion-clinic-harassment-after-roe

[Turning sexual hangups into policy? Theocrats go after porn as a public health threat, and...] There’s ‘nothing more timid’ than a man watching porn, Josh Hawley says "There is no risk involved, no exposure to hardship or danger in the least" Promoting sex and relationships that are risky, difficult, dangerous?
https://www.kansascity.com/news/politics-government/article275458201.html

KS Republican county chair says LGBTQ friendly pastors "signed a contract with Satan," plans to "make it hostile to that group of people...small sliver of society...have them move elsewhere, that does a huge amount to shut this  down,”
https://themercury.com/news/republicans-revel-in-divine-plan-to-turn-kansas-into-conservative-sanctuary/article_4a9bbd54-a6fd-5d05-b06f-41785cf4eff6.html

Apparently afraid of prosecution under anti-abortion laws, doctors told patient threatened with a miscarriage "at high risk of life-threatening complications" they could do nothing.  Violating law requiring hospitals to treat patients in emergencies?
So anti-abortion laws make doctors damned if they do (abort pregnancy for patient facing high risk of severe complications) and damned if they don't (by failing to provide emergent care).
https://www.propublica.org/article/two-hospitals-denied-abortion-miscarrying-patient-breaking-federal-law

[More physicians driven away by bans on caring for patients demonized by sectarian extremists] Austin doctors who treated trans kids leaving Dell Children’s clinic after AG Paxton announces investigation
https://www.chron.com/news/houston-texas/article/talk-investigation-forces-tx-doctors-treat-trans-18098101.php

After quacky COVID herd immunity proponent and former Trump administration staffer Dr Scott Atlas invited to speak at DeSantis transformed New College commencement, students raise money to support alternative event
https://wusfnews.wusf.usf.edu/education/2023-05-10/with-former-trump-appointee-speaking-at-their-graduation-new-college-students-plan-alternative-commencement

Doctors forced out by laws restricting treatment of patients with pregnancy complications pushed by extreme sectarians: "Doctors... fleeing the state due to new abortion restrictions....[fearing] 'Being tried as a felon simply for saving someone’s life'"  
https://www.cnn.com/2023/05/13/us/idaho-abortion-doctors-drain

[Reminder: laws based on extreme sectarian religious views impose them on those of other faiths, and harm doctors and patients] Texas doctors depart as attorney general investigates hospital’s gender-affirming care
https://www.theguardian.com/us-news/2023/may/18/texas-hospital-inquiry-doctor-exodus

Follow the Money: Who Funds Attacks on Democracy

It's not just Russia and hostile foreign powers who threaten democracy behind the scenes.  Domestic greed is still a factor. 

Another example of how big national right-wing dark money came to small town to finance local school board candidates who wanted to ban books. We need to figure out who is paying for this, and what's in it for them  
https://www.bostonglobe.com/2023/05/06/nation/how-school-board-race-blue-state-illinois-became-nationally-funded-cage-match/

"Republicans...play this...game of supporting the  wealthy and big business behind the scenes... but making it appear...that they're on the side of the little person....going after the wokeness is a good way to do it...that's not  a bread and butter issue"
https://www.bbc.com/news/business-65428204

[One big corporation refuses to bow down to DeSantis' anti-woke threats.  Will others realize pumping money into extremists' political coffers is bad for business?] Disney Pulls Plug on $1 Billion Development in Florida
https://www.nytimes.com/2023/05/18/business/disney-ron-desantis-florida.html

 

 

The Plot Thickens - How Corrupt was the Trump Administration Under Which Health Care (and the Rest of the US) Operated from 2017 - 2021?

This week, reports appeared that former US President Donald Trump, the Trump Organization of which he is the principal owner, and other people connected to the Trump Organization are the subjects of a special grand jury investigation going on in New York City.  As the Washington Post reported,

 Manhattan's district attorney has convened the grand jury that is expected to decide whether to indict former president Donald Trump, other executives at his company or the business itself, should prosecutors present the panel with criminal charges, according to two people familiar with the development.

Furthermore,

 The move indicates that District Attorney Cyrus R. Vance Jr.’s investigation of the former president and his business has reached an advanced stage after more than two years. It suggests, too, that Vance thinks he has found evidence of a crime — if not by Trump, by someone potentially close to him or by his company.

Vance’s investigation is expansive, according to people familiar with the probe and public disclosures made during related litigation. His investigators are scrutinizing Trump’s business practices before he was president, including whether the value of specific properties in the Trump Organization’s real estate portfolio were manipulated in a way that defrauded banks and insurance companies, and if any tax benefits were obtained illegally through unscrupulous asset valuation.

The district attorney also is examining the compensation provided to top Trump Organization executives, people familiar with the matter have said.

To my knowledge, even though the grand jury could return no indictments, such an investigation of a former president and his business is unprecedented in modern times.  It suggests the possibility that this particular president was more unethical and corrupt than any other, and that he might turn out to be the only actually criminal president.  Thus it suggests that all our concerns about unethical practices, conflicts of interest, and corruption of the Trump administration, and their effects on corruption in other sectors, particularly health care, were not unfounded.

Thus, I will take this opportunity to review these concerns.

  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 from 2017 - 2021 only seemed to be getting worse, given the increasing evidence that the Trump administration was 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, 2018, 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 accommodations 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.

Further reports on Trump and associates' conflicts of interest and corruption appeared through 2019, as further documented in this post.

Discussion

We noted in our last summary post on conflicts of interest and corruption in the Trump administration that the topics of corruption, health care corruption, and the likely corruption of the Trump administration remained largely anechoic.   

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.

Once Trump left office, there has not been much more discussion.  There have been brief reports in the media that many investigations of Trump and cronies are ongoing.  For example, an article in the
Washington Post in March 2021 noted "the [NY] state attorney general has subpoenaed his lawyers, his bankers, his chief financial officer — even one of his sons.... Former president Donald Trump is also facing criminal investigations in Georgia and the District of Columbia related to his efforts to overturn the 2020 election."  Also, "In Washington, D.C. Attorney General Karl A. Racine (D) has also opened a criminal investigation into Trump’s actions on Jan. 6" and "the Justice Department, in the meantime, is conducting a broad investigation of the Jan. 6 Capitol attack."  Yet, as we documented here, prior to becoming president, Trump and his associates enjoyed practical impunity, escaping convictions and penalties multiple times. There is no certainty he will not maintain his impunity in the future.

Trump is no longer president, but he enjoys continuing support from many in his party, and has suggested he might run again.  How will we ever make a meaningful dent in health care corruption if we cannot end the impunity of our top political leadership? 

Update: State of Play in US Health Care Dysfunction Prior to the Coronavirus Pandemic

 Introduction: the Sorry History of US Health Care Dysfunction

We have been talking about health care dysfunction for a very long time, starting with a publication in 2003.

To better understand health care dysfunction, I interviewed doctors and health professionals, and published the results in Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).  In that article, I postulated that US physicians were demoralized because their core values were under threat, and identified five concerns:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research studies

After that my colleagues and I have tried to raise awareness of these and related issues, now mainly through the Health Care Renewal blog.  We also set up FIRM - the Foundation for Integrity and Responsibility in Medicine,  a US non-profit organization, to try to provide some financial support for the blog.

It has been a slog.  For years  health care dysfunction, at least we we defined and discussed it, was practically a taboo topic.  From 2003 through 2016 we felt there were only a few incremental improvement in some aspects.  However, the advent of Donald Trump and his "base," and the first years of the Trump presidency expanded the scope and increased the intensity of health care dysfunction.  It got bad enough that the phrase "health care dysfunction" actually made it to a presidential debate, albeit a Democratic primary debate, in November, 2019.  On that occasion we summarized what we thought were the ongoing issues. 

Since then, things have only gotten worse. Then in 2020 the coronavirus pandemic spread around the globe.  That only provided more opportunities for the Trump administration to amplify dysfunction.

Now, on the occasion of the Trump administration's apparent defeat in the presidential election (setting aside for the  moment any legal or extra-legal challenges to the results), I will update what the state of play in health care dysfunction was prior the pandemic.  At a later time we will discuss how the pandemic gave Trump et al an opportunity to supercharge health care dysfunction.

The Multiple Dimensions of Health Care Dysfunction Pre-Pandemic

Since 2003 we have broadened our thinking about what constitutes and causes US (and more global) health care dysfunction. Early on we noticed a number of factors that seemed to enable increasing dysfunction, but were not much discussed.  These factors notably distorted how medical and health care decisions were made, leading to overuse of excessively expensive tests and treatments that provided minimal or no benefits to outweigh their harms.  The more we looked, the more complex this web of bad influences seemed.  Furthermore, some aspects of it seemed to grow in scope during the Trump administration.

A brisk summary of these often complex issues follows.

 Threats to the Integrity of the Clinical Evidence Base

The clinical evidence has been increasingly affected by manipulation of research studies.  Such manipulation may benefit research sponsors, now often corporations who seek to sell products like drugs and devices and health care services.  Manipulation may be more likely when research is done by for-profit contract research organizations (CROs). When research manipulation failed to produce results to sponsors' liking, research studies could simply be suppressed or hidden.  The distorted research that was thus selectively produced was further enhanced by biased research dissemination, including ghost-written articles ghost-managed by for-profit medical education and communications companies (MECCs). Furthermore, manipulation and suppression of clinical research may be facilitated by health care professionals and academics conflicted by financial ties to research sponsors.

These issues did not get much attention since November, 2019, during the Trump presidency, pushed aside by the administration's "flooding of the zone" with distractions.

 Deceptive Marketing

The distorted evidence base was an ingredient that proved useful in deceptive marketing of health care products and services. Stealth marketing campaigns became ultimate examples of decpetive marketing.  Deceptive marketing was further enabled by the use of health care professionals paid as marketers by health care corporations, but disguised as unbiased key opinion leaders, another example of the perils of deliberate generation of  conflicts of interest affecting health care professionals and academics.

These issues also did not get much attention since November, 2019.

Distortion of Health Care Regulation and Policy Making

Similarly, 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.

More recently,  as we noted here, we became aware of efforts by foreign powers to spread such disinformation for political, not just financial gain, e.g., 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

Furthermore, 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.

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 (look here).   We found multiple 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.

Since November, 2019, cases of US government officials traversing the revolving door continued (look here).

Bad Leadership and Governance

Health care leadership was often ill-informed.  More and more people leading non-profit, for-profit and government have had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.  Lately, during the Trump administration, 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 look here).  We had not previously expected leaders of government to be personally knowledgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values. Often business trained leaders put short-term revenue ahead of patients' or the public's health.  In addition, 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. Then, we started seeing appointed government health care leaders who lacked medical, health care or public health background or expertise but also whose agenda also seemed to be overtly religious or ideological, without even a nod to patients' or the public' health (look here).
 
Leaders of health care organizations increasingly have conflicts of interest.  Moreover, we have found 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.

In the Trump administration, corrupt leadership extends from the corporate world to the highest levels of the US government.  We discussed the voluminous reports of conflicts of interest and corruption affecting top leaders in the executive branch, up to and including the president and his family (look here). 

Since November, 2019, periodic updates about the President Trump and family's extensive conflicts of interest, and particularly how some of his conflicts appear to violate the US Constitution (eg, look  here).  Not unexpectedly, the latest version of Transparency International's Corruption Perception Index showed that the public perceived the US government under Trump has a worsening corruption problem (look here). 

One cannot expect effective enforcement of ethics rules and anti-corruption laws in such an environment.

Abandonment of Health Care as a Calling

A US Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members, leading to the abandonment of traditional prohibitions on the commercial practice of medicine.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be "commercialized, nor treated as a commodity in trade."  After then, it ceased trying to maintain this prohibition. Doctors were pushed to be businesspeople, and to give making money the same priority as upholding their oaths. Meanwhile, hospitals and other organizations that provide medical care are increasingly run as for-profit organizations. The physicians and other health care professionals they hire are thus providing care as corporate employees, resulting in the rise of the corporate physician.  These health care professionals may be further torn between their oaths, and the dictates of their corporate managers. 

 These issues also did not get much attention since November, 2019.

Perverse Incentives Put Money Ahead of Patients, Education and Research

We have extensively discussed the perverse incentives that seem to rule the leaders of health care. Financial incentives may be large enough to make leaders of health care organizations rich.  Incentives often prioritize financial results over patient care.  Some seem to originate from the shareholder value dogma promoted in business school, which de facto translates into putting current revenue ahead of all other considerations, including patient care, education and research (look here).

These issues also did not get much attention since November, 2019.

 Cult of Leadership

Health care CEOs tend now to be regarded as  exalted beings, blessed with brilliance, if not true "visionaries," deserving of ever increasing pay whatever their organizations' performance.  This phenomenon has been termed "CEO disease" (see this post).  Afflicted leaders tend to be protected from reality by their sycophantic subordinates, and thus to believe their own propaganda.

 These issues also did not get much attention since November, 2019.

Managerialism

Leadership of health care organizations by managers with no background in actual health care, public health, or biomedical science has been promoted by the doctrine of managerialism which holds that general management training is sufficient for leaders of  all organizations, regardless of their knowledge of the organizations' fundamental mission.

These issues also did not get much attention since November, 2019.

Impunity Enabling Corrupt Leadership

Most cases involving corruption in large health care organizations are resolved by legal settlements.  Such settlements may include fines paid by the corporations, but not by any individuals.  Such fines are usually small compared to the revenue generated by the corrupt behavior, and may be regarded as costs of doing business.  Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements.  The former were originally meant to give young, non-violent first offenders a second chance (look here).  However, in most instances in which corruption became public, are no negative consequences ensue for the leaders of the organizations on whose watch corrupt behavior occurred, or who may have enabled, authorized, or directed the behaviors.

These issues also did not get much attention since November, 2019.

Taboos

Some of the above topics rarely appeaedr in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant. 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.  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.

However,in the Trump administration,  we began to also note examples of government officials 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 (look here).

These issues also did not get much attention since November, 2019.

Discussion

In 2017, we said that it was time to consider some of the real causes of health care dysfunction that true health care reform needs to address, no matter how much that distresses those who currently most personally profit from the status quo.

Furthermore, in 2019 we asserted that all the trends we have seen since 2017 are towards tremendous government dysfunction, some of it overtly malignant, and much of it likely enabling even worse health care dysfunction.

Now that there is the prospect of a new US administration, we hope health care and public health professionals, patients, and all citizens will have a much more vigorous response to it.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways. As the coronavirus pandemic rages, the need to make our health care and public health less dysfunctional is increasingly apparent.  If not now, when? 

The President Baselessly Accuses Physicians of Inflating COVID-19 Case Rates for Financial Gain. Will Health Care Leaders Finally Challenge Him?

Introduction: the Trump Administration's Attacks on Whistleblowers

A major component of US (and global) health care dysfunction has been the anechoic effect, the ability of those in power to silence discussion of topics that might put them in a bad light.  At risk is anyone who might become a whistle-blower about poor quality care or patient safety problems; malfeasance, corruption or crime; etc.    Whistle-blowing is never easy for health care professionals.  Those who do so have been ostracized, lost jobs or been subject to lawsuits.  

 

The Trump administration has a history of intimidating health care whistle-blowers.  For example, in 2019 we noted how the administration silenced scientists in the NIMH who might disagree with a Trump tweet about mental health and violence, and a CDC official about the relationship between climate change and public health.  In February, 2020, we noted how the administration tried to intimidate a whistle-blower at the DHHS who reported deficiencies in early management of coronavirus patients. In May, 2020, we noted how Trump himself tried to verbally intimidate the President of the American Association of Nurse Practitioners when she complained in a White House meeting about the lack of personal protective equipment in facilities caring for COVID-19 patients. 

That was bad enough, but then I heard the news today, oh boy. 

Trump Claims Doctors Over-Report COVID-19 to Make More Money

In the last week, at the end of the run up to the election, President Trump doubled down.  He blamed the entire US medical profession for inflating the severity of COVID-19, which is at odds with his happy talk message that we have "turned the corner" on the virus.

On Oct 26, 2020, per Boston.com:

At a campaign rally in Waukesha, Wisconsin on Saturday, Trump told his supporters that 'doctors get more money and hospitals get more money' if they say people died from COVID-19 rather than their comorbidity — a conspiracy theory that has been debunked — as the president pressed his case that the United States is 'rounding the turn' on the pandemic, despite public health officials stressing repeatedly that the opposite is true.

On Oct 31, 2020, per CNN:

President Donald Trump on Friday baselessly claimed that doctors are inflating the coronavirus death count for monetary gain while cases, hospitalizations and deaths surge across the country.

'Our doctors get more money if someone dies from Covid. You know that, right? I mean our doctors are very smart people. So what they do is they say 'I'm sorry but everybody dies of Covid,' ' Trump said, without citing any evidence, at a rally in Waterford Township, Michigan.

In addition, per another CNN report on the same date, he also said:

'With us, when in doubt -- choose Covid,' Trump said. 'Now they'll say 'Oh that's terrible what he said,' but that's true. It's like $2,000 more, so you get more money.'

Meanwhile, we learned that this attack on physicians was part of a long-standing strategy.  Per CNN on October 28, 2020:

President Donald Trump's son-in-law and senior adviser, Jared Kushner, boasted in mid-April about how the President had cut out the doctors and scientists advising him on the unfolding coronavirus pandemic, comments that came as more than 40,000 Americans already had died from the virus, which was ravaging New York City.In a taped interview on April 18, Kushner told legendary journalist Bob Woodward that Trump was 'getting the country back from the doctors' in what he called a 'negotiated settlement.' 

So,

'Trump's now back in charge. It's not the doctors.'

The statement reflected a political strategy. Instead of following the health experts' advice, Trump and Kushner were focused on what would help the President on Election Day. By their calculations, Trump would be the 'open-up president.'

So Trump was willing to disregard the advice of public health and health care professionals, and to verbally attack and intimidate them to support the happy talk of his election strategy, even if that meant more disease, more morbidity, and more deaths.  

Finally, Influential Health Care Professionals Speak Out

Numerous individual health care professionals, particularly those on the front lines of the pandemic, have spoken out about the Trump administration's mismanagement of the crisis. They have emphasized issues such as the lack of adequate personal protective equipment in health care facilities; the need for personal action to reduce the spread of infection; and the folly of premature reopening of the economy (look here and here).  They have actively fought disinformation about the pandemic, including that disseminated by Russia and other Trump allies, and by Trump himself (look here). Yet until the last week there were only a few instances of physicians in positions of leadership and influence willing to support their colleagues on the front lines in their challenge to President Trump.

In September, after the Trump administration's total mismanagement of the coronavirus pandemic had become manifest, and in response to its efforts to turn the CDC, the lead US public health agency, into a propaganda outlet, we complained that no health care leaders, "no chairpersons, deans, chancellors, vice-presidents for health affairs, university presidents; or journal editors, hospital executives, leaders of professional societies, executives of health care corporations, etc, etc were willing to publicly challenge Trump and his top collaborators.  Such leaders so far have also been unwilling to challenge Trump's efforts to spread disinformation."

Since then, editors of two major British medical journals have condemned the actions of the Trump administration.  Lancet Oncology and the prestigious British Medical Journal have published editorials calling out Trump.  

Yet the first instance of a real challenge to Trump from the leaders of US health care did not come until October, 2020.  At least it was from the editor and editorial board of perhaps the best-known American medical journal, the New England Journal of Medicine. They called for Trump to be voted out of office for "dangerous incompetence."

Now that Trump has tried to intimidate physicians in general, days before the election, there is the beginning of pushback from a few leaders of medical societies and academic institutions.  Per Boston.com:

The American College of Emergency Physicians issued a statement rebutting Trump’s  claim, calling it 'reckless and false' that doctors are over-counting deaths related to COVID-19.

'To imply that emergency physicians would inflate the number of deaths from this pandemic to gain financially is offensive, especially as many are actually under unprecedented financial strain as they continue to bear the brunt of COVID-19,' the group wrote. 'These baseless claims not only do a disservice to our health care heroes but promulgate the dangerous wave of misinformation which continues to hinder our nation’s efforts to get the pandemic under control and allow our nation to return to normalcy.'

 Also,

 Ashish Jha, dean of the Brown University School of Public Health, didn’t mince words. 

'This is crap,' he wrote of the conspiracy theory pushed by the president. 'Everyone knows it.'

In a thread on Twitter, he laid out in detail the debunking of the theory, blasting Trump for continuing to peddle it. 

'While doctors and nurses are dying on the front lines, our leaders aren’t working to get them protective equipment,' Jha wrote. 'Instead, they are falsely accusing our front line providers of fraud. It’s reprehensible.'

Per Forbes on Oct 31, 2020:

The president of the American College of Physicians characterized Trump's comments as 'a reprehensible attack on physicians' ethics and professionalism.'

Per CNN:

Susan Bailey, the president of the American Medical Association, said in a statement that the claim that doctors are overcounting Covid-19 patients or 'lying to line their pockets is a malicious, outrageous, and completely misguided charge.' 

Conclusion

Better late than never. Kudos to the ACEP, ACP, AMA, and the Dean of the Brown School of Public Health. (Full disclosure: I am a voluntary faculty member at the Alpert Medical School at Brown University.)  

But where are all the leaders of the other medical societies, and all the other US academic medical institutions, not to mention the leaders of US hospitals and other health care organizations? The pandemic is getting worse and the election in three days.

We said in May:  

So health care professionals trying just to uphold their mission to put patients' and the public's health first have stumbled into a conflict far beyond anything we have seen in our lifetimes.  Upholding the mission will be difficult, unpleasant, quite likely dangerous.  The danger is not just from the virus, but from our fellow humans.  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 increased 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?'

It is Halloween, October 31, 2020.  Again, "if not now, when?"

 

 

Will US Health Care Leadership Challenge President Donald Trump's Propagation of Coronavirus Disinformation, a Major Source of the "Infodemic"?

Introduction: The Plight of Health Care Professionals Who Challenge the "Infodemic"

The coronavirus pandemic has been accompanied by a disinformation pandemic, sometimes called the "infodemic."  We have discussed how individual health care professionals trying to counter disinformation by educating patients and the public have encountered resistance, opposition and worse.  Here we discussed how health care professionals who sought to educate demonstrators who advocated quickly "reopening" the economy about the perils of doing so were subject to screams, insults, and charges they were "crisis actors."  Here we discussed how health care professionals who tried to counter disinformation online were subject to online challenges, insults and threats, and worse, how President Trump's campaign was organizing a cadre of "extremely pro-Trump" professionals who would parrot his messages, no matter how disinformative.

The Worsening Infodemic

Since then the disinformation problem has gotten much worse.  A recent study by Islam and colleages(1)

identified 2,311 reports of rumors, stigma, and conspiracy theories in 25 languages from 87 countries. Claims were related to illness, transmission and mortality (24%), control measures (21%), treatment and cure (19%), cause of disease including the origin (15%), violence (1%), and miscellaneous (20%). Of the 2,276 reports for which text ratings were available, 1,856 claims were false (82%).

So the challenge to health care professionals from disinformation has gotten much worse. On August 18, 2020, the New York Times reported

Doctors on the front lines of the global pandemic say they are fighting not just the coronavirus, but also increasingly combating a never-ending scourge of misinformation about the disease that is hurting patients.

The Times article included multiple anecdotes suggesting that the infodemic is directly harming patients:

An internist in New York treated a vomiting patient in May who drank a bleach mixture as part of a fake virus cure found on YouTube.

And in June a paramedic in Britain aided a clearly sick man who had refused to go to a hospital after reading misleading warnings about poor coronavirus treatment on social media.

Also,

Dr. Ryan Stanton, an emergency room physician in Kentucky, said a number of sick patients had waited until it was nearly too late to visit a hospital because they were convinced by what they had read online that Covid-19 was fake or 'no big deal.'

Similarly, the article by Islam et al noted estimates of the numbers of people who may have had adverse effects because of actions they took in response to disinformation: 800 dead and 5876 hospitalized world-wide after "consuming methanol as a cure for coronavirus"; "rumors have been the reported cause of 30 deaths in Turkey;" etc.

According to the Times article, health professionals who tried to challenge disinformation did not find it easy:

An emergency room doctor in Illinois was accused in April of profiting from naming coronavirus as the cause of a patient’s death, a rumor spreading online.

Also,

Some doctors say they face abuse when they participate in online discussions to correct the record.

And,

Dr. Mell, the physician in Illinois, encounters regular abuse from Facebook users when he has pushed back on false information.

Presumably efforts to combat disinformation should be informed by understanding of its sources.  The Times article briefly discussed physicians opinions of them. 

Before the pandemic, medical professionals had grown accustomed to dealing with patients misled by online information, a phenomenon they called Dr. Google. But in interviews, more than a dozen doctors and misinformation researchers in the United States and Europe said the volume related to the virus was like nothing they had seen before. They blamed leaders like President Trump for amplifying fringe theories, the social media platforms for not doing enough to stamp out false information and individuals for being too quick to believe what they see online.

A Major Source of the Infodemic: the US President and His Cronies

It would have been unthinkable a few years ago, but some physicians now are willing to state that a major source of dangerous health care disinformation is the current US president.

[Trump Chicago Hotel]


 In fact, the media has been replete with accounts of such disinformation propagated by President Trump.  Multiple  articles have cataloged examples of such disinformation.  The most recently updated were in published  in August, 2020, in the Washington Post, and the Atlantic.

Here is a summary of instances of disinformation that Mr Trump has peddled related to the coronavirus pandemic.  Sources are the two articles above or as noted.

Epidemiology, Diagnosis, Prognosis

The coronavirus is the same as influenza: "This is a flu.  This is like a flu." (from the Washington Post, March, 2020.)  However, coronavirus differs from the flu in its structure, epidemiology and clinical manifestations.

The coronavirus pandemic would spontaneously diminish or vanish, e.g., "disappear," "fade away," or "go away."  There is no rationale for this, and no trend in this direction in the US.

The pandemic is already going away, e.g., “Coronavirus numbers are looking MUCH better, going down almost everywhere,” and cases are “coming way down.”  The national case rate did decrease for a time, but then greatly increased, and now is considerably higher than it was a few months ago.

COVID-19 is not a severe disease, especially for children, e.g., children are "virtually immune," "99% of COVID-19 cases are 'totally harmless'" There is no evidence children are immune.  Cases in children are now rising.  The rate of significant morbidity or death is much higher than 1%.

Tests for coronavirus in the US are extremely accessible, e.g., "anybody that needs a test gets a test," "we're going up proportionally very rapidly," the US has done more testing "than all other countries combined."  There have been multiple reports of shortfalls in and inaccessibility of testing.

The US case rate is high because the US testing rate is so high: "There is a rise in Coronavirus cases because our testing is so massive and so good, far bigger and better than any other country." (from the Independent, July, 2020.)  By many measures, the US testing rate is lower than that of many other developed countries.

If testing stopped, then there would be no more cases, e.g. "If we stop testing right now, we'd have very few cases, if any." (from the Independent, June, 2020.)  This appears to be an instance of the logical fallacy of the appeal to ignorance, often characterized as "absence of evidence does not imply evidence of evidence" (see this from Logically Fallacious). 


Prevention, Management, Treatment

Hydroxychloroquine is safe and effective as a treatment or preventative drug, e.g., "I happen to be a believer in hydroxy.  I used it.  I had not problem,"  There is no good evidence that hydroxychloroquine is an effective treatment or preventative measure.  There is evidence that it has important and not rare adverse effects.

Bleaches or disinfectants could be administered internally for prevention or treatment  (from the New York Times, April, 2020.)  Doing so actually would be extremely dangerous, and possibly fatal. Note that there is reason to suspect that Trump's disinformation on this topic has harmed people. After he publicly discussed using bleach or disinfectant internally as a treatment for coronavirus, calls to poison control centers seemed to rise (from Vox, April, 2020.)  The article by Islam et al noted instances of patients harmed by ingesting disinfectant.

No Organized Challenges to Trump's Disinformation from Health Care Professionals

Donald Trump has extensively promoted disinformation about the coronavirus.  As US President, he commands a substantial "bully pulpit."  Essentially everything he says publicly is reported by US and foreign media.  He holds forth on Twitter daily, reaching millions of followers.  Thus his information is influential, and apparently dangerous.

Health care professionals have seen patients whose beliefs about the coronavirus pandemic are now apparently inspired by disinformation, including specific points pushed by Mr Trump.  These beliefs have led to dangerous actions, and at times adverse effects.  Professionals sworn to put their patients' welfare ahead of all other concerns are thus in a bind, needing to challenge the leader of the richest country in the world to persuade their patients to avoid dangerous choices.

While physicians on the front lines are now struggling with how to best deal with the disinformation influencing their patients coming from the highest office in the US, they have gotten little support from their leaders.  I found only a few instances of physicians in positions of leadership and influence willing to challenge President Trump.

The most direct challenge was found in an editorial in the British Medical Journal by two American authors, both academics at respected institutions, one a full professor in a global health institute.  The authors had the courage to entitle their article "Donald Trump: a political determinant of covid-19." (2)  They asserted that

After the US confirmed its first case of covid-19 on 22 January 2020, Trump responded with false reassurances, delayed federal action, and the denigration of science.

In particular, they were willing to state:

Trump’s anti-scientific pronouncements during covid-19 have been particularly perilous. On 28 February, he said that the coronavirus would soon disappear on its own 'like a miracle.' On 21 March, he promoted the anti-malarial drug hydroxychloroquine for 'use immediately' as a treatment, despite the lack of evidence for its effectiveness. His promotion triggered 'panic-buying, skyrocketing prices, and overdoses in malaria-prone regions in Africa and South Asia,' and led to shortages of the drug for those who need it to treat other conditions such as lupus, for which it has proved benefit. Rick Bright, the director of the US agency that oversees covid-19 vaccine development, says he was removed from his post because he questioned Trump’s promotion of hydroxychloroquine. On the day that the CDC advised the public to wear face masks, Trump said he would not wear one himself. On 23 April, Trump suggested that injecting disinfectant or bringing 'light inside the body' could cure covid-19, prompting experts to urgently warn the public against inhaling or ingesting bleach.

Beyond this moral clarity, I could find only one other instance of a senior academic physician directly challenging Trump, and that was only indirectly about Trump's enthusiasm for disinformation.  From the Independent, July, 2020:

A leading professor of medicine has called president Donald Trump 'unteachable' on the subject of masks and said that it indicates he is not competent to manage the response to the coronavirus pandemic.

In an appearance on CNN, Dr Jonathan Reiner, professor at the George Washington School of Medicine & Health Sciences, responded to the president’s latest remarks regarding the wearing of masks.

'He is unteachable and I can’t understand it. His failure to understand this simple public health measure, his reluctance to accept the advice of all of his public health experts, makes me wonder whether he is qualified now to manage this.'

I have so far found no other instances of leading academics, like professors, chairpersons, deans, chancellors, vice-presidents for health affairs, university presidents; or of journal editors, hospital executives, leaders of professional societies, executives of health care corporations, etc, etc who were willing to publicly challenge Trump's disinformation.  I have found no official statements from any of these institutions or organizations that challenge Trump's disinformation. 

At best, medical societies have put out statements reiterating the need to base policy about the pandemic on the best evidence.  For example, the American College of Physicians put out a statement that supported "the use of scientific expertise, based on the best available evidence, in the fight against COVID-19." However, these statements do not explain the context, that is, how the current president has denigrated scientific expertise and evidence as informative in efforts to manage the pandemic.

Fighting a deadly pandemic is hard enough.  It is gut wrenching that the fight is being subverted by political leaders spreading disinformation.  It is sad that front line clinicians are hardly supported by those who claim to lead them.  Where is the courage?  Where is the outrage?

"If not now, when?"


References

1.  Islam MS, Sarkar T, Khan et al. COVID-19-related infodemic and its impact on public health: a global social media analysis. Am J Trop Med Hyg 2020. Link here

2. Yamey G, Gonsalves G. Donald Trump: a political determinant of covid-19. Brit Med J 2020; ; 369 doi: https://doi.org/10.1136/bmj.m1643. Link here.