Thursday, October 15, 2020

Adding (Corrupt Financial) Insult to (Coronavirus Pandemic) Injury

We have frequently discussed the voluminous evidence that President Trump, his family and his cronies have many more conflicts of interest, and have acted corruptly orders much more frequently than any other US administration (see this summary).  These conflicts of interest and corrupt actions likely have badly hurt the country and its people.  

Now a new story suggests that the administration's selective dissemination of information about the coronavirus pandemic may have enabled the enrichment of its supporters while simultaneously endangering public health.  This may be a new low.

Warning Donors and Supporters While Deceiving the Public

A report by the New York Times on October 15, 2020 suggested that early on top Trump administration officials warned favored donors and supporters that the coronavirus was much more dangerous than the administration had admitted publicly.  This allowed the recipients to personally profit: 

On the afternoon of Feb. 24, President Trump declared on Twitter that the coronavirus was 'very much under control' in the United States, one of numerous rosy statements that he and his advisers made at the time about the worsening epidemic. He even added an observation for investors: 'Stock market starting to look very good to me!'

But hours earlier, senior members of the president’s economic team, privately addressing board members of the conservative Hoover Institution, were less confident. Tomas J. Philipson, a senior economic adviser to the president, told the group he could not yet estimate the effects of the virus on the American economy. To some in the group, the implication was that an outbreak could prove worse than Mr. Philipson and other Trump administration advisers were signaling in public at the time.

The next day, board members — many of them Republican donors — got another taste of government uncertainty from Larry Kudlow, the director of the National Economic Council. Hours after he had boasted on CNBC that the virus was contained in the United States and 'it’s pretty close to airtight,' Mr. Kudlow delivered a more ambiguous private message. He asserted that the virus was 'contained in the U.S., to date, but now we just don’t know,' according to a document describing the sessions obtained by The New York Times.

The document, written by a hedge fund consultant who attended the three-day gathering of Hoover’s board, was stark. 'What struck me,' the consultant wrote, was that nearly every official he heard from raised the virus 'as a point of concern, totally unprovoked.'

The consultant’s assessment quickly spread through parts of the investment world. U.S. stocks were already spiraling because of a warning from a federal public health official that the virus was likely to spread, but traders spotted the immediate significance: The president’s aides appeared to be giving wealthy party donors an early warning of a potentially impactful contagion at a time when Mr. Trump was publicly insisting that the threat was nonexistent.

Those Who Got the Information Were Trump Cronies and Supporters

 Note that those most likely to hear about the more realistic and dire, but non-public predictions of Trump insiders were people who were supporters of and donors to Trump et al at the Hoover Institute, whose board

includes the media mogul Rupert Murdoch and the venture capitalist Mary Meeker, neither of whom attended the meetings in February

Also,

The Hoover Institution has close relations with the Trump administration, and the White House has pulled from its ranks to fill top positions. Joshua D. Rauh, one of the White House economists addressing the Hoover crowd on Feb. 24, has returned to the institution, where he worked previously. Kevin Hassett, who moderated the panel and has served as the chairman of the White House Council of Economic Advisers, is now a Hoover Institution fellow.

Receiving Information Enabled Personal Profit

Those who heard about the Trump administration insider's non-public concerns soon acted on them, thus profiting from their enhanced knowledge of the pandemic to come:

'Short everything,' was the reaction of the investor, using the Wall Street term for betting on the idea that the stock prices of companies would soon fall.

That investor, and a second who was briefed on the Hoover meetings, said that aspects of the readout from Washington informed their trading that week, in one case adding to existing short positions in a way that amplified his profits

 


Corruption that Endangered Public Health

 Note that the Times article stated

it is not apparent that any of the communications about the Hoover briefings violated securities laws. The Justice Department and the Securities and Exchange Commission would have several hurdles to clear before establishing that Appaloosa or other funds that received insights from Mr. Callanan, either directly or through intermediaries, acted improperly.

However, consider this: The Trump administration had a duty to manage the growing coronavirus pandemic so as to protect the lives and health of the American people.  The administration had access to considerable information about the pandemic which was not widely available.  We know from reporting by Bob Woodward that President Trump knew how serious the pandemic was likely to be, but concealed that information to prevent "panic." In particular, per Reuters, September 9, 2020:

'I wanted to always play it down,' Trump told author Bob Woodward on March 19, days after he declared a national emergency. 'I still like playing it down, because I don’t want to create a panic.'

Yet, the Trump administration did not act on the information it had.  Many public health experts believe its inaction resulted in the loss of thousands of lives, and resulted in many more cases of COVID-19, some quite morbid that might have been prevented by more forceful action.  Trump avoided effective action while constantly reassuring the public. Meanwhile, his appointees were giving Trump supporters and donors cause to think that the pandemic would actually be quite serious.  Some of them took advantage of that information to make financial transactions, like selling stocks short, enabling them to personally profit.

Transparency International defines corruption as

Abuse of entrusted power for private gain

Whether or not they were legal, the actions above by Trump and his political appointees appeared to have abuse their entrusted for the private gain of their supporters and donors.

We have frequently discussed, most recently here, the many conflicts of interest affecting and corrupt action by Trump, his family, and his cronies.  This case above adds to that list.  

We know of one way that the conflicts of interest generated by Trump's continued ownership of the Trump Organization may have enabled his mismanagement of the coronavirus pandemic. We discussed here and here how concerns about financial losses incurred by the Trump Organization due to lockdowns and other restrictions by state and local public health authorities to manage the pandemic may have influenced Mr Trump to urge premature reopening of the economy.  Thus he may have prioritized his personal finances over public health.

However, the danger of the apparent corruption revealed by the newest case seems more direct. Trump and cronies' restricted dissemination of information about the pandemic allowed enrichment of their supporters while endangering the population at large. In any case, once again, private profit trumped public health.

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, October 04, 2020

For Coronavirus Pandemic Management, In Johnson and Johnson and Pfizer Trump Trusts: Public Health at Risk ... Due to Corruption?

In 2003 we found that health care professionals felt one reason for US health care dysfunction was that it was increasingly "dominated by large, bureaucratic organizations which do not honor ... [its] core values"(1)  These organizations included big health care corporations like pharmaceutical, biotechnology and device companies, and large non-profits like hospital systems.  Since then, the power of the largest health care organizations has only increased.  Now we learn how President Trump seems to have ceded control of the management of the coronavirus pandemic to a few big pharmaceutical companies.

In "Massive Companies" Like Johnson and Johnson and Pfizer, Not the FDA, We Trust?

The first US presidential debate included a performance by the president which was likened to something out of professional wrestling. In addition, as reported by StatNews on September 29, 2020:

Throughout a turbulent, disorganized, and hostile debate, Trump highlighted his government’s efforts on vaccine development, pledging, dubiously, that the country is 'weeks away from a vaccine' and contradicting high-level officials within his own government who have suggested it will be months, at least, before a vaccine is available.

And

Trump viewed vaccines and his government’s vaccine moonshot, known as Operation Warp Speed, as the centerpiece of a pandemic response and his campaign rhetoric.

Yet Trump continued to undercut two officials central to that effort: Moncef Slaoui, Warp Speed’s director, and Robert Redfield, the director of the Centers for Disease Control and Prevention. They are 'both wrong' for standing by published timelines for vaccine distribution, Trump said, which show vaccines will be widely available to the U.S. public by mid-2021.

 So

At one point, Trump even appealed to drug companies’ trustworthiness on vaccine safety, asking Biden at one point: 'You don’t trust Johnson & Johnson, Pfizer?'

This mirrored what he had said a few days before.  Per the New York Times on September 23, 2020, in the context of threatening to counter efforts by the FDA to impose strict efficacy and safety standards on coronavirus vaccines, apparently so he could speed them to market and then claim a major victory against the pandemic, Trump said

he had 'tremendous trust in these massive companies' that are testing the vaccines, adding, 'I don’t know that a government as big as' the federal government could do as well.

In "massive companies," like Johnson and Johnson and Pfizer we trust? 

Trump Has Benefited from the Actions of Leaders of Massive Corporations, Including Johnson and Johnson and Pfizer

Making pandemic management policy under the motto of  "in massive companies we trust" fits with Trump's coziness with big corporate leadership, particularly that of  Johnson and Johnson and Pfizer. 

Health Care Corporations, Their Executives and Board Members Supported Trump's Political Causes

Trump's campaign has benefited from massive support from big corporations, including pharmaceutical companies, specifically Johnson and Johnson and Pfizer


Large health care corporations have funded dark money organizations that  strongly supported Trump and his agenda.  For example,Johnson and Johnson made large donations to the US Chamber of Commerce, which at that time "mostly endorses Republican candidates" and had contributed to a campaign to support Trump's appointment of US Supreme Court Justice Kavanaugh (look here).  

Johnson and Johnson and Pfizer are members of pharmaceutical trade organization PhRMA, which also acts as a political funding organization.  According to Sludge on April 6, 2020:

[The] Job Creators Network has been funded by Pharmaceutical Research and Manufacturers of America (PhRMA)

And,

The Job Creators Network was founded in 2011 by billionaire Home Depot co-founder Bernard Marcus, a major GOP donor who spent more than $7 million through outside groups to help elect Trump in 2016. Marcus has said that he plans to spend part of his fortune to help re-elect Trump in 2020.

We have noted that prior to the 2018 election, health care corporate CEOs often gave large political donations heavily biased in favor of Republicans.  For example, the CEO of Pfizer, Ian Read, gave $145K to Republicans, but only $26K to Democrats (look here).

Also, Trump appointed Robert (Woody) Wood Johnson IV, heir of the family which founded Johnson and Johnson, and major Johnson and Johnson shareholder, as ambassador to the UK.   The New York Times reported in July, 2020, that Johnson's support of Trump included using his official position to tout Trump's golf resort in Scotland as a site for the British Open. Johnson's monetary support for Trump's causes included

$1.2 million to the Republican National Committee and the Trump Victory fund, as well as another $1 million to America First Action, a super PAC supporting Mr. Trump’s re-election.

Health Care Corporations, Their Executives and Board Members Patronized Trump's Properties to His Personal Benefit

The biggest owner of the Trump Organization is President Trump, so he personally profits from revenue to it. Health care corporate managers and owners, including those of Johnson and Johnson and Pfizer, and health care corporate lobbyists, including one who worked for Pfizer, patronized Trump Organization properties directly or indirectly.  For example, according to the Observer in 2013,

Johnson & Johnson heiress Libet Johnson loved the Trump International Hotel and Tower [in New York]—so much so that it’s nearly impossible to keep track of [all the condominiums she owned in it]. So difficult, in fact, that we lost count.

 

Lobby, Trump International Hotel, Washington, DC

Big corporate donors, including Pfizer, supported the Trump Inauguration Committee, which then spent considerable sums at the Trump International Hotel in Washington DC, to Trump's personal benefit (see Newsweek, January, 2019).  Prominent Pfizer lobbyist Kenneth M. Duberstein is a long-time member of Trump's Mar A Lago resort in Florida (New York Times, 2017).

Trump's Coziness with Managers and Owners of Massive Corporations, Including Johnson and Johnson and Pfizer

Health Care Corporate Executives Got Access to Trump

Trump has spent a lot of time meeting with top executives and owners of big corporations, including health care corporations. For example, as reported by Becker's Hospital Review in April, 2020, 27 health care executives were appointed to Trump's economic revival task force (during and after the pandemic), including Albert Bourla, the CEO of Pfizer, and Alex Gorsky, the CEO of Johnson and Johnson.

Back in 2017, Johnson and Johnson CEO Gorsky was appointed to Trump's Manufacturing Council.  He temporarily left that position after Trump refused to disavow the right-wing extremists who marched in Charlottesville, but then was put "on the guest list Tuesday for dinner at [Trump's] Bedminster [golf club]."  After that, Trump seemed to be promoting Johnson and Johnson products, particularly Spravato touted as a treatment for opioid dependence (look here).

Health Care Corporate Executives and Lobbyists Appointed to Government Leadership Positions Affecting Health Care

We have noted that many of Trump's political appointments to leadership positions in government that affect health care came through the revolving door from health care corporations and lobbying firms that worked for them.  For example, the current Secretary of the Department of Health and Human Services (DHHS) is a former top Eli Lilly executive.

 


Several top positions as DHHS were filled by former lobbyists for big pharma and other health care corporations (look here). Particularly, Daniel Best went from Pfizer to DVS and then to DHHS as a Senior Advisor (look here.)

Also, Dr Scott Gottlieb, a former commissioner of the US Food and Drug Administation (FDA) under Trump soon became of member of Pfizer's board of directors (look here).

Should Trump Trust Johnson and Johnson and Pfizer?

Trump's affinity for Johnson and Johnson and Pfizer may be based on personal relationships and perceived political common interests, as well as on how he has politically and personally benefited from the actions of their leaders and owners. That affinity should not be sufficient for him to trust them to run a coronavirus pandemic response.  Arguing against placing so much trust in them are their corporate track records of misbehavior.  

On Health Care Renewal, we have been tracking ethical misadventures by big health care organizations for a long time.  The records of Johnson and Johnson and Pfizer stand out, but not in a good way.  To summarize what we have discussed about each...

Johnson and Johnson

Derived from our previous blog posts - 

 2010
- Convictions in two different states for misleading marketing of Risperdal
- A guilty plea for misbranding Topamax

2011
- Guilty pleas to bribery in Europe by DePuy subsidiary
- A guilty plea for marketing Risperdal for unapproved uses  (see this link for all of the above)
- A guilty plea to misbranding Natrecor by subsidiary Scios (see post here)

2012 
  - Testimony in a trial of allegations of unethical marketing of the drug Risperdal (risperidone) by the Janssen subsidiary revealed a systemic, deceptive stealth marketing campaign that fostered suppression of research whose results were unfavorable to the company, ghostwriting, the use of key opinion leaders as marketers in the guise of academics and professionals, and intimidation of whistleblowers. After these revelations, the company abruptly settled the case (see post here).
-  fined $1.1 billion by a judge in Arkansas for deceiving patients and physicians again about Risperdal (look here).
-  announced it would pay $181 million to resolve claims of deceptive advertising again about Risperdal (see this post).

2013
-  settled case by shareholders alleging that management made misleading statements and withheld material information about manufacturing problems (see this post)
-  Janssen subsidiary pleaded guilty to a charge of misbranding Risperdal, and settled for a total of $2.2 billion allegations that it promoted the drug for elderly demented patients and adolescents without an indication, and despite evidence of its harms (see this post).
 -  DePuy subsidiary agreed to settle with multiple plaintiffs for $2.5 billion allegations that it sold defective mental-on-metal artificial hip, and hid evidence of its harms .
-  Janssen subsidiary was found by two juries to have concealed harms of its drug Topamax (see this post for this and above case).
-  Ethicon subsidiary's Advanced Surgical Products and two of its executives agreed to settle charges by US FDA that is sold mislabeled products used to sterilize equipment such as endoscopes (see this post).
- fined by European Commission for anticompetitive practices, that is, collusion with Novartis to delay marketing generic version of Fentanyl (see this post).

2014 
- DePuy subsidiary settled Oregan state charges that it marketed the ASR XL metal-on-metal hip joint prosthesis without disclosing its high failure rate (see this post).

2015
-  found by jury to have concealed harms of Risperdal.
-  Ethicon subsidiary found by jury to have concealed harms of its vaginal mesh device.
-  McNeil subsidiary pleaded guilty to marketing adulterated Tylenol. (see this post for three items above.)

2016
- subsidiary Aclarent settled allegations that it sold its Stratus device for unapproved uses.  Two former executives of that subsidiary also were found guilty of distributing misbranded and adulterated devices (see this post)  

2018
- settled allegations that subsidiary Actelion used illegal kickbacks to market Tracleer for an inflated price (see this post)

2019
- found by Oklahoma judge to have launched a deceptive marketing campaign for opioids (see this post)

And we recently learned that Johnson and Johnson settled allegations of deceptive marketing of surgical mesh in lawsuits in multiple states (per the AP, May 202, here)

Pfizer

 From this post:

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

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

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

Thereafter,

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

Note that other companies involved in Trump's crash project to develop a coronavirus vaccine, preferably in time to influence the 2020 election, Astra Zeneca and Merck, also have questionable track records. 

Summary

Health care is increasingly dominated by large organizations who may threaten the values of health care professionals.  Now in a pandemic the US President seems determined to trust in a few large pharmaceutical corporations rather than public health experts and health care professionals.  His trust may be based on his personal affinity for the leadership of such corporations, and the cozy relationships they have cultivated with him. Worse, it may be based on how he has politically benefited and personally profited from their actions.  To the extent that Trump has ceded control of the pandemic to large corporations because he has politically benefited and personally profited from them, his actions appear to fit the ethical definition of corruption, as defined by Transparency International:

the abuse of entrusted power for private gain

Meanwhile, the pandemic has been steadily worsening, and as of this week, the president himself, along with key political allies have been infected. 

Thus, at a crucial time, the country is increasingly being run by a cozy group of insiders with ties to both government and industry.  Top health care (and other) corporate management is increasingly merging with the current administration in one giant corporatist entity. This merger is not in the interests of peoples' or the public's health, especially in a time of pandemic.  Instead, benefits will go to the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people.  At times the actions of the current administration, and in particular, its maximum leader, may be abuse of power for private gain, apparently corruption, and in this instance, health care corruption.  This fits a pattern of wholesale corruption and conflicts of interest at the top of the administration that we have often decried, most recently here.

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

However, before thinking about true health care reform, we need top accomplish wholesale government reform. We need to excise the deception, crime and corruption at the heart of our government and restore government by the people, of the people, and for the people. 

Reference

1.  Poses RM. A cautionary tale: the dysfunction of American health care.  Eur J Inte Med 2003; 14: 123-130.  Link here.

Sunday, September 20, 2020

Attempts to Transform the CDC into a Propaganda Outlet and the Silence of the Health Care Leaders

First they came for the CDC staffers, but I was not a CDC staffer so I did nothing...

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

- with apologies to Martin Niemoller (look here


The US is continuing to suffer during the coronavirus pandemic.  Meanwhile, the lead US government public health agency, the Centers for Disease Control and Prevention (CDC) has suffered two attempts by the Trump administration to transform it into a propaganda outlet.

Mysterious Revisions of Pandemic Management Guidelines to Hinder Testing of Exposed Persons

This story broke in late August, 2020.  As reported by the New York Times on August 25, 2020:

The Centers for Disease Control and Prevention quietly modified its coronavirus testing guidelines this week to exclude people who do not have symptoms of Covid-19 — even if they have been recently exposed to the virus.

The new guidelines went against public health practice for managing epidemics.  People who have been exposed are at increased risk of infection.  Infected people may not have symptoms but may still transmit the virus to others.  Identifying infected people allows them to be quarantined, and any further contacts to be traced.  In particular, as the NYT article pointed out:

Although researchers remain unsure how often asymptomatic people unwittingly transmit the coronavirus, studies have shown that the silently infected can carry the virus in high amounts. The evidence is more clear-cut for pre-symptomatic people, in whom virus levels tend to peak just before illness sets in — a period when these individuals might be mingling with their peers, seeding superspreader events. Notably, experts can’t distinguish asymptomatic people from those who are pre-symptomatic until symptoms do or don’t appear.

No Obvious Justification and No One Accountable for the Change

The CDC did not initially provide a clear justification of the change:

The reasons behind the surprise shift in testing recommendations are unclear. In response to an inquiry from The New York Times, a representative for the C.D.C. directed the questions to the U.S. Department of Health and Human Services. 

A report from ABC News on August 26 quoted Admiral Brett Giroir of the White House coronavirus task force:

This is evidence-based decisions that are driven by the scientists and physicians, both within the CDC, within my office in the lab task force, and certainly amongst the task force members

However, he did not provide any of the evidence on which it was supposedly based, or any logic underlying the change based on this evidence.  Nor did he make clear who was accountable for the change

 I worked on them. Dr. Fauci worked on them. Dr. Birx worked on them. Dr. Hahn worked on them. Dr. Atlas provided input. So, it's kind of hard to know how much was written by one person at this time

On the other hand, a CNN report from the next day suggested that the change came due to political pressure:

A sudden change in federal guidelines on coronavirus testing came this week as a result of pressure from the upper ranks of the Trump administration, a federal health official close to the process tells CNN, and a key White House coronavirus task force member was not part of the meeting when the new guidelines were discussed.

'It's coming from the top down,' the official said of the new directive from the Centers for Disease Control and Prevention.
 
An AP article from August 26 included speculation about the real reasons for the change:
 
Dr. Carlos del Rio, an infectious diseases specialist at Emory University, suggested in a tweet that there are two possible explanations.

One is that it may be driven by testing supply issues that in many parts of the country have caused widely reported delays in results of a week or more, he suggested.

 Admitting problems providing testing might be a reason to consciously temporarily limit testing, of course, but not to pretend the testing would not be useful.  Then

Another possible explanation for the change is that President Donald Trump simply wants to see case counts drop, and discouraging more people from getting tested is one way to do it, del Rio said in his tweet.

A Washington Post article on August 27, 2020 explained this further:

The revised guidelines come as President Trump has feuded with the CDC and the Food and Drug Administration, both parts of the Department of Health and Human Services, and marginalized officials who would ordinarily play leading roles in a pandemic response. He has repeatedly said that he did not like that more testing had revealed more cases.

'I said to my people, ‘Slow the testing down, please!’ ' Trump said at a rally two months ago. Aides said he had been speaking tongue-in-cheek. But asked later whether he had been kidding, Trump replied, 'I don’t kid.'

Reducing testing, of course, would reduce the number of apparent, not real cases, allowing Trump to exaggerate his ability to manage the pandemic

On September 17, 2020, the source of the controversial change in the CDC guideline was somewhat clarified again according to the New York Times:

A heavily criticized recommendation from the Centers for Disease Control and Prevention last month about who should be tested for the coronavirus was not written by C.D.C. scientists and was posted to the agency’s website despite their serious objections

The source of the change was 

the Department of Health and Human Services [which] did the rewriting and then 'dropped' it into the C.D.C.’s public website, flouting the agency’s strict scientific review process.

'That was a doc that came from the top down, from the H.H.S. and the task force,' said a federal official with knowledge of the matter, referring to the White House task force on the coronavirus.

Yet neither that nor earlier reports explained who at "the top" directed the change.

And soon the change it self disappeared as mysteriously as it appeared.  On September 18, 2020 per the AP:

U.S. health officials on Friday dropped a controversial piece of coronavirus guidance and said anyone who has been in close contact with an infected person should get tested.The Centers for Disease Control and Prevention essentially returned to its previous testing guidance

Criticism of the Change

 Public health and health care professionals criticized the changes, e.g.,  per the AP article of August 26, 2020:

Dr. Tom Frieden, who was head of the CDC during the Obama administration, said the move follows another recent change: to no longer recommend quarantine for travelers coming from areas where infections are more common.

'Both changes are highly problematic' and need to be better explained, said Frieden, who now is president of Resolve to Save Lives, a nonprofit program that works to prevent epidemics.

Also, Dr Leana Wen wrote an op-ed for the Washington Post on August 26, 2020:

you don’t have to be a public health expert to know the CDC’s guidance is nonsensical.  

In MedPage Today of August 28, 2020:

pulmonologist William Janssen, MD, section head of Critical Care Medicine at National Jewish Health, said the new guidance recommending testing for fewer people 'flies in the face of everything we have been told and understand about this disease.'

Also,

Another pulmonologist at National Jewish Health, Kenneth Lyn-Kew, MD, called the CDC move 'a step backwards.'

'The CDC was flat out wrong and the epidemiologists there know this,' he said, adding that testing and tracing are cornerstones of epidemiology.

Major health care organizations also criticized the change. The AMA issued a statement:

Suggesting that people without symptoms, who have known exposure to COVID-positive individuals, do not need testing is a recipe for community spread and more spikes in coronavirus. When the Centers for Disease Control and Prevention (CDC) updates a guidance the agency should provide a rationale for the change. We urge CDC and the Department of Health and Human Services to release the scientific justification for this change in testing guidelines

The American Association of Medical Colleges asserted:

These CDC guidelines go against the best interests of the American people and are a step backward in fighting the pandemic. The AAMC urges the CDC to return to its earlier testing recommendations

The Chair of the Board of Regents of the American College of Physicians wrote that the organization:

supports the use of science, based on the best available evidence, in the fight against COVID-19. Public health agencies should not be subjected to pressure or be influenced to issue policies that are not based on evidence and expert recommendations of their own scientists.

 Also

The recent revision of the CDC’s COVID-19 testing guidelines of asymptomatic individuals lacks transparency and clarity, sending a confusing message to both physicians and the public on appropriate and necessary testing that will ultimately help to mitigate the spread of COVID-19.

Summary

So far we only know that someone at "the top" of the government directed the change in the CDC guidelines.  No person or group has stepped forward as accountable. No one at any US government agency has explained the rationale for the change, much less provided clear evidence and logical reasoning underlying it.  The best explanation for the change seems to be that it fit President Trump's message. It would have made his administration's problems organizing adequate testing for coronavirus less apparent.  By reducing testing, it would make the rate of the spread of disease temporarily appear lower, allowing Trump to exaggerate his ability to manage the pandemic.

Yet I could find no health care or public health professional, or any leader of a health care organization willing to criticize "the top" of the US government for directing the change, to criticize the opaque, apparently evidence-free process that produced the change, or to question whether the change was meant to fit with Trump's propaganda, that is, his claims of brilliant management of the pandemic. 

Trump Political Appointees Attempt to Intimidate CDC Staff to Manipulate Publications in the Morbidity and Mortality Weekly

White House Installed Pro-Trump Propagandist with No Health Care or Public Health Background as Head of Public Relations for DHHS

 The second case began in April, 2020.  Then Politico reported:

 The White House is installing Trump campaign veteran Michael Caputo in the health department’s top communications position

Caputo was given the title of Assistant Secretary for Public Affairs. He has an unlikely background to have been named head of public relations for the Department of Health and Human Services (DHHS). He has no apparent background in health care or public health. Also, Politico noted:

Caputo is an intense Trump loyalist whose recent book 'The Ukraine Hoax,' alleged a conspiracy behind Trump’s impeachment.

Furthermore

 Caputo is a longtime friend of Trump ally Roger Stone and former Trump campaign chairman Paul Manafort, both of whom were convicted of crimes in the last two years. 

Then CNN reported:

The new spokesman for the Department of Health and Human Services in a series of now-deleted tweets made racist and derogatory comments about Chinese people, said Democrats wanted the coronavirus to kill millions of people and accused the media of intentionally creating panic around the pandemic to hurt President Donald Trump.

In particular,

In a series of tweets on March 12, Caputo responded to a baseless conspiracy theory that the United States brought the coronavirus to Wuhan, China, by tweeting that 'millions of Chinese suck the blood out of rabid bats as an appetizer and eat the ass out of anteaters.'

 
CNN had many more graphic examples.  
 
Also, Mother Jones reported more about Caputo's involvement in Russia and Ukraine:
 
A longtime Republican operative who was ousted from a job on Trump’s 2016 campaign, Caputo recently worked to boost discredited claims alleging that Ukraine, not Russia, meddled in the 2016 election.
 
In particular, Caputo was alleged to have been involved in political dirty tricks on behalf of Trump in 2016:
 
In June 2018, the Washington Post reported that ... [Caputo] and Stone had met in 2016 with Henry Oknyansky, a Russian expat living in Florida, who wanted to sell damaging information about Hillary Clinton. Caputo, in text messages with Stone the Post obtained, referred to Oknyansky as 'the Russian.' Though no deal was reached, news of the meeting seemed to contradict claims both Stone and Caputo had made in testimony to the House Intelligence Committee. Both men denied any contact with Russians during the 2016 campaign.
 
Also, Caputo was alleged to have been involved in creating propaganda or disinformation about Ukraine's supposed intervention in the 2016 campaign, and Hunter Biden's actions there:
 
Last year, Caputo, along with other figures in Trump’s orbit, turned his focus to Ukraine. He says he travelled there last August to try to bolster the theory that Ukrainians interfered in 2016 election to help Clinton. He subsequently wrote a book, titled The Ukraine Hoax: How Decades of Corruption in the Former Soviet Republic Led to Trump’s Phony Impeachment, which pushes discredited allegations, including claims that former Vice President Joe Biden intervened in Ukrainian affairs to help his son, Hunter. Caputo produced a documentary offering similar allegations that aired in January on the rabidly pro-Trump One America News. Giuliani starred in a separate OAN series which pushed similar claims based his own trip to Ukraine.

 
Yet  despite Caputo's record as an unscrupulous political operator, and allegations that he was involved in peddling propaganda and disinformation, his appointment drew no outcry.

Assistant Secretary for Public Relations of DHHS Orchestrated Intimidation to Distort the Morbidity and Mortality Weekly Report

Somehow Caputo and the associates he brought to the DHHS managed to avoid much public notoriety for a few months.  Then on September 11, 2020 Politico reported that Caputo and his associates had been quietly busy.  Their apparent mission was to turn the respected CDC public health publication, the Morbidity and Mortality Weekly Report, into a vehicle for pro-Trump propaganda.  Politico noted that:

The CDC's Morbidity and Mortality Weekly Reports are authored by career scientists and serve as the main vehicle for the agency to inform doctors, researchers and the general public about how Covid-19 is spreading and who is at risk. Such reports have historically been published with little fanfare and no political interference, said several longtime health department officials, and have been viewed as a cornerstone of the nation's public health work for decades.

But since Michael Caputo, a former Trump campaign official with no medical or scientific background, was installed in April as the Health and Human Services department's new spokesperson, there have been substantial efforts to align the reports with Trump's statements, including the president's claims that fears about the outbreak are overstated, or stop the reports altogether.

In particular, Caputo et al tried to

retroactively change agency reports that they said wrongly inflated the risks of Covid-19 and should have made clear that Americans sickened by the virus may have been infected because of their own behavior

and

halt the release of some CDC reports, including delaying a report that addressed how doctors were prescribing hydroxychloroquine, the malaria drug favored by Trump as a coronavirus treatment despite scant evidence

To underscore that the effort was to promote Trump's political self-interest

an aide to Caputo berated CDC scientists for attempting to use the reports to 'hurt the President' in an Aug. 8 email sent to CDC Director Robert Redfield and other officials that was widely circulated inside the department and obtained by POLITICO. 'CDC to me appears to be writing hit pieces on the administration,' appointee Paul Alexander wrote, calling on Redfield to modify two already published reports

Alexander tried to gain control of the contents of the MMWR, calling

 on Redfield to halt all future MMWR reports until the agency modified its years-old publication process so he could personally review the entire report prior to publication, rather than a brief synopsis. Alexander, an assistant professor of health research at McMaster University near Toronto whom Caputo recruited this spring to be his scientific adviser, added that CDC needed to allow him to make line edits — and demanded an 'immediate stop' to the reports in the meantime.

Apparently CDC staffers resisted Caputo, Alexander et al, so that eventually contents untouched by their manipulations did become public.

One day after the Politico article, the New York Times  confirmed its essential findings

Current and former senior health officials with direct knowledge of phone calls, emails and other communication between the agencies said on Saturday that meddling from Washington was turning widely followed and otherwise apolitical guidance on infectious disease, the Morbidity and Mortality Weekly Reports, into a political loyalty test, with career scientists framed as adversaries of the administration.

The Times called Caputo's work a "bullying operation."  

The Washington Post also confirmed the Politico report after gaining access to emails sent by Alexander.

The Assistant Secretary's Actions Became Bizarre, and He Resigns Citing Mental Health Issues

As soon as the story of his attempts to "bully" the MMWR became public, Caputo's actions became more bizarre.  On September 14, 2020, the New York Times reported:

The top communications official at the powerful cabinet department in charge of combating the coronavirus made outlandish and false accusations on Sunday that career government scientists were engaging in 'sedition' in their handling of the pandemic and that left-wing hit squads were preparing for armed insurrection after the election.

Michael R. Caputo, the assistant secretary of public affairs at the Department of Health and Human Services, accused the Centers for Disease Control and Prevention of harboring a 'resistance unit' determined to undermine President Trump, even if that opposition bolsters the Covid-19 death toll.

Then he announced:

he personally could be in danger from opponents of the administration. 'If you carry guns, buy ammunition, ladies and gentlemen, because it’s going to be hard to get,' he urged his followers.

He went further, saying his physical health was in question, and his 'mental health has definitely failed.'

'I don’t like being alone in Washington,' Mr. Caputo said, describing 'shadows on the ceiling in my apartment, there alone, shadows are so long.'

 One day later Politico reported an announcement:

Today, the Department of Health and Human Services is announcing that HHS Assistant Secretary for Public Affairs Michael Caputo has decided to take a leave of absence to focus on his health and the well-being of his family

Alexander also left the agency 

Since Caputo's departure, Politico published an article detailing how he placed "his own loyalists and Trump veterans" into public relations positions at the DHHS. 

Also, the New York Times published an article detailing some of his efforts to bully CDC staff,

Mr. Caputo moved to punish the C.D.C.’s communications team for granting interviews to NPR and trying to help a CNN reporter reach him about a public relations campaign. Current and former C.D.C. officials called it a five-month campaign of bullying and intimidation.

For instance, after Mr. Caputo forwarded the critique of Dr. Schuchat to Dr. Redfield, C.D.C. officials became concerned when a member of the health department’s White House liaison office — Catherine Granito — called the agency to ask questions about Dr. Schuchat’s biography, leaving the impression that some in Washington could have been searching for ways to fire her.

In another instance, Mr. Caputo wrote to C.D.C. communications officials on July 15 to demand they turn over the name of the press officer who approved a series of interviews between NPR and a longtime C.D.C. epidemiologist, after the department in Washington had moved to take ownership of the agency’s pandemic data collection.

'I need to know who did it,' Mr. Caputo wrote. A day later, still without a reply, Mr. Caputo wrote back. 'I have not received a response to my email for 20 hours. This is unacceptable,' he said.

Efforts to Turn the MMWR Into Propaganda Criticized byAcademics in Public Health and Health Care, and the CEO of the Robert Wood Johnson Foundation

Per the Politico article above, Jennifer Kates, leader of the Kaiser Family Foundation's global health work

defended the CDC's process as rigorous and said that there was no reason for politically appointed officials to review the work of scientists.

Per the New York Times article above, Dr. William Schaffner, an infectious disease specialist at Vanderbilt University who sits on the external editorial board of the Morbidity and Mortality Weekly Report, said Caputo's operation 

undermines the credibility of not only the M.M.W.R. but of the C.D.C. And the C.D.C.’s credibility has been tarnished throughout Covid already

Per USA Today on September 13, 2020:

The interference is not just anti-science but disinformation intended to deceive the American public, said Dr. Eric Topol, a professor of molecular medicine at the Scripps Research Institute in La Jolla, California.

'This is outright egregious. It’s despicable,' Topol said, accusing Redfield and other leaders of allowing the agency to be hijacked by politics.

Also,

 On Twitter, Dr. Sherri Bucher, a global health researcher, wrote, 'There are no words to articulate how horrific this is. Trust & credibility, shattered, overnight. MMWR has been, for a long time, one of the most reliable, steadfast, scientific resources; unquestioned veracity, impeccable reputation for quality of data/analysis. No longer.

The Washington Post published an op-ed by Dr Erin Marcus, a professor of clinical medicine at the University of Miami Miller Medical School:

Caputo’s manipulation is appalling. If left unchecked, it could have disastrous consequences for the reputation and reliability of the CDC, which has already been battered by the U.S. response to covid-19. It could also prove devastating for medical practice in the United States more broadly.

In Scientific American, Dr Richard Besser, the CEO of the Robert Wood Johnson Foundation, wrote an op-ed entitled "We can't allow the CDC to be tainted by politics," noting:

 To meddle with, delay or politicize these [MMWR] reports would be a form of scientific blasphemy as well as a breach of public trust that could undermine the nation’s efforts to fight the coronavirus.

Summary

So to summarize, the White House put a pro-Trump political operative who had allegedly been involved in producing propaganda and disinformation in support of Trump to oversee all Department of Health and Human Services communications.  He and his hired cronies tried to bully and intimidate DHHS, particularly CDC staff, and to distort the contents of the renowned MMWR to support the Trump message.  Had these efforts succeeded they would have seriously impeded efforts to control the coronavirus pandemic by undermining the dissemination of scientific evidence needed for pandemic management and clinical care for affected patients.  

I found several academic public health and health care professionals willing to criticize Caputo and cronies' actions.  I found one leader of a prominent health care foundation willing to at least implicitly criticize them.  I found no one willing to hold accountable anyone at the "top" of the government who hired Caputo or encouraged his actions.  On this case, I could find no leader of a health care organization other than Dr Besser willing to say anything at all.   

Conclusions

Last month, we noted how disinformation about the coronavirus pandemic is being disseminated by the US president. 

Since then, two major efforts to use the CDC, the lead US public health organization, to support President Trump's political messaging, in effect, to function as a political propaganda outlet.  Individual US academic and practicing public health and health care professionals have been willing to decry these efforts, though not to directly hold Trump and his top lieutenants in the executive branch accountable.  In some cases, leaders of major medical organizations have been willing to state the principles that should have been upheld within the government.  

However, 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.

To be charitable, such leaders may be to used to a kinder, gentler era to be able to fully comprehend that parts of the US government meant to be apolitical advocates for public welfare, such as the CDC, are being pushed to become part of an incipient Ministry of Propaganda.  



Fighting a deadly pandemic is hard enough.  It is gut wrenching that the fight is being subverted by political leaders spreading propaganda and disinformation.  It is sad that front line public health and health care professionals are hardly supported in their work by those who claim to lead them.  Where is the courage?  Where is the outrage?

"If not now, when?"

 

Friday, September 11, 2020

Tales From The Telly

1. Introduction. This post might just as easily be entitled "tales from the crypt," so far down the netherworld chute have American public health and medical workers been plunged. Nowadays whenever I speak to fellow physicians and tell them I've moved on from my own front line patient care, we exchange these utterances: they say "congratulations, I'm envious" and I say "my condolences." But the topic for today is more focal: telemedicine in the Age of Coronavirus.

Telemedicine, or "telemed," doesn't quite fit neatly into my ongoing series on why my dander's up. So for now let's set it aside and come back another time. It turns out that telemed—remote diagnosis and treatment using telecoms—is, like so many other innovations in health care, a two-edged sword. Let's look at it and see if we can come up with provisional answers to what, exactly, it means, beyond fear of face-to-face, to see its use soaring these days.

I've observed telemedicine now in a number of settings—lots of testimonials from colleagues, family, friends, and in just one instance myself as patient. Most of this is quite recent, for reasons we'll get to. I've never practiced it, never had time on my schedule to Zoom into some patient's bedroom. That's just an artifact of the timing. But I used to teach about it. And now it's arrived like gangbusters after languishing for decades in the ever-hopeful hearts of long standing organizations (here, here) devoted in part or in full to digital medicine.

The "why" for this onrush of telemedicine exposure is an easy one. In the Before Times, we had reimbursement problems that impeded it. All the other barriers, by, say 2010, were secondary. All our clocks now have a thick black line between BC and AD. Before Coronavirus versus After Donald.

Back in the BC, we can't get it paid for. Now, in the almost-AD: HHS rushes out new emergency regs, enabling telemed. With the pandemic, the new regs arrived just when providers, deprived of adequate PPE and in some cases a big chunk of salary, really needed the option. Whether they actually approved of it or not, different story. Necessity is the mother. All the rest is dross.

The above remarks set the stage. We just need to remind ourselves in passing: there's just not much scientific evidence for this technology's safety or efficacy. Rather, like so much else in digital medicine, telemed is probably here to stay because of one or another regulatory or epidemiologic crisis. Contrariwise, it's not an evidence-based imperative, at least not with respect to clinical results. For providers, of course, it may well mean survival, a different story.

So until we get more convincing science, here, for this blog's intrepid readers, are some narrative bits and bites to chew on: telemedicine, the good, the bad, and the ugly.

2. The Good. The single telemed session I undertook as a patient, reviewing some physiatric maneuvers, went rather well. So, too, did a family member's. When teaching about telemedicine I used to fret to think about its lack of touch. A cardiologist recently related some of his difficulties he'd had—the need to evaluate heart and lung sounds, to feel the liver—and how he recently almost lost a patient by relying on telemed. In that case, the common dreaded complaint of "I'm so tired" proved to stem from complete heart block. But this cardiologist didn't diagnosis his patient's CHB by telemed. He did it when he had the good sense to send that patient to the ER.

Conversely, I watched a vertigo patient properly and fully worked up, including appropriate neurologic testing. Vertigo is so often of the benign positional variety that this all made sense, with discussion of all the diagnostic and therapeutic maneuvers, the extensive taking of a history that can nail some diagnoses, and discussion of follow-up. There are lots of instances where such outcomes are possible. Physical therapy is another area where a session may go quite well.

Then, still in the "good" column, there's the public health benefit. An Associated Press release about telemedicine and coronavirus in Florida recently—this was late August—underscores the benefit. The AP release, available widely, e.g. here, didn't seem to get a lot of traction beyond its own republication. Maybe it was just drowned out by late summer vacation blues, gladiatorial politics, and whatever other Daily Outrage we're all lately subjected to.

In a relatively underserved area of Jacksonville, the site (or one site) of the GOP Convention days earlier, an aging public health nurse, like so many health workers faced with COVID-19, had a telemed session with a family physician, Dr. Cain. Both belonged to a minority community especially hard hit by the virus. Which is to say, hard hit by recent Florida politicians' methodical dismembering of the state's public health infrastructure. Privatization is one causative element of the systematic down-rating of public health in places like Florida. Ideology is undoubtedly another. Poor people's bodies are a favorite target of budget-cutters. They really don't matter, right? So those bodies get thrown under the bus. Always were.

Telemedicine can be a boon to the underserved, a patch on our deficits in social justice and public health. That was the case for Ms. Wilson, Dr. Cain's patient, who received assistance and did well. In the right hands—largely, I'd say, telemedicine offered by academic health centers (AHCs), but also in community hands such as Dr. Cain's—it can make a difference in narrowing the gap. Further, lest we view this as somehow second class, many patients in all socioeconomic categories prefer it—see the next section below—to going in and sitting around in waiting-rooms at either AHCs or community clinics.

3. The Bad. That's true even in the best of times. But as we know, right now we're not in those times.

On to the bad and the ugly. For the reader's consideration I submit a recent report (personal communication) from a colleague—a highly educated and sophisticated tech CEO—who'd enrolled as a patient in one of those "with six you get egg roll" deals with a telemedicine start-up. Right now a great number of telemedicine providers are based on free-standing start-ups: I know this because on a daily basis I receive at least one entreaty from such companies to throw my own hat in their ring. (Which was damned tempting by the way.) I've lost count, and I wonder whether there's any way to count up the entities that provide which kind of care. If there is, please add a comment below and tell me where that study's to be found.

Meantime, let's just put out there a typology—then let me how many of each you think there are.

  1. Academic centers' operations, now rampant, and generally fairly good (or as good as Zoom), in the AD time of coronavirus
  2. Dr. Cain's operation and other, similar, community-based ones (private/small group)
  3. Start-ups, which might or might not be conceived as extensions of physical docs-in-boxes
You tell me. Meantime, having talked to a lot of providers and patients who earn, or save, cash by participating in the doc-in-a-box style telemed shops, I'd like to tell my tech confrere's tale. Actually, let me let him tell it in his own words, substituting StartUp for the particular telemed company name.

I was overdue for my yearly physical, and since I had a subscription to StartUp, I decided to use the telehealth service for my physical.  I didn't have any major complaints, but I wanted to get some routine labs taken to make sure all was well.  I fired up the ... app and after giving a brief description of my concern and a few minute wait, I was virtually face to face with a doctor.  I've been on Propecia in the past, and have recently started it again during the COVID lockdown.  I knew my family physician often ordered a PSA test while I was on Propecia, so I thought it would be prudent to ask for the lab to be included in my blood work.  Things didn't go so well. 
Me:  I'm on Propecia, and I know my family doctor often ordered a PSA test in the past, can we include that? 
Doctor:  What's Propecia? 
Me: It's Finasteride. 
Doctor: Is that something your doctor prescribed? 
Me: Yes. 
Doctor [emphasis added here and below]: Well, they don't like us to order labs that require followup, so... 
Me: OK (I figured at this point it wasn't worth arguing the finer details of [StartUp] policy and I was reasonably sure the PSA would have been normal) 
Doctor: I'm ordering the labs, but sometimes they don't go through, so if there's a problem, just contact support and they'll sort things out.  Also, don't forget to follow up once you get the results. 
OK, so other than not knowing what Propecia is, not being able to order the PSA test and the fact that none of the tests might actually have been ordered, the call went pretty well. 
I made an appointment with Quest Diagnostics through the ... app for early the next morning to have the blood drawn.  After arriving at Quest and signing in, I was told there weren't any lab tests that had been requested for me.  I was prepared for this, and showed the receptionist the StartUp lab order PDF.  She looked at it and quickly said that they couldn't accept this as the order didn't include the doctor's name and she wouldn't know where to send the results.  I left, went back to the car, launched StartUp and requested another virtual consult.  After explaining to the doctor what Quest told me, he said it was strange but that he would re-request the labs. 
Armed with the new lab request, I went back to Quest, and spoke to the same receptionist.  She noted that it looked like someone "had done something" but there still weren't any lab tests to be found.  She also noted that their systems "weren't connected to anyone else".  At this point, I pushed back as I was fairly certain the lab tests were lurking in the Quest system and it was possible that the receptionist just didn't have experience or training with StartUp lab orders.  After some back and forth I was able to get her to enter the number provided with my lab order and was cleared to get the test.  As an added bonus, the Quest receptionist incorrectly told me that my insurance had been cancelled, only to later realize that she had entered my ID number incorrectly.- 
This was on a Friday, so I expected I would receive results early the following week.  On Tuesday I received a notification that my labs were available in the Quest portal.  I checked out the labs and then opened the StartUp app to initiate a follow up call to review the results.  Only one problem, according to StartUp the labs were still pending.  I sent a message to StartUp support and they said that normally results are available in the app as soon as the lab has them and that they would work with engineering to figure out what had happened.  Twenty Four hours later, there's still no word from engineering and the labs are still listed as pending in the app.  
I am lucky enough to have a distinguished physician as a friend who was kind enough to look over the labs and give me the all clear.  Without this connection, I would have been left wondering about the results and given that the StartUp doctor didn't seem familiar with Propecia (a common medication), I'm not sure I would have fully trusted their evaluation of the results.

It's no wonder that people who go to doc-in-a-box (or NP-in-a-box) sites typically do so for only the simplest and most straightforward complaints. And it's no wonder that the venture and hedge funds that capitalize these outfits do so in many cases while advertising they focus only on high-yield, low-risk diagnoses such as erectile dysfunction and contraception. Maybe the odd UTI or URI.

Oh, and colleagues who work for them tell me they exercise all sorts of mind-control, telling the providers what to say and what they can't say. Sadly, docs do this stuff (in category 3 above), often to moonlight and they just swallow their gall. Easy enough on the 'net to find out, however, exactly what they think about working for these outfits. But how many patients buy into it, as my colleague did, not knowing all this background?

In so many cases, therefore, it's all just another golden exercise in American ingenuity and lapping the cream. In no way is it, in its free-standing version, a response to the challenge of improving health care. Rather, it's the usual and sad response to improving investors' wallet contents.


4. Footnote: the Price of Admission. You can't do telemedicine without a good connection. But many who might most advantageously avail themselves of telemed consultation don't have that adequate connection. For those who'd like to read more about this conundrum, Brookings has just published a Techtank blog, by Visiting Fellow Tom Wheeler. He offers useful solutions in a piece entitled "broadband in red and blue," with some concrete and hopeful ways of redressing what's essentially yet another AD (After Drumpf) problem: the way the US has been closing the Digital Divide more assiduously for red than for blue states. The challenge, per Wheeler: "[t]here are almost three times as many Americans without a broadband subscription in blue urban areas than in red state rural areas."

People currently thinking about back-to-school issues, and kids' telelearning, probably aren't thinking quite as much about telemedicine, despite the striking parallel. But they should. Before they get sick.

The problems of telemedicine mirror those of the larger society, as does health equity mirroring societal equity. This will come as a surprise, no doubt, to precisely no one. Let's hope after November we get to putting the solutions, and the promises of telemedicine, into more socially just practice.

Sunday, August 30, 2020

President Trump and Surrogates Continue to Hold Campaign Events Enabling Spread of the Coronavirus: Had Enough Yet?

While the US continues to suffer from one of the worst outbreaks of the novel coronavirus pandemic to beset any developed nation (look here), national, state and local political leaders in the US who support President Trump have continued to hold events and otherwise behave in ways that seem designed to increase the spread of coronavirus. Multiple instances included leaders purposefully avoiding wearing face masks and social distancing in instance in which disease transmission was likely, eg, government meeting and political session, and engineering crowded events in which social distancing and wearing of face masks were rare (look here and here).



Three weeks since we last discussed this topic, as the US presidential race heats up, we have noted multiple instances in which President Trump and his campaign surrogates have again promoted multiple crowded, socially not distant events at which few attendees wore masks. At some of these events, the practices promoted by the organizers went against state or local laws or regulations.  And these practices are continuing to be associated with disease spread.

Listed in chronological order according to the date of the reporting:

Trump Campaign Events in Three States

As reported by the AP (via PBS) on August 19, 2020:

Iowa

During Pence’s Des Moines event, chairs arranged in small clusters six feet apart were quickly abandoned as many in the audience of about 200, few in masks, moved within a few inches of each other. Dozens crowded together afterward to get an autograph or nod from Pence.

Wisconsin

in Wisconsin on Monday, Trump absolved his audience of health precautions, along the way mocking the racial justice protests he has railed against for weeks.

In an aircraft hangar in Oshkosh, Trump flaunted violations of the state’s distancing and masking guidelines — recommendations also promoted by the federal Centers for Disease Control and Prevention — as he spoke to hundreds of supporters, most not wearing face coverings.

'This was supposed to be just a quick, little small gathering,' Trump said, joking that 'We’re supposed to have 50 people, right?'

'We’ll call it a peaceful protest, that way we can do whatever we want,' Trump added.

'This is like a rally,' Trump added, before telling supporters: 'I hereby grant you a pardon.'

Later in Wisconsin,

On Wednesday, Pence addressed a crowd at a metal fabricating pant in Darien, Wisconsin, where the crowd stood and sat close together, many people not wearing masks despite a statewide order requiring them indoors.

Arizona

At Tuesday’s similarly raucous rally in Yuma, Arizona, supporters sat on closely packed-in chairs and bleachers, and stood on a balcony as they chanted 'four more years!' While the hangar was open on one side overlooking Air Force One on the tarmac, it nonetheless felt stuffy inside in the stifling heat. Most in the crowd did wear official 'TRUMP' and 'MAGA' masks, though many did not.

To summarize, Trump campaign events were crowded and attended by people without face masks, and thus appeared designed to violate local rules about public health.  Trump himself mocked such rules and public health practices.

Republican National Convention Site, Charlotte, North Carolina

As reported by the Charlotte Observer on August 24, 2020:

Face masks were supposed to be worn at the Republican National Convention in Charlotte. In addition to North Carolina’s COVID-19 statewide mask mandate, RNC staff agreed to enforce the rule inside the convention center.

But on the floor of the RNC, strict coronavirus protocols quickly fell by the wayside Monday.

Social distancing was expected too — in addition to COVID-19 symptom screening and testing — to prevent a virus flareup as more than 300 delegates gathered at the Charlotte Convention Center Monday, in a dramatically scaled-down RNC to renominate President Donald Trump.

But many inside were seen not wearing masks and some attendees shook hands and huddled in tight-knit circles as the RNC recessed awaiting the arrival of Vice President Mike Pence. Among delegates and convention staff, some people did wear masks. Still others did not or were seen wearing face coverings ineffectively, such as having the mask slung below their chins.

Note that the management of the convention proceedings appeared to go against local public health rules..  Yet after local public health authorities reminded convention management of that, the problems continued.

Mecklenburg Public Health Director Gibbie Harris said Monday she contacted the RNC about the lack of masks and social distancing, observed not only by journalists inside the convention hall but also easily seen on live streams from the event.

'I have just shared concern about the lack of mask wearing and social distancing in the room at the RNC Roll Call Meeting with the RNC Convention staff,' Harris said in a statement Monday.

'I have been assured that they are working hard to address these issues. All attendees agreed to comply with the requirements prior to attending and were informed that these requirements would be enforced.'

Yet just a few hours later, delegates swiftly converged near the stage of the Richardson Ballroom as Trump concluded his remarks, holding up smartphones to snap a picture of their presidential nominee. Attendees, packed close to one another, danced the YMCA — with many still not wearing face coverings.

Further note that the Republican convention organizer's lax approach occurred at a time when transmission of coronavirus is a major concern in Charlotte.

The Charlotte area continues to grapple with the highest coronavirus case levels in North Carolina, though crucial trends — including hospitalizations and the test positivity rate — continue to improve. There have been 24,260 coronavirus cases and 282 related deaths among Mecklenburg residents as of Monday afternoon, according to state and local health officials said.

Thus it is not surprising that within days several convention attendees proved to be infected.  As reported by the Charlotte Observer on August 28, 2020:

Two attendees and two local support staff at the Republican National Convention in Charlotte tested positive for COVID-19, Mecklenburg County and GOP officials announced Friday.

The disclosures come after county health officials raised concerns about a lack of social distancing and mask wearing during the roll-call vote to renominate President Donald Trump for a second term on Monday — despite strict health protocols that were supposed to be followed. The GOP is defending the safety procedures it had in place.

Local health officials said the county instructed those who were infected to isolate immediately, and people who came in close contact with them should also quarantine themselves. A county spokeswoman did not respond to questions on whether the orders were followed.

To summarize, despite assurances that the event would promote best public health practices, the organizers allowed crowding and unmasked or inadequately masked attendance, even after public health officials had warned them about problems.  Probably due to the lack of public health preventive measures, attendees are already beginning to test positive for infection.


Republican National Convention Site, Washington DC

Melania Trump's Speech

As reported by CNN on August 26, 2020:

Those who attended first lady Melania Trump's speech in the White House Rose Garden that capped the second night of the Republican National Convention were not required to get tested for coronavirus, a person who attended the speech told CNN.

Despite that,

The vast majority of those attending did not wear masks, and the chairs provided for attendees did not appear to be placed six feet apart.

Trump's Nomination Acceptance Speech

According to the New York Times, August 28, 2020:

The chairs were packed in tightly on the White House lawn. Hundreds of people in the crowd had not been tested for the coronavirus upon attending.

The mostly maskless guests were seated cheek by jowl for hours....

Again, no masks, no social distancing, no observance of local public health rules.


Campaign Rally in Manchester, New Hampshire

As reported by NPR on August 28, 2020:

President Trump returned to New Hampshire Friday night, fresh off the Republican National Convention, for a rally at Manchester Airport.

For the hundreds of supporters in attendance, the atmosphere was that of a festival. Many wore Trump-themed clothing. Others wore T-shirts celebrating right-wing figures ranging from Fox News host Tucker Carlson to Brazilian President Jair Bolsonaro.

A minority wore masks, which are now required in New Hampshire at gatherings of more than 100 people. And many in the crowd jeered when an announcer on the PA system suggested they don them.

Again, no masks, no social distancing, and apparent public contempt for public health rules

Disease Spread Among Secret Service Agents Protecting Trump

Finally, the evidence that the Trump campaign is actually promoting the spread of COVID-19 is growing.  As reported by the Washington Post on August 28, 2020:

When President Trump gave a speech to a group of sheriffs in Tampa late last month, his decision to travel forced a large contingent of Secret Service agents to head to a state that was then battling one of the worst coronavirus surges in the nation.

Even before Air Force One touched down on July 31, the fallout was apparent: Five Secret Service agents already on the ground had to be replaced after one tested positive for the coronavirus and the others working in proximity were presumed to be infected, according to people familiar with the situation.

Then,

After the incident in Tampa in July, two agents who were assigned to stand guard at Trump’s private club in Bedminster, N.J., fell sick with coronavirus symptoms this month while the president golfed. It was his third trip there this summer.

In summary,

In the past two months, dozens of Secret Service agents who worked to ensure the security of the president and Vice President Pence at public events have been sickened or sidelined because they were in direct contact with infected people, according to multiple people familiar with the episodes, who spoke on the condition of anonymity to describe the incidents.

Trump's apparent disregard for the health of those who have sworn to protect him appears to be generating some unprecedented discontent.  A more rigorous program of coronavirus tests for agents was instituted:

after some discontent and anxiety percolated inside the agency earlier this summer, with agents and officers privately complaining that the White House and the Secret Service were not properly addressing the risks they faced on the road, according to people familiar with the concerns. Testing and protective equipment had been offered sparingly and inconsistently, some argued.

Even more pointedly,

this new virus that has killed nearly 180,000 Americans in eight months has prompted some to ask a new question: Should they be required to risk contracting a lethal disease — and infecting a loved one — to secure an event that does not follow health protocols?


Discussion

There is growing evidence that wearing face masks decreases the likelihood the wearer will transmit or contract the infection, and the likelihood that any such infection will be severe.  Keeping people physically separate, particularly by more than six feet, and particularly when they are indoors, also decreases transmission in either direction.

Nevertheless, after the Trump administration failed to effectively shield the US from the coronavirus pandemic, while peddling disinformation about the disease and its effects, the president continues to act in ways that actually promote further spread of the virus.  The perversity of his behavior is even being acknowledged by those sworn to protect him.  As reported by the Washington Post,

Never before has the Secret Service run up against a president so intent on putting himself first regardless of the costs, including to those around him,' said Ned Price, a national security expert and former CIA analyst.

While the Secret Service is having doubts, some Trump supporters deny the risks they are taking on his behalf.  Those who attend his campaign events, especially those who choose not to wear masks, have an elevated risk of becoming infected, and once infected, of transmitting infection to their friends and family.  Those who are already infected when they arrive at an event, even if asymptomatic, are at risk of spreading the disease to his other supporters.  Trump's careless, if not malevolent approach to public health at his campaign events is likely to hurt his own supporters before it hurts others.

Yet, perhaps rendered  stupid by Trump's propaganda and disinformation, they remain blissfully ignorant.  For example, as reported by NPR at the New Hampshire rally,

The COVID-19 pandemic was on the mind of many attendees. Timothy Parnell, an engineer who lives in Seabrook, said Democrats’ criticism of Trump’s handling of the coronavirus is 'absurd.'

'The only way the president could have done better is if he was psychic,' Parnell said. 'He took advice from the scientists; he asked for advice.'

Yet the evidence that Trump repeatedly disregarded, and often contradicted scientists' advice is clear.

Furthermore, as reported by the AP from a Pence event in Iowa,

Rob Mudd, who drove 120 miles from Cedar Falls to see Pence, was among those not wearing a mask. 'Is the disease real? Yes,' said Mudd, 53. 'So is the fear mongering.'

Likewise, Justin Chance, from suburban Des Moines, shook his head when asked why he, too, wore no mask. 'I just don’t believe all the hype,' said Chance, 55. 'I just don’t worry about it.'

Yet the US death rate for coronavirus this year has already exceeded 180,000.

Maybe his supporters are reassured about what Trump said in Oshkosh, “I hereby grant you a pardon.”   Of course, the coronavirus does not care if Trump gave someone "a pardon."  It could infect, and even kill such a person regardless.

Maybe the more Trump supporters fall ill, or see their friends and family members fall ill, the more they will doubt Trump's pretensions at royal pardons.  But that may take a long time, during which there may be a lot of disease and death.  Meanwhile, Trump will be able to do more and more damage to patients' and the public's health.

Instead of waiting, I hope my fellow professionals will step up now. It is time for us to tell every patient what they need to know to protect themselves from a deadly pandemic.  It is time for us to use every forum to reach the public with the message.  And it is surely time to call out the president and his supporters for their perverse and malevolent enabling of a deadly disease.

I know many health care professionals are afraid of appearing partisan.  It is not partisan to speak up for common sense public health measures to combat a deadly pandemic.  If there was ever a time for us health care professionals, especially those in the most senior and/or leadership positions to speak up, it is now.  Who will hear the call?

"If not now, when?"