Wednesday, January 06, 2021

Whoops, Dander Way Back Up: What's With the Vaccines?

Abbreviations used in this posting.

DIC: Disinformationist In Chief
DOPH: Department of Public Health; DOH: Department of Health
EHR: Electronic Health Record
ICC: Infection Control Committee
MAGA: Make America Great Again.
NDMA: National Defense Mobilization Act.
NIMBY: Not In My Back Yard
OMG: Oh My Gosh.
PH: Public Health
QR: the Quarterly Report
SCM: Supply Chain Management
PPE: Personal Protective Equipment
STM: Science, Technology and Medicine in US context. 
VA: Veterans Administration.
WH: the White House
WTF: What The Fig.

________________________________________

Time to Dive Into the COVID Territory. WTF: It's the Vaccines. 

OK, it's probably way past time for me to get away from this old "got my dander up" thing. Seems it gets up way too often anyway. Maybe this is the last one. Caution: it runs long. For a quick read, just take in the bullet lists.

Two topics I've stayed away from last year and this. One's the VA. I opined on the VA quite a bit around 2018-2019, as it got lost in MAGAville. Nothing last year or this. I still care deeply about it; once worked there. But it's stuck on a sort of ethical and political Möbius Strip. I find little truly new to say.

Then for the past year, the coronavirus, on which our chief blogger Dr. Poses has recently written most eloquently.

But OMG, just like everyone else I've been thinking about this slow motion viral train wreck of health policy pretty much non-stop. So belatedly allow me to weigh in on the most recent car to derail: the failure of vaccine delivery.

I anticipated everything else, along the lines of  Dr. Poses's above "don't say we didn't warn you" post. Just not this.

First car to derail was disinformation on the very gravity of the situation. That segment of this grotesque puzzle palace was confounded and distorted by the instant disinformation that's becoming the hallmark of our era. It's been discussed here in this blog. Go the search box and search on it.

The second car to derail was the endless dispute over public health protective policy—the absurd arguments over whether or not to mask or distance, whether "citizens should have to accept government interference"—and this was a not unanticipated failure of national leadership over PPE and all the other aspects of public health preparedness. Knew how the DIC had gutted PH planning. Saw that coming.

But not this. Didn't see this one. Didn't see this with the vaccines.

The third car to derail was over how to manage the explosion of patients. Again larded with disinformation, much of it from the DIC, Dr. Birx sitting there at the WH looking for a place to disappear into the floor. You could see that coming.

But not this.

The one car that never derailed, thanks to some extraordinary scientists we'll profile in the coming disinformation blog, was vaccine development. Didn't see that coming either, but in this case in a good way. This was the dog that didn't bark. Just worked. Tony Fauci, on whose NIH clinical service yours truly once worked for a short time, knows the story well. It's just not the story people ask him to tell.

(In an unusual collaborative effort, HCR's bloggers will soon take a longer collaborative shot at the science of this crisis in light of the parallel crisis of disinformation.)

*****

Most Blew It. One Didn't.

But before that, and before today's story becomes staler than it already is, we interrupt this program to look at today's most egregious problem: getting vaccines into arms. It's getting reported, just not nearly enough. It's semi-anechoic, almost as though too diffuse for reporters to spend time on. So I will.

Diffuse, yes, this story. But you can get to those findings. When you do, they're not pretty.

As I said, this one I didn't see coming. Probably should have. This business of getting shots into arms, isn't just down to the DIC. He's now on his way out. But he's got a whole lot of local, state, and institutional henchmen and henchwomen. These people knew the challenges. They just sat back anyway and didn't plan. They played the competitive SCM game on vaccines, as they had on PPE. They cried poor. They decried, rightly so, the lack of guidance and funds from above.

But in this most life-and-death of situations, they blew it. They blew it through bureaucratic inertia and timidity and poor planning. They can't claim they needed to wait until the vaccine to "practice" the proper measures to get vaccines into arms, or lack of a model.

Because the model is there. It's called the State of Israel.

There are governors, mayors, hospital administrators and other managers, both here in the US and abroad who have a whole lot of 'splainin' to do. It's true, interestingly, in most but not all nations. (We'll come back to Israel.) So the US is not alone but that's cold comfort when we look at the history. A tiny bit of that history is as follows.
  • In STM, in the mid- to late-20th century, we had moon shots and such. Mostly government run but with a huge number of private contractors. There was coordination but admittedly benefited most of all Big Government and Big Industry.
  • We've had much more recent efforts at space exploration that morphed into true public-private collaborations. Still mostly Big Government and Big Industry. 
  • Preview of coming post: we've had barely-noticed efforts for over a quarter century to do the hard science. These efforts centered in publicly funded labs at non-profit institutions, and in a few quarters of the then-nascent biopharma industry. Without such efforts, results described in the next, fourth bullet would've never occurred. This quietly benefited every man, woman and child.
  • Now we have those public-private efforts since early 2020: newly visible, highly laudable, efforts to produce immunization protocols for COVID-19 at "Warp Speed." Yes, warp speed after 25 years of science. But nonetheless, remarkable. As pure science, but not as PH applied science.
  • What's been missing, throughout: attention to "the last six feet," to the mechanisms of cooperation and health care delivery that must, in a pandemic, supersede the usual habits of mind of managerial cultures, those focusing on the quarterly report, on the latest technology, and the high margin care centered in hospitals.
Putting a shot into an arm is neither high-tech nor high-margin. So the above final bullet is a bummer. It's a train wreck that was waiting to happen. And now it's happened. Now we have a way to abate the  pandemic, we're still letting it happen. Not only by allowing disinformationist anti-vaccinationism to go unopposed, but even more importantly by not getting shots into people's arms.

Sure, the professors of public health and medicine, seeking to exhibit appropriate gravitas and aequanimitas when approached by journalists and the talking-head media, will exclaim that all will get better fast. (There are exceptions: a few public health people have demonstrably got their dander up about this. Nowhere nearly enough, at least not publicly. Ranting doesn't get you promoted. It gets you fired.)

We can hope that quietly, behind the scenes, some of those same "we have to be patient" people are getting to the right places at the right time to actually make things happen.

It's an unnecessarily lugubrious process, and it's lamentable. I haven't actually yet found a medical colleague who disagrees.

How much should we care if that process is lacking in standardization from state to state, or country to country? That's one of the many paradoxes: dinging somebody else because there wasn't standardized guidance from above doesn't absolve institutions from failing to pull all the stops using their own criteria and protocols. It doesn't absolve them from flirting with all the media adulation over "look how diverse we are" or playing up the "hero" sobriquet, while putting too few doses in arms even in terms of available vaccine supply.

Right now, in the US, of available doses, those shipped to and received by organizations designated as vaccination sites, way under half of those doses are getting into arms. I get asked a lot: why aren't they? [The NY Times just published a piece rehearsing all this, here. What I write here is sort of a counterpoint to that Times piece.] You can guess the reasons I get as well as I can. Lack of staff (true); spoilage or sabotage (much in the news but de minimis); lack of guidelines (special pleading); on and on. So what if my people are getting one in three doses in arms, while that guy's people are only getting one in five in? Find your own local numbers. They're out there.

You won't like what you see.

OK, now let's talk details. Pause for a moment and consider how one nation got it right. If not pure gold standard and not a one-size-fits-all, a benchmark of sorts. Not because the Israeli PH folks are smarter. Or have better medicine or better vaccinology. Or more socialist. Or less capitalistic. Or more capitalistic. None of those is true. OK, maybe in part because they can bend capitalism differently, looking beyond the quarterly report.

Here's what Israel did. I've pulled this from multiple sources but found especially useful the recent article from the Jerusalem Post, on which I rely heavily. [And, now added post-publication, this important piece from Brookings.] The author lists nine reasons for success. None of them is: "we're just really smart."  My comparative comments follow each bolded claim.

1. Universal healthcare. "Community services are ubiquitous in Israel."

But wait! Even those in the US who do have insurance, and access to most services, can't get vaccinated and don't know when they will. The continuum-of-care clearly creates momentum. But people all over the US are busting their buns trying to participate. They're waiting for dozens of hours in snaking lines.
 
Seems we can reach out to individuals, but not to populations.

2. People trust their health funds. Trust and infrastructure didn't happen overnight in Israel.

But wait! Even those who trust their physicians—despite what you may have read, most Americans of all ethnicities, at least those with personal physiciansm do have that trust—can't get to the doses. The doses are being heavily guard-railed to protect those giving them against accusations of...what? Unfairness? Queue-jumping? Just being overwhelmed?

3. A focus on prevention.

OK, I buy this one. It would be hypocritical to criticize our margin-, QR-, and fractionated care-oriented health system and not buy the importance of the tilt-to-prevention effect.

4. Israel knows emergencies: “we know how to mobilize.”

But wait: didn't we used to know how to mobilize? Can you spell "NDMA"? Um, no. But maybe Uncle Joe can.

5. A lot of people work for the health funds  A clinic in every neighborhood. A big workforce.

But wait! Don't we have a huge medical workforce? I bet it's bigger per capita than Israel's. Don't we have a NDMA? In any case the actual OECD numbers tell a different story. Israel has a middling number of doctors (3.1) per thousand inhabitants, while the US has a slightly lower (2.6) number. For nurses, the other way around, our 11.9 to Israel's 5.0. The real story, therefore, no doubt resides in the way these personnel are actually deployed. (And for workforce redeployment, long lead times are admittedly needed, even with the right financial incentives.)
 
Fact is, nonetheless: the vaccine lines could have delivered far more doses per hour and arms per vial if managers had just temporarily redeployed personnel instead of making sure high-margin services didn't suffer at hospitals who got the vaccine. Managers do three things really well: protect the brand. Control the message. Amp the quarterly report. Non-profits, same as for-profits.

It's the NIMBY effect. "We can't run the {fill in the blank} if you take all our nurses." (I paraphrase.) But don't exaggerate. Take a few from each site, be fair, spread the pain, get shots in arms. We could've already done this.

6. Experience vaccinating a lot of people.

But wait! Like the guy on the exhibit-hall floor at the auto show, "yeah, we got that." Roll up a refrigerated truck, boys. Community-based delivery sites have largely if not entirely been left out. They shouldn't have. 

 “We run vaccination campaigns all the time,” [one nurse] said. “We do it every winter."

But wait! We do it too. Why aren't CVS and others already putting doses in arms right now? Money, you say? This really sounds like special pleading after the many billions spent on getting the vaccine developed. It's quite simply, even at the local and state levels, managerial incompetence and timidity. How else to explain that at fancy places like Stanford, interns, residents and respiratory therapists got the shaft while "orthopedic surgeons, nurses treating outpatients, and a dermatologist [were vaccinated]?" This absurdity was replicated all over the country. 

What a colossal piece of mismanagement. Maldistribution, non-planning, and waste. More on that in the final two sections of this posting.

7. Data and technology. "The health funds all work with computerized records that feed data securely...."

Wait, what!?! For decades, major legislation, in the military, at the VA, and for at least two decades in the civilian sector we've had enormous investment in digitizing records. Admittedly the EHR too has been far too fractionated, as InformaticsMD and others have written in this blog, as have others. But technology, or rather lack thereof, is not the reason we've blown it.

8. Communication. Israel "ran a widespread TV, radio and newspaper campaign encouraging people to take the vaccine...."

But wait: we just spent almost a billion dollars on media campaigns for one run-off election in one state. That would buy a whole lot of trucks carrying ultra-cold refrigerators. In the meantime the "commuication" goal is more about getting above the 70% uptake level than it is about getting shots into arms based on available doses. (New York State currently has an anemic but attractive such advertising effort, a start). It's not like we've got people in miles-long lines chickening out at the last minute. What's happening at the last minute is that, where they're allowed to queue up based on age, people over a certain age are getting turned away at the door after hours-long waits.

9. The spirit of the People of Israel. "[I]n the end, it comes down to the people...."

But wait: hogwash! There's nothing wrong with the American people, who're rapidly coming around to the realization this is a ticket back to their old lives. We'll have plenty more to say about anti-vaccinationism (are you listening Robert Kennedy?) in a coming blog. Meantime, one can only say hogwash: it's not the people. It's the leadership. Again, not just national but local and everything in-between.

Result: more than a million citizens vaccinated in Israel in the first two weeks. Compare that with, say, France, which as of this writing has vaccinated 2000 people despite having received somewhere in the range of 0.5-1.5M doses. (Personal correspondence; see also this link.)

It's not knowledge or know-how. It's a sense of community and, most of all, a history of organization. What do we have? Fractionation. Can't blame it on scale: "they're such a small country." There's an awful lot about our national government that works superlatively well, on a huge scale, even when intermittently under-funded, because there was a will to make it so. Social Security pulls it off. And being small and prosperous doesn't mean much, when US per capita spending in healthcare, top in the world is just about quadruple that OECD described with respect to Israel.

Fractionation is, now, literally, killing us. And our leaders, including locally, are the most fractionated of all.

*****

Where Is Everyone Else? How's The World Doing?

Is there a will to combat this fractionation? I'm not convinced there is. But let's at least survey the ruins.

Since the US inaugurated its vaccination effort I conducted an e-mail survey of individuals whose interest and acuity I trust, in six countries including the US and in six states within the US. It was balanced for gender and ethnicity. All of these individuals are medical or public health professionals, including specialists in lung and infectious diseases; or they have experience in fields such as public health history or health administration. The uptake, i.e. response rate, was over ninety percent. Everything they told me has likely changed already, so where I can make it at all meaningful I provide only broad-stroke data. With that caveat in mind here are some of my findings.

The USA.

In the US, we're all over the map. But some data points stand out.
  • Comorbidities have been down-graded in importance. "Too complex." (I don't buy that.) Age has largely become a surrogate for comorbidity. I can actually argue this one both ways.

  • At least two physicians in my respondent group, one in California and one in Pennsylvania, are immunocompromised and have been denied even a place on the schedule. The given reason, interestingly, was not that immune status is unimportant. Rather, these physicians are community-based with no longer active hospital affiliations. So: no hospital to resort to for access to the jab. As of today, 1% of Californians have received immunization—unclear if this is a first injection or whole series. Hunch: the former.

  • In Tennessee, rightly we think, the elderly have been given opportunities to sign on and get early vaccination. The chosen cut-point was 75 and older. In some counties the schedules already run out to February, but at least folks can plan. One site to which 75 year old people were invited filled its schedule in two hours. Its county seat mayor "criticized the state for lack of a coordinated response or effective communication throughout the pandemic." Meanwhile this state is just full of contradictions: in one hospital, Saint Thomas Rutherford, it seems fully 60% of the medical staff is refusing the vaccine. Maybe this is why the powers-that-be are opening it up to non-immunocompromised, non-institutionalized elders. Also looks as though more responsibility has been already been given to CVS-like entities, e.g. Walgreens in Tennessee. Some sources say large pharmacy chains will play a larger part outside the crowded east coast.

  • (We know, admittedly if only from the media—no professional informants here—that Florida got a gubernatorial thumb-on-the-scale for its old folks. Whoops. They've been lining up and camping out overnight, then turned away. I'll try to update this if I get real numbers. Otherwise, it's just murky and a predictable if confusing result of the old GOP thumb-on-the-scale.)

  • In Colorado, the state university's health system and Kaiser shoulder a lot of the burden. Seniors aged 70 and higher are in a high category and either are being, or soon will be, lining up for the jab. Respondents in this state think 70+ year old citizens will be brought in somewhere around February—maybe. "Watch your social media." On the other hands, we're told by some informants on a conference call, health providers in Ohio are even worse off than those in Colorado. 

  • There appears to be even somewhat clarity or planning in two of the biggest states that on 4 November 2020 went blue, New York and Pennsylvania. I've not seen statistics for doses shipped, but the results seem abysmally haphazard for planning, prioritizing, or jabs-per-vial. The caveat is those data are so closely held, perhaps the health departments know. But no one I ask does.

  • Pennsylvania is particularly interesting. Per instructions from the state's Health Secretary, with one key exception the vaccine's distributors across the state are supposed to vaccinate health workers even if they are not associated with their specific hospital or system. Specifically there is to be a 10% set-aside for clinicians who do not have hospital affiliations. The key exception is Philadelphia, where there is a very large, very elaborate, very diverse and very managerial committee supposedly overseeing the distribution, negating the state's otherwise 10% set-aside.

    Informants in Philadelphia have seen no evidence that all this is working, with a Tower of Babel emerging instead. The state's website is full of highly bureaucratic and highly prescriptive language about what to do. But probably because they're simply overwhelmed, hospital officials, including MDs, seem to have given up on being proactive with communications or even answering e-mails. Unlike places like Massachusetts General and Stanford, many major department chairs in a preeminent institution are not yet vaccinated (personal communication). As of yesterday, 100k residents of Pennsylvania and New Jersey—very likely, I think, with New Jersey predominating per capita—since late December.

  • In any case, it's clear that in these states, where we're told only "frontline health workers and nursing home residents and staff are currently eligible," no one can really say that any of these words are true. It's a black hole. But with a combined population of over 21M for the above two states, the uptake is less than 5%. Hey, a lot better than California, if we can believe what's written above. (But these are all moving-target figures, so I'm not sure even I believe them.) It's not bad. But in densely populated mid-Atlantic states, it's still nowhere good enough. The numbers are too low and they're inequitable when even health workers and immunocompromised patients aren't getting vaccinated.

  • Back to New York for just a moment. In a cleverly crafted distro, the media-savvy governor, Andrew Cuomo, said three weeks ago that

    New York will begin vaccinating people with underlying health conditions as soon as late January, Gov. Andrew Cuomo said on Wednesday, as hundreds of thousands of vaccine doses are heading to the state in the coming weeks. The vaccination program is getting underway as the pandemic continues to surge in New York. The positive rate in the last day reached 6.21% out of 160,947 COVID-19 tests and 95 people died of the virus. There are now 6,097 people in the hospital due to COVID-19. But the vaccines are seen as the light at the end of the tunnel. New York is receiving nearly 170,000 doses of the COVID-19 vaccine from Pfizer and expects to receive 300,000 doses of a Moderna-manufactured vaccine in the coming weeks after its expected approval. Frontline health care workers and nursing home residents are scheduled to be vaccinated first. In the second phase, New Yorkers with underlying health conditions will be given the vaccine, which will be distributed by "regional hubs" led by health care networks on the local level. "It's a medical procedure," Cuomo said. "It will be handled by medical officials. There will be no political favoritism." New York's vaccination program will be conducted in multiple phases, with healthy adults and children going last. A vaccine program could run until September to reach a normal level of immunity in the country. The first non-clinical trial vaccines were administered this week in New York and the country. Plans for the second phase of the distribution program are due Jan. 1, Cuomo said. The goal, he added, is to make New York the first COVID-free state in the country.

    It's a week after January 1st. I find no evidence that this critical Phase 2 plan is anywhere in sight. Like Rachel Levine in Pennsylvania, lots of lofty "guiding principles," but awfully hard in any well-defined way to see the boots on the ground. And the bootprints are running in circles.

  • In Rhode Island the state's DOH is falling far short of its responsibilities in terms of communicating with clinicians. One expert, highly placed in the national firmament of Internal Medicine, notes that exactly the same problems noted above for Pennsylvania, with unequal access, obtain in lower New England, with physicians having to resort to Facebook to look for communications. He notes that

    The DOH has fallen short in its communication with the provider community on what they should expect - 'where' and "how" - even if the "when" is murky because of frequently-changing delivery numbers. "Soon" and "we're working on it" are not enough. Another unforced error, in my view, is the way they drew the distinction between physicians who are seeing COVID+ patients and those who are not ("high-risk" vs. "low-risk"). As a result, primary care physicians are in the 1d priority group, along with other types of workers, including "death professionals." In a high-prevalence environment and with a virus that has a long pre-symptomatic infectious phase as well as a high percentage of asymptomatic infections, drawing such lines misses the point that all of us who have face-to-face contact with patients are at increased risk (especially if they are breathing, with all due respect to the funeral directors). [Italics mine.]

    On the other hand, community clinicians can't be expected to do the planning. They run on shoestring budgets. So round and round it goes, the circle of blame-shifting and planning deficits continues, and few get to know what's going on in this part of New England. Wait: it sounds like the mid-Atlantic, a pattern appearing everywhere.

Europe.

Maybe we shouldn't be surprised to hear things aren't much better in Europe. For those countries I don't cover, a good recent summary, from The Guardian, is here. There are a few surprises, though, the first being where it all started: Italy. But not in a good way.
  • Italy. Despite the vaunted construction of many design-forward, primrose-shaped (the COVID symbol in Italy) vaccine centers, distribution has been slow. One informant writes (my emphasis added) that

    [h]ere in Italy the policy is set by the ministry of health, then the organization/implementation is of each region. As of now, but things are no doubt going to be reset going ahead, the first to be treated are the retirement homes (guests + employees working in contact with the guests) and the personnel of the public hospitals (doctors nurses cleaning etc.), then will be treated the family doctors, the elders +80 and the individuals which are fragile (i.e. those who would be at higher risk if they get the virus). The discussion is ongoing if the +80 and the fragile will be reached by the family doctors who would treat them at home if needed. Then will be treated the doctors+nurses+.... of the private hospitals. Discussion is ongoing about when to treat the dentists (and, I assume other similar categories). I think that, if this all will not become a nightmare, which is quite likely to happen, it will be our turn around April-May. [Italics mine.]
    The government is organizing special vaccination gazebos which are being installed right now. Discussion is being raised about when to treat the inmates and it appears to be considered a priority because of the closed environment.
    I am asking myself what will be the approach about all those unable to decide for themselves. The individuals less than 16 won’t be treated for now (no vaccine exists yet here for them). As of now there is no obligation for anybody to get the treatment and as you may imagine there is a major discussion about this, at least for certain categories. In Italy there is in fact a substantial chunk of doctors-nurses-etc. refusing the treatment (from 10 to 30+%)....

    Another informant from the same region wrote me that "[w]e hear that after doctors, nurses, first line health workers, people working in nursing homes, we shall start with vulnerable and people over 80 years old," and on the same idea a WhatsApp message came through stating a typical Tuscan village's "casa famiglia" had been that day fully vaccinated.

    Why are the first- and hardest-hit in such continued difficulty? One informant writes that in Italy they have the "same questions here [as in US] about organization of this all (one of the problems here is of hiring new people, we seem to be late about that). We are very late with the organization, this is ridiculous, they had plenty of time to get organized!! Will see in the next weeks, they are working to overcome the problems. It will also depend from what is going to be the percentage of Pfizer, more difficult to handle. Also, it appears that there will be a shortage of vaccine, issue raised by Pfizer who urges the approval of other producers."

  • France. For the entire world, but especially the European countries, a chart available from Oxford University's superb Global Change Data Lab demonstrates how these countries' efforts start up, stall out and scud along the x-axis with no proper, Israeli-style organizational accelerants. Slide the slider and you will see. Missing from the dataset entirely is France, whose Health Ministry just announced "a possible inscription [registration]" program [italics mine] for "those wanting to get vaccinated." A Paris-based informant tells us in an e-mail that "[i]n France we will be vaccinated in another life." Such exclamations of course reflect frustration as much as anything else, but for France the numbers really do seem dismal: Pfizer doses expected to be received by the nation at large are as follows (in millions): by 12/30/2020, 1.16. By 01/06/2021, another 0.68. On or around 02/19/2021, another 1.60. Paltry.

  • UK. Sort of a special case, because PH authorities in the UK are sort of like their current leader and arguably a big chunk of his followers: all over the map, even more than in the now-recovering US. My one respondent so far gives few numbers but notes uneasiness over lack of evidence for all the sleight-of-hand tricks being announced to alter dosage amounts and scheduling. A quick look at the above Oxford site, however, tells some of the story numerically. (The "daily doses administered" graph, with time-scale slider, is especially informative.)  In the first three weeks of getting shots in arms, in the rolling 7-day average, Russia and Canada just slide along the bottom a nanometer above the horizontal axis; the UK scuds along, in parallel with them. somewhere just under 50k doses/day. That's less than one one-thousandth of the population. Onward to 2024! And that's with a National Health Service and an emphasis on primary care. Interestingly, the curve for the US, though nowhere nearly as impressive of that of Israel, does have a nice 45° slope, showing a zenith of about 350k doses per day. Oh, wait, if that levels off, it's again on-to-2024. (But we can rely on a continued uptick, right? Right?) 

  • Germany. I've received no response from German colleagues thus far. But the Oxford data puts Germany just above Croatia and below Canada. One plausible report from a day or two ago makes the following points based on data from the Robert Koch Institute. Just over a quarter million people have received COVID-19 vaccine in Germany as of January 4th, including more than 114,600 residents of nursing homes and around 123,100 medical staff. That's only a week a half into the effort. "Germany has registered nearly 1.8 million coronavirus cases and about 35,000 [deaths]. The German government has emphasized that vaccines would be in short supply at the beginning and that it was necessary to prioritize. Citizens over 80 years of age as well as staff and residents of old people's and nursing homes are among the first group to get inoculated. The first 1.3 million vaccine doses were delivered to Germany at the end of 2020. The government plans to distribute 670,000 vaccine doses every week from January 2021 onwards.
Conclusion

By now I suspect the reader will have concluded, as I have, that pandemonium reigns pretty much everywhere. With that one exception. For decision-making, fractionation and arbitrariness are the rule. Everything seems ad hoc. "Things will get better" is the only mantra in leaders—let's call them "leaders"—in efforts to sound hopeful by telling us "watch this space." The problem is that January 20th is two weeks away and Uncle Joe doesn't—can't—in any plausible scenario hit the ground running with this issue. It's almost as though every leader took their cue from the orange man in the WH. Wait it out and do as little planning—as little troop-muscling and -mustering—as possible. An at best limited defense: hand-sitting was too easy to do when the dollars weren't flowing from above.

It's a war. But we're not on a war footing. I know: military historians will tell us that at the beginning of wars there's actually been a huge amount of noise and inefficiency in systems of planning and execution. Every politician, in deciding on how draconian to be about enforcing social-preventive measures, had one eye on the health realities, another eye on their economic realities, and yet another (I know) on their own reelection. The social-prevention mistakes were in some sense unforced errors.

But what shall we say about the monumental error to duck local leadership on vaccine planning? We know that many may answer "without adequate budgets, what's the point?" I believe that's too facile. Both expert (clinical / PH) and non-expert (political) leadership needed to step up months ago and work together to put in place flexible, effective, adequately-staffed, vaccine-delivery plans. Even lack of precise knowledge of numbers-of-vials-expected come squarely under the "flexibility" umbrella.

That doses are being received and not distributed is inexcusable.

That doses are being denied, based on over-rigid or contrived local criteria, is inexcusable.

We could have done better. One country pulled it off. The rest of the developed world has also taken its eye off the ball. We're all playing hot-potato with this one, while people die. Forget the public-health system we wish we had. Even with the public health we have, we should have done better.

Wednesday, December 23, 2020

Trump's Horrendous Mismanagement of the Coronavirus Pandemic: Don't Say You Weren't Warned

 The Washington Post published just the latest in a growing genre, short-term retrospectives on how the Trump administration horrendously mismanaged the coronavirus pandemic.  (See earlier examples here in Vox and here in the New York Times)  While no country was able to cruise through the pandemic, and some arguably have done as badly or worse as the United States, our country seemed uniquely positioned to fight a pandemic and lead the world in doing so.  We were the richest, spent the most on health care, and had an enviable record - at least prior to the Trump administration - pandemic preparedness.

However, so far we have failed, badly, fatally, and shamefully.

We Warned You

We cannot claim any ability to predict pandemics.  We never predicted this one.  However, on Health Care Renewal we published warning starting in early 2016 that were Donald J Trump to be elected president of the US, he would prove to be uniquely badly qualified to lead on health care and public health.

No Health Policy, No Health Policy Advisers, Word Salads in Response to Health Care Questions

In February, 2016 we posted that while Trump was then a leading candidate, he had "no health plan" and "no health care policy advisers." 

His one major health care proposal at the time was to somehow reduce the cost of drugs by $300 billion.  He did not seem to then realize that $300 billion was the then estimated total cost of drug spending. When asked about the mandate provided by the Affordable Care Act his response appeared to be a "word salad."  When asked about health policy during a debate, "Mr Trump only seems to have repeated the notion of selling health insurance across state lines to increase competition, interrupted by non sequiturs insulting Senator Rubio and insurance executives.  The Minnesota Post writer and I could find absolutely no other content."  

My conclusion at the time was:

We live in perilous times when a candidate with such reckless approaches to critical problems continues to attract adulation.

Given this, should it be a surprise that President Trump had no real public health policy, and undermined standard public health approaches to pandemic prevention? 

Per the Vox timeline above, as early as on January 22, 2020, Trump said to CNBC

We have it totally under control.  It's one person coming in from China, and we have it under control.  It's - going to be just fine.

A History of Promoting Health Care Related Scams

In March, 2016, we posted about the Trump Network, a scam that involved the selling of apparently worthless nutritional supplements using equally worthless diagnostic tests. 

The basis of the scam was a "network-marketing" (or allegedly "pyramid marketing") scheme in which individuals got monetary incentives not just for selling vitamins and tests, but for recruiting new marketers. In this case, the company sold "nutritional supplements" supposedly custom-designed for each customer based on results of a proprietary urine test.  However, 

there appeared to be no publicly available data on how the tests worked, what they actually tested, or how accurate they were.  Then there was no data about how the test results could rationally be used to suggest particular mixes of vitamin supplements.  Also, there was apparently no public data about what vitamins were in the potions sent to consumers, their purity, their strength, etc.

Worse, there was no evidence that any of this provided any benefits to the people who ended up taking the vitamins.

Trump bought the company that initially innovated this scheme and rebranded it the Trump Network in 2009.  He then enthusiastically marketed its products, and careers marketing them. Marketing videos that include Mr Trump are still readily available online,



In the video, Mr Trump said "Americans need a new plan. They need a new dream. The Trump Network means to give millions of people a new hope." 

Nonetheless, by 2011 the Trump Network was finished. 

My conclusions then were:

What damage could such a leader do to health care?  And what other damage could a man who so cavalierly fleeced the little people with his dubious nutritional product marketing scheme  do, especially to the little people who now so unconditionally support him?

Is there a better example showing why we as a society need to completely rethink who gets to become our leaders?  My only hope is we can do that rethinking in time to prevent a disaster.  

How did that work out for you? 

Based on this, is it any surprise that President Trump promoted unproved "cures" for COVID-19 such as hydroxychloroquine; hired "experts" who promoted herd immunity in lieu of a vaccine, which would likely result in millions of deaths were it to be implemented; and even suggested that people should ingest bleach to prevent infection?

According to the Vox timeline, as early as on March 19, 2020, "Trump incorrectly claims that the Food and Drug Administration approved the antimalarial drug hydroxychloroquine for treating Covid-19."

Denying Asbestos-Related Disease, PTSD and Chronic Traumatic Encephalopathy, Asserting Vaccines Cause Autism and Pornography is a Major Public Health Hazard

In November, 2016, just before the election, we posted a catalog of medical/ health care/ public health nonsense that Donald Trump had disseminated.  

These included denying that asbestos is an important health hazard; that post-traumatic stress disorder is a manifestation of weakness, not a mental health problem; that chronic traumatic encephalopathy is "a little ding on the head," not a potentially severe neurological condition; and that vaccines cause autism.  In addition, the 2016 Republican Party platform that Trump endorsed asserted that pornography is a major public health hazard.  

My conclusion at the time was:

It is disturbing when one candidate for the most powerful political office in the US repeatedly disregards the best clinical and public health evidence, and offers ill considered opinions about public health that could potentially harm patients.

Based on this, is it surprising that during a pandemic, President Trump seemed to declare war on biomedical, clinical and public health science, and on professionals who try to implement scientifically based health care and public health?

According to the Vox timeline, as early as on April 17, 2020, "Trump calls on his supporters ... to 'liberate' Michigan, Minnesota, and Virginia...." Those supporters later threatened health care professionals advocated a more scientific approach. 

Summary

The history was there.  We were warned.  We paid a tremendous price.  Will we be smarter next time? Will we survive next time?



Friday, December 04, 2020

All the President's Disinformationists

The coronavirus pandemic has been accompanied by a pandemic of disinformation, sometimes called the "infodemic."  In the US, while it would have seemed unthinkable up to 5 years ago, the biggest source of disinformation has been President Donald Trump (look here).


Trump lost the 2020 election, and barring an overt coup attempt may be gone by January 20, 2021.  However, that does not mean we should expect the infodemic to go away as well.  In fact, another big source of disinformation since the onset of the pandemic has been Trump's faithful followers, including politicians at national, state, and local levels in the US.  We noted the onset of disinformation about the virus propagated by Trump supporters here, including the case of Senator Tom Cotton (R-AK), who pushed the erroneous idea that the coronavirus originated in a Chinese laboratory in Wuhan. 

Since then we have noted many other cases in which Trump supporting US politicians have peddled disinformation about the pandemic. We present here some notable cases that have gotten attention in the news media, in chronological order by publication date.

Joanne Wright, candidate for US House of Representatives in California, Promoted Conspiracy Theories about Pandemic Origin

Sen Cotton's ill-conceived theories quickly inspired other Trump true believers.

As reported by The Hill, March 2, 2020:

A GOP House candidate in California has repeatedly tweeted conspiracy theories regarding the novel coronavirus, a fast-spreading flu-like disease that has spurred a wave of online misinformation.

The tweets, from Republican hopeful Joanne Wright, underline how widespread coronavirus-related conspiracy theories have become as even politicians tout debunked claims linking the disease to governments and public figures.  

Wright has tweeted multiple times over the last few weeks about the coronavirus, suggesting the virus may be manmade or even connected to prominent Democrats, the Los Angeles Times first reported.

In one tweet, from Feb. 28, Wright questioned whether Microsoft founder Bill Gates is connected to the virus, a conspiracy theory that has made its way from the fringes of the online ecosystem to the center. She also tied the coronavirus, also known as COVID-19, to Democratic mega-donor George Soros and former Democratic presidential candidate Hillary Clinton

'Doesn’t @BillGates finance research at the Wuhan lab where the Corona virus was being created?' Wright tweeted, earning hundreds of retweets and likes. 'Isn’t @georgesoros a good friend of Gates? Isn’t it always when @HillaryClinton tweets that fire and brimstone hits us? Check Gates Foundation and Clinton Foundation for stock sells.'

The day before, responding to a tweet espousing a largely debunked theory on the origins of the virus from Sen. Tom Cotton (R-Ark.), Wright tweeted, 'The Corona virus is a man made virus created in a Wuhan laboratory. Ask @BillGates who financed it.'

Wright was defeated in the primary election, but other Republicans soon jumped into the fray.

Former Congressman Ron Paul (R-TX), Father of Current Sen Rand Paul (R-KY), Dismisses Coronavirus Death Rate Estimates

As reported on March 18, 2020 by Politifact:

Calling Fauci 'the chief fearmonger of the Trump Administration,' Paul wrote in a column on his website that Fauci 'testified to Congress that the death rate for the coronavirus is 10 times that of the seasonal flu, a claim without any scientific basis.'

At the time, Politifact said that in fact there was good, if incomplete evidence for Dr Fauci's estimate of the death rate.  The current consensus is still that the coronavirus death rate is approximately ten times that of seasonal influenza.

Fooling people into thinking that COVID-19 is no worse than seasonal influenza likely would lead them to think they need no more precautions against it than they take for influenza.  It also distracts them from considering that one reason that influenza is now not so much feared is that a relatively effective vaccine for it is widely available.

Rep Louis Gohmert (R-TX) Claimed Germany has a "Powder" that can Cure Coronavirus

On April 20, 2020, the Independent reported:

 Republican congressman Louie Gohmert falsely claimed that Germany is using a powder to help prevent health care workers from contracting Covid-19.

Earlier this month, during an interview with KLTV in Texas, Mr Gohmert claimed that health care workers were being protected from coronavirus by the substance.

'It is being used in Germany as a mist,' Mr Gohmert said. 'Health care workers go through a misting tent going into the hospital and it kills the coronavirus completely dead not only right then.'

'Any time in the next 14 days that the virus touches anything that’s been sprayed it is killed.'

This was nonsense

Head of the German Hospital Association, Dr Jörn Wegner, told Ms Mekelburg [of Politfact] that the congressman’s claims are incorrect.

'What your congressman said is absolute nonsense,' Dr Wegner said. 'There are no such tents and there’s no powder or magical cure.'

Note that Rep Gohmert had scoffed at wearing a mask to prevent infection, but then became infected with  COVID-19 (look here).

Deceiving people into thinking that effective chemical measures to eliminate COVID-19 exist may lead to them neglecting simple preventative measures that actually may work. 

Republican Speaker of the Pennsylvania House of Representatives Mike Turzai Said Children Without Underlying Conditions Are Not at Risk from COVID-19

As reported by the Philadelphia Inquirer, May 14, 2020:

 'Guess what, they’re not at risk unless they have an underlying medical issue,' said Turzai, whose comments came in a video he recorded from his Allegheny County home and later shared on social media.

Note that

Turzai declined to provide any evidence that he relied on when he made this claim.

However,

it’s true that children are far less susceptible than adults. But his claim that other children are totally safe is incorrect, according to a study published recently in the medical journal JAMA Pediatrics.

Again, fooling people into thinking that COVID-19 is less dangerous that it is may lead them to neglect public health guidelines.

Republican Candidates for the US House of Representatives Promoted Trump's Use of Hydroxychloroquine to Prevent COVID-19

On May 23, 2020, the Daily Beast reported:

'@realDonaldTrump taking hydroxychloroquine to ward off coronavirus is a kick-ass move that proves why he is the bravest and strongest of all American presidents,' James P. Bradley, a Republican U.S. House candidate in California, tweeted. 

'You’d have to be extremely naïve to believe that none of these Democrats knocking @POTUS are also taking hydroxychloroquine as a preventative measure,' Errol Webber, a GOP congressional candidate in California, tweeted after Trump touted taking the drug. 

In an interview, Lauren Boebert, a Republican congressional candidate in Colorado running to the right of GOP incumbent Scott Tipton, criticized those who were quick to go against the treatment. 

'With the way the media hates President Trump, if taking hydroxychloroquine was truly bad for him, they’d be encouraging it rather than having a meltdown,' Boebert tweeted on May 20.

 Also,

In Congress, two sitting House members also promoted in media interviews their own experience with the drug, including Roger Marshall. The Kansas doctor is running in a crowded GOP U.S. Senate primary in the reliably red state and looking to win out over longtime Trump supporter Kris Kobach. 

He told The Wall Street Journal earlier this week that he and members of his family were taking the drug prophylactically.

'I would encourage any person over the age of 65 or with an underlying medical condition to talk to their own physician about taking hydroxychloroquine and I’m relieved President Trump is taking it,' Marshall told the Journal

Also,

A conspiracy-filled approach to the issue came from Josh Barnett, an Arizona GOP challenger in the state’s deeply Democratic 7th District whose chances at making it to the House are slim. 

He tweeted: 'If hydroxychloroquine is soooooo dangerous then why are Democrats so against @realDonaldTrump taking it? Do they suddenly care about him and his health? LOL NO! Its because it works and they don't want anything to fix Covid and rev this economy back up.'

However, the article also noted that by the time of its publication

By late April, Trump’s own Food and Drug Administration warned that 'hydroxychloroquine and chloroquine have not been shown to be safe and effective for treating or preventing COVID-19.'

Research on the drug has continued to be troubling since. A new study published Friday by The Lancet also failed to show a 'a benefit of hydroxychloroquine,' when it comes to COVID-19 and more alarmingly described 'a greater hazard for in-hospital death with COVID-19.' 

Note that Bradley, Webber and Barnett lost in the general election.  However, Boebert won a seat in congress, and Marshall won a seat in the Senate. 

Again, pretending that effective treatments for COVID-19 exist may lead to people to neglect prevention measures. 

North Carolina Lieutenant Governor Dan Forest Announced Masks "Don't Work"

As reported by WRAL on July 8, 2020:

Lt. Gov. Dan Forest, who’s running for governor against incumbent Democrat Roy Cooper, said scientific evidence doesn’t support mask mandates.

'There have been multiple comprehensive studies at the deepest level held to scientific standards in controlled environments that have all said for decades, masks do not work with viruses,' he told a reporter for The Hendersonville Times-News.

However,

His statement overlooks recent studies, news stories, CDC guidance and the advice of one of President Trump’s top pandemic advisors. While face coverings alone can’t guarantee protection from a virus, recent studies show they do reduce the risk of spreading the virus. 

Clearly, deceiving people into thinking that masks have no benefits will mitigate against them using face coverings that may reduce viral spread and reduce their own likelihood of infection



Rep Dan Crenshaw (R-TX) Minimized COVID-19 Risk

Per the Intercept on July 17, 2020:

Between Memorial Day and mid-June, Texas’s hospitalization rate shot up by 36 percent, a fact that Crenshaw has downplayed. 'If you just hear 36 percent increase, that does sound like a lot. … In reality, it’s under 500 additional hospitalizations out of a state of 30 million people,' he said on his podcast. 'So it’s really not a lot. … We’re so far away from being in over-capacity or even close to it that it’s laughable.'

When a Harris County judge said around the same time that Texas 'may be approaching the precipice of a disaster' Crenshaw blasted her for 'pure and simple fear mongering.'

In response,

More than 100 doctors, medical professionals, and emergency room physicians in the Houston area have signed their names to a letter condemning Republican Rep. Daniel Crenshaw for spreading misinformation during the Covid-19 pandemic, which has been ravaging the Texas city hard in recent weeks.

Specifically,

Dan Crenshaw, on the other hand, has spewed lies for the past four months — minimizing the threat we face and spreading dangerous disinformation for self-indulgent headlines

Of course, people who believe Crenshaw's disinformation are less likely to take actions to reduce the spread of the virus and their own risk of infection. 

Former Kansas Secretary of State, then Republican Senate Candidate Kris Kobach Claimed that Death Rate from COVID-19 was Inflated to Hurt Political Chances of President Trump

The Independent reported on July 28, 2020:

Kris Kobach, who is running for a Senate seat in Kansas and previously served as its secretary of state, appeared on a YouTube channel and claimed the number of cases and deaths was a lie.

'I believe that the numbers are being cooked,' he said. 'The books are being cooked.'

During his interview on the show National File, Mr Kobach said hospitals were misdiagnosing coronavirus cases and repeated Mr Trump's claims that more testing would result in higher numbers.

'There are so many things that are happening that indicate that they are overstating the positive numbers. Of course, we've all heard about hospitals, they will test someone who comes in for a liver problem, or for an auto accident, and they test positive and they are – or people who die of something else, but they're also Covid-positive, they'll be treated as a Covid death,' Mr Kobach said.

'And of course, the fact that we have whatever the number is, five times, four times as many tests now as we did in March. And so, if you're testing a greater population, you're going to see a proportional increase in the number of positive results.'

Kobach offered no proof of his allegations of "cooked" numbers, and no evidence that these numbers were exaggerated has appeared since.  His claim that high numbers are mainly a result of increased testing has been refuted by later increases in hospitalization and death rates.  The claim amounts to the logical fallacy of the appeal from ignorance (also called appeal to ignorance), that is, per Logically Fallacious:  

The assumption of a conclusion or fact based primarily on lack of evidence to the contrary.  Usually best described by, 'absence of evidence is not evidence of absence.'

Kobach (and Trump and many others) implied that if we were to try less vigorously to find cases of COVID-19, there would be fewer cases of it.  In reality, there would just be fewer diagnosed cases.  People who had COVID-19, but were undiagnosed, would be more likely to spread the disease than those who were correctly diagnosed, and less likely to receive medical care that might reduce their symptoms or risk of death.

Kobach lost in the Kansas primary.

Republican Arkansas State Senator Jason Rapert Promoted Hydroxychloroquine as COVID-19 Cure

On August 31, 2020, THV11.com reported:

Republican State Senator Jason Rapert used his position as chair of a key legislative committee to hear from doctors who support the use of hydroxychloroquine in the fight against COVID-19 and to grill the state health secretary over the department's guidance when it comes to prescribing the drug.

'I've got people in this state, in my own district, who were given Hydroxychloroquine and it turned them around,' said Rapert of Conway, who co-chairs the Joint Insurance and Commerce committee.

He chaired a hearing in which hydroxychloroquine proponents provided anecdotes of patients who received the drug and got better.  However, there is no good evidence that the drug benefits patients with COVID-19.  Some people who got the drug may have gotten better, but that does not mean that the drug caused them to get better.

Again, conning people into believing that there are simple, cheap drugs that effectively treat the disease may lead them to think there is no point in trying to prevent the spread of infection.

Sen Joni Ernst (R-IA), and Senator-Elect Roger Marshall (R-KS) Claimed COVID-19 Death Rates were Exaggerated

First on September 2, 2020, the AP reported:

Ernst said she ... is 'so skeptical' of the official numbers.

'These health care providers and others are reimbursed at a higher rate if COVID is tied to it, so what do you think they’re doing?' she said to the crowd on Monday, according to a report by the Waterloo-Cedar Falls Courier.

 Also,

'I heard the same thing on the news. ... They’re thinking there may be 10,000 or less deaths that were actually singularly COVID-19. ... I’m just really curious. It would be interesting to know that.'

At that point,

The Centers for Disease Control and Prevention report that the disease has infected more than 6 million people in the U.S. and killed about 185,000 Americans. Of those deaths, 1,125 were reported in Iowa, according to the state website at midday Wednesday.  

Sen Ernst's skepticism may have derived from posts from supporters of conspiracy theory QAnon,

In recent tweets, supporters of QAnon misrepresented CDC figures, stating that the government’s health agency had reduced the number of U.S. COVID-19 deaths to just over 9,000. Trump tweeted the false information, which was later taken down by Twitter for violating platform rules.

Of course, it would be easy for a sitting US Senator to see the best evidence available about COVID-19 death rates, and to get advice from experts in public health about such rates.  

So, Per the Iowa Starting Line, September 4, 2020:

Condemnation from across the Iowa medical community has been relentless this week in the wake of Sen. Joni Ernst’s suggestion hospitals are inflating the number of COVID-19 cases and deaths for financial gain. 

On  September 6, 2020, The Hill reported that then Representative

Marshall, who is a doctor, pointed to the theory based on the 6 percent statistic in a Facebook post Sunday.

'This week the CDC quietly updated its COVID-19 data to reflect the number of deaths from COVID-19 only,' he wrote, adding that it was 'only 6%,' according to a screenshot posted by KSNT.

Facebook removed the post, with a spokesperson saying it violated 'our policies against spreading harmful misinformation about COVID-19 since it misstates CDC data about the deadliness of the disease.'

It would appear to be unethical for a physician to deliberately spread such disinformation that might mislead people into thinking that COVID-19 is not a serious problem.

Sen Rand Paul (R-KY) and Michigan Senate Majority Leader Mike Shirkey (R-Clarklake) Claimed Herd Immunity is Beneficial

On September 23, 2020, Forbes reported:

Dr. Anthony Fauci slammed Sen. Rand Paul (R-Ky.) during a Senate hearing on the federal response to the coronavirus pandemic Wednesday when Paul incorrectly claimed that the high number of infections in New York show that lockdowns don’t work, and when Fauci challenged him, noting the current low positive test rate in the state, Paul erroneously said it is lower because of herd immunity.

Fauci said Paul 'misconstrued' what happened in New York, adding that Paul has done so 'repetitively in the past,' and while mistakes were made, the state has gotten its positive test rate to '1% or less' because they’ve followed CDC guidelines—and Fauci accused Paul of “not listening” to what CDC Director Robert Redfield said about the infection rate and not understanding herd immunity. 

Ashish Jha, the dean of Brown University’s School of Public Health said Paul 'almost' understands the complex issues of immunity and cross-reactivity and keeps sharing 'nonsense that is largely incorrect,' while 'Dr. Fauci patiently lays out the facts.'

Again, as a Senator Paul could easily get access to the best data and opinions from top experts.  Again, Rand Paul is a physician, so it would appear to be unethical for Paul as a physician to be spreading such "nonsense." 

On October 10, 2020, MLive.com reported:

Michigan’s top Senate Republican lawmaker says he is in favor of rolling back many of the measures put in place by Gov. Gretchen Whitmer’s administration to limit COVID-19 spread and believes 'an element of herd immunity' needs to happen in the state.

In comments to MLive following a rally protesting strict COVID-19 restrictions, Michigan Senate Majority Leader Mike Shirkey, R-Clark Lake, said he feels Michigan residents understand that COVID-19 is real, contagious and requires precautions.

'I just simply don’t believe we need to continue to have the oppressive mandates that we’ve had,' he said. 'There’s no business that I know of that will put their customers, their employees, their patrons, their families at risk.'

In response, as reported by the Detroit News on October 12, 2020, a group of experts including

Dr. Joshua Sharfstein at Johns Hopkins Bloomberg School of Public Health; Dr. Thomas File, president of the Infectious Diseases Society of America; Dr. Tom Frieden, former director of the U.S. Centers for Disease Control and Prevention; Dr. Ashish Jha at the Brown University School of Public Health; and Dr. Carlos Del Rio at Emory University School of Medicine

Wrote a letter

'If 'herd immunity' were to begin after about 80% of the state’s population has been infected, as some believe, then 6.5 million more Michiganders would still need to contract COVID-19,' the experts wrote. 'At the current mortality rate, this would mean ​more than 30,000 additional deaths — more than four times the number of deaths to date.'

So by promoting "herd immunity" as a public health policy in the absence of a vaccine, these legislators would likely condemn many people to die.  Such promotion of herd immunity may approach a crime against humanity, given that the definition of such crimes according to the United Nations includes:

any of the following acts when committed as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack: 

...

Other inhumane acts of a similar character intentionally causing great suffering, or serious injury to body or to mental or physical health.

South Dakota Republican Governor Kristi Noem Said Increased Testing Led to an Apparent Surge in Cases

On October 14, 2020, the AP reported:

South Dakota Gov. Kristi Noem on Tuesday blamed South Dakota’s recent surge in coronavirus cases on an increase in testing, even as the state saw a new high in the number of people hospitalized by the virus.

There are currently no open general-care hospital beds in the southeastern part of the state, which contains the two largest hospitals, according to the Department of Health. Hospitals are dealing with both an increase in COVID-19 patients and people needing other medical care. The hospitals in Sioux Falls do have about 41% of their Intensive Care Units available.

'We have triple the amount of testing that we are doing in the state of South Dakota, which is why we’re seeing elevated positive cases,' Noem said. 'That’s normal, that’s natural, that’s expected.'

The Republican governor did not explain how an increase in hospitalizations would be connected to an increase in testing. The state has also seen one of the nation’s highest positivity rates for testing in the last 14 days, according to Johns Hopkins researchers. The roughly 23% positivity rate is an indication there are more infections than tests are indicating.

Note that Governor Noem again seemed to be employing the appeal from ignorance logical fallacy.  Her use of this fallacy to deceive people into thinking that the virus is less prevalent than it is could lead them to neglect reasonable precautions to prevent its spread.

Sen Ron Johnson (R-WI) Claimed Wisconsin had "Flattened the Curve" While Cases were Increasing, and Promoted Hydroxychloroquine as a Treatment of COVID-19

 On October 21, the Milwaukee Journal-Sentinel reported:

Wisconsin on Wednesday reported a record 48 deaths from the coronavirus and admitted its first patient at a field hospital as U.S. Sen. Ron Johnson falsely claimed the state had flattened its curve of COVID-19 deaths. 

The Republican from Oshkosh contended the public had been tricked into 'mass hysteria' a day after state Rep. Joe Sanfelippo, the chairman of the Assembly Health Committee, maintained there is nothing more the government can do to combat an illness that had killed 1,681 in Wisconsin as of Wednesday. 

'Generally deaths are still pretty flat because we've flattened the curve,' Johnson said during a call hosted by business lobbying group Wisconsin Manufacturers & Commerce. 'We've gotten better at treating it.'


But

He made the comments just hours before the state released figures showing the last seven days were the deadliest of the pandemic, with 173 deaths due to the virus between Oct. 14 and Wednesday.

So

 Health officials don't see the issue the way Johnson does.

'Of course the curve has not flattened and we don't have the virus under control,' said Patrick Remington, a former Centers for Disease Control and Prevention epidemiologist and director of the preventive medicine residency program at the University of Wisconsin-Madison.

 Then, on November 20, 2020, the Journal-Sentinel reported that during a Senate hearing:

held this week by U.S. Sen. Ron Johnson, R-Wisconsin, about controversial treatments for COVID-19, including hydroxychloroquine — a drug that studies have found to be ineffective and in some cases dangerous when treating the disease.

During the hearing, Johnson pushed a baseless theory that the medical community was working to deny patients drugs such as hydroxychloroquine because they were cheaper than other treatments.

However

The U.S. Food and Drug Administration revoked the emergency use authorization for hydroxychloroquine in June because of its lack of effectiveness and cited its potential for serious cardiac adverse events and other potential serious side effects.

Dr Ashish Jha, Dean of the Brown University School of Public Health

later tweeted, 'Today was a very, very odd day.'

He added that 'the hearing was a testament to how politicized science has become.'

'I shared evidence of studies that have failed to find benefit of HCQ,' Jha tweeted. 'Three other witnesses shared personal experiences. And suggested my testimony was reckless because it would deny people access to lifesaving HCQ.'

He added, 'I found myself defending evidence, doctors, and scientists. There are key issues we need Congress to be airing right now. Hydroxychloroquine isn't one of them.'

Summary

Once upon a time, politicians usually realized what they did not know about science, health care, and medicine, and so consulted with experts before making pronouncements on such topics.  Now they seem not to know what they do not know, and may delight in propagating rank disinformation for political benefit.

So, since the beginning of the coronavirus pandemic in the US, prominent Republican politicians have asserted:

- conspiracy theories about the origins of the pandemic (eg, it came from a Chinese laboratory, Bill Gates was somehow responsible, etc)

- that the case rates and death rates have been exaggerated, partly by "excess testing," or by health care professionals for financial gain, or by others to politically damage President Trump

- that unproven therapies actually can treat the infection

- but that herd immunity without a vaccine can be safely achieved 

All were false, and all mirrored similar disinformation spread by President Trump and his associates (look here). 

In the US, the pandemic is currently out of control.  Cases,  hospitalizations, and deaths are at record levels.  A major cause of this disaster is that many people in the US are refusing to follow reasonable public health guidelines, including remaining physically distant from other people as much as is practical, wearing a face covering when such distancing is not possible, and frequent hand washing.  Much of this resistance is fueled by ignorance, misleading information, and disinformation.  President Trump has been a major source of disinformation, along with his followers and supporters, and with hostile foreign powers and various anonymous sources.

Trump may be on his way out, but his followers seem committed to propagating disinformation.  Some of his most influential are Republican politicians, including members of congress, members of state legislatures, and various state and local officials.  All of them could easily have access to accurate information and expert opinion the pandemic.

Shame on them for ignoring evidence and logic, and instead spreading disinformation that may be increasing disease, disability, and death.  

It is up to all of us to combat such disinformation whenever we can, and call out and condemn its perpetrators.  History will not look kindly on them.  Meanwhile, there are lives to save.