Wednesday, March 28, 2018

The Dander Riseth Ever Higher: Shulkin Case Emblematic of Dysfunction

What follows is numero sesto if memory serves in a series of what gets one's dander up in this era of dysfunctional health care. Of course it seems these days our news in Health Care Renewal is so often all about focal dysfunction mirroring much broader problems of governmental and societal dysfunction. It's in this context that I learned just now of the current VA Secretary's ouster while overseas in a country that does things in many ways much more effectively.

Today we blog about this one issue only. It seems to perfectly encapsulate the Reality Show-cum-wrestling match that our Republican leadership has morphed into. Oh, wait, maybe it didn't morph. It was always that way, perhaps, and people are just now twigging to that fact.

David Shulkin, the Emblematic Case. In this series I've written before about how Shulkin was undermined by his own communications people once those political-appointee ideologues smelled blood in the water over his perceived transgression--like many others'--in accepting gifts and padding overseas travel.

But how did those guys win? Shulkin resisted their efforts but ultimately they got to their boss, Donald Trump, anyway. After trying to out-wait Shulkin in hopes he'd not have to utter those infamous words "you're fired" to someone for whom he'd promised never to do that, Trump dropped the axe.

But to what end? Is our president so enamored of privatizing an improving VA health system that he'd go back on his word and risk the ire of so many vets? Make no mistake, a very large percentage of vets love their VA medical care. I worked in it myself, back in the day, and am acutely aware of its problems past present and future. But Shulkin was not only making it better, he was handing the president a lot of his most conspicuously successful legislative victories.

Nope, none of this explains it. There's only one thing that can. The burger-meister himself is rudderless. And his increasingly whacked-out toadies, the ones who know how to survive the snake-pit and play him, are successful at turning the boss against reasonable conservatives like Shulkin. What's so scary is that it's whimsical. Are we going to create a whole new gi-normous cadre of vets from World War III, this time not only with amputations but also radiation poisoning?

Oh, and one more thing. These political hacks now clearly believe every voter will, in perpetuity, continue implacably to believe in Ronald Reagan's dictum that government in never the solution, but always the problem. Hence, effectiveness in delivering health care on Shulkin's part is something that to them is at best a cognitive inconvenience, at best a full-on tautology: "good government health care" as oxymoron. Ultimately this flaw in reasoning and resulting inhumanity can only be solved at the ballot box. Are there enough vets out there whose dander is as far up as mine?

Addendum. Dr. Shulkin has gone public in an elegant op-ed pieces in his former boss's favorite newspaper, the New York Times. Most definitely worth a read.

How Do We Counter Health Care Disinformation Under a Disinformer-in-Chief?

"Don't worry, things could be worse.  And sure enough, things got worse."

Disinformation in Medicine and Health Care

Stealthy, deceptive systematic marketing, lobbying, and policy advocacy campaigns on behalf of big health care organizations, often pharmaceutical, biotechnology and medical device companies, have long been a subject of Health Care Renewal.  A relatively recently revealed example was the stealth marketing campaign used by GlaxoSmithKline to sell its antidepressant Paxil.  This campaign included manipulating and suppressing clinical research, bribing physicians to prescribe the drug, use of key opinion leaders as disguised marketers, and manipulation of continuing medical education.  Other notable examples included Johnson and Johnson's campaign to sell Risperdal (look here),  and the infamous Pfizer campaign to sell Neurontin (look here and here).   Notably, stealth marketing seemed to be one reason for the growing popularity of narcotics (opioids) starting in the 1990s (look here).

The organization and complexity of stealth marketing, lobbying and policy advocacy campaigns have often been sufficient to characterize them as disinformation.  For example, we characterized the campaign by commercial health insurance companies to derail the Clinton administration's attempt at health reform in the 1990s, as described by Wendell Potter in his book, Deadly Spin, as just that (look here).  The tactics employed in that campaign included: use of front groups and third parties (useful idiots?); use of spies; distractions to make important issues anechoic; message discipline; and entrapment (double-think).

Many of the stealth marketing campaigns we discussed came to light through regulatory and law enforcement action.  For example, the public was made aware of the GSK stealth marketing of Paxil due to Eliot Spitzer's prosecution in 2004 (documented in Side Effects by Alison Bass).  Ultimately, that campaign resulted in a settlement including a multi-billion dollar fine in 2012 (look here).

So we have long advocated better awareness of these insidious disinformation campaigns, and more vigorous regulatory and law-enforcement action against them.   Thus we were aghast in 2017 when a accomplished stealth  health care marketer transited the revolving door to wind up in a top federal position, on the President's Council of Economic Advisors (look here).

That was bad.  Worse, now it appears that the disinformers are in charge of all regulation and law-enforcement.

Disinformation at the Heart of the Current President's Election Campaign

Cambridge Analytica's Appropriated Facebook Data

Less than 10 days ago, the New York Times broke a complex story about the disinformation campaign at the heart of the Trump presidential campaign in 2016.  The campaign used

private information from the Facebook profiles of more than 50 million users without their permission, according to former Cambridge employees, associates and documents, making it one of the largest data leaks in the social network’s history. The breach allowed the company to exploit the private social media activity of a huge swath of the American electorate, developing techniques that underpinned its work on President Trump’s campaign in 2016.

Note that

The data Cambridge collected from profiles, a portion of which was viewed by The Times, included details on users’ identities, friend networks and 'likes.' Only a tiny fraction of the users had agreed to release their information to a third party.

Thus the campaign was based on inappropriately and unethically accessed, that is, hacked data from millions of people.  Such data hacking may prove to be illegal (see below). 


According to a companion article in the Guardian, Cambridge Analytica was linked to and its work based on that of a company called SCL Group,

one of whose subsidiaries, SCL Elections, would go on to create Cambridge Analytica (an incorporated venture between SCL Elections and Robert Mercer, funded by the latter). For all intents and purposes, SCL/Cambridge Analytica are one and the same.

Notably, SCL Group's

expertise was in 'psychological operations' – or psyops – changing people’s minds not through persuasion but through 'informational dominance', a set of techniques that includes rumour, disinformation and fake news.

Per the NY Times, Christopher Wylie, who blew the whistle on Cambridge Analytica et al,

said of its leaders: 'Rules don’t matter for them. For them, this is a war, and it’s all fair.'

'They want to fight a culture war in America,' he added. 'Cambridge Analytica was supposed to be the arsenal of weapons to fight that culture war.'
Per NPR, Wylie later told a UK parliamentary committee

Donald Trump makes it click in your head that this has a much wider impact. I don't think that military-style information operations is conducive for any democratic process.


They don't care whether or not what they do is legal as long as it gets the job done
Thus it seems pretty clear that Cambridge Analytica/ SCL were in the disinformation business, and were happy to use various tactics, probably unethical and some likely illegal, to accomplish psychological operations to manipulate their subjects.

Overlaps with Trump Campaign

The company leveraged the unauthorized Facebook data:

Under the guidance of Brad Parscale, Mr. Trump’s digital director in 2016 and now the campaign manager for his 2020 re-election effort, Cambridge performed a variety of services, former campaign officials said. That included designing target audiences for digital ads and fund-raising appeals, modeling voter turnout, buying $5 million in television ads and determining where Mr. Trump should travel to best drum up support.

Note that Cambridge Analytica was run by some of Mr Trump's closest associates, including Steve Bannon, a Cambridge Analytica board member, who became Trump's third campaign director, and then a top White House strategic advisor, and Robert Mercer and his daughter Rebekah, investors and board members, who were notable Trump donors and gurus of related political causes. Although the firm first attached itself to the campaign of Ted Cruz, after that lost steam,  according to a Washington Post article

the Mercers switched their allegiance to Trump and pitched their services to Trump’s digital director, Brad Parscale. The company’s hiring was approved by Trump’s son-in-law, Jared Kushner, who was informally helping to manage the campaign with a focus on digital strategy.

Kushner said in an interview with Forbes magazine that the campaign 'found that Facebook and digital targeting were the most effective ways to reach the audiences. . . .We brought in Cambridge Analytica.' Kushner said he 'built;' a data hub for the campaign 'which nobody knew about, until towards the end.'
 Thus the Cambridge Analytica/ SCL disinformation campaign, built on hacked data, was done in the service of the Trump campaign, and with apparent full knowledge, acquiesecence, and sometimes active cooperation of top campaign leaders.  Mr Trump, of course, was ultimately responsible for the actions of his campaign, although none of the reporting so far speaks to his day-to-day participation in the Cambridge Analytica/ SCL disinformation campaign.

A Platform Built on Manipulated Emotion

It appears that the campaign used a variety of disinformation techniques.  It is striking that these techniques were ultimately used to push themes and policies that Cambridge Analytica/ SCL had developed prior to their involvement with Trump, not merely the themes and policies that Trump and his advisers had devised.  Furthermore, these  themes and policy positions later used by the Trump campaign were based not on ideology or policy research, but on the hidden fears and resentments of people assessed by Cambridge Analytica in its "psychographic" analysis campaign. Again, according to the Washington Post article,

The data and analyses that Cambridge Analytica generated in this time provided discoveries that would later form the emotionally charged core of Trump’s presidential platform, said Wylie, whose disclosures in news reports over the past several days have rocked both his onetime employer and Facebook.

'Trump wasn’t in our consciousness at that moment; this was well before he became a thing,' Wylie said. 'He wasn’t a client or anything.'

The year before Trump announced his presidential bid, the data firm already had found a high level of alienation among young, white Americans with a conservative bent.

Furthermore, a later Washington Post article stated,

Cambridge Analytica used that information, together with insights gained from focus groups with angry Americans, to identify issues and target voters. Bannon supplied the ideological focus of wanting to remake America and billionaire Robert Mercer provided the money. Neither Bannon nor Mercer has publicly commented since the allegations emerged.


'One of the things that started to emerge was that we literally heard these sort of narratives about Washington as something that was, like, gross and disgusting, that was dirty,' Wylie said.

So his team tested the phrase 'drain that swamp' to see if people would respond to it on social media. After all, they had access to the data of millions of Facebook users without their knowledge.

And people responded. Through the internet and Trump’s speeches, the slogan became one of the campaign’s most identifiable soundbites.

Perhaps it is the idea of building a wall along the Mexican border that best illustrates Wylie’s work for Cambridge Analytica.

Bannon, Wylie said, was obsessed with the idea of separating the U.S. from the rest of the world so the country can rediscover itself. Trump’s campaign for a wall along the Mexican border is not really about stopping immigrants, Wylie said.

'It’s to embody separation,' he said. 'If you can embody that separation and you can further distance in the minds of Americans us here in America and them elsewhere, even if it is just across a river, or just across a desert, then you have won that culture war.'
So "drain the swamp" was not a catch phrase for fighting corruption, but a hook to deep-seated fears of contamination, and "build the wall" was not a policy position to literally build a physical wall, but a hook to deep-seated fears of otherness.  Yet in office Mr Trump has continued to use these slogans as if they were policy positions, and has remained fixated on building a physical wall.  As we discussed here, there is plenty of evidence that he has fostered, not fought corruption. 

Use of "Proxy Organizations"

Great Britain's Channel 4 interviewed Mr Nix, the CEO of Cambridge Analytica, posing as potential clients. As reported by the Guardian,

Turnbull said the company sometimes used 'proxy organisations', including charities and activist groups, to help disseminate the messages – and keep the company’s involvement in the background.

Use of proxies and third parties are commonly used disinformation tactics.

Questions of Illegality

Claims of Impunity

During the Channel 4 undercover interview, Mr Nix claimed impunity,

When the undercover reporter expressed worries that American authorities might seize on details of a dirty campaign, Nix said the US had no jurisdiction over Cambridge Analytica, even though the company is American and is registered in Delaware.

'I’m absolutely convinced that they have no jurisdiction,' he told the purported client. 'So if US authorities came asking for information, they would simply refuse to collaborate. 'We’ll say: none of your business.''

Maybe his beliefs in impunity facilitated his comfort with the use of some apparently illegal tactics.

Violation of UK Data Privacy Laws

The UK has stringent laws on data privacy.  Its Information Commissioner's Office is apparently actively investigating whether Cambridge Analytica/ SCL violated them.  Late last week, the Guardian reported  

Investigators from Britain’s data watchdog have spent nearly seven hours searching the London offices of Cambridge Analytica.

Eighteen enforcement officers entered the Cambridge Analytica headquarters in London’s West End on Friday night to search the premises after the Information Commissioner’s Office (ICO) was granted a warrant to examine its records.

The officials concluded the search at about 3am on Saturday.
According to CBS News, at least three US states are now investigating whether the company broke US laws by accessing the Facebook data.

Work on a US Campaign by Foreign Nationals

As implied above, Cambridge Analytica and SCL were basically UK operations.  A Guardian article noted the apparent illegality of involvement in US political campaigns by foreign nationals.  The organization's own lawyers warned its leaders that

'Any decision maker must be a US citizen or green card holder,' the memo, seen by the Observer, warned. It also provided a brief legal history of cases involving foreign involvement in election campaigns, drawn up by a lawyer at the firm founded by former New York mayor Rudy Giuliani.


It was clear that as a company largely run and staffed by Britons and Canadians, apart from Bannon and Mercer at the top, Cambridge Analytica – which was to go on to work on Donald’s Trump presidential election campaign – had a looming problem.

The management's response appeared to be subterfuge.

Two employees confirmed that they were still answering ultimately to Nix throughout the mid-term election campaigns that ended in November 2014. In total, more than a dozen foreigners, including Britons and Canadians, filled strategic roles in campaigns across the US.

'We were really speaking directly to the voters in a number of states,' said one former employee, who served on a team with several people who were not US citizens or green card holders.

It is understood that some were working on tourist visas. Another ex-employee claimed that they had been provided with letters to give to US border control officials where needed, stating that they would not be working there.

It seems likely that the Cambridge Analytica/ SCL work for the Trump campaign was mainly accomplished by citizens of countries other than the US.

Coordination with PACs

 Great Britain's Channel 4 interviewed Mr Nix, the CEO of Cambridge Analytica, posing as potential clients. As reported by the Guardian, not only did he boast of his influence in the Trump campaign,

Senior managers then appeared to suggest that in their work for US clients, there was planned division of work between official campaigns and unaffiliated 'political action groups'.

That could be considered coordination – which is not allowed under US election law. The firm has denied any wrongdoing. Also,

In another exchange, Tayler describes an apparently planned division of spending on the campaign trail, with the candidate organising positive' messages, with negative attack ads left to the super Pacs, which may engage in unlimited political spending independently of the campaigns.

'As part of it, sometimes you have to separate it from the political campaign itself ... campaigns are normally subject to limits about how much money they can raise. Whereas outside groups can raise an unlimited amount.'

'So the campaign will use their finite resources for things like persuasion and mobilisation and then they leave the ‘air war’ they call it, like the negative attack ads to other affiliated groups.'

Note that,

The Campaign Legal Center has accused Cambridge Analytica over allegations of illegal coordination of this nature.

It has filed evidence with the FEC alleging that the super Pac Make America Number 1 made illegal contributions to Trump’s campaign, 'engaging in unlawful coordinated spending by using the common vendor Cambridge Analytica'.

Boasts of Greater Nefariousness

Great Britain's Channel 4 interviewed Mr Nix, the CEO of Cambridge Analytica, posing as potential clients.  As reported by the NY Times, he boasted that the organization had capabilities more nefarious than those above:

We can set up fake IDs and websites, we can be students doing research projects attached to a university, we can be tourists. There’s so many options we can look at.

He also mentioned apparent extortion:

But you know equally effective can be just to go and speak to the incumbents and to offer them a deal that’s too good to be true, and make sure that that’s video-recorded, you know. These sorts of tactics are very effective, instantly having video evidence of corruption, putting it on the internet, these sorts of things.

Finally, he discussed apparent extortion in the form of classic KGB style honey-traps.

Or, Mr. Nix said, they could 'send some girls around to the candidate’s house — we have lots of history of things'

The reporter asked what kind of girls, and Mr. Nix said they could find some Ukrainian women. 'I’m just saying, we could bring some Ukrainians in on holiday with us you know,” Mr. Nix replied. “You know what I’m saying.'

'They are very beautiful,' he said. 'I find that works very well.'

Whether Cambridge Analytica/ SCL actually undertook such activities, particularly on behalf of the Trump campaign, is unknown.  However, their leadership clearly had no qualms about considering them to be options.


An international organization, Cambridge Analytica/ SCL based in the UK, led by Trump confidantes including his last campaign leader and former White House strategic adviser Steve Bannon, and major Republican donors and hedge fund magnates Robert and Rebekah Mercer, worked with the Trump 2016 campaign, particularly coordinating with digital coordinator Brad Parscale.  Cambridge Analytica/ SCL leveraged Facebook private data on millions of people, obtained from most without their specific permission, to create a "psyops" political disinformation campaign featuring emotional appeals to voters' internal psychology, coupled with a variety of other tactics.  The campaign used foreign workers within the US, and apparently coordinated with political action committees, possibly violating US law.  The appropriation of private Facebook data possibly violated UK law.  The Cambridge Analytica/ SCL CEO also boasted that the organization was capable of various dirty tricks, including several species of extortion.

It is unclear to what extent, if any, this disinformation campaign helped Mr Trump to win the presidency.  But clearly we now have a president whose campaign was apparently happy to employ disinformation on a grand scale, likely violating US and UK laws in the process, to win election.

We have long advocated better awareness of insidious disinformation campaigns in health care, which we previously separated into stealth systematic marketing, lobbying, and policy advocacy campaigns.  Furthermore, we have long advocated more vigorous regulatory and law-enforcement action against them.  Remember that many of the stealth marketing campaigns we discussed came to light through regulatory and law enforcement action.

Yet what sense does that make when the federal regulators and law enforcers operate under a regime that was perfectly happy to use disinformation to secure its election?

It apparently makes no more sense than advocating for better federal law enforcement measures to reduce conflicts of interest and corruption in health care under an extraordinarily conflicted and corrupt regime (look here.)

The fish is rotting from the head. 

So in parallel with what we said then, the only way we can now address health care deception, crime, and corruption is to excise the deception, crime and corruption at the heart of our government.

Thursday, March 22, 2018

And the Dander Keeps On Rising

This is número cinco in our series of attempts to shed some of this dander. But it keeps on rising. Here are two recent reports both relating to the life-on-the-ground of North American rank and file physicians, especially as that life increasingly revolves around data entry and digital madness over and above everything else.

Are physicians suffering from acute, maybe by now chronic, PTSD? In the 20 March 2018 number of the important Boston Globe-affiliated newsfeed STAT, Elizabeth Métraux, a prolific staffer and author at the eminent organization Primary Care Progress, gives us another quite useful take on physician burnout. An Iraq War veteran herself, the author gives us a provocative title that
pretty much says it all: "I experienced trauma working in Iraq. I see it now among America’s doctors." Her diagnosis is stark.
[A]s a health care advocate who has struggled with PTSD, it’s clear to me that many of our country’s health care providers are struggling with trauma, as well. And we’re doing little to support them.
Here's another snippet of conversation she recently had with a phyhsician colleague who'd also served in Iraq.
You know, I’d go back to the field any day. Beats practicing in my clinic. ... I didn’t become a doc to put up with billing codes and power struggles. I thought that PTSD would hit when I came home from Fallujah. It’s so much worse when I come home from the office. Truth is, I’ve lost my sense of purpose.
In what she terms "tiny betrayals of purpose," the death of 1000 tiny cuts, she outlines the extent to which the endless obsession by bosses with data entry and charge capture, the eight-minute patient encounter, the constant deflection of attention away from the patient all the while marketing and admin people are trumpeting "patient-centered everything" to their "customers," all of these have taken their toll.

Unfortunately, the usual caveat applies: making the diagnosis is a lot more straightforward than establishing the right therapy for the PTSD viewed by every student who rotates through a preceptor's community office: rapidly driving the best and brightest young physicians away from primary care. The author suggests the patient turn around and ask the physician how she is doing. But much more structural reform will be needed to curb these excesses and reverse these trends. Higher pay would be a fabulous start, not to mention forgiveness of medical school loans.

Less empathic but no less important: revenge of the EHR--more paper records than ever, revealing private information. A fascinating research letter published the same day in JAMA (behind paywall), out of several hospitals in Toronto, Ontario, reveals still more new--but actually, hardly new at all--issues raised by perverse effects of Electronic Health Records. More, not less, paper documents are being discarded because of the EHR. The investigators spent about half a year auditing all the recycling-bound paper from five hospitals. The results are arresting. Here are the key take-aways. Bear in mind the context: these institutions had Protected (Personal) Health Information (PHI) policies; they also had recycling bins and shredders where they needed to be.

  • Nearly a ton of paper was examined including nearly 3000 discrete documents.
  • The study was multi-institutional.
  • Every hospital contained examples--lots of examples--of PHI discarded in both in- and out-patient settings.
  • Over 2500 documents containing PHI were found, including over 1000 with highly sensitivbe information (defined as including both diagnoses and descriptions of patients' conditions).
  • The vast majority of these documents were found in out-patient settings.
  • The highest proportion of PHI-containing documents was found in physicina offices--not hospitals or institution-bound clinics.
  • Paper records were impossible--in distinction to electronic privacy breathes--to trace with respect to identifying responsible individuals.
  • The authors reported no actual harms accruing to the documents' discovery.
The biggest drawback of this study was its focus on recycling materials, as opposed to other random discards. But recycling does not means properly-disposed-of, so the data are important. Most important is the Revenge Effect, to quote from Edward Tenner's important analysis of technology's impact, of the EHR.

To any of those of us who've lived this scenario, it all sounds drearily familiar. EHR allows managerialism to run rampant in terms of up-coding and adherent to more often than not perverse incentives around Meaningful Use of EHRs. Not to mention outright abuse. But it actually produces all sorts of other perverse effects. One near and dear to our hearts is the "credit" for printed "Clinical Summaries cited as "performed" in EHR databases, but actually abandoned on printers. And, when retried, lacking any information on the clinical plan--essentially only listing medication lists that are often dangerously erroneous.

Now, from Toronto, but we already knew this, we're reminded that EHR didn't do away with paper. Because so much paper comes in and gets scanned to EHR, it is rather more pervasive--but now discarded in the wrong palce--than ever.

Tuesday, March 20, 2018

Mrs. Smith Goes to Washington

Newly-appointed Minnesota Senator Tina Smith is off to an energetic start, challenging the powers-that-be in Washington, starting with Big Pharma.  She recently wrote to the CEOs of five drug companies, noting the gigantic tax windfalls reaped by their companies after the fall passage of the tax cut bill, and enquiring whether any of that money might enable them to reduce the skyrocketing prices of prescription drugs.

I am sure every one of the five CEOs privately gave a big horse laugh at the very thought. Each of them believes that their duty to the shareholders is precisely to exact the maximum possible amount from the public for their products, so lowering drug prices never entered their tiny minds. Instead, they announced stock buybacks and in some cases dividends, after the size of the windfall became apparent.  Senator Smith also enquired whether they had made increases to research and development investments after the tax changes, as well as asking about stock buybacks and monetary bonuses to company officials.

Tina Smith can’t possibly be so naïve as not to understand the actual priorities of the CEOs (her husband of many years is an investment manager). Nonetheless, her letters make an excellent point. Pharma’s frequently-invoked rationale for high drug prices – that they need to swell their profits to afford research – is utterly bogus. And every step that gets the public to understand that is valuable.

Although informed people do understand that, a lot of pretty intelligent members of the public who haven’t thought about it too deeply are still buying the falsehood, as I’ve found from talking to co-workers. So, thanks, Senator Smith!