Sunday, July 15, 2018

A Physician Who Had Run Clinics Which Proselytized Patients is Now a Government Health Care Leader Positioned to Enforce Her Religious Beliefs on Patients and Citizens Who Do Not Hold Such Beliefs

Introduction: Physicians' Values and Organizational Missions

Physicians professional values require them to put the interests of their individual patients ahead of all else, including the physicians' self interest.  The AMA Principles of Medical Ethics, for example, includes

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

Similarly, in health policy and public health, the goal ought to be putting the health of patients as a group, and the public at large, ahead of other considerations.

However, we have often discussed how leaders of large health organizations seemed to put other considerations ahead of individual patients', patients' collectively, or the public's health.  Most of those examples of mission-hostile management involved putting organizational finances, or the leaders' own finances ahead of patients' and the public's health.  For example, in 2017 we discussed a New York hospital CEO who seemed to put revenue generation in support of his own very generous paycheck ahead of quality of care and patient safety (look here).  Also, the revered Mayo Clinic seemed to let patients with more remunerative commercial insurance coverage get attention before poor patients who have only government insurance, despite its stated mission "providing the best care to every patient" (look here).  Before November, 2016, our examples of mission-hostile management were mainly hospitals and health systems, insurance companies, and pharmaceutical, biotechnology and device companies.


That was then.  This is now.

A Physician Who Seemed to Put Her Religious Beliefs Ahead of Patients' Interests

Late this spring, we noticed the appointment of a US government health care leader which raised concerns about mission hostile management, but in a new dimension. The appointment was summarized by Rewire on May 30, 2018,

Diane Foley, who ran a Christian organization operating two Colorado anti-choice 'crisis pregnancy centers,' or fake clinics, was quietly installed on Tuesday as deputy assistant secretary for population affairs, where she will lead the office responsible for the Title X federal family planning program.

The U.S. Department of Health & Human Services (HHS) said little about Foley in its announcement of her appointment to the Office of the Assistant Secretary for Health, saying she 'has a long and distinguished career working in the healthcare and the public health arenas.'

Foley will oversee the Office of Population Affairs (OPA), which administers Title X, a program providing family planning and related services to more than 4 million primarily low-income people in the United States, many of whom face systemic barriers to health care.

While Dr Foley's purview would be providing family planning services, she seems to opposed to the provision of most conventional family planning services,not only abortion, which is admittedly controversial, but also including contraception, and adoption.  For example, as reported by Tonic (a part of Vice News) on June 5, 2018, she said in a speech on 2016 that a pregnant woman has three choices

parent the child, give it up for adoption, or have an abortion .... She said that having the baby is thought of as 'death to [the parents] and the life they thought they were going to have,' adding, 'The next choice is, let’s do an adoption plan. Well, that’s a double death, because not only does it interrupt [the parents] plans for the next several months, right? But then their child is going to be adopted, and they’re going to grow up thinking they’ve been abandoned by their parents. So they’re going to have all kinds of issues with their life. So that’s a double death. That’s worse.'

Given her opposition to adoption, it is not much of a surprise that she seems opposed to even talking about the simplest forms of contraception. The Rewire article stated,

Foley suggested that it may be considered 'sexually harassing' to demonstrate in a classroom how to use a condom on a banana, the Colorado Springs Independent reported in 2010.
Foley is a physician.  Another Tonic (from Vice) article on June 5, 2018, noted that an official DHHS statement about Dr Foley's hiring stressed,

that Foley is a board-certified pediatrician with 30 years of experience, most recently in private practice in Colorado.
 
The DHHS official leadership bio for Dr Foley went into more detail,

Dr. Foley is a graduate of Marion College (now Indiana Wesleyan University) and of Indiana University School of Medicine. She is a Diplomat of the American Board of Pediatrics, a member of the Society of Adolescent Health, and served on numerous other national boards and committees.

Also,

Dr. Foley has spent her professional career in the clinical practice of pediatrics with a focus on adolescent health. Originally from Indiana, Dr. Foley founded and served as medical director of Northpoint Pediatrics shortly after completing a residency in pediatrics. She spent the next seventeen years establishing what is still one of the largest pediatric practices in central Indiana. During this same period, she also served as a pediatric clinical instructor for pediatric and family practice residency programs at the Indiana University School of Medicine. Dr. Foley’s areas of special interest are adolescent gynecology, prevention and treatment of sexually transmitted diseases, healthy family formation, and global health, all of which she continued to focus on after her move to Colorado in 2004.

Most recently, she was in part-time clinical practice at a certified Centers for Medicare & Medicaid Services Critical Access Hospital in Lamar, Colorado.
As a physician, Dr Foley's prime directive was to put the interests of individual patients ahead of her self-interest.  If Dr Foley had religious convictions that would not allow her offering women patients mainstream management approaches to family planning, for example, adoption or contraception planning, Dr Foley could have chosen to practice in a setting where she need not have ever offered those options, for an example relevant to pediatrics, neonatology.  However, it seemed that Dr Foley chose to explicitly put herself in situations where she could combine proselytizing with practice.  As described in a Slate article of June 1, 2018, stated,

Until last year, she was the president and CEO of the Life Network, an organization that operates two anti-abortion crisis pregnancy centers in Colorado Springs that run abstinence-only education programs for teens. The purpose of crisis pregnancy centers is to convince women not to have abortions, sometimes after luring them in with deceptive advertising that makes them seem like abortion clinics or general health facilities. 'Through our pregnancy centers we have the opportunity to see God use the miracle of ultrasound to change and save lives,' Life Network’s website says. The first element of its mission is 'presenting the gospel of Jesus Christ.'
The fundamentally deceptive nature of these clinics seem to suggest that Dr Foley violated another provision of the AMA Principles of Medical Ethics

II. A physician shall uphold the standards of professionalism, be honest in all professional interactions,...

Thus, rather than avoid clinical situations in which abortion would be considered to be a management option, she chose to work in such settings in order to try to prevent patients from having abortions, based on religious grounds.  She worked in what looked like clinics, but which were dedicated to preaching the gospel.

Furthermore, the organization Dr Foley ran also specifically sought to deter young women from using conventional contraception. Tonic (part of Vice News) reported that the organization Dr Foley led

Life Network, the organization that Foley led until 2017, offers 'sexual risk avoidance programming,' aka abstinence-only sex ed, for middle and high school students, under the moniker Education for a Lifetime. As part of her work with that program, Foley told a reporter in 2010 that it’s too difficult to teach teenagers how to use condoms and that demonstrating how to use a condom on a banana could be considered 'sexually harassing.'

As an aside, in an interview reported by Tonic, Dr Foley seemed to espouse views on adverse effects of abortion that are unsupported by clinical research evidence,

'The way abortions are done, there is not enough supervision or regulation for them and it puts women at risk. There are not the same standards as other surgical centers, there are not the same requirements in terms of having the same hospital privileges in case something goes wrong,' she said. 'What I'm concerned about is that there is a sense that it's healthcare for women and there are a lot of things about it that are not good healthcare," Foley added. Abortion care has significantly lower complication rates than other common procedures (like wisdom tooth extraction and tonsillectomy), and patient satisfaction rates are much higher than they are for general medical care.

Another falsehood Foley has repeated, and that her former company Life Network also claims is true, is that abortion causes lasting mental-health problems. In a September 2016 presentation for Charis Bible College where Foley was introduced as the president of Life Network, she claims ... that this is a condition with an accepted diagnosis:

'There is actually a true, emotional diagnosis that is now starting to be recognized—even though if you look at national media and secular media, they still try to ignore the fact—but there is actually a diagnosis called post-abortion stress and also post-abortion traumatic syndrome, that is a result directly of someone having an abortion or being involved with an abortion that happens,' she said. 'Here is the thing that is incredible to me. I am a trained physician, went through training, got not one single lecture throughout the course of my training about this situation.'

The American Psychiatric Association does not recognize post-abortion syndrome or any related category as an identifiable mental health condition in the DSM-V , a manual that defines and classifies mental disorders.

 So Dr Foley seemed to have engineered an ostensibly clinical career that put her in a position to proselytize patients in the guise of medical practice, not only about abortion, but about contraception.  It is not at all obvious that Dr Foley limited her anti-abortion, anti-contraception, and presumably even anti-adoption preaching to women who agreed with her religious views and who had no interest in any of these options.

Discussion

Dr Foley is certainly entitled to her religious views.  She is also entitled as a physician to avoid situations in which normal standards of care would push her to provide services to patients that conflict with her religious conviction.  But she is not entitled as a physician to proselytize in the guise of medical practice.

Furthermore, as a leader in a government health agency, she is not entitled to use that agency's power to enforce her personal religious beliefs on patients who do not hold such beliefs.  Given her career, though, there is every reason to worry that she will do so.  Furthermore, it was not clear why she was selected for this powerful government leadership position other than to allow her to proselytize.

We recently discussed other examples of people appointed to top positions in the US Department of Health and Human Services who seemed very hostile to the organization's mission.  Again, it seemed unlikely that these people were appointed for any reason other than to attack the mission.

Furthermore, like Dr Foley, they seemed to have been appointed to impose their personal religious views on the American population.  As we stated then, they all seem to be in a postion to undermine fundamental principles of US government enshrined in the Constitution, including prohibiting the government from establishing a religion or preventing the free expression of any religion, and equal application of the laws and provision of due process to all people, again regardless of their religious beliefs, race, ethnicity or sex.

We have been writing about health care dysfunction since 2003, and publishing this blog since 2004.  A major concern all along has been how threats to health care professionals' core values generate  health care dysfunction.  Up through 2016, these threats came principally from large private health care organizations.  While the US government was not always as good at defending these values as it could have been, at least it rarely presented its own set of active threats.  Under Trump, that situation has been changing for the worse.  This is obviously hugely dangerous, (and made more so by the regime's threats to other core values of US society, to US law, and the US Constitution.)

To prevent the decline and fall of US health care, and maybe the entire US experiment in representative democracy, health care professionals, academics, patients and citizens concerned about health care will have to join up with the larger populace to defend our core values while they still have any force.    



Sunday, July 08, 2018

"Hope in a Bottle" - Components of Purdue Pharma Stealth Marketing Campaign for Oxycontin Revealed by Legal Documents from Tennessee

Introduction: Disinformation and Stealth Marketing Campaigns

Back in the distant past the US government made some attempt to hold big health care corporations to account for misleading marketing practices.  We learned a lot about these practices from documents revealed in the resulting litigation, and in particular, about stealthy, deceptive systematic marketing, lobbying, and policy advocacy campaigns on behalf of big health care organizations, often pharmaceutical, biotechnology and medical device companies.  For example, in 2012 we found out about the stealth marketing campaign used by GlaxoSmithKline to sell its antidepressant Paxil.  This 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).  We also found that stealth marketing seemed to be partially responsible 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).

Nowadays, the current Trump administration does not seem interested in pursuing unethical or corrupt practices by big health care corporations.  A health care corporate fraud strike force was downsized by the Trump administration as we noted in July, 2017.  By May, 2018, legal actions by the US government against apparently corrupt acts by large US health care organizations seemed to be falling off.  Only one significant settlement had made that year.  Bloomberg published a report with the headline, "White-Collar Prosecutions Fall to 20-Year Low Under Trump," on May 25, 2018.  Meanwhile, the administration pulled one former stealth marketer through the revolving door to serve in the White House (look here), and has been  pushing its own disinformation campaigns (look here).
 
However, some state attorneys general and local prosecutors have picked up the baton.  In particular, as the opioid epidemic continues, they have filed many lawsuits against corporations that profited from narcotics sales.

Sleazy Marketing Tactics Used to Sell Oxycontin

And glory be, one such lawsuit has led to the disclosure of the shady marketing tactics used by the now notorious Purdue Pharma to sell Oxycontin.  Several news reports summarized the lawsuit filed by the Tennessee Attorney General against that company.  As described by the Knoxville News Sentinel,

The lawsuit, filed by Tennessee Attorney General Herbert H. Slatery III, uses Purdue’s own company records and its staffers’ own words to show the firm’s founders and executives pushed medical providers to prescribe increasingly high doses of OxyContin for longer periods — even after Purdue promised the state it would stop.

It lays bare a marketing campaign that was highly regimented and highly profitable, built upon a foundation of lies and trickery, and specifically targeted Tennessee’s most vulnerable medical providers and patients, including the elderly and veterans.

'Purdue summarized the marketing for its opioid products with the tagline, ‘We sell hope in a bottle’ in one of the company’s hiring guides for incoming marketing employees,' the lawsuit revealed.



Targeting the Beleaguered

Hope could best be sold through the prescriptions of the most beleaguered prescribers:

Purdue told its sales staffers to target medical providers who were overworked, serving poor communities in Tennessee and had less training, calling them 'high value prescribers' who could be easily persuaded to increase prescriptions and dosages of OxyContin.
To do this, most likely the pharma representatives used psychological manipulation, such as assuring the practitioners that the representatives were their true friends in a hostile health care environment.  Such tactics were well-documented in articles by Ahari and Fugh-Berman, e.g., look here and here

Perverse Incentives for Sales Reps

The company provided perverse incentives to its pharmaceutical representatives (perverse, at least, from the standpoint of the patients' welfare and health professionals' values):

Sales staffers’ bonuses were tied to how well they pushed 'super core' providers — the Tennessee prescribers handing out OxyContin prescriptions at a rate guaranteed to cause fatal overdoses — to keep pushing the drug on their patients.

The firm even had a 'toppers club' for sales staffers who pushed the most OxyContin, awarding them trips and cash, the lawsuit stated.

Deceptions and Third-Party Strategies

Although none of the Tennessee pharma reps were "medical professionals," they

were trained to position themselves as medical experts and then supply providers with carefully scripted lies about the addictive and deadly properties of OxyContin, the internal records show.

'Do (providers) believe (in) me on info?' one sales staffer wrote. 'Buy-in … (Provider) buys me first.'
Again, to do this they likely traded on the misguided trust of the physicians generated by the representatives' psychological manipulations.

Practitioners were supplied with biased, and in today's argot, fake literature to give to the physicians,

literature from fake advocacy groups touting the safety of opioids and labeling the growing opioid epidemic as 'pseudoaddiction' that would level off if providers simply prescribed more OxyContin.

Sales staffers were trained to teach providers that the best way to keep patients from addiction was 'to actually prescribe more and higher doses' until the 'symptoms' of addiction went away, the lawsuit stated.

The suit claimed that Purdue set up a "third party strategy," using "astroturf" organizations to pretend that influential health care professionals and sincere patient advocates supported ever increasing narcotics use:

The firm funded the creation of advocacy groups with names such as the American Pain Society and American Pain Foundation, and pamphlets, videos and social media campaigns to convince Tennesseans that OxyContin was a wonder drug — even as the number of fatal overdoses tied to it began to skyrocket.

The firm specifically targeted veterans with a web campaign titled 'Exit Wounds,' and called OxyContin the 'gold standard' for pain treatment.

'Long experience with opioids shows that people who are not predisposed to addiction are unlikely to become addicted to opioid medications,' veterans were told. 'When used correctly, opioid pain medications increase a person’s level of functioning.'
Third party strategies have been widely used in public relations/ propaganda/ disinformation campaigns. 

Profits Before Patients, and the Law

Purdue Pharma reps were instructed to keep pushing narcotic prescribing by physicians who were in danger of being sanctioned.

The lawsuit reveals Purdue’s sales staffers were instructed to ignore police warnings, indictments and overdose deaths involving Tennessee medical providers and to continue to call on them to hand out high-dose OxyContin — the firm’s most profitable brand — so long as they still had prescription pads.

The lawsuit and Purdue’s internal records link the firm’s sales staffers to some of Tennessee’s most notorious pill mill doctors, including one of the largest such operations in East Tennessee.

Purdue staffers called one medical provider, who is not identified in the lawsuit, 48 times — after law enforcement told the firm the provider had prescribed fatal doses of OxyContin and was running a cash-for-pills clinic.

A Nashville Public Radio report additionally noted that

According to the lawsuit, Purdue reps also continued to call on doctors after:

Law enforcement identified two particular doctors responsible for significant diversion
Credible reports of patient overdoses
A provider admitting to heroin addiction
Muggings over controlled substances outside a pharmacy linked to a provider
Admission by a provider he was running a pill mill
Observing a patient being coached in a waiting room
Choreographed pill counts and urine screenings
Standing-room-only waiting rooms
Clearly, generating more revenue by selling more drugs trumped respect for ethics or the law. 

Summary

Thus, Purdue Pharma appeared to use the same sort of multi-pronged deceptive marketing approach to ramp up prescriptions of its potent narcotics, even as more and more people became addicted.

While we have been (probably appropriately) distracted by larger scandals, managers of big health care corporations have continued their cynical tactics that put profits ahead of patients, and ahead of professional values. It is likely that deceptive marketing, and full blown stealth marketing is flourishing even more in the shadows created by a government that seems to put the profits of President and family's company ahead of taking "care that the laws be faithfully executed."

At least to some degree state law enforcement is beginning to step into the breach.  As a Tenessee attorney who is also involved in lawsuits against Purdue said (per NPR)  "I think it helps all of us engaged in this fight to better understand what has happened and ultimately to get more quickly and more efficiently to a resolution,..."

So to conclude,

 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.

Sunday, July 01, 2018

Growing Health Care and Grand Governmental Corruption - But Still Anechoic After All These Years

Here we go again.  We have long been concerned about health care corruption as a major cause of health care dysfunction. Our last post on the topic was in January, 2018.


Summary: the Corruption of Health Care Leadership as a Major Cause of Health Care Dysfunction

As we wrote in August, 2017, Transparency International (TI) defines corruption as
Abuse of entrusted power for private gain

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.

Also,
Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.

The report got little attention.  Health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,
However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects somewhere else, mainly  presumably benighted less developed countries.  At best, the corruption in developed countries that gets discussed is at low levels.  In the US, frequent examples are the "pill mills"  and various cheating of government and private insurance programs by practitioners and patients.  Lately these have gotten even more attention as they are decried as a cause of the narcotics (opioids) crisis (e.g., look here).  In contrast, the US government has been less inclined to address the activities of the leaders of the pharmaceutical companies who have pushed legal narcotics (e.g., see this post). 

However, Health Care Renewal has stressed "grand corruption," or the corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements that result in fines that small relative to their  multi-billion revenues without admitting guilt.  Almost never are top corporate managers subject to any negative consequences.

While we at Health Care Renewal have written about this for years, we saw little improvement.  However, in the past few years we began to feel a little more encouraged.  For example, we had long complained that US law enforcement had not been devoting enough effort going after the corruption of the leadership of large health care organizations, thus effectively allowing these leaders' impunity. However, the US Department of Justice during the Obama administration made some modest attempts to decrease such impunity.  One such measure was the formation of a Health Care Corporate Strike Force.

As reported by Law.com,

the strike force was created in the fall of 2015, with five dedicated lawyers working on about a dozen of the most complex corporate fraud cases in the health care space.

Andrew Weissmann, the then-chief of the DOJ’s fraud section, told a health care conference in April 2016 that the section was placing 'a heightened emphasis' on corporate health care fraud investigations. He pointed to the recently established Corporate Fraud Strike Force that he said would focus resources in investigation and prosecution of larger corporate health care law violations, as opposed to smaller groups or individuals.

Unfortunately, that strike force was downsized by the Trump administration as we noted in July, 2017.  Perhaps that could have been viewed as just a minor setback.

However, we noted in May, 2018, that legal actions by the US government against apparently corrupt acts by large US health care organizations seemed to be falling off.  At that point, we found only one significant settlement made this year.  We also found a report by Bloomberg, with the headline, "White-Collar Prosecutions Fall to 20-Year Low Under Trump," on May 25, 2018.

 Increasing Evidence of Corruption in the Trump Administration


We had noted in January that corruption in the US was becoming even more systemic, and worse, it appeared that the administration itself was fundamentally corrupt. We noted sources that summarized Trump's personal, family, and the Trump administration's corruption, a website, entitled "Tracking Trump's Conflicts of Interest" published by the Sunlight Foundation, and two articles published in the Washington Monthly in January, 2018, "Commander-in-Thief," which categorized Mr Trump's conflicted and corrupt behavior.  The second, "A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

The evidence of corruption has only gotten more substantial since then.

April, 2018: The New York Magazine Timeline

In April, 2018, New York Magazine published "501 Days in Swampland," a time-line of  starting just after the 2016 presidential election.   Its introduction included,
The rewards of government would now be reaped by a single man — and the people would bear the cost.

More than at any time in history, the president of the United States is actively using the power and prestige of his office to line his own pockets: landing loans for his businesses, steering wealthy buyers to his condos, securing cheap foreign labor for his resorts, preserving federal subsidies for his housing projects, easing regulations on his golf courses, licensing his name to overseas projects, even peddling coffee mugs and shot glasses bearing the presidential seal. For Trump, whose business revolves around the marketability of his name, there has proved to be no public policy too big, and no private opportunity too crass, to exploit for personal profit.

The timeline was  organized by mode of malfeasance.  Pages were devoted to how foreign governments and private entities curried favor with Trump by lavish spending at his hotels, golf clubs, and other properties.  More pages were devoted to dubious dealings by Trump's family and friends, and officials in his administration.  Yet more recounted relationships with lobbyists and "petty graft."

Although it was not focused on health care corruption, some of the cases it listed involved health care and public health:

[Under Trump's Hotel in DC - 2017]

7/17 E-cigarette-makers hold their annual conference at the hotel. Ten days later, the FDA announces it will delay federal oversight of e-cigarettes until 2022.

Note that this suggests not just regulatory capture, but the possibility of a quid pro quo bribe.

[Under Officials & Their Pals - 2017]

1/24 During his confirmation as secretary of Health and Human Services, Tom Price fails to disclose an insider deal he got on $520,000 in stock in a biotech company. As secretary, he will be in a position to approve a drug the company has developed.

[2018]


1/31 CDC chief Brenda Fitzgerald is forced to resign over her purchase of stock in one of the world’s largest tobacco companies. She bought the shares a month after taking over the agency tasked with reducing tobacco use.

[Under Lobbyistss & Other Sleaze - 2018]

1/29 Alex Azar, a former lobbyist who worked his way up to the presidency of a drug company, is sworn in as secretary of Health and Human Services. Azar, whose company hiked the price of insulin and other drugs under his watch, is now in charge of making drugs more affordable.

[Under Petty Graft - 2017]

6/2 David Shulkin’s chief of staff falsifies an email to suggest that the VA secretary needed to travel to Europe to receive an award. Shulkin’s 11-day trip with his wife, most of which was devoted to sightseeing, cost taxpayers $122,344.

8/4 HHS Secretary Tom Price takes a private jet at taxpayer expense to St. Simons Island, an exclusive resort where he owns land. The trip, like many of the 26 flights Price took on corporate jets, could have been accomplished with a routine commercial flight.

9/29 HHS Secretary Price is forced to resign over the nearly $1 million in taxpayer money he spent taking military planes and private jets, often to visit family and friends.

This list also included several other examples, not directly health care or public health related, suggesting quid pro quo bribery.  For example, in 2017 at the Trump International Hotel in Washington, DC:

10/4 At its annual board meeting, the National Mining Association is addressed by three Cabinet members: Commerce Secretary Wilbur Ross, Labor Secretary Alexander Acosta, and Energy Secretary Rick Perry. 'Coal is fighting back,' Perry exults over breakfast with the country’s top mining executives. 'Clearly the president wants to revive, not revile, this vital resource.' Five days later, the Trump administration announces the repeal of Obama’s Clean Power Plan, which would have encouraged states to replace coal with wind and solar energy. The plan would have cut climate-warming pollution from coal plants by a third and saved taxpayers and consumers as much as $93 billion a year. The venue for the mining board’s meeting: the Trump International Hotel in Washington, D.C.




So the evidence base of conflicts of interest and outright corruption is becoming more massive, includes cases relevant to health care and public health, and includes examples that seem like outright bribery.


June, 2018: the ProPublica Database of Spending at Trump Properties

In June, 2018, ProPublica reviewed questionable spending amounting to $16.1 million since the beginning of Trump's candidacy for president at Trump properties by the US government, and by Trump's campaign, and by state and local governments.  Its introduction included,

Since Donald Trump declared his candidacy for president in late 2015, at least $16.1 million has poured into Trump Organization-managed and branded hotels, golf courses and restaurants from his campaign, Republican organizations, and government agencies. Because Trump’s business empire is overseen by a trust of which he is the sole beneficiary, he profits from these hotel stays, banquet hall rentals and meals.

Note that

The use of taxpayer dollars at Trump hotels is under scrutiny in a closely watched lawsuit in Maryland federal court. The District of Columbia and the state of Maryland sued Trump, citing a venerable anti-corruption provision of the U.S. Constitution known as the Emoluments Clause. It prohibits any financial gift, or emolument, from benefiting a sitting public official, including the president.

June, 2018: Public Citizen's Corporate Presidency's Hotel Swamplandia

Meanwhile, Public Citizen released a report on money spent at Trump's hospitality properties.  

In its introduction

For those seeking to get on Trump’s good side, it certainly helps to fork over some cash at one of his properties. There simply is no other plausible explanation why so many companies, business groups and foreign governments are spending big money eating, drinking, socializing and sleeping at Trump’s properties around the country. And there’s always the chance that the president himself will show up, as he did in June....

Also,

Trump came to office with the most blatant corrupting conflicts of interest in the history of American politics, so what followed should not be a surprise. By spending money at his properties, corporations and foreign governments are being transparent about their desire to curry favor with the president and influence the Trump administration’s policies.

Information on how much is being spent at Trump properties for political events is available, but remains unknown for the vast majority of spenders at Trump properties. An exception was the Saudi embassy, whose $270,000 in spending at the D.C. hotel was disclosed through a PR firm’s filing with the Justice Department. That said, we were able to document $1.75 million in spending, with more than half coming from the Republican Party.

Examples of spending by health care and public health related organizations included

Allign Technology [medical device company]
American Association of Orthodontists
Curetivity Foundation [supports St Jude Hospital]
National Drug & Alcohol Screening Association
University of Wisconsin
Vapor Technology Association [trade assocation for manufacturers of e-cigarettes]

So it seems that various large health care and public health related organizations are happy to shovel money  into the Trump Organization, and hence into the pocket of the president himself, if doing so can advance their business agendas.


Meanwhile Corruption, Even of a President, Remains a Virtually Taboo Topic

And still, we don't talk about it. 

 As noted above, corruption in health care has always seemed a taboo topic.  In November, 2017, we noted that once again, a report by Transparency International that showed that in an international survey of corruption perceptions, substantial minorities of US respondents thought that US corruption was increasing, and was a particular affliction of the executive and legislative branches of the national government, other government officials, and top business executives.  There was virtually no coverage of these results in the US media, just as there was virtually no coverage of a 2013 survey that showed 43% of US respondents believed that US health care was corrupt.

Similarly, the reports listed above have generated little discussion.  Despite the extensive and ever-increasing list of apparently corrupt acts by the Trump and cronies, grand corruption at the top of US government, with its potential to corrupt not just health care, but the entire country and society, still seems like a taboo topic.  The US news media continues to tip-toe around the topic of corruption, in health care, of top health care leaders, and in government, including the top of the US executive branch.  As long as such discussion seems taboo, how can we ever address, much less reduce the scourge of corruption?  The first step against health care corruption is to be able to say or write the words, health care corruption.


But even if we can take that step, when the fish is rotting from the head, it makes little sense to try to clean up minor problems halfway towards the tail. Why would a corrupt regime led by a president who is actively benefiting from corruption act to reduce corruption? The only way we can now address health care corruption is to excise the corruption at the heart of our government.