April, 2019, Update: How to Challenge Health Care Corruption Under a Corrupt Regime?

In these last few weeks, the US news has been dominated by the release of a redacted verion of the Mueller report which included extensive evidence of questionable behavior by President Trump, his campaign, and various Trump associates.  This week, an editorial in Mother Jones suggested:

The Russia scandal was never, in the main, about whether the president would be prosecuted for a crime. It was, and is, about a bigger issue: A wealthy politician who hoped to profit from pandering to a foreign autocrat put his own financial interests above those of his country, who abetted a foreign attack, and who lied about it to those he swore to serve.

There is a word for this, but it’s not collusion. It’s corruption.

The editorial suggested that journalists have not done an adequate job pursuing the underlying "rot" in the US government and the Trump administration:

And rather than laying off investigating it, as too many are suggesting now, journalism needs to back up and look at the whole thing.

It seems to be a great idea, but in fact, some journalists, scholars, bloggers, etc have been looking at corruption for a long time, including health care corruption, and corruption in the US government.  The problem, however, is that much of the discussion of corruption has been anechoic.

Background: Health Care Corruption

As we wrote in August, 2017, Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.

the scale of corruption is vast in both rich and poor countries.

Also,

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

The report got little attention.  Health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,

However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

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

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

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

We have been posting about this for years at Health Care Renewal, while seeing little progress on this issue.

Health Care Corruption in the Context of a Corrupt Government

Instead, things now only seem to be getting worse, given the increasing evidence that the Trump administration is corrupt at the highest levels.   In January, 2018, we first raised the question about how health care corruption could be pursued under a corrupt regime.  We noted sources that summarized Trump's. the Trump family's, and the Trump administration's corruption..  These included a website, entitled "Tracking Trump's Conflicts of Interest" published by the Sunlight Foundation, and two articles published in the Washington Monthly in January, 2018. "Commander-in-Thief," categorized Mr Trump's conflicted and corrupt behavior.  A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

In July, 2018, we addressed the Trump regime's corruption again  By then, more summaries of Trump et al corruption had appeared.   In April, 2018, New York Magazine published "501 Days in Swampland," a time-line of  starting just after the 2016 presidential election. In June, 2018, ProPublica reviewed questionable spending amounting to $16.1 million since the beginning of Trump's candidacy for president at Trump properties by the US government, and by Trump's campaign, and by state and local governments. Meanwhile, Public Citizen released a report on money spent at Trump's hospitality properties.


In October, 2018, we summarized the content of the voluminous Tracking Corruption and Conflicts of Interest in the Trump Administration summary appearing in the Global Anti-Corruption Blog. The blog organized corrupt activities within the Trump administration into the following categories:

1. U.S. Government Payments to the Trump Organization

2. Use of the Power of the Presidency to Promote Trump Brands

3. U.S. Government Regulatory and Policy Decisions that Benefit Business Interests of the Trump Family and Senior Advisors

4. Private and Foreign Interests Seeking to Influence the Trump Administration Through Dealings with Trump Businesses

Not only was the report voluminous, the October version of the report requiring 26 pages to print, it suggested that many examples of corruption by Trump et al were not one-offs, but were long-term activities.  For example, every time President Trump travels to on of the properties he owns through the Trump Organization, for example, has Mar-a-Lago resort in Florida, the US government is obligated to pay Trump himself through that organization for various expenses, e.g., the Secret Service renting golf carts at Mar-a-Lago.  Each time that happens it seems to violate the "domestic emolument clause" of the US Constitution, which prohibits state or US government payments to a President for anything other than his salary.  Also, foreign governments and corporations seeking to promote specific government policies in their self-interest, similarly seeking favorable regulations, or other seeking to influence government actions in their favor are making periodic payments to the Trump Organization, such as buying accomodations or paying for events at Trump properties.  When foreign governments do so, that appears to violate the "foreign emoluments clause" of  the US Constitution, which prohibits payments by a foreign government to the US President.

Updates on the Corruption of the US Government


New Source: Bloomberg's "Tracking the Trump Team's Conflicts and Scandals"

Bloomberg produced an interactive guide, most recently updated in March, 2019, and divided into sections on individual members of the team, including Trump and his family, Trump appointees, and associates and outside advisers.

New Source: the Citizens for Responsible Ethics in Washington's Blog

CREW is a non-profit organization whose goal is "to reduce the influence of money in politics and help foster a government that is ethical and accountable."It produces a blog with very frequent posts that center on conflicts of interest and corruption affecting Trump and associates.  For example, recent posts included: "IRS Commissioner Charged with Releasing Trump Tax Returns Profits from Trump-Branded Property" and "Turkish Interest Group Event Kicks Off at Trump Hotel, with Government Sponsors."

New Source: Zach Everson's 1100 Pennsylvania Avenue

Threre are so many instances of violations of the foreign and domestic emoluments clause occurring just at the Trump Organization hotel in Washington, DC that there is now a blog and newsletter dedicated to essentially daily reporting about them.

Updates of the Global AntiCorruption Blog's "Tracking Corruption and Conflicts of Interest in the Trump Administration"

Since October, the report has been updated nearly monthly .  These updates suggest new variations on these corrupt themes, for example: November, 2018, Interior Secretary Ryan Zinke's "shady property development deal;"January, 2019, questions of illegal actions by Trump's inaugural committee;
March, 2019, possible special treatment by the Government Services Administration of the Trump Organization's flagship Trump International Hotel in Washington, DC; and April, 2019, how Trump-connected lobbyists are directing clients to book rooms at that hotel.


Updates of the Sunlight Foundation's "Tracking Trump's Conflicts of Interest"

At the same time, the Sunlight Foundation's "Tracking Trump's Conflicts of Interest" project is also frequently updated.  Note that its main webpage includes links to weekly reports about relevant issues.  For example, the most recent is " This Week in Conflicts: Redacted Mueller Report Released, Undisclosed Cash Flow from Inaugural Ball and Mueller Explains Why His Family Left Trump’s Golf Club"


Discussion

Since October, the evidence of pervasive conflicts of interest and outright corruption affecting President Trump, his family, the Trump Organization, and his administration continues to mount.  The totality of the array of unethical and probably illegal activities has become mind numbing.  To underscore what we wrote in October

So the driver of US health care corruption may now be the executive branch of government and its relationship with the Trump family and cronies, trumping even the influence of health care corporate corruption.

That corruption appears to be ongoing, getting worse not better, and is not receiving adequate notice.

In November, 2017, we noted that another 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, despite, or perhaps because of their tremendous scale, the reports about Trump related corruption 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.

So we welcome any additional attention to health care corruption, or the larger corruption within the US government that is making health care corruption even harder to address. We thus specifically welcome Mother Jones' added emphasis on this topic.


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.

The Rise of Ideologically or Theologically Based Medicine, Public Health, and Health Policy - Recent Examples

I have long been a proponent of evidence-based medicine (EBM), and evidence-based health care, public health, and health policy.  EBM, for example, is about medical-decision making based on critical review of the best applicable evidence from clinical research informed by knowledge og biology and medicine, of the patient's biopsychosocial circumstances, the patient's values, and of ethics and morality.  We have discussed challenges to EBM based on manipulation and suppression of clinical research, often in the financial interests of those hawking particular medical products of services.

A newer challenge to evidence-based medicine, health care, public health and health policy seems not to be commercial, but ideologically or theologically based.  I noticed the following recent cases that illustrate this concern. 


Theologically Based Medicine and Public Health Promoted at the DHHS

In July, 2018, we discussed the case of Dr Diane Foley, who was appointed Deputy Assistant Secretary for Population Affairs in the US Department of Health and Humas Services (DHHS).  At the time we noted that Dr Foley publicly proclaimed that adoption of children is harmful because it is a "double death;" and teaching children about barrier contraception is harmful because it is "sexually harassing."  Dr Foley also ran an organization called Life Network, which ran so-called "crisis pregnancy centers," which ran abstinence-only sexual education programs in part based on Dr Foley's beliefs about the harms of teaching about barrier contraception.  There seems to be no good evidence about the sort of harms Dr Foley attributed to adoption or barrier contraception.


Nonetheless, on April 4, 2019, ReWire reported that the DHHS would give control of  Title X federal family planning and teen pregnancy prevention and the Office for Adolescent Health (OAH), which administers the Teen Pregnancy Prevention Program to the Office of Population Affairs, which is run by Dr Foley.  In response, Senator Patty Murray (D-WA),

the ranking Democrat on the Senate appropriations subcommittee with oversight over HHS, questioned the Trump administration’s motivations behind the plan. 'It is unclear how the reorganization will result in better policies and services for those served by these offices, including adolescents, women, low-income communities, and individuals with infectious diseases, including HIV/AIDS,' she wrote. 'In fact, it is difficult to understand how this reorganization does anything other than consolidate control at HHS headquarters and prioritize ideology over the needs of the women, teenagers, and children the affected programs serve.'

In fact, there is reason to believe that Dr Foley based her beliefs more on her ideas about theology than on a political ideology.  Life Network's website has stated (see our post linked above) 

'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.'

Thus the Trump administration seems to be consolidating power over US government family planning programs in the hands of an individual who is basing her decision making not on medical or public health evidence, but on her version of a particular type of Christian theology.

Ideologically or Theologically Based Public Health Policy about Pornography Promoted in Another State Legislature

NBC Montana reported on April 16 that Montana legislators are the latest to join the quest to label pornography a public health hazard.  

One resolution state house lawmakers are taking up in Helena would label pornography as a public health hazard in Montana.

If passed, Montana would have to address pornography through education, research and state policy.

The state would have to implement measures to prevent pornography exposure and addiction, offer recovery help, and create programs that hold broader influences accountable.

The proposed resolution included assertions that, for example, pornography causes

violence and abuse of women and children by presenting rape and abuse of women and children as harmless

and

psychological and physical distress, deviant sexual arousal, difficulty in forming or maintaining intimate relationships, and problematic or harmful sexual behaviors and addiction

and

increases sex trafficking of women, sex trafficking of children, child sexual abuse, and child pornography;

Yet as we noted in March, 2019, there is no clear evidence supporting any of these assertions.  So Montana Republican legislators join those in Arizona, and also those in Kansas, Utah, and Idaho (look here)  in pushing legislation that attacks the "public health" hazards of pornography based on no clear evidence.

The genesis of the notion that pornography is a dire public health hazard is not clear.  As we noted here, though, in Utah, at least, beliefs about pornography could come from the doctrine of the Church of Latter Day Saints, which includes:

'depiction, in pictures or writing, that is intended to inappropriately arouse sexual feelings' to be 'a tool of the adversary,' the descriptor Mormons often use for Satan.

At any rate, since the proponents of these measures all seem to be Republicans, there also is suspicion that their beliefs about pornography are ideologically-based.

Ideologically Based Beliefs About Vaccination Policy Espoused by President Trump, the Governor of Kentucky, and in Multiple State Legislatures

We recently discussed how a Russian disinformation campaign has led parents in the US and elsewhere to avoid vaccinating their children for various diseases, in turn leading to outbreaks of measles in the US and other countries. Along with this disinformation campaign, various government leaders have also espoused views about the benefits and harms of vaccination, and vaccination policy that are virtually free of evidenciary support.

In March, 2019, the Louisville Courier Journal reported on the example set by the Republican Governor of Kentucky. 

Gov. Matt Bevin said in a radio interview Tuesday that he deliberately exposed all nine of his children to chickenpox so they would catch the disease and become immune.

'Every single one of my kids had the chickenpox,' Bevin said in an interview with WKCT, a Bowling Green talk radio station. 'They got the chickenpox on purpose because we found a neighbor that had it and I went and made sure every one of my kids was exposed to it, and they got it. They had it as children. They were miserable for a few days, and they all turned out fine.'

Governor Bevin seemed to imply that chickenpox is an annoying disease, but one that does not cause severe adverse effects.  However, varicella is not innocous.  According to the CDC clinical summary, it can cause secondary bacterial skin infections in children.  Rarely in children, but more commonly in adolescents, adults, pregnant women, and people with immunocompromise, it can cause severe complications including pneumonia, sepsis, and various other secondary bacterial infections.  Varicella is highly contagious, so unvaccinated children can infect other unvaccinated people who are more susceptible to complications.

Yet Governor Bevin ignored all that.  His rationale for not vaccinating his own children and not mandating varicella vaccine for other children was conveyed in his interview.

Bevin also suggested that the government stay out of mandating vaccines. In Kentucky, varicella (chickenpox) is among vaccines mandated for all children entering kindergarten, though parents may seek religious exemptions or provide medical proof that a child has already had the disease.

'And I think, why are we forcing kids to get it?' Bevin said in the radio interview, speaking about the chickenpox vaccine. 'If you are worried about your child getting chickenpox or whatever else, vaccinate your child. ... But for some people, and for some parents, for some reason they choose otherwise. This is America. The federal government should not be forcing this upon people. They just shouldn’t.'

So his ideology that "the federal government should not be forcing this upon people" seemed to trump any risks children run because their parents choose to not vaccinate them, even just "for some reason."

The Louisville Courier Journal also interviewed "Dr. Robert Jacobson, a pediatrician and expert in vaccines and childhood diseases at the Mayo Clinic in Rochester, Minnesota,

Before vaccination was available, chickenpox killed as many as 100 adults and children a year, he said.

'I think it is taking a big risk that you don’t need to take,' Jacobson said. 'It's not just a risk your children are going to have. You're putting other people in the community at risk because of your decision.'

 Note that this is not the first time that Governor Bevin expressed beliefs about public health that were not evidence-based.  In this post, we noted that in 2018 he suggested that mass school shootings are due to exposure to television shows about zombies, and in 2019 he suggested that exposing children to severely cold weather is risk free.  So he does seem consistent in the absurdity of his public health beliefs.  Unfortunately, he is in a position to endanger the public's health according to these beliefs. 

There are other US state level political leaders who seem to rely on idology rather than evidence in making decisions about health care and public health.  On April 16, 2019, Politico reported widespread attempts by Republican state legislators to free people from requirements that they vaccinate their children,

Democrats in six states — Colorado, Arizona, New Jersey, Washington, New York and Maine — have authored or co-sponsored bills to make it harder for parents to avoid vaccinating their school-age children, and mostly faced GOP opposition. Meanwhile in West Virginia and Mississippi, states with some of the nation’s strictest vaccination laws, Republican lawmakers have introduced measures to expand vaccine exemptions, although it’s not yet clear how much traction they have.

In Washington state, which has one of the biggest measles outbreaks, a bill in the state Senate to narrow vaccine exemptions passed through the health committee without the support of a single Republican. The same thing happened in legislative committees in Colorado and Maine over the past week.

Again, the Republicans seemed to base their attempts to decrease vaccination requirements on their ideology of expanding personal choice.

many are loath to diminish the right of parental control over their children’s bodies, and yield that power to the government.

Politico provided an example of a New York state legislative leader who opposed a bill that would limit religiosu exemptions to vaccination mandates.

Andrew Raia, ranking Republican on the New York Assembly’s health committee, said he wouldn't support the bill. While not totally convinced by constituents who link their children’s autism on vaccines, and unaware of any real religious injunction against vaccination, he said, 'I’m not a religious leader, and I’m not a scientist either, so it’s my job to weigh both sides.'

I suggest that his arguments are at best evidence free, but also could have been

complicated by the fact that President Donald Trump and two of his Republican primary foes, Sen. Rand Paul (R-KY) an ophthalmologist, and Ben Carson, a neurosurgeon who is now HUD secretary, both voiced support for disproven theories linking vaccine to autism during a 2016 debate.

In fact, as reported by the (UK) Independent in 2018,

On more than 20 occasions, Mr Trump has tweeted about there being a link between vaccines and autism, something experts at the government’s leading public health institute say is not true. He also repeated the claim during a Republican primary debate, a remark that was immediately dismissed as false by the Autistic Self Advocacy Network.

Summary

Outbreaks of infectious diseases previously considered controlled now bedevil the US and other developed countries.  They seem to be caused in part by parents' resistance to vaccinating their children, despite strong evidence that the vaccines are relatively effective and have harms that exceed their benefits, both for the children vaccinated and the public health.  In turn, the resistance to vaccination seems increasingly inspired by government leaders whose actions are based on ideology, or sometimes theology.

The ideologically based arguments seem to come from some sort of a crude libertarianism that holds that parents should be free to choose not to vaccinate, more or less regardless of the effects of their decision on their children, or other people.  Such arguments should alarm health care professionals who are sworn to put the patients' and the public's health ahead of other concerns, including political ideology.

The theologically based arguments are also concerning because they seem to be an attempt to use the govenrment to promote a particular set of religious beliefs ahead of patients' and the public's health, and to impose these beliefs on people of other faiths.  This apparently contradicts the US constitutional prohibition against governmental establishment of religion.

True health care reform would require government officials to use evidence, rather than personal ideology and particularly rather than their own religious beliefs when making health care and public health policy. 

The HIV Epidemic, and Now the Measles Outbreak: The Russian Connection

I am old enough to remember having measles as a child, a thoroughly unpleasant experience.  Some children had much unhappier results of measles than I did.  So as a parent, I was happy to see that a reasonably effective measles vaccine had practically eliminated the disease from the US and most developed countries.

However, we currently are in the midst of a measles outbreak in the US.  The current number of reported cases for the first three months of 2019 is greater than all cases reported in 2018.  (See this CDC update.)  Other so-called developed countries are also seeing more cases of measles.  Why has measles returned?  A likely cause is the number of parents with negative opinions about the vaccine is rising, and their clamor to exempt their own children is getting louder (look here for just the latest example.)

The negative opinions seem not to come from reasoned arguments based on logic and facts, but from disinformation campaigns.


Prelude: the 1980s Soviet Disinformation Campaign About HIV

How disinformation can disrupt public health is a story which seemed to have been largely forgotten until 2016.  That year, how the campaign to control HIV in the 1980s was impeded by disinformation  was brought up again after so many years by the Washington Post.  The article opened

On July 17, 1983, a small pro-Soviet Indian newspaper called the Patriot published a front-page article titled 'AIDS may invade India: Mystery disease caused by US experiments.' The story cited a letter from an anonymous but 'well-known American scientist and anthropologist' that suggested AIDS, then still a mysterious and deadly new disease, had been created by the Pentagon in a bid to develop new biological weapons.

'Now that these menacing experiments seem to have gone out of control, plans are being hatched to hastily transfer them from the U.S. to other countries, primarily developing nations where governments are pliable to Washington's pressure and persuasion,' the article read.

The Patriot's article was subsequently used as a source for an October 1985 story in the Literaturnaya Gazeta, a Soviet weekly with considerable influence at the time. The next year, it ran on the front page of a British tabloid. After that, it was picked up by an international news wire. By April 1987, it was suggested that the story had appeared in the major newspapers of more than 50 countries.

The problem? The story was patently false. 

It was a product of a deliberate Soviet disinformation campaign.  A New York Times article from 2017 amplified the specifics:

Called Operation Infektion by the East German foreign intelligence service, the 1980s disinformation campaign seeded a conspiracy theory that the virus that causes AIDS was the product of biological weapons experiments conducted by the United States. The disease disproportionately impacts gay men, and the Reagan administration’s slow response had escalated into suspicions in the gay community that the United States government was responsible for its origins.

'The K.G.B. picked up on that, and added a new twist with a specific location: Fort Detrick, Md.,' where military scientists conducted biological weapons experiments in the 1950s and 1960s, said Douglas Selvage, the project director at the Office of the Federal Commissioner for Stasi Records in Berlin.

The K.G.B. campaign began with an anonymous letter in Patriot, a small newspaper published in New Delhi that was later revealed to have received Soviet funding. It ran in July 1983, under the headline 'AIDS May Invade India: Mystery Disease Caused by U.S. Experiments' and pinned the origin of the disease to Fort Detrick.

The choice of Patriot was deliberate, said Thomas Boghardt, a military and intelligence historian who traced how the campaign unfolded. 'It had no explicit links to the Soviets and was an English-language newspaper easily accessible to a global audience.'

'The Soviets intuitively understood how the human psyche works,' Dr. Boghardt said. He said the playbook was simple but effective: Identify internal strife, point to inconsistencies and ambiguities in the news, fill them with meaning and 'repeat, repeat, repeat.'

A September 1985 memo to Bulgarian intelligence from the East German secret police served as a conduit. The disinformation campaign aimed, according to the Stasi, 'to generate, for us, a beneficial view by other countries that this disease is the result of out-of-control secret experiments by U.S. intelligence agencies and the Pentagon involving new types of biological weapons.'

A month later, the Soviet journal Literaturnaya Gazeta published a paper titled 'Panic in the West or What Is Hiding Behind the Sensation Surrounding AIDS.' It included accurate information about the disease and Fort Detrick but cited the Patriot letter to connect the dots.

The paper received international attention and its allegations were repeated around the world including in Kuwait, Finland and Peru. CBS News, black newspapers, the gay press, niche publications critical of the C.I.A. and the right-wing presidential candidate Lyndon LaRouche all promoted the conspiracy theory. (Mr. LaRouche flipped the claim on its head, accusing the Soviets of using AIDS as a weapon.)

Background on Soviet Disinformation

An earlier 2017 article in the Guardian expanded the background about Soviet use of disinformation:

Unlike misinformation, disinformation is constructed to be deliberately false, with the intention of sowing discord in enemy ranks. While there are undoubtedly historical examples, the industrialisation of disinformation emerged with the modernisation of media and mass communication. This is reflected in the etymology of the word itself, which by the advent of second world war had arisen independently in both Russian and English to characterise the spread of propaganda across Europe. Russia quickly recognised its enormous potential, and as early as 1923 the GPU (forerunner to the KGB) had established an office dedicated to it.

Disinformation fast became an integral part of Soviet intelligence, and by the birth of the KGB in the 1950s, it had become an essential component in the doctrine of 'active measures', the art of political warfare. Active measures included media manipulation, the use of front groups, counterfeiting of documents, and even assassinations when required. It was the very heart of Soviet intelligence, described by KGB Major General Oleg Kalugin as:

'... not intelligence collection, but subversion: active measures to weaken the west, to drive wedges in the western community alliances of all sorts, particularly Nato, to sow discord among allies, to weaken the United States in the eyes of the people of Europe, Asia, Africa, Latin America, and thus to prepare ground in case the war really occurs.'

Throughout the cold war, the Soviets were virtuosos in creating tensions between allies. In particular, they excelled at the use of 'black propaganda': crafting damaging material which purported to be from the other side. These attempts were nebulous and prolonged, and included Operation Neptune, a 1964 attempt to use forged documents with the intention of implying western politicians had supported the Nazis. While this was quickly exposed as a counterfeit, other ruses were more successful. Whilst dezinformatsiya was targeted chiefly at the US, it was largely ignored there until 1980, when a Soviet forgery of a presidential document claimed that the administration was supportive of apartheid. This got some traction in US media, and so appalled president Jimmy Carter that he demanded a CIA inquiry.

In fact, by the 1980s, Soviet disinformation was an old story.

Ladislav Bittman wrote in The KGB and Soviet Disinformation: an Insider's View, published in 1985 that disinformation is part of what the Soviets called

'active measures' directed by the KGB ... designed for internal demoralization and erosion of power in targe countries [p 2]

He later wrote [p 48]

Disinformation is a carefully constructed false message leaked into an opponent's communication system to deceive the decision-making elite or the public.  Disinformation can be of political, economic, miliary or even scientific nature. To succeed, every disinformation message must at least partially correspond to reality or generally accepted views....

Then he noted that each message is crafted so that [p 56]

it dissuades leaders of the target country from critical analysis of the deceptive segments.  The overall purpose is not only to deceive but to cause damage to the target.  The victim of disinformation  must be led to inflict harm upon himself, directly or indirectly - either by acting agains his own interests on the basis of spurious intformation or by remaining passive when action is needed.

These elements of disinformation now may seen as echoed in the Russian campaign to manipulate the 2016 and 2018 US elections to favor now President Donald Trump and his supporters, and in some of the UK campaign for Brexit. 


The 2015 Measles Epidemic

As the years passed, and the USSR fell, the notion of disinformation seemed to fall into the dustbbin of history.  Yet, in early 2015, before anyone thought of Donald Trump as a presidential candidate, there was a small US measles epidemic.  In February, 2015, the New York Times discussed the strange inability of some then Republican candidates for the presidency to discuss the issue clearly.

The politics of medicine, morality and free will have collided in an emotional debate over vaccines and the government’s place in requiring them, posing a challenge for Republicans who find themselves in the familiar but uncomfortable position of reconciling modern science with the skepticism of their core conservative voters.

As the latest measles outbreak raises alarm, and parents who have decided not to vaccinate their children face growing pressure to do so, the national debate is forcing the Republican Party’s 2016 presidential hopefuls to confront questions about whether it is in the public’s interest to allow parents to decide for themselves.

Gov. Chris Christie’s trade mission to London was suddenly overshadowed on Monday after he was quoted as saying that parents 'need to have some measure of choice' about vaccinating their children against measles. The New Jersey governor, who is trying to establish his credibility among conservatives as he weighs a run for the Republican nomination in 2016, later tried to temper his response.

Then,

Senator Rand Paul of Kentucky, a physician, was less equivocal, telling the conservative radio host Laura Ingraham on Monday that parents should absolutely have a say in whether to vaccinate their children for measles.

'While I think it’s a good idea to take the vaccine, I think that’s a personal decision for individuals,' he said, recalling his irritation at doctors who tried to press him to vaccinate his own children. He eventually did, he said, but spaced out the vaccinations over a period of time.

The Times article speculated that

The vaccination controversy is a twist on an old problem for the Republican Party: how to approach matters that have largely been settled among scientists but are not widely accepted by conservatives.

In fact, Mr Christie had walked into a similar controversy earlier, about Ebola:

As concern spread about an Ebola outbreak in the United States, physicians criticized Republican lawmakers — including Mr. Christie — who called for strict quarantines of people who may have been exposed to the virus. In some cases, Republicans proposed banning people who had been to the hardest-hit West African countries from entering the United States, even though public health officials warned that would only make it more difficult to stop Ebola’s spread.

It all seemed odd.  After all, a lot of conservatives up to that time cultivated an image of hard-headed realism. Why would understanding of the favorable benefit/ harm profile of the measles vaccine, or of public health measures used to combat diseases like Ebola not be accepted by conservatives?

A 2018 Study of an Internet Based Disinformation Campaign About Vaccination

In 2018, a study of the role of twitter bots and Russian trolls in online vaccine discussions appeared (Broniatowski DA et al.Weaponoized health communication: Twitter bots and Russian trolls amplify the vaccine debate. Am J Pub Health 2018; 108: 1378-1384. Link here). It was an observational study designed to compare "'bots'—accounts that automate content promotion—and 'trolls'—individuals who misrepresent their identities with the intention of promoting discord."
 
To summarize its methods:

In our first analysis, we examined whether Twitter bots and trolls tweet about vaccines more frequently than do average Twitter users. In a second analysis, we examined the relative rates with which each type of account tweeted provaccine, antivaccine, and neutral messages. Finally, in a third analysis, we identified a hashtag uniquely used by Russian trolls and used qualitative methods to describe its content.

To summarize its results:

Compared with average users, Russian trolls (χ2(1) = 102.0; P < .001), sophisticated bots (χ2(1) = 28.6; P < .001), and “content polluters” (χ2(1) = 7.0; P < .001) tweeted about vaccination at higher rates. Whereas content polluters posted more antivaccine content (χ2(1) = 11.18; P < .001), Russian trolls amplified both sides. Unidentifiable accounts were more polarized (χ2(1) = 12.1; P < .001) and antivaccine (χ2(1) = 35.9; P < .001). Analysis of the Russian troll hashtag showed that its messages were more political and divisive.

The authors' discussion of results asserted:

Russian trolls and sophisticated Twitter bots post content about vaccination at significantly higher rates than does the average user. Content from these sources gives equal attention to pro- and antivaccination arguments. This is consistent with a strategy of promoting discord across a range of controversial topics—a known tactic employed by Russian troll accounts. Such strategies may undermine the public health: normalizing these debates may lead the public to question long-standing scientific consensus regarding vaccine efficacy. Indeed, several antivaccine arguments claim to represent both sides of the debate—like the tactics used by the trolls identified in this study—while simultaneously communicating a clear gist (i.e., a bottom-line meaning).

Note that they felt these results were applicable to the 2015 measles outbreak:

We recently found that this strategy was effective for propagating news articles through social media in the context of the 2015 Disneyland measles outbreak.

So here we have at least some evidence suggesting that the Russians were mounting a modern version of a disinformation campaign focused on scientific information meant to sow discord in the US and perhaps other developed countries, and to enable its victims to harm themselves or their children by dissuading them from measles and perhaps other generally beneficial vaccination.  Probably because disinformation had largely not been the subject of polite conversation since the fall of the Soviet Union and the disappearance of the old KGB (or at least, its name), US public health authorities and politicians  had failed to critically analyze what was going on.


The 2018 study got a bit of attention, and several authors suggested some responses.  In StatNews Beier and Sullivan suggested lessons learned:

First, we’ve learned that the Russians operate from a playbook that links seemingly disparate events. In the case of both AIDS and vaccine safety, they exploited pre-existing cynicism among groups or individuals outside the mainstream, planting doubts without apparent Russian links. For vaccines, Russians exploited a controversial report in the Lancet (that was later retracted by the journal) to exacerbate skepticism of vaccine safety so more parents would decline to vaccinate their children. (To be sure, the article had already generated home-grown anti-vaccine sentiment in the U.S.)

Second, we need to pay closer attention to public health measures that generate fear among those they are intended to protect, like vaccinations for children or fluoridated water.

Third, we must pay special attention to areas in which the West is widely seen as 'winning' compared to Russia — in this case public health — making them targets for disinformation campaigns.

The authors then suggested what should be done:

The federal government must take the lead on alerting the media and the public to the risks of purposefully misleading disinformation attacks. Public officials, including President Trump, must show a greater dedication to truth and facts. Whenever a prominent public official espouses support for baseless science, it helps those trying to subvert democracy. By relying on a swamp of bogus science, Russia has exploited loving parents with false, misleading, and dangerous information.

The federal government needs to work with the tech community to develop programs and algorithms to detect threats to our vital health information infrastructure from harmful lies about public health. Once such attacks are detected, Americans must work together to erect cyberwalls to thwart them.

That seemed well-intentioned, albeit unrealistic.  In particular, why would you expect the Trump regime, which appeared to gain power with the help of Russian disinformation (look here), suddenly turn into a tough, clear-headed foe of such disinformation?

Junaid Nabi in Project Syndicate made some more global suggestions:

health officials and experts in both developed and developing countries need to understand how this online misinformation is eroding public trust in health programs. They also need to engage actively with global social media giants such as Facebook, Twitter, and Google, as well as major regional players including WeChat and Viber. This means working in tandem to create guidelines and protocols for how information of public interest can be disseminated safely.

In addition, social media companies can work with scientists to identify patterns and behaviors of spam accounts that try to disseminate false information on important public-health issues. Twitter, for example, has already started using machine-learning technology to limit activity from spam accounts, bots, and trolls.More rigorous verification of accounts, from the moment of signing up, will also be a powerful deterrent to the further expansion of automated accounts.

Again, this seems well-intentioned.  But why expect social media companies, which seemed to be making lots of money through the viral spread of both information and disinformation, to be so helpful?

Of course, none of that happened. Now we are in yet another measles outbreak, considerably bigger than the one in 2015, with no end in sight.

Discussion

Life used to be so simple.  We used to write about propaganda and disinformation used to market health care goods and services (stealth marketing campaigns), and advocate for policies favorable to private health care organizations, usually under the auspices of pharmaceutical/ biotechnology/ device companies, health insurance companies, and hospital systems  (stealth health policy advocacy and stealth lobbying).  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).


While these efforts were done to improve corporate bottom lines and thus enhance the income of top corporate management, at least these organizations had some interest in providing or facilitating health care.

Although I had heard about Soviet disinformation, and even thought that some of the modern techniques used by big corporations for marketing and advocacy were uncomfortably close to disinformation, I, like many others, was not particularly worried about disinformation again used as a powerful weapon by a hostile foreign power.  How naive I was.  

Now we see propaganda and disinformation in the service of hostile and authoritarian foreign states meant to disrupt more democratic governments, whatever the cost in human health and lives.  And we see at best indifference to this problem on the part of politicians who may benefit from such foreign largesse.  (The hope in the StatNews piece that President Trump would become more dedicated to truth and facts was already naive at the time of publication.)

So we may need much more energetic and muscular solutions to the propaganda and disinformation that is now rotting our already dysfunctional health care system.  We cannot complacently expect a conflicted and corrupt government executive to help us.  Health care professionals, and all people who care about health care and the public health are going to have to stop wringing our hands and actually do something.  Or measles outrbreaks will be the least of our problems. 

First the NIH Came for the Iranian Born Legal US Resident Scientists

Transparency, honesty, and collaboration are necessary to do science, including biomedical and clinical science right.  In the US, the National Institutes of Health (NIH) have always had a good reputation for transparency, honesty and collaboration, although they have had some revolving door and conflict of interest issues of late (look here, here, here here, and here).

However, an April 3 article in the Washington Post suggests that things are going downhill. The lede was:

The National Institutes of Health is requiring all visitors — including patients — to disclose their citizenship as a condition of entry, a policy that has unnerved staff scientists and led to recent disputes with at least two Iranian scientists invited to make presentations, only to be blocked from campus.

The most important point was that although the two scientists were born in Iran, they were both legal US residents who had apparently lived in this country for a long time.

In one incident, a Georgetown University graduate student arriving for a job interview was held up at security, then allowed to proceed to one of the campus buildings. But as he prepared to make a presentation, NIH police arrived, removed him from a lab and escorted him off campus, according to a complaint Monday to a group that represents staff scientists.

In another, a brain researcher said he was told to leave, then delayed at security for nearly an hour filling out online forms. After interventions by NIH police and other officials, he was told an exception had been made that would allow him to deliver his presentation to the two dozen waiting researchers.

Both men had green cards and U.S. driver’s licenses and had previously visited NIH without incident.

There was no obvious reason,other than their Iranian birth, to be suspicious of these two men. In particular,

'I am very surprised and disappointed that there are all these restrictions,' said the brain researcher, who spoke on the condition of anonymity to avoid jeopardizing his relationships at NIH. He said he worked at NIH from 2009 to 2014 on an H-1B visa and had been invited to speak on his specialty last week. As recently as two months ago, he said, he had no problem entering the campus.

The actions seemed to have had their genesis in a post 9/11 policy that was never previously enforced.

NIH officials say the policy is not new — although they acknowledge posting a sign recently that says all visitors must disclose their citizenship in the NIH security building, known as the Gateway Center. People who work at the Bethesda, Md., campus said they had never heard of such questioning until the past few weeks.

An April 2 email obtained by The Washington Post describes a senior-level meeting Tuesday, at which the chief executive of the NIH Clinical Center, James Gilman, recounted how a long-standing policy 'was never followed, and apparently in the past few days, security started following it, including signs at the visitor entrances that say they will ask for it [citizenship],' according to a person who attended the meeting.

The excuse may be that the agency has recently come under congressional pressure to be more vigilant about industrial espionage, especially having to do with China.

In recent months, NIH and the FBI have warned U.S. scientists to beware of Chinese spies intent on stealing biomedical research from NIH-funded laboratories at universities.

Under pressure from lawmakers, led by Sen. Charles E. Grassley (R-Iowa), NIH said in January it had referred 12 allegations of foreign influence over U.S. research to the HHS inspector general.

What the reported events had to do with China or industrial espionage is not obvious.  The Post article did suggest that

NIH — a research institution built on collaboration — is apparently following protocols used by federal security agencies that deal with highly sensitive or classified information and require top-secret security clearances for their employees. Visitors to those facilities must disclose their citizenship, and foreign nationals are provided with a badge different from those worn by U.S. citizens, security officials said.

Again, why the NIH should be viewed as similar to agencies dealing with top-secret information is unclear.

At least some NIH scientists are voicing concern about the new policies

One NIH researcher, G. Marius Clore, forwarded a complaint Monday to an elected committee that represents scientific staff, according to a summary of his remarks obtained by The Post. In the summary, Clore is quoted as saying that the incident involving the Georgetown graduate student is 'something that [NIH leadership] needs to address right away. If this sort of thing gets out, nobody is going to want to come and work at NIH.'

An Apology, but No Clear Changes

A second Washington Post story, of course published late on a Friday, indicated that Dr Francis Collins, Director of the NIH, apologized for the treatment of the two Iranian born US legal residents:

In an email Friday to all NIH personnel, Collins said he is 'deeply troubled' that a Georgetown University graduate student was interrupted during a presentation that was part of an application for a postdoctoral fellowship and escorted from campus. He said he has 'extended a personal apology to this individual.'

'I also have learned of another non-U. S. citizen who had to miss the first day of a two-day meeting because of visitor clearance issues. I am also reaching out to that person to express regret,' Collins wrote.

In the email, Collins said the visitor clearance process 'was mishandled by security staff.'

Note that he did not acknowledge that the two scientists were legal US residents.

More importantly, Dr Collins did not personally acknowledge responsibility for his security staff's actions, indicate that he actually could control their actions, or promise any change in the policy.  At best, his email stated:

This policy has not been well communicated.

Further,

We are reviewing procedures associated with this policy to ensure that all our guests, no matter where they are from, are treated with utmost respect and consideration, and that NIH staff understand their responsiblities in ensuring the necessary requirements are met.

Again, he did not state that NIH security would stop asking visitors about their citizenship, or would not restrict access to non-secret activities or facilities according to peoples' place of birth.

So far, despite its implications, this case seems to be relatively anechoic.  The first WaPo article has appeared in other papers, and a summary of it appeared in The Scientist.  However, I have found nothing more so far other than the WaPo story of the "apology."

Discussion

Impeding collaborations at the NIH with scientists who come from particular disfavored countries obviously could impede the progress of biomedical and clinical science.

Note that the WaPo article suggested that citizenship questions are also being asked of patients entering the campus, raising the spectre of patients born in disfavored countries being denied care.  That could obviously harm their care.

Furthermore, active discrimination by a US government agency against scientists and patients according to their place of birth seems to deny their "equal protection under the law," as promised by the 14th amendment to the US Constitution.

Finally, a government institution involved in science and health care discriminating against people according to their ethnicity has a certain whiff of dictatorship and fascism. This whiff is accentuated under a regime that has a track record of singling out people by their ethnicity and/or religion.  As we noted here, its previously proposed bans of immigrants from certain countries has already impacted health care.  As Martin Neimoller famously wrote regarding the Nazi regime in Germany,

First they came for the socialists, and I did not speak out—because I was not a socialist.

Then they came for the trade unionists, and I did not speak out— because I was not a trade unionist.

Then they came for the Jews, and I did not speak out—because I was not a Jew.

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

 Visitors stand in front of the quotation from Martin Niemöller that is on display in the Permanent Exhibition of the United States Holocaust Memorial Museum. Niemöller was a Lutheran minister and early Nazi supporter who was later imprisoned for opposing Hitler's regime. - US Holocaust Memorial Museum

Who will speak for the Iranian born scientists kept out of the NIH?

It certainly make sense for the US to be on guard for industrial espionage.  But this goes way too far. 

Why Did the Head of the Center for Medicare and Medicaid Services Outsource Communications Functions to Private Public Relations Firms? - Ethical and Legal Questions

There is now never a dull moment at the Center for Medicare and Medicaid Services (CMS) an agency of the US Department of Health and Human Services (DHHS).  Its current director, Seema Verma, has developed a more efficient way to combine conflicts of interest with self-interest, bad management, and possibly worse.

Outsourcing CMS Communications to Private Public Relations Firms


In summary, Politico reported

The Trump appointee who oversees Medicare, Medicaid and Obamacare [Seema Verma] quietly directed millions of taxpayer dollars in contracts to Republican communications consultants during her tenure atop the agency — including hiring one well-connected GOP media adviser to bolster her public profile.

The communications subcontracts approved by Centers for Medicare and Medicaid Services Administrator Seema Verma — routed through a larger federal contract and described to POLITICO by three individuals with firsthand knowledge of the agreements — represent a sharp break from precedent at the agency. Those deals, managed by Verma’s deputies, came in some cases over the objections of CMS staffers, who raised concerns about her push to use federal funds on GOP consultants and to amplify coverage of Verma’s own work. CMS has its own large communications shop, including about two dozen people who handle the press.

The move to give large contracts to outside public relations (PR) firms seems unprecedented and seems unnecessary.  Per CNN

whether the issue was Medicare, Medicaid or Obamacare, prior heads of the agency were often quoted, profiled and in the news, so current officials said they’re puzzled why so much work is being outsourced.

'The head of Obamacare doesn't need outside consultants to get reporters to talk to her,' said one CMS official, who asked for anonymity. 'The job pitches itself.'

Ethical and Legal Issues

In addition, outsourcing communications to private PR firms raises multiple ethical, and possibly legal questions:

'Outsourcing communications work to private contractors puts the agency's ability to protect ‘potentially market-moving’ information from premature disclosure at considerable risk,' said Andy Schneider, a Medicaid expert who worked at CMS during the Obama administration and is now a researcher at Georgetown University.

Also,

But some career CMS staff have voiced their concerns to political appointees within the agency about routing taxpayer dollars to GOP consultants and helping a federal official like Verma improve her personal brand, said two individuals aware of those conversations. Oversight groups also have raised concerns, saying the behavior, as described to them by POLITICO, would appear to cross ethical lines.

'There are a host of ethical and contractual problems with appointees steering contracts to political allies and subcontractors, and possibly a violation of the ban on personal services contracts if the work is being performed at the direction of the appointee,' Scott Amey, general counsel of the Project on Government Oversight, told POLITICO. 'Contracts are supposed to be above reproach, with complete impartiality, and without preferential treatment, and the HHS Inspector General should review this [Porter Novelli] contract and the activities under it to ensure they are proper.'

The choice of PR firms led to the concerns about steering contracts to "political allies."

The subcontracts are part of a $2.25 million contract administered by Porter Novelli, an international public relations firm that performs a wide variety of government services. CMS’ new top communications official Tom Corry confirmed the arrangement. Two other individuals said CMS also spent at least $1 million on earlier contracts with GOP communications consultants.

One subcontract is with Pam Stevens, a longtime GOP media adviser who specializes in setting up profiles of Republican women. A second subcontract is with Marcus Barlow, whom Verma worked with in Indiana and considered hiring as a top communications official in 2017 before he was blocked by the White House.

And,

A third contract is with Nahigian Strategies, a firm run by a high-profile pair of brothers. Keith Nahigian consulted with several GOP presidential campaigns; Ken Nahigian briefly led President Donald Trump’s presidential transition team in 2017.

In other words, hiring contractors because of their political affiliations for the purposes of burnishing the image of particular government bureaucrats appears to be an abuse of power.


Also, Porter Novelli subcontracted with one Brett O'Donnell, who was involved in the following controversial episode which could be interpreted as a threat to the free press, which is protected by the Bill of Rights:

In a February 2018 incident, contractor Brett O'Donnell barred a Modern Healthcare reporter from a media call for refusing to alter a story that had rankled Verma. CMS officials walked back that threat within days and said a week later that Porter Novelli’s subcontract with O’Donnell, a longtime GOP consultant, would not be renewed. But CMS never provided any explanation of O’Donnell’s role or responsibilities. O’Donnell declined to comment for this article.

We wrote about his incident here. 

Given that federal officials like Verma swear

I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same;

for Ms Verma to have enabled the hiring of a contractor who tried to suppress press freedom could certainly be interpreted as mission-hostile management, or worse. 

Questions About Conflicts of Interest


Although not mentioned in the Politico article, the choice of Porter Novelli as the main contractor may raise concerns about conflicts of interest, it seems to me.


Porter Novelli is a huge public relations firm.  It has substantial business with the government.  However, it is also known for its "health and wellness" practice, per its profile in EverythingPR.  According to SourceWatch, its clients have included multinational pharmaceutical companies: Pfizer, Wyeth, and GlaxoSmithKline.  One of the practice's leaders once was Peter Pitts, who frequently spun stories to advance pharma interests, and who founded the Center for Medicine in the Public Interest (CMPI), which received considerable money from pharma and has often seemed to be an advocate for the industry.  Some examples of Pitts' work were discussed here, and his apologia for opioid manufacturers here.


Discussion

Perhaps there is more to come on this story.  Today, Politico reported that after the publicity of Ms Verma's contract with Porter Novelli et al, those contracts have been suspended. 

 Previously, US News & World Report noted that

House Energy and Commerce Chairman Frank Pallone on Friday called on an inspector general to investigate a report that a top health official appointed by President Donald Trump spent millions of taxpayer dollars on GOP communications consultants.

Also,

Pallone called the contracts a 'highly questionable use of taxpayer dollars' and wants investigators to determine how the contracts got approval and if there was any breach of regulations and ethical guidelines.'

'Given that this agency should be spending tax dollars to ensure Americans can access quality health care, it is particularly egregious that it is using millions to ensure its Administrator has access to outside public relations and image building services,' Pallone said in a statement.

'I intend to ask the HHS OIG [the U.S. Department of Health and Human Services Office of Inspector General] to immediately begin an investigation into how these contracts were approved, whether all regulations and ethical guidelines were followed, and why taxpayers are stuck paying for these unnecessary services. This is not the way to drain the swamp.'

In any case, the Trump administration continues to come up with new and innovative conflicts of interest affecting health care policy and regulation.  We have discussed the rotational velocity of the revolving door that has supplied health care industry stalwarts to become government health care policy-makers and regulators (most recent example is here, and most recent example involving CMS is here).   Now a top DHHS official has decided to commission and big PR firm well known for its pharmaceutical industry clients to promote her attempts to bolster "her tenure running Medicare and Medicaid ... marked by attacks on both programs and their beneficiaries," per a commentary in the National Memo.

This is not the first time we have discussed Ms Verma's conflicts of interest.  Here we noted how she advised the Indiana, Kentucky, and at least seven other states' Medicaid programs while working for Hewlett-Packard, a contractor for those programs.  (Note that Hewlett-Packard was also a big Porter Novelli client, per SourceWatch.)  But she continues to expand her reputation for mingling government functions and commercial interests.

Ms Verma also apparently has used outsourcing to add a propaganda element to government communications (Recall that public relations was just the term Bernays picked because he thought sounded better than "propaganda.")  Furthermore, that propaganda seemed meant not to improve the health of the public, but to enhance Ms Verma's personal image. That seemed to be an abuse of power, in my humble opinion.

Moreover, there was at least one incident in which the propaganda function may have turned into a threat against press freedom (the O'Donnell incident above), and hence was certainly an example of mission-hostile management, and could easily also be viewed as an abuse of power.

We have long written about conflicts of interest, but until 2016, our cases were mostly conflicted academics, health care professionals, or leaders of private health organizations, e.g., hospitals, academic organizations, pharmaceutical companies etc.  Now the most striking cases are coming from the Trump regime.

We have long written about self-interested and mission hostile management, but again, until 2016, our cases were mostly about leaders of private health organizations.  Now the most striking cases are coming from the Trump regime.

How can be talk about true health care reform without talking about true reform of our current government?