Thursday, July 02, 2020

Parlous Times—so Why Is My Dander Down?

Yes, these are parlous times, my friends, with all sorts of threat levels bouncing up and down and up again to all sorts of new heights. I've personally felt almost paralytic, in this present "Dander" series, about repeating the latest outrages from Trump-land and Corona-land.  (Lather. Rinse. Repeat.) What is there new to say? The outrages are all there, still, but with a single, over-arching theme.

To quote the great philosopher, Frankie Valli, "It's a sign!!!" The sign: a new system of governance run by a cabal of family and cronies, no inspectors-general in sight, and a whole lot of unconfirmed "acting" secretaries, under-secretaries, under-under-secretaries and under-under-under secretaries.

I've written about this syndrome in HCRenewal before, in connection with the Veterans Administration. Look it up right here in HCRenewal (e.g., here). It's a systemic neurological disorder we could call MS: Mar-a-Lago Syndrome. In this disorder the federal government is paralyzed not by the Deep State, but a pernicious Deep Nonstate of golf buddies, far-right pundits and other self-dealing defilers of democracy.

Oh, where are the mere managerialists we used to go after in HCRenewal? We do miss them so! Lather. Rinse. Repeat.

Anyway, we're in the summer of 2020 and lives have been lost. The system stays awash in waste and cronyism. I just couldn't muster writing more about it: after all what was new? It's all MS and the thousand flushes of oppositional, know-nothing populist careerism that go along with it. All courtesy of a motley crew of hackers, sadly gullible flat-earthers by the barrelful, and one particular political party busy pushing itself and the rest of us off the deep end. All exploiting the hell out of each other. Only one, the US Senate's leadership, has an internally-valid long-term goal—the judiciary—that purports to make the exercise worthwhile. Everybody else can just bump along in their miserable gerrymandered "corporations are people" lives, liking it or lumping it.

And yet: along the way, something strange seems to be happening. It's true that, yoked together and spurring on their steeds, our four horsemen of the apocalypse—America's flawed democracy, its corrupt GOP, the pandemic and its exposed systemic racism—continue to rampage. But look underneath all this, in health care and just maybe in the larger society, there are young hopeful shoots, sprouting somehow in the mud below. And that is something new and worth writing about.

So just now, oddly enough the dander's down. (Provisionally. Check in again in, oh, four to five months.)

Some years ago Dr. Poses, this blog's venerable editor, already pointed out how HCRenewal's message has begun to "go mainstream." Now and again, he points out further new examples.

Maybe this mainstreaming of the message—health care independence and integrity—somehow relates to a couple of major shifts in the medium, or mediums, that carry the message. The first, social networks, have worked in part to the detriment of good government. But they also enable ground-up protest in a new communications ecosystem.

Another part of this ecosystem, less evident to lay people and leaders but potentially a potent force, is the advent of a new and more independent-minded generation of science and medicine journal editors, with their accompanying editorial boards. Here we find some more of the tender young shoots, exemplifying the change that genuinely seems afoot. Let me cite three recent examples.

  • The Annals of Internal Medicine has gone from strength to strength in recent years. Under its current editor, Christine Laine, the first woman to hold that post, Annals now boasts its highest-ever impact factor [C. Laine MD, personal communication]. That's an impact in general medicine, the nation's largest specialty, boasting over a million page views per month.

    The current number of Annals, for mid-June 2020, offers an article entitled "a cautionary tale," describing last year's "orphaning" of the entire house staff of Hahnemann University Hospital. Both the content and the very fact of the publication of this article are noteworthy. The article that follows, in its title, asks "is it time to more fully address teaching religion and spirituality in medicine?" (answer: "truly caring").



    But stick for the moment with the Hahnemann debacle. The article, written by three former Drexel University College of Medicine (DUCOM) faculty members who're now spread to the four winds, probes the "diametrically opposed goals of hospital owners and educational leaders" that led to an enormously disruptive hospital closure on the verge of a pandemic, a tsunami that orphaned nearly 600 trainees and that faculty quite simply "found hard to believe."

    Those of who were around in the 1990s didn't find it so hard to believe. The authors allude to the prehistory of the Hahnemann bankruptcy in the earlier one endured by Allegheny, or "AHERF" in the late 1990s. They don't insist on the earlier one prefiguring the later one, "the largest orphaning event" in medical history, in any causal or direct fashion. But I'd argue precisely that: at the least, it made it much, more likely.

    The reason, simply, a circumstance to which to their credit the authors point, was the original sin of the deal that bailed out a medical school (pre-bankruptcy MCP-Hahnemann, post-bankruptcy Drexel) and a group of hospitals (originally Tenet Healthcare). The original sin is embodied in their noting that at the critical moment, "Drexel and Hahnemann released separate talking points for P[rogram] D[irector]s, but these documents contained discordant information." The American system of GME, like the US Constitution, contains any number of these poison pills wherein only norms serve as guardrails against disaster: in this case, the manner in which hospitals—recall that Tenet was a for profit system, and one for which both education and research are distinctively secondary—control the medical education dollars coming to them from Medicare reimbursements. "Discordant information": how can you lose?

    The departure of hundreds of residents, with all its displacement of both faculty and trainees, and with all its emotional turmoil, hardly seems like something that would cheer one up. And on its face, it's not. One can hardly overestimate the pain these authors and their colleagues went through. But what strikes me is the fact that this whole crummy system is no longer anechoic: that those within it are out there on the hustings, stating the lessons learned, trying to create the antibodies that might protect against future such occurrences. And Annals gladly published this excellent exposition-cum-cautionary tale.
  • In the same week that I received this number of Annals, I received the 25 June 2020 number of The New England Journal of Medicine. NEJM, also a super-high-impact journal, changed editorship—just a few months before the onset of the pandemic— much more recently than Annals. One waited to see whether it, too would be, shall we say, feminized. (Be clear: in this case "feminization" is for me an uncomfortable shorthand for what I dearly hope my commentators below will suggest a better word, and more or less an unmitigated good.)

    I grew up in a tradition of ritualistic CPCs—clinicopathologic conferences—in my own medical school and in key journals such as NEJM. A case would be presented of a patient who had to die. They had to die because the autopsy findings would be tortuously predicted by the academic physician as the solution to a diagnostic dilemma. This would be followed by a learned exposition of the histology and gross pathology of the disease that furnished the answer to the puzzle. Sometimes the clinician even got it wrong. The pathologist of course was always right, He—it was virtually always a he—always got the last word.

    But what the CPC model did was to reify the classic post-Laennec medical model of equating medical decision making to its laboratory-based problem-solving narrative. This began to change a bit beginning in the Journal's post-Ingelfinger and post-Relman eras, where editors began to stress correlations of clinical findings with those of the new molecular biology and immunochemistry. Now the patient didn't even have to always die! But the classic medical model, even then, was preserved. Riddle me a riddle: bench science, properly coupled with bedside wisdom, will provide the answer.

    Imagine my surprise then to find the CPC of a few weeks ago, entitled "a girl with severe psychological distress after family separation," focused on "trauma-informed care" in which the clinical outcome was not "a post-mortem examination was performed" or "a diagnostic procedure and laboratory study were performed." Here "a diagnosis and management decisions were made" and both clinical and patholgocial diagnoses were "post-traumatic stress disorder."

    The graphic is that of a cartoon pediatrician with an immigrant child, blowing bubbles together.

    Make no mistake: this is both a scientific and literary breakthrough, and a political statement. It is enormously heartening to view such a sea change in one of our most august journals. It tell us that a new, younger leadership in academic medicine is stepping up to address the socioeconomic problems that are now—far more than whether or not SARS-CoV-2 does or does not interact with ACE inhibitor agents—threatening health care in the more dire existential fashion.

    Can we extrapolate from these straws-in-the-wind? Is medicine becoming less anechoic and able to counter the threats against it? I know of no other recent precedent, but there's one from classical antiquity: the very bedrock of our medicine today, the Hippocratic tradition. In his magisterial 1995 work Hippocrates in an Age of Pagans and Christians, Owsei Temkin of Johns Hopkins showed how the classical traditions of independent medicine were able to persevere even in a later era in which they were threatened by religious authority. It was a close call then and it's a close call now: viz., the decision by a mere five to four, just a few days ago, preserving the physician's right without hindrance to provide services to a pregnant woman.

    Sometimes it comes down to one vote. And, granted, it ain't over until it's over: in November, voters in the United States will, in momentous fashion, decide the future direction not just of their own people but of the healthcare they're going to get going forward.
  • What's going on here? In truly extraordinary circumstances, leaders in medicine seem to be not abandoning the scientific model, but expanding it to incorporate insights and perspectives drawn from ethics and the social sciences, including economics. (The Allegheny-Hahnemann case is a classic example of business-economics-gone-wrong through failures of basic socioeconomic analysis.) Even in the non-clinical literature, if you take even a cursory look, you can find these tender young sprouts of freedom.

    The journal Cell, in a number published last month, began with an editorial entitled "Science has a racism problem," stating that "We are the editors of a science journal, committed to publishing and disseminating exciting work across the biological sciences. We are 13 scientists. Not one of us is Black." But what followed was even more astounding. Amidst articles discussing matters such as how "Epitope pools detect CD4+ and CD8+ T cells," in the very next number of the journal, Duke neuroscientist and MD-PhD Kafui Dzirasa provides his account of how "[f]or Black scientists, the sorrow Is also personal." This article has been widely reprinted and sent out to many thousands of physicians who practice in domains as far away from cell biology as orthopedics. It is worth quoting in extenso, and speaks for itself.

I am a medical doctor and a scientist; the first African American awarded a PhD in neuroscience at Duke University. I have led a National Institutes of Health-funded research lab for almost a decade, and I was awarded the Society for Neuroscience Young Investigator Prize in 2019. I am an American Association for the Advancement of Science Alan I. Leshner Public Engagement Fellow, and I have hosted TEDMED three times. I am a scholar, teacher, mentor, speaker, and mental health advocate. I have served on national commissions, I have advanced federal policy, and I have even held court with a president of the United States. I have published in Cell scientific journals, and as a peer reviewer, I have worked to advance the scientific rigor of my colleagues. Yet, most days, I am unseen and unknown. As I watched a knee slowly, mercilessly, and inhumanly extinguish yet another black life, I was overwhelmed by anger and sorrow, and at this very moment, I am terrified to run on the trail near my home. I am a black academic in America.

That these three examples of medical communication all point to inherent problems in American medicine, no doubt in world medicine as well, is daunting in one sense. But in another it is undaunting. It shows us how far we have left to go. By looking in the mirror and recognizing that they share the challenges of the larger society, medicine and science have at least a fighting chance of transcending them—and in doing so, regain their independence. The manner in which these authors have taken the knee, and in doing so stood very, very tall, shows us a path of speaking truth to power. In doing so, and in our anticipation of their being heard, they give us hope.

Sunday, June 28, 2020

Do Cry for Those in Arizona: What Happens When Politicians Disregard Health Care and Public Health Professionals During a Pandemic

Introduction: Health Care Professionals Vilified After They Caution Against Premature Reopening During the Pandemic

As we discussed in April, 2020, after the curve of the coronavirus pandemic began to flatten in the first heavily affected areas in the northeast US, supposedly popular protests, broke out calling for the end of onerous social distancing measures, ostensibly to let the economy recover.  President Trump then jumped in, calling for the "liberation" of multiple states from these  measures.

Trump wrote: 'LIBERATE MINNESOTA' and then, 'LIBERATE MICHIGAN' and then, 'LIBERATE VIRGINIA, and save your great 2nd Amendment. It is under siege!'

As these protests multiplied, health care professionals responded by staging counter-protests to warn people about the danger of premature "reopening."  For their pains, they were often vilified.  In particular, we noted that one brave ICU nurse silently stood at the capitol of Arizona.

'She would spend the next few hours standing silent, her facial expressions partly hidden behind her medical mask. Her body standing rigid in surgical scrubs.'

For that, she was insulted, scorned and generally screamed at by flag-waving protesters, some of whom carried signs about an overblown crisis and a 'pretend-demic'.

The state Republican chairwoman even accused her of one of the "actors playing parts."

In that and a later post we noted how these "reopening" protests were egged on by right-wing politicians, including President Trump himself; infiltrated by extreme right-wing groups, including armed militias; accompanied by threats of death and violence to counter-protesters and anyone preaching restraint; and organized and funded by right-wing political organizations, often allied with Trump, and often funded by plutocrats.  It was unclear whether more than a small minority of the protesters were truly concerned about the economic costs of delaying reopening.  Rather, they seemed mainly about pushing a political agenda which had little to do with public health or health care.

Was this any way to make health care and public health policy?  Nonetheless, these protests, which were orders of magnitude smaller than those which later broke out after the death of George Floyd, and pressure from Trump et al seemed to induce Republican state leaders to reopen early and quickly.

Now the health care professionals' warning are shown to be valid.  Consider the case of Arizona.

Health Care Professionals Inundated as Coronavirus Surges

As documented by the Washington Post on June 25, 2020:

Arizona has emerged as an epicenter of the early summer coronavirus crisis as the outbreak has expanded, flaring across new parts of the country and, notably, infecting more young people.

Maricopa County, which includes Phoenix, is recording as many as 2,000 cases a day, 'eclipsing the New York City boroughs even on their worst days,' warned a Wednesday brief by disease trackers at Children’s Hospital of Philadelphia, which observed, 'Arizona has lost control of the epidemic.'

This came after Arizona became the poster child for early and quick reopening. "The state’s cases began rising dramatically about May 25, 10 days after Ducey allowed the state’s stay-at-home order to expire...." said a local public health expert.

The Republican Governor seemed to be reacting directly to Trump's push to "liberate" states:

Trump, who was urging governors to jump-start their economies, was coming to Arizona to tour a Honeywell plant and to convene a discussion about issues facing Native Americans.

The day before the president’s visit, Ducey announced plans to accelerate the reopening of his state’s economy, lifting restrictions on salons and barbershops and allowing restaurants to resume dine-in service. A chart displaying the number of new cases, which did not show the 14-day decline recommended by White House guidelines, 'really doesn’t tell you much,' Ducey said at his May 4 news conference.

In the Washington Post's summary:

At critical junctures, blunders by top officials undermined faith in the data purportedly driving decision-making, according to experts monitoring Arizona’s response. And when forbearance was most required, as the state began to reopen despite continued community transmission, an abrupt and uniform approach — without transparent benchmarks or latitude for stricken areas to hold back — led large parts of the public to believe the pandemic was over.

Stories coming out of Arizona are starting to resemble those that came out of New York at its peak of pandemic induced misery.  On June 24, 2020, the Arizona Republic published a vivid anecdote of yet another person who scoffed at the virus, and then became ill.

Jimmy Flores, 30, met up with his close friends at the bars in Scottsdale on a Saturday night in June.

'This bar was super packed. I was kind of concerned because I was like, man, everyone's tight, they have limited cups. Some people were sharing drinks, it was weird,' said Flores, who also shared drinks with his friends at a bar in north Scottsdale that night.

He ended up hospitalized for over a week. He "was discharged home Monday, but breathing is still a challenge and he is taking multiple medications."  He started posting about his case on Facebook, but his friends thought he was being "political."  Now he says, "I really care about people not going through this and that they have to take this seriously because it really hurts."



[Old Town, Scottsdale in happier times]


And the New York Times published an op-ed on June 26, 2020 from an emergency department physician sadly mirroring the tales of despair coming out of New York only a few months ago. 

Patients are evaluated, stabilized and admitted to an inpatient medical team. But many admitted patients remain in the emergency department, 'boarding' while awaiting transfer to the hospital wards because there are no more intensive-care beds available in the hospital or there is insufficient staff to care for them in the beds that are available.

Because of that, far fewer emergency department beds are available for people with non-Covid-19 health conditions and medical emergencies. So sick people wait for an emergency department bed to become available. The surge in cases night after night shows no sign of slowing and it is terrifying.

The media has reported how few hospital beds are available in the state. But even if we had enough beds, it wouldn’t matter if our staff wasn’t physically and emotionally well enough to attend to the people occupying those beds. Many hospital systems have chosen to furlough staff and tighten belts even as health care teams were beginning to feel the psychological strain of the pandemic. Physicians are a small part of our clinical care teams. We are profoundly limited in what we can do without the support of nurses, paramedics, emergency and intensive-care technicians, respiratory therapists, radiology technicians, environmental services workers, social workers, case managers, unit coordinators, clinical pharmacists and others.

Health care workers are exhausted. Staffing shortages and increasing fatigue are the new normal for emergency departments, intensive-care units and Covid-19 units, and across hospital wards. Staffing levels are being set with an emphasis on 'productivity' as determined by financial calculations rather than clinical severity or the complex needs of our patients and the community we serve.

Finally,

Emergency medical and critical-care team members are canaries in the coal mine. When we are understaffed and overworked, when there is no staff to triage patients, when more and more patients are piling up at the emergency department door, the system breaks down, then people break down. You can borrow ventilators (until you can’t) and make more personal protective equipment (we hope). You cannot magically produce more nurses, respiratory therapists, physicians or other professionals.

And things are getting worse every single day.  The Arizona Republic reported June 28, 2020:

Arizona cases of COVID-19, the disease caused by the new coronavirus, increased by more than 3,850 cases on Sunday — the highest number of cases in a single day, according to data released by the Arizona Department of Health Services.

Arizona's total identified cases rose to 73,908 on Sunday with 1,588 known deaths, according to the most recent state figures. That's an increase of 3,857 confirmed cases, or 5.5%, since Saturday.

Inpatients with suspected or confirmed COVID-19 and ventilator and ICU bed use again hit record highs Saturday, while emergency department visits dropped from Thursday's record of 1,249, according to the daily report from the Arizona Department of Health Services.

As of Saturday, 85% of current inpatient beds and 87% of ICU beds were in use for COVID-19 and other patients.

But it did not have to happen.  Had Arizona's political leadership paid attention to the message of one brave ICU nurse back in April, or numerous messages from other health care and public health professionals, had they resisted President Trump's constant exhortations that the economy comes first, and that coronavirus is not a big problem, the pandemic would likely have been better controlled in Arizona, and elsewhere, than is actually the case.

 So do cry for those in Arizona.

Summary


Traditionally, political leaders have trusted health policy experts, and health care and public health professionals to help them make health policy.  In the past, political leaders listened to such experts and professionals when planning for epidemics and pandemics, and addressing new health and public health emergencies.

However, in our new (ab)normal, many political leaders follow the lead of the current president, Donald Trump, and his party.  They seem unworried that the president has a record of peddling lies and disinformation (look here), and has a record of conflicts of interest and corruption goes far beyond any conceivable precedent (look here). They accept Trump's multiple assurances that the coronavirus pandemic is either a hoax, or "fake news," or inconsequential, or fading away (look here).  They shrug when Trump scoffs at public health measures meant to slow viral spread, such as face masks (look here).  They put extreme politics, ideology, and sectarianism (look here) ahead of science, logic, and the warnings of experts.

So, health care professionals trying to uphold their mission to put patients' and the public's health first have stumbled into a political conflict far beyond anything we have seen in our lifetimes.  Upholding the mission is proving to be difficult, unpleasant, and now dangerous.  The danger is not just from the virus, but from our fellow humans putting their politics and ideology ahead of all else.  That does not make the mission any less important.  Innocent lives are still hanging in the balance.

We could retreat in fear from the powerful opposition we have stirred up.  That would allow complete politicization of the management of the coronavirus pandemic, doubtless leading to even more disease and death (and ironically, even worse economic disruption).  Retreating would betray our patients and make a mockery of our mission.  Or we could persist.  What will it be?

"And if not now, when?"

ADDENDUM (30 June, 2020) - This was re-posted by the Naked Capitalism blog here.



Thursday, June 11, 2020

Health Care Corporate Leaders Have Pledged Their Support for Racial Justice and Harmony: Will They Renounce Their Previous Support of a Very Racially Divisive Politician?

Leaders of big health care organizations frequently profess their social responsibility, and traditionally have avoided political partisanship.  However, their actions have not always been consistent with these sentiments.

Now, in response to the police killing of George Floyd and subsequent protests, many health care leaders pledged their support for racial peace and justice.  However, some of these leaders have previously supported  political leaders whose actions may have contributed to the current crisis.

Recently there were two cases showing vivid contrasts between health care leaders' pronouncements and their and their organizations' recent actions.

CEOs Condemn Racism

CVS CEO Larry Merlo

Early out of the gate was Larry Merlo, CEO of CVS, who released a statement to his employees on June 1, 2020:

The turmoil we are witnessing grows out of a long and deep history in our country, and as a nation we must focus on the injustices and discrimination that continue to divide us. I remain hopeful that we can find a way to move forward in unity to solve the nation’s most pressing issues.

In our workforce and in our communities, CVS Health’s commitment to inclusion and belonging is unwavering. It is critical to those we serve and grounded in our company values. We are a diverse community here at CVS Health – all 300,000 of us – and that diversity is one of our key strengths. It shows up in how we care for one another – walking in each other’s shoes, joining forces for the greater good and respecting one another no matter what our race or ethnicity. We will continue to uphold the commitment of mutual respect in everything we do. Discrimination and intolerance have no place in our business and will not be permitted in any form.


Johnson and Johnson CEO Alex Gorsky

On June 3, 2020, CNBC reported:

Johnson and Johnson CEO Alex Gorsky said Wednesday that white men need to 'do more listening' in the wake of George Floyd’s death at the hands of Minneapolis police.

'I realize that can be difficult,' Gorsky said during an interview with CNBC’s 'Squawk Box.' 'I think there’s no way you can just move through a checklist without I think demonstrating empathy and an understanding of some of the deep-seated nature and experiences the [black] community has had and is currently experiencing.'

Gorsky announced Tuesday that J&J is committing $10 million over the next three years 'to fighting racism and injustice in America' as people across the United States and other parts of the world protest against police killings of blacks.

'As the CEO of the world’s largest health-care company, I must state unequivocally that racism in any form is unacceptable, and that black lives matter,' he said in a LinkedIn post. 'And as a white man, I also need to acknowledge the limits of my own life experience and listen to those who have faced systemic injustice since the day they were born.'


CEOs' Friendliness with and Support for President Donald Trump


President Trump's recent actions have fanned the flames of racial discord. Here are just a few examples of news about what is still an evolving story: He called for a tough, militarized response to peaceful protests after the killing of George Floyd.  He tweeted "when the looting starts, the shooting starts," and  called protesters "thugs" (see Washington Post, May 29, 2020.)  He told governors to "dominate" the streets (see Washington Post, June 1, 2020.)  His Attorney General arranged the clearance of peaceful protesters out of Lafayette Square near the White House using teargas and flash bang grenades so Trump could have a photo opportunity at a nearby church (see New York Times, June 3, 2020.)  He pushed to call out 10,000 active duty US troops to quell a protest in Washington DC that was largely peaceful (see Reuters, June 7, 2020).

That seems like the opposite of "focusing on injustice and discrimination," or "fighting racism."  However, in contrast with their current proclamations about racial harmony and inclusion, and against racism, these two CEOs have shown their friendliness to and support for President Donald Trump.


CVS CEO Larry Merlo



Merlo's stance on racial inclusivity and harmony, and against racism does not seem to fit with the CVS track record of quietly supporting a dark money non-profit organization whose main mission seemed to be providing political support for Trump, and was once led by people with very different views on race, as we posted in 2018.

CVS was revealed to have been contributing to a "dark money" organization called America First Policies (AFP), ostensibly a "social welfare" charity, but actually an organization devoted to promoting the Trump agenda.  While CVS said its support for AFP was related to the organization's tax reform agenda, it also promoted various policies that seemed to contradict the CVS ethics and social responsibility policies.  In addition, the relationship between CVS and AFP only came to light after some AFP leaders were found to have made racist and pro-Nazi proclamations.  When the unsavory nature of the AFP leaders' utterances came to light, a CVS spokesperson announced the company would sever ties with AFP.  However, to my knowledge, CVS never clearly explained why it was giving money to the group in the first place, and how doing so was consistent with its stated policies and goals.

CVS past support for an organization led by professed racists seems inconsistent with Mr Merlo's recent commitment to inclusion and belonging.  One wonders if he will renounce his company's previous actions.

In 2018, we also noted that CVS was making substantial contributions to the US Chamber of Commerce, which despite its bland name, some asserted had become a major source of "dark money" support for politically right-wing and pro-Trump causes.  In 2019, we noted that CEO Merlo, like many of his fellow health care corporate CEOs at the time, had become very partisan in his personal political giving.  All the money he gave around the time of the 2018 election to organizations identified with either major political party went to the Republican party.



Now that he has proclaimed his anti-racist credentials, one wonders if Mr Merlo will renounce his previous direct and indirect support of Mr Trump and his associates?

Johnson and Johnson CEO Alex Gorsky

Again, Johnson and Johnson CEO Gorsky's stance on racial inclusivity and harmony, and against racism does not seem to fit well with the company's and Gorsky's track record of coziness with Trump.

In 2017, after a rally by white nationalists in Charlotte, Virginia lead to conflicts between them and counter-protesters. Many of the latter were injured, and one was killed, Trump initially refused to take any stand against the rally, and suggested that both sides were equally responsible.  After that, some corporate leaders broke with Trump, but  at first not Gorsky.  As the outrage about Charlottesville grew, Gorsky dropped his membership in Trump's Manufacturing Council, but one year later, but then returned to Trump's in-group, as reported by CNBC:

The manufacturing council was also disbanded in August of 2017, following a wave of public resignations from its CEO members in the wake of Charlottesville.

One of these came from Alex Gorsky, who leads Johnson and Johnson. Gorsky called Trump’s response to the rally 'unacceptable,' and said in a statement that it 'has changed our decision to participate in the White House Manufacturing Advisory Council.' Nonetheless, Gorsky is on the guest list Tuesday for dinner at [Trump's] Bedminster [golf club]. A spokesman for the company did not respond to a request for comment.

In February, 2020, Vanity Fair reported that the meeting that included Trump and Gorsky at Bedminster resulted in some very suspicious activity.  Trump seemed to assume the role of salesman for a drug Johnson and Johnson just put on the market:

On March 5 [2018], Trump signed a little-noticed order to create “a national roadmap to empower 'veterans and end suicide.' That was the same day, it turned out, that the Food and Drug Administration approved the sale of Spravato, an antidepression drug manufactured by Janssen Pharmaceuticals, a J and J subsidiary.

Then,

Trump continued to be a booster of Spravato, which analysts have estimated could earn some $600 million for J and J by 2022. At a June 12 White House meeting convened to discuss the opioid crisis in America, Trump urged Robert Wilkie, who replaced Shulkin as the secretary of veterans affairs, to essentially back the truck up for Spravato at the V.A. because, Trump said, it would result in an “incredible” drop in suicide among veterans. He even offered to negotiate the price of the drug with J&J. 'I think they’ll be very generous with you,' Trump told Wilkie. 'And if you like, I’ll help you to negotiate.'

The next year,

But Trump, being Trump, was not done trumpeting the drug. In August 2019, at an AMVETS conference in Louisville, Kentucky, he repeated his view that Spravato was 'incredible' and said he’d ordered the Department of Veterans Affairs to 'get as much of it as you can from Johnson and Johnson.'

The Trump promotion of the Johnson and Johnson drug is now under investigation. 'the House Committee on Veterans’ Affairs has demanded documents and information from the V.A.

Finally, the Vanity Fair included a reminder that Trump has not only been cozy with Gorsky, but a member of the family that founded Johnson and Johnson who also may be one of the company's bigger investors:

Trump’s ambassador to the U.K., Woody Johnson, is the great-grandson of one of the founders of J and J and, reportedly, continues to own more than 1.5 million shares in the company, worth around $217 million. His net worth is said to be around $4 billion. He donated $1 million to Trump’s inaugural committee.

So it appeared that the CEO of Johnson and Johnson, and a big shareholder in the company who is descended from its founder went out of their way to cozy up to Trump, who appears to have reciprocated by doing some marketing for its drug, and possibly improperly using his executive powers to increase its use.


Furthermore, in 2018 we noted that Johnson and Johnson, like CVS, was making substantial contributions to the US Chamber of Commerce, which despite its bland name, some asserted had become a major source of "dark money" support for politically right-wing and pro-Trump causes.


Now that Gorsky is so devoted to "fighting racism and injustice," given all that Trump has done to fan the flames of racial conflict after the death of George Floyd, one wonders if Gorsky will denounce his previous coziness with Trump?


Discussion

After the killing of George Floyd, the CEOs of two large health care corporations publicly espoused  racial harmony and inclusion and condemned racism.  Both these CEOs had become very friendly with President Trump, and appeared very comfortable with his policies, despite the history of non-partisanship among leadership of the health care field.

Trump, however has sought to amplify racial conflict since protests began in response to the death of Mr Floyd.  Will these CEOs now renounce their previous coziness with and support of President Trump? 

There are bigger questions. Will there now be more attention to how health care corporations have preached social responsibility, and lately racial harmony while they were quietly pushing their own agendas, which often undermined these worthy goals?  Will health care organizations disclose their ties to political leaders, including contributions to "dark money" groups? Will there be new calls for accountability for those who lead the most powerful organizations in health care?  Will there be investigations into this or other forms of regulatory capture? Will there be penalties for resulting conflicts of interest?  Or will the leaders once again manage to make even discussions of their failings taboo?    


 

Tuesday, May 26, 2020

More Attempts to Intimidate Health Care Professionals Who Try to Educate About Coronavirus

Introduction

Physicians and other health care professionals are sworn to put patients' interests ahead of all else, and to uphold the integrity of education and science in health care.  This may put them in the uncomfortable position of speaking up when doing so offends vested interests.  Whistle-blowing is never easy for health care professionals.  Those who do so have been ostracized, lost jobs or been subject to lawsuits. 

So we were not surprised when cases appeared of health care professionals who spoke out about unsafe hospital practices during the coronavirus pandemic. Hospital management were not pleased at being made to look bad, so the whistle-blowers were warned, threatened, and sometimes fired.  We had seen a precursor case in which hospital professionals got in similar kinds of trouble for blowing the whistle on unsafe practices in caring for Ebola virus patients in 2014 (look here).

During the coronavirus pandemic, health care professionals have tried to educate patients and the public about the effects of the disease, and what it takes to mitigate a pandemic in the absence of effective prevention or treatment approaches.  That may have not seemed like whistle-blowing.  What powerful people could such education possibly offend?  Yet many of the professionals who did so have found themselves more directly threatened then were the whistle-blowers who protested actions by health care organizations in an earlier era.

We have previously discussed one set of illustrative examples. Health care professionals who sought to educate demonstrators who advocated quickly "reopening" the economy about the perils of doing so were subject to screams, insults, and charges they were "crisis actors" (look here).  Journalists discovered that the "reopening" protests attracted political extremists, and were funded  and organized by opaque right-wing groups, President Trump's supporters, and shady plutocrats. The protests seemed not to be about the economic damage pandemic mitigation measures had done to workers and small businesses.  It seemed that in our new political reality, powerful political interests are vested in pushing a rapid reopening not only in their economic self-interest, but in the interests of politicians who wanted to make the economy appear to thrive, no matter what the human cost. 

Continuing efforts by health care professionals to educate patients and the public about coronavirus have thus made them into targets of powerful political interests.

Trump Stirs Up His Supporters Against Health Care Professionals Who Might Question His Word


President Trump himself has berated qualified health care professionals who tried to speak the truth, even in the mildest terms, about the coronavirus pandemic.  We previously discussed his charges  that those who complained about lack of personal protective equipment (PPE) were only motivated by a desire for personal fame (look here).

On May 6, CNBC reported a newer example:

A nurse found out Wednesday what happens when you contradict President Donald Trump on how well coronavirus response efforts are going while standing near him in the Oval Office.

Trump clapped back at that nurse, Sophia Thomas, who said that access to sufficient supplies of personal protective equipment 'has been sporadic.' Her comments came during a National Nurses Day event at the White House meant to honor those first responders.

Trump upon hearing a less-than-glowing description of the front lines, quickly shot back, 'Sporadic for you, but not sporadic for a lot of other people.'

Note that Ms Thomas speaks from some authority.  She is President of the American Association of Nurse Practitioners.  As such, she seemingly tried to defuse the conflict, but Trump would have none of that:

After Trump’s testy response, Thomas said, 'Oh, no, I agree Mr. President.'

But Trump continued, folding his arms, 'Because I’ve heard the opposite.'

'I’ve heard that they are loaded up with gowns now.'

'And initially we had nothing, we had empty cupboards, we had empty shelves, we had nothing, because it wasn’t put there by the last administration,' he said, referring to former President Barack Obama.

Trump then noted that he had traveled to a Honeywell factory in Phoenix a day earlier, to tour a production line that is making 'millions of masks a month.'

'We have other factories being built now for masks, and for the most part I mean, that was fine,' Trump said, referring to the nurse.

'But I’ve heard that we have tremendous supply to almost all places,' he said.

'Tremendous supply.'

Never mind that the Trump administration has been in power for over three years, and thus had plenty of time to remedy any shortages that may have been left by the previous administration.  Never mind that Ms Thomas' view was supported by

a report by the inspector general for the federal Health and Human Services Department found that hundred of U.S. hospitals were experiencing serious shortages of PPE as well as equipment including thermometers and diagnostic testing kits.

Of course, Trump would have none of the IG's report either, either:

Trump, who disputed the report’s findings, last week moved to replace that inspector general, Christi Grimm.

It was in Trump's political interests to make it appear that his administration had made short work of the coronavirus pandemic.  Beyond that, his message seemed to be that the word of Trump overrides evidence and logic.  Like the Ingsoc movement in Orwell's 1984, he claims the power of making "2+2=5"  

Online Attacks On Health Care Professionals Who Tried to Educate about COVID-19

So it also should not be surprising that health care professionals who sought to educate the public and patients, online or in-person about coronavirus were subject to ad hominem invective, but also attacks on their facts and logic.    

On April 28, 2020, Buzzfeed News reported on what happens when health care professionals spoke  out online about coronavirus disinformation:

Eric Sartori arrived home on April 19 after working in the COVID-19 unit of a community hospital in Arizona. After reading social media posts claiming the virus was a hoax, the intensive care nurse opened Facebook and vented.

'While we're busy working to save people's lives we're also growing really concerned about the conspiracy theory BS that's seeming to become a bigger problem than #covid19,' he wrote.


What happened next?

Sartori’s Facebook post was shared more than 22,000 times. He’s received support from the post, but it has also attracted conspiracy theorists. 'I've had people asking me if I'm paid by Bill Gates. They think I'm a crisis actor. It shows me how easily people can be manipulated.'

Furthermore, he got this response from one man:

'He just kept pushing and pushing, and he was saying horrible things. He called me a faggot. He said I should die. A whole bunch of horrible, nasty things,' Sartori said. 'And then I found out that he actually works in health care. He works for some organizations that deliver things to my hospital.'

Then there was the case of the nurse who

blocked family members and friends on social media after they began spreading claims about the virus not being real and calling for stay-at-home orders to end. 'I have hidden so many people that my Facebook feed is essentially just ads at this point,' she said.

People who used to come to Swiers for health advice now view her work with suspicion.

On May 6, NBC reported the case of Dr Hadi Halazun,

At the end of another long shift treating coronavirus patients, Dr. Hadi Halazun opened his Facebook page to find a man insisting to him that 'no one's dying' and that the coronavirus is 'fake news' drummed up by the news media.

Hadi tried to engage and explain his firsthand experience with the virus. In reply, another user insinuated that he wasn't a real doctor, saying pictures from his profile showing him at concerts and music festivals proved it.

'I told them: 'I am a real doctor. There are 200 people in my hospital's ICU,' said Halazun, a cardiologist in New York. 'And they said, 'Give me your credentials.' I engaged with them, and they kicked me off their wall.'

Also,

'These anti-vaccination people were telling me I'm a sheep,' Halazun said. 'Dr. Fauci this, Bill Gates that. And I don't really care what you think about Bill Gates. It doesn't affect me. But it does affect me when they tell me what we're doing is not real and that the hospitals are really empty. It hurts.'

So,

Halazun has since stopped engaging with the trolls on Facebook, some of whom claimed that 'the hospitals are empty' and that the virus was part of a plot to vaccinate or microchip U.S. citizens — just two of the many conspiracy theories that have swirled around the coronavirus.

Essentially these health care professionals attempts to educate the public about the science of pandemic, and the logical measures that could be used to manage them.  They were met not just with insults, but with claims their facts were a "hoax," and what they are doing "is not real."  These responses to health care professionals represents only some of the disinformation about the coronavirus pandemic now rampant on social media and the internet.

The identity and the motivations of the people propagating this disinformation are unclear.  It is known, though, that coronavirus disinformation has been promoted by the Trump administration, its supporters, and President Trump himself (look here).  It has also been spread by ideologues, people selling quack cures, and various national governments, including that of Russia (look here).  


Patients Refusing to Wear Face Masks in Medical Facilities

The attacks on the evidence and logic used by health care professionals to educate the public and patients about the coronavirus pandemic are now shading into direct attacks on the professionals and their patients.   

As Vox reported on May 21, 2020:

A urologist in Florida, who requested anonymity because of fear of losing his job, tells Vox he had his first patient refuse to wear a mask on May 13. The doctor works at a private clinic, which recently instituted a policy requiring all patients to wear a mask while in the building to minimize transmission of the virus. The patient was given a mask at the front desk, but refused to put it on.

'The nurse asked him to put his mask on if he wanted to be seen,' the urologist said. 'He got verbally aggressive with her, saying he had a right not to wear a mask, and that we were denying his constitutional rights.' The clinic manager was summoned to speak with the patient, and explained that the mask was to protect both him and the medical staff. 'He continued to refuse, so the administration asked him to leave.'

At that point, the patient called 911 to complain he was being denied medical care. 'We’re a private property, not an emergency room,' the urologist said. 'We’re not required to treat him, and he was not having an acute emergency. I think he just had a very poor understanding of what his rights were.'

The dispatcher declined to send an officer to the scene, but the clinic then called the police. 'He ended up walking out of the building before the cops showed up.'

Note that the US Constitution is about the roles and limitations of the US government, not about how private organizations manage their affairs.


There have been other examples:

The patient was 'ranting and raving,' she says. 'He said he had been trying to get it and hadn’t caught it, so he didn’t think he needed to wear a mask. I wish I could be that confident and willing to take everyone in this building’s lives into my hands.'

Despite his refusal to don a mask, the patient was cared for, although staff wore gowns and masks as if he had Covid-19.

And this:

Ryan Shannon, an ER doctor in Florida, describes a patient refusing to wear a mask, even though she was in a room next to an immunocompromised person at high risk of severe Covid-19 illness and death. 'She refused, threw the mask on the floor, and proceeded to berate myself and my staff for being a part of the ‘conspiracy and hoax’ that is Covid-19,' he wrote in a May 11 Facebook post.

After the patient’s refusal to follow guidelines, her husband insisted on sitting in the part of the waiting room designated for patients with respiratory complaints like Covid-19, instead of in his car as he was instructed.

And this:

Sue Krohn-Taylor is an administrator at a 72-apartment low-income senior living facility in the large town of Grand Island, Nebraska, where a resident has tested positive for Covid-19. She says she’s been battling some residents who refuse to wear masks, and is exhausted.

'This week, the son of one of the residents told me I was taking away their liberties by making them wear a mask in the common areas,' she says. 'If they were only harming themselves, I would back off, but they are placing each and every resident here, and my staff, and our families in harm’s way.'

'I can fight the virus, but fighting the lies is what becomes overwhelming,' she says.

Now it is patients who call straightforward epidemiology a "hoax." Not only do some patients vilify health care professionals who profess evidence and logic about the coronavirus pandemic, but now they physically resist logical  measures to suppress the pandemic.  Who might be encouraging them who has a vested interest in ... people not wearing masks?

Once again, the question may have a political answer.  As we discussed here, President Trump has repeatedly refused to wear a mask in public, as have other members of his administration.  This behavior went against the recommendations of the Centers for Disease Control and Prevention (CDC). The reasons he has publicly subverted his own administration's experts' recommendations is not clear, but in the post above, we noted an AP news story on May 7, 2020 

Trump has told advisers that he believes wearing one [a mask] would 'send the wrong message,' according to one administration and two campaign officials not authorized to publicly discuss private conversations. The president said doing so would make it seem like he is preoccupied with health instead of focused on reopening the nation’s economy — which his aides believe is the key to his reelection chances.

Now others are imitating his behavior in a way that threatens health care professionals and other patients.  Once again, health care professionals seeking to protect their patients' and their own safety have fallen afoul of the vested political interests of those in control of the executive branch of the US government. 

Trump Campaign Tries to Line Up Physician Cadre to Parrot His Views

Not only has President Trump exhibited hostility to health care professionals who contradict his magical thinking about the coronavirus, his campaign is trying to develop a cadre of physicians willing to parrot his message, and discredit any messages from health care professionals seen as competing with his.  The campaign is looking for physicians willing to amplify the message that "2+2=5"

As reported by AP on May 20, 2020:

Republican political operatives are recruiting 'extremely pro-Trump' doctors to go on television to prescribe reviving the U.S. economy as quickly as possible, without waiting to meet safety benchmarks proposed by the federal Centers for Disease Control and Prevention to slow the spread of the new coronavirus.

The plan was discussed in a May 11 conference call with a senior staffer for the Trump reelection campaign organized by CNP Action, an affiliate of the GOP-aligned Council for National Policy. A leaked recording of the hourlong call was provided to The Associated Press by the Center for Media and Democracy, a progressive watchdog group.

CNP Action is part of the Save Our Country Coalition, an alliance of conservative think tanks and political committees formed in late April to end state lockdowns implemented in response to the pandemic. Other members of the coalition include the FreedomWorks Foundation, the American Legislative Exchange Council and Tea Party Patriots.

A resurgent economy is seen as critical to boosting President Donald Trump’s reelection hopes and has become a growing focus of the White House coronavirus task force led by Vice President Mike Pence.

Tim Murtaugh, the Trump campaign communications director, confirmed to AP that an effort to recruit doctors to publicly support the president is underway, but declined to say when the initiative would be rolled out.

The implied goal is to find physicians who will uncritically accept the word of Donald J Trump

Murtaugh said the campaign is not concerned about contradicting government experts.

'Our job at the campaign is to reflect President Trump’s point of view,' Murtaugh said. 'We are his campaign. There is no difference between us and him.'

So this an effort to use tame physicians to cloak in their white coats Trump's political agenda which contradicts CDC pandemic management recommendations.  It is apparently meant to undercut any arguments about the potential public health effects of premature "reopening" of the economy.  The AP interviewed Dr. Wafaa El-Sadr, an epidemiology professor at Columbia University’s Mailman School of Public Health as saying:

having doctors relay contradictory information on behalf of the president is 'quite alarming.'

'I find it totally irresponsible to have physicians who are touting some information that’s not anchored in evidence and not anchored in science,' El-Sadr said. 'What often creates confusion is the many voices that are out there, and many of those voices do have a political interest, which is the hugely dangerous situation we are at now.'

The Trump campaign seems to want to specifically minimize the danger of COVID-19 infection.  AP talked to Matt Schlapp,"chairman of the American Conservative Union, which hosts the annual Conservative Political Action Conference attended by conservative luminaries," who participated in the call:

It’s important to get the message out there that most people recover from corona. Most people are not in mortal danger with corona and that we can safely open up the economy.

However, this contradicts well known data, for example

As of Tuesday, more than 1.5 million Americans had tested positive for COVID-19, with more than 91,000 deaths reported nationwide.

The effort to develop a cadre of physicians who uncritically accept the word of Trump already seems to be underway.  As The Hill Reported on May 21, 2020,

More than 600 physicians signed a letter organized in part by a conservative group that warns President Trump against a lengthy economic shutdown because of the coronavirus.

The doctors call such closures a "mass casualty" event.

The letter was spearheaded by Simone Gold, a California emergency medical specialist. Jenny Beth Martin, the cofounder of Tea Party Patriots, helped organize the letter and get it to the White House.

It was released as the Trump campaign has been actively soliciting the support of pro-Trump physicians, according to The Associated Press.

Note that the Tea Party Patriots is one of the right-wing political organizations that has tried to line up a cadre of physicians who uncritically "reflect President Trump's point of view."  It has also been an organizer of the "reopen" protests, including those in which included the vilification of health care professionals who tried to counter-protest in support of social distancing and other pandemic control measures, and to warn of disease resurgence were reopening rushed (look here).


The Hill stated that the first author of the letter, Dr Gold

said in an interview with The Hill she doesn't want to be seen as political, and is merely concerned about the negative medical impacts of the shutdown. Gold described it as a 'grassroots' effort and rejected characterizations of it as a 'political movement.'

However, the AP article noted that Dr Gold

is listed as a member of the Save Our Country Coalition on the group’s website. She has recently appeared on conservative talk radio and podcast programs to advocate for the use of hydroxychloroquine, an anti-malaria drug that Trump says he is taking because he believes it can prevent COVID-19 even though his own administration has warned it can have deadly side effects. Gold said she has prescribed the drug to two of her patients with good results.

The Food and Drug Administration warned health professionals last month that the drug should not be used to treat COVID-19 outside of hospital or research settings due to sometimes fatal side effects.

Also,

Gold told AP on Tuesday she started speaking out against shelter-in-place and other infection control measures because there was 'no scientific basis that the average American should be concerned' about COVID-19. Like the president, she is advocating for a fast reopening, and argues that because the majority of deaths so far have been the elderly and people with preexisting conditions, younger people should be working.


One wonders why a physician who is not "political" would choose to do such interviews.  One also wonders why she has been advocating for for hydroxychloroquine in the absence of any clear evidence that it does more good than harm for patients with COVID-19? One further wonders where she found "scientific basis" to say the average person should not be "concerned" about the pandemic?


So  the Trump campaign, in league with a group that sponsored "reopen" protests, is cultivating a group of pet physicians who are happy to "reflect" the word of Donald J Trump, even when the word is the epidemiological equivalent of "2+2=5". 

Discussion

 As we said before, many dooctors and other health care professionals traditionally have not been very interested in health policy, and often have avoided activism, much less any appearance of partisanship.  Pushed by the suffering of COVID-19 patients and their own vulnerability in the pandemic, many have tried to educate the public about the need to suppress the pandemic through social distancing and various physical measures.

This has given some an impetus to protest unsafe conditions in health care facilities (look here), and to try to educate "reopening" protesters about the medical and public health risks of premature efforts to decrease the economic effects of the pandemic (look here).  Yet that put them in uncomfortable positions.  Hospital managers did not appreciate their protesting when it put management in a bad light.  Some "reopening" protesters responded to their educational counter-protesting with anger and vilification.  Now extreme political interests, specifically including President Trump and his supporters have targeted health care professionals whose educational efforts might undercut Trump's message of triumph over the pandemic resulting in a "transition to greatness."  Thus, while health care professionals have sought to educate about the facts and logic of an epidemiological approach to pandemic management, the Trump administration has contradicted obvious truths, and proclaimed delusional solutions.

The health care professionals have been saying the equivalent of "2+2=4" when the country's leadership proclaims its power to say "2+2=5" Whether health care professionals like it or not, Trump and company have turned health care education, and science-based reasoning, into political acts.


So health care professionals trying just to uphold their mission to put patients' and the public's health first have stumbled into a conflict far beyond anything we have seen in our lifetimes.  Upholding the mission will be difficult, unpleasant, quite likely dangerous.  The danger is not just from the virus, but from our fellow humans.  That does not make the mission any less important.  Innocent lives are still hanging in the balance.

We could retreat in fear from the powerful opposition we have stirred up.  That would allow complete politicization of the management of the coronavirus pandemic, doubtless leading to increased disease and death (and ironically, even worse economic disruption).  Retreating would betray our patients and make a mockery of our mission.  Or we could persist.  What will it be? "And if not now, when?"



1931 Soviet propaganda poster by Yakov Guminer, via WikiMedia

Sunday, May 17, 2020

Extremists, Guns, Militias, Threats of Violence - Is This Any Way to Debate Public Health and Pandemic Management?

In April, the rising curve of COVID-19 cases in the US started to flatten in response to fairly strict social distancing and collective public action (look here for latest data).  Despite this success, supposedly popular protests, albeit very small, broke out calling for the end of these onerous measures, ostensibly to let the economy recover, as we noted here.  Protesters were egged on by President Trump, who called to "liberate" various states, and thus end social distancing and physicial prevention measures, despite the recommendations of the Centers for Disease Control and Prevention (CDC) and his own coronavirus task force.

At these "reopening" protests, there were signs of political extremism.  At some, health care professionals who counter-protested to support social distancing and other measures to curtail disease spread were vilified.  Since then, it has become glaringly obvious that these protests and the arguments about backing off from pandemic suppression efforts have become caught up in an increasingly ugly political reality.  We have noticed some specific trends.

Local Political Leaders Endorsed Extremism

Not only the "reopening" protesters, but their supporters among local political leaders have endorsed extremist symbolism and viewpoints.  Recent examples follow in chronological order per when they were reported.  

Ohio State Senator Compares State Health Director, Who is Jewish, to the Nazis and Anti-Christ

Per Raw Story on April, 22, 2020, after Ohio Health Director Amy Acton suggested letting people who are immune from COVID-19 get a certificate to that effect, State Sen. Andrew Brenner’s wife, Sara Marie Brenner tagged her husband with a Facebook post that included:

This is the mark of the beast type talk.

Also,

'This is worse than China, for heaven’s sake,' they added. 'This actually feels like Hitler’s Germany where you had to have blonde hair and blue eyes to be able to function anywhere, and you were damned otherwise. When are people going to say enough is enough?'

The lawmaker signaled his endorsement of his wife’s post by vowing 'we won’t let that happen in Ohio,' in a Facebook comment.

Kentucky State Representative Endorses White Supremacist Militia Member

During an early May "reopen" protest in Louisville, per the Courier-Journal on May 3, 2020:

State Rep. Savannah Maddox, a Republican from Dry Ridge who alleged Kentucky's government has made residents 'prisoners in your own homes' during the rally, was pictured standing next to a woman wearing military-style gear and carrying a gun while flashing a hand signal associated with white supremacist groups.


Also,

Tara Brandau, the woman in the photo making the hand gesture, posted the picture to her Facebook page with an endorsement of Maddox.

Brandau lists her hometown as Live Oak, Florida, on her Facebook page, which includes photos of her at several recent protests of coronavirus restrictions in other states. Brandau posted another picture to her Facebook page with a group of people at the Kentucky protest wearing military-style gear, several of whom are flashing the same 'OK' hand gesture, which has become a prominent symbol of white supremacist groups in recent years, according to the Anti-Defamation League.

According to the Southern Poverty Law Center, Brandau is an active member of the Florida Three Percenter Security Force, a far-right militia movement and paramilitary group. She also has ties to the League of the South, which the SPLC labels a secessionist neo-Confederate hate group.

Louisiana Representative Compares Stay at Home Orders to Nazi Dictatorship

As reported by Big Easy magazine on May 12, 2020, Representative Dodie Horton:

compared the stay-at-home restrictions to living under 'Nazi Germany.'

Ironically, Rep. Horton was primarily concerned with her inability to attend church on Sundays during the lockdown.

'What happened to separation of church and state?' she first queried, neglecting to mention that the public health order did not specifically target any religious practices.

'Can the fire marshal still be able to go in and close a business down [under HCR 58]? Can the Department of Health still close down restaurants? Our tax dollars – are they paying for that?'

'I mean, are we in Nazi Germany?'

The magazine got a response from Aaron Ahlquist, Regional Director of the Anti-Defamation League’s South Central Region.

To make a comparison of the Governor’s order to protect the health and welfare of the residents of Louisiana to a brutal regime that intentionally tried to exterminate the Jewish people and other vulnerable communities, is not only inaccurate, but cheapens the horror of Nazi Germany and the losses experienced by the victims


So anyone who would openly oppose the "reopen" movement by supporting public health measures against coronavirus, including measures advocated by the US government and the President's coronavirus task force could expect to be vilified as a "Nazi," (even if you are Jewish), or the Devil.


Guns and Militias

"Reopening" protests increasingly included people dressed in pseudo-combat gear, sometimes carrying military style weapons.  Many of these were apparently members of militia groups.  The most vivid examples are from protests in Michigan, although armed protesters have also appeared at "reopen" rallies in Pennsylvania (look here) and Virginia (look here).

Armed Protesters Invade Michigan State Capitol



The most obvious example occurred in late April. Per the Independent, April 30, 2020:

Michigan politicians have decided to don bulletproof vests when going to work as armed protesters defy lockdown orders.

State Senator Dayna Polehanki, a Democrat, revealed the protective decision some of her colleagues were making when sharing a picture of protesters on Twitter on Thursday.

In the picture, multiple men in the Michigan State Capitol building were armed with guns.

She wrote: 'Directly above me, men with rifles yelling at us. Some of my colleagues who own bulletproof vests are wearing them. I have never appreciated our Sergeants-at-Arms more than today.'

When contacted by The Independent, the senator shared a picture of her colleague Senator Sylvia Santana, a Democrat, wearing a bulletproof vest and face mask while working.

The Guardian's coverage on the same day noted:

One protest sign outside the statehouse on Thursday read: 'Tyrants get the rope.'

But protesters also included

militia group members carrying firearms and people with pro-Trump signs

In particular,

Members of the Michigan Liberty Militia were at the protest, armed with guns, and one member said that the group was there as a 'security detail' for the event organizers, MLive.com reported. The Southern Poverty Law Center, which monitors American extremist organizations, includes a 'Michigan Liberty Militia' among its list of extreme antigovernment groups.

Note that the AP reported in retrospect on May 13, 2020, that the armed protesters may have also been members of the "boogaloo" movement (see below).
Another anti-lockdown rally is planned for Thursday at the state Capitol in Lansing, Michigan, site of an angry protest last month that included armed members of the Michigan Liberty Militia. Michigan Gov. Gretchen Whitmer, a Democrat, has been the target of violent threats on Facebook forums, including a private one called 'The Rhett E. Boogie Group.'

Later, via NBC News, May 2, 2020, an article written by Michigan State Senator Mallory McMorrow noted that the protests also numbered:

protestors with a swastika, Confederate flags or a massive Trump 'bridge' float.

Given all that symbolism, it should not be surprising that Trump as quick to endorse his apparent supporters, per  the Guardian on May 1, 2020:

A day after armed protesters against Michigan’s stay-at-home order entered the statehouse in Lansing, Donald Trump once again expressed support for the rightwing movement.

Michigan’s Democratic governor, Gretchen Whitmer, should he said 'make a deal' with the demonstrators.

'The governor of Michigan should give a little, and put out the fire,' the president wrote in a tweet on Friday morning. 'These are very good people, but they are angry. They want their lives back again, safely! See them, talk to them, make a deal.'

So at this one "reopen" protest, protesters carried signs with Nazi and Confederate symbolism.    Armed militia members appeared, and pushed into the capitol building.  Yet, protesters also carried signs in support of President Trump, who later endorsed them as "very good people."

Later Protests at Michigan Capitol

Protests at the Michigan state capital have continued, although the armed protesters seemed deterred from their most recent protest by a bit of rain. Per the Guardian, May 14, 2020:

dozens of conservative protesters descended on the state capitol on Thursday morning.

Some arrived armed with assault rifles while others held up signs portraying the governor with a Hitler moustache and one speaker taunted police and called for Whitmer to be pulled outside and arrested for breaking the law with her emergency orders.

But the fears of serious violence that had preceded the event proved unfounded. Instead, a steady downpour and lightning pushed most of the protesters to their vehicles after about 90 minutes.






So anyone who would openly oppose the "reopen" movement by supporting public health measures against coronavirus, including measures advocated by the US government and the President's coronavirus task force could expect attempts at intimidation, even by members of armed militias. 

Threats of Violence Against "Reopening" Opponents

Beyond the vilification of health care professionals acting as counter-protesters (see our post here), some "reopening" supporters made apparent threats of violence against their perceived opponents. 

Death Threat Against Governor of Kentucky

In the context of protests of Governor Beshear's lock-down of businesses, per The Hill on April 22, 2020: an attorney, John Troutman, was on Facebook

reportedly having an exchange about protests planned in opposition to Beshear’s stay-at-home order amid the coronavirus pandemic

when  he stated

with any luck the Gov will be the one at whom the shooting will be directed

Just for emphasis, he also referred to the story of

William Goebel. For those of you who don't know the history...it's a good read...

The Hill explained:

Goebel, Kentucky’s 34th governor, was shot in 1900 the day before being sworn in after a divisive election and died four days later. He remains the only state governor in United States history who was assassinated during a contested election.

Boogaloo Militia Fans Threaten Various Violence

The background came from the New York Times, May 3, 2020:

Last month, the Department of Homeland Security warned law enforcement officials throughout the United States of the mobilization of violent extremists in response to stay-at-home measures, according to a senior law enforcement official and a congressional staff member, who were not authorized to discuss the warning publicly.

A department memo dated April 23 noted the recent arrests of individuals who had threatened government officials imposing coronavirus-related regulations. The memo was distributed to law enforcement “fusion centers” that counter terrorism nationwide and to congressional committees, the officials said.

In particular, there is a loosely set of people who could be called the "boogaloo" movement:

Some label their expected second civil war 'the boogaloo,' and experts have tracked a spike in interest in the term on social media, plus a proliferation of advice on how to prepare.

The name is a pop culture reference derived from a 1984 movie flop that became a cult classic called “Breakin’ 2: Electric Boogaloo.” It went through various mutations and emerged sometimes as the “Big Igloo” or the “Big Luau.” That is why adherents sometimes wear Hawaiian shirts, say those who track them. Many such shirts were in evidence when armed protesters stormed the state capital in Lansing, Mich., Thursday and they have appeared in rallies across the country.

Specific threats came from people tied to this movement:

Timothy R. Wilson, 36, an extremist suspected of planning an attack on a Missouri hospital, was killed in a shootout with F.B.I. agents in late March. An F.B.I. statement said he was 'motivated by racial, religious, and anti-government animus.'

The federal government sought to harness the pandemic as an 'excuse to destroy our people,' Mr. Wilson wrote on an online channel for violent neo-Nazi groups, Dr. Squire said, while also describing it as a Jewish 'power grab.'

An Arkansas man, Aaron Swenson, 36, had used an alias to 'like' more than a dozen 'boogaloo' Facebook pages, said the Tech Transparency Project report. He then went on Facebook Live on April 12 to announce that he was hunting for a law enforcement officer to ambush and execute in Texarkana, Texas, where the police arrested him, according to a police statement.

Mr. Swenson, who remains in jail on $85,000 bail, was charged with making terroristic threats, evading capture and carrying a weapon illegally. 

Furthermore,

In March, a Missouri man with ties to neo-Nazis was shot and killed when FBI agents tried to arrest him. Timothy Wilson, 36, was planning to bomb a hospital in the Kansas City area on the day that a COVID-19 stay-at-home order was scheduled to take effect, authorities said. Wilson told an undercover FBI agent that his goal was 'to kick start a revolution' and referred to his plans as 'operation boogaloo,' according to an agent’s affidavit.

Militia Member Planning to Attend Colorado "Reopen" Rally Arrested for Possession of Pipe Bombs

Per Vice News, May 4, 2020:

A Colorado man was arrested Friday when federal agents found pipe bombs at his home, hours before the anti-lockdown rally that he reportedly planned to attend at the state Capitol.

Bradley Bunn, 53, allegedly told agents that he planned to use the bombs against law enforcement if they attempted a forced entry, according to an arrest affidavit.

Federal agents with the FBI and ATF reportedly became aware of Bunn after a series of aggressive social media posts, according to an anonymous official who spoke to ABC News after being briefed on the case.

The Denver Post also reported that Bunn, who’s allegedly a member of an anti-government militia, boasted online that he’d bring high-powered weapons to the state’s Capitol for the protest.

Threats Against People who Complained about Violations of Washington's Stay at Home Order

Per the Seattle Times, May 9, 2020:

Two Facebook pages during the past week posted names, emails and phone numbers of state residents who had complained to the state about businesses allegedly violating Gov. Jay Inslee’s stay-at-home order. Some of the complainants say the Facebook posts have generated threats of violence and harassment against them.

One group publicizing the names, the Washington Three Percenters, has promoted the stay-at-home protests, and one of its leaders spoke at Saturday’s demonstration.

On its Facebook page, the far-right group of self-described 'God fearing Patriots,' had this message: 'Want to snitch on your neighbor? Don’t expect to hide behind you (sic) computer screen.' With the message, the group provided a link to a spreadsheet containing the names and contact information of people who made reports to the state.

In one case,

A woman on the list shared by the Washington Three Percenters said she quickly got threatening emails and phone messages. The woman, who lives in King County and asked not to be identified because of threats to her safety, had reported a business she said she believed was operating improperly despite Inslee’s stay-home order.

She sent The Seattle Times a voice message that she said was left on her phone. A man says, 'You got 48 hours to get the [expletive] out of Washington, or I am coming for you, and your loved ones.'

Note that the Three Percent group is also related to the "Boogaloo" militia.  Further note that a Kentucky state legislator seemed to endorse another member of the Three Percenters who appeared a "reopen" protest in that state (see above).  

Michigan Governor Threatened on Facebook Before "Reopen" Rally

Per the Detroit Metro Times, May 11, 2020:

Dozens of angry Michiganders, fueled by conspiracy theories and disinformation about the coronavirus, are promoting violence and mobilizing armed rallies against Gov. Gretchen Whitmer on Facebook, in violation of the social media company’s policies.

On Sunday, after being contacted by Metro Times, Facebook removed one of the groups, Michigan United for Liberty, and deleted posts on others for violating the company’s policy against inciting violence. Facebook announced last month that it will remove groups and events that encourage people to defy social-distancing measures. Facebook also is investigating the other groups.

'We removed one group for violating our policies and will remove any other violations as we continue our review,' a Facebook spokesperson tells Metro Times.

Assassinating Whitmer is a common theme among members of the groups. Dozens of people have called for her to be hanged.

'We need a good old fashioned lynch mob to storm the Capitol, drag her tyrannical ass out onto the street and string her up as our forefathers would have,' John Campbell Sr. wrote in a group called 'People of Michigan vs. Gov. Gretchen Whitmer,' which had nearly 9,000 members as of Monday morning.

Steve Doxsie had the same idea: 'Drag that tyrant governor out to the front lawn. Fit her for a noose.'

'Either President Trump sends in the troops or there is going to be a midnight lynching in Lansing soon,' Michael Smith chimed in.

There were many more. Note that some of the threats came from a "Boogaloo" related group as discussed above.

 So anyone who would openly oppose the "reopen" movement by supporting public health measures against coronavirus, including measures advocated by the US government and the President's coronavirus task force could expect not merely attempts at intimidation, but threats of violence and even death.  There have been instances in which people have made concrete preparations to carry out such threats.

Discussion

Many dooctors and other health care professionals traditionally have not been very interested in health policy, and often have avoided activism, much less any appearance of partisanship.  Pushed by the suffering of COVID-19 patients and their own vulnerability in the pandemic, many have tried to educate the public about the need to suppress the pandemic through social distancing and various physical measures.

This has given some an impetus to protest unsafe conditions in health care facilities (look here), and to try to educate "reopening" protesters about the medical and public health risks of premature efforts to decrease the economic effects of the pandemic (look here).  Yet that put them in uncomfortable positions.  Hospital managers did not appreciate their protesting when it put management in a bad light.  Some "reopening" protesters responded to their educational counter-protesting with anger and vilification.

Health care professionals must open their eyes about whom and what they are up against.  The "reopen" protests seem to be more about a particularly ugly version of politics rather than economic concerns.  Political supporters of "reopen" protests are no more afraid of vilifying those who disagree with them than are the protesters themselves.   Protesters include armed militia members trying to intimidate their opponents.  "Reopen" campaigns often generate threats of violence against perceived political enemies.

Further, as we documented here, the "reopen" protests are supported by powerful, often opaque right-wing political groups, backed quietly by some of the country's richest plutocrats.

Even more intimidating, "reopen" protesters often pledge allegiance not to obscure cult leaders, but to the President of the United States, Donald J Trump.  Trump, after all, helped to fan the flames of the protests by calling for the "liberation" of some states led by Governors of the opposing political party, as noted here.  Finally, as discussed above, Trump clearly has signaled his support even for protesters who dress to intimidate in pseudo-military garb and carry guns into state capitol buildings, apparently threatening armed insurrection.

So health care professionals trying just to uphold their mission to put patients' and the public's health first have stumbled into a conflict far beyond anything we have seen in our lifetimes.  Upholding the mission will be difficult, unpleasant, quite likely dangerous.  The danger is not just from the virus, but from our fellow humans.  That does not make the mission any less important.  Innocent lives are still hanging in the balance.

"And if not now, when?"