Sunday, September 20, 2020

Attempts to Transform the CDC into a Propaganda Outlet and the Silence of the Health Care Leaders

First they came for the CDC staffers, but I was not a CDC staffer so I did nothing...

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

- with apologies to Martin Niemoller (look here


The US is continuing to suffer during the coronavirus pandemic.  Meanwhile, the lead US government public health agency, the Centers for Disease Control and Prevention (CDC) has suffered two attempts by the Trump administration to transform it into a propaganda outlet.

Mysterious Revisions of Pandemic Management Guidelines to Hinder Testing of Exposed Persons

This story broke in late August, 2020.  As reported by the New York Times on August 25, 2020:

The Centers for Disease Control and Prevention quietly modified its coronavirus testing guidelines this week to exclude people who do not have symptoms of Covid-19 — even if they have been recently exposed to the virus.

The new guidelines went against public health practice for managing epidemics.  People who have been exposed are at increased risk of infection.  Infected people may not have symptoms but may still transmit the virus to others.  Identifying infected people allows them to be quarantined, and any further contacts to be traced.  In particular, as the NYT article pointed out:

Although researchers remain unsure how often asymptomatic people unwittingly transmit the coronavirus, studies have shown that the silently infected can carry the virus in high amounts. The evidence is more clear-cut for pre-symptomatic people, in whom virus levels tend to peak just before illness sets in — a period when these individuals might be mingling with their peers, seeding superspreader events. Notably, experts can’t distinguish asymptomatic people from those who are pre-symptomatic until symptoms do or don’t appear.

No Obvious Justification and No One Accountable for the Change

The CDC did not initially provide a clear justification of the change:

The reasons behind the surprise shift in testing recommendations are unclear. In response to an inquiry from The New York Times, a representative for the C.D.C. directed the questions to the U.S. Department of Health and Human Services. 

A report from ABC News on August 26 quoted Admiral Brett Giroir of the White House coronavirus task force:

This is evidence-based decisions that are driven by the scientists and physicians, both within the CDC, within my office in the lab task force, and certainly amongst the task force members

However, he did not provide any of the evidence on which it was supposedly based, or any logic underlying the change based on this evidence.  Nor did he make clear who was accountable for the change

 I worked on them. Dr. Fauci worked on them. Dr. Birx worked on them. Dr. Hahn worked on them. Dr. Atlas provided input. So, it's kind of hard to know how much was written by one person at this time

On the other hand, a CNN report from the next day suggested that the change came due to political pressure:

A sudden change in federal guidelines on coronavirus testing came this week as a result of pressure from the upper ranks of the Trump administration, a federal health official close to the process tells CNN, and a key White House coronavirus task force member was not part of the meeting when the new guidelines were discussed.

'It's coming from the top down,' the official said of the new directive from the Centers for Disease Control and Prevention.
 
An AP article from August 26 included speculation about the real reasons for the change:
 
Dr. Carlos del Rio, an infectious diseases specialist at Emory University, suggested in a tweet that there are two possible explanations.

One is that it may be driven by testing supply issues that in many parts of the country have caused widely reported delays in results of a week or more, he suggested.

 Admitting problems providing testing might be a reason to consciously temporarily limit testing, of course, but not to pretend the testing would not be useful.  Then

Another possible explanation for the change is that President Donald Trump simply wants to see case counts drop, and discouraging more people from getting tested is one way to do it, del Rio said in his tweet.

A Washington Post article on August 27, 2020 explained this further:

The revised guidelines come as President Trump has feuded with the CDC and the Food and Drug Administration, both parts of the Department of Health and Human Services, and marginalized officials who would ordinarily play leading roles in a pandemic response. He has repeatedly said that he did not like that more testing had revealed more cases.

'I said to my people, ‘Slow the testing down, please!’ ' Trump said at a rally two months ago. Aides said he had been speaking tongue-in-cheek. But asked later whether he had been kidding, Trump replied, 'I don’t kid.'

Reducing testing, of course, would reduce the number of apparent, not real cases, allowing Trump to exaggerate his ability to manage the pandemic

On September 17, 2020, the source of the controversial change in the CDC guideline was somewhat clarified again according to the New York Times:

A heavily criticized recommendation from the Centers for Disease Control and Prevention last month about who should be tested for the coronavirus was not written by C.D.C. scientists and was posted to the agency’s website despite their serious objections

The source of the change was 

the Department of Health and Human Services [which] did the rewriting and then 'dropped' it into the C.D.C.’s public website, flouting the agency’s strict scientific review process.

'That was a doc that came from the top down, from the H.H.S. and the task force,' said a federal official with knowledge of the matter, referring to the White House task force on the coronavirus.

Yet neither that nor earlier reports explained who at "the top" directed the change.

And soon the change it self disappeared as mysteriously as it appeared.  On September 18, 2020 per the AP:

U.S. health officials on Friday dropped a controversial piece of coronavirus guidance and said anyone who has been in close contact with an infected person should get tested.The Centers for Disease Control and Prevention essentially returned to its previous testing guidance

Criticism of the Change

 Public health and health care professionals criticized the changes, e.g.,  per the AP article of August 26, 2020:

Dr. Tom Frieden, who was head of the CDC during the Obama administration, said the move follows another recent change: to no longer recommend quarantine for travelers coming from areas where infections are more common.

'Both changes are highly problematic' and need to be better explained, said Frieden, who now is president of Resolve to Save Lives, a nonprofit program that works to prevent epidemics.

Also, Dr Leana Wen wrote an op-ed for the Washington Post on August 26, 2020:

you don’t have to be a public health expert to know the CDC’s guidance is nonsensical.  

In MedPage Today of August 28, 2020:

pulmonologist William Janssen, MD, section head of Critical Care Medicine at National Jewish Health, said the new guidance recommending testing for fewer people 'flies in the face of everything we have been told and understand about this disease.'

Also,

Another pulmonologist at National Jewish Health, Kenneth Lyn-Kew, MD, called the CDC move 'a step backwards.'

'The CDC was flat out wrong and the epidemiologists there know this,' he said, adding that testing and tracing are cornerstones of epidemiology.

Major health care organizations also criticized the change. The AMA issued a statement:

Suggesting that people without symptoms, who have known exposure to COVID-positive individuals, do not need testing is a recipe for community spread and more spikes in coronavirus. When the Centers for Disease Control and Prevention (CDC) updates a guidance the agency should provide a rationale for the change. We urge CDC and the Department of Health and Human Services to release the scientific justification for this change in testing guidelines

The American Association of Medical Colleges asserted:

These CDC guidelines go against the best interests of the American people and are a step backward in fighting the pandemic. The AAMC urges the CDC to return to its earlier testing recommendations

The Chair of the Board of Regents of the American College of Physicians wrote that the organization:

supports the use of science, based on the best available evidence, in the fight against COVID-19. Public health agencies should not be subjected to pressure or be influenced to issue policies that are not based on evidence and expert recommendations of their own scientists.

 Also

The recent revision of the CDC’s COVID-19 testing guidelines of asymptomatic individuals lacks transparency and clarity, sending a confusing message to both physicians and the public on appropriate and necessary testing that will ultimately help to mitigate the spread of COVID-19.

Summary

So far we only know that someone at "the top" of the government directed the change in the CDC guidelines.  No person or group has stepped forward as accountable. No one at any US government agency has explained the rationale for the change, much less provided clear evidence and logical reasoning underlying it.  The best explanation for the change seems to be that it fit President Trump's message. It would have made his administration's problems organizing adequate testing for coronavirus less apparent.  By reducing testing, it would make the rate of the spread of disease temporarily appear lower, allowing Trump to exaggerate his ability to manage the pandemic.

Yet I could find no health care or public health professional, or any leader of a health care organization willing to criticize "the top" of the US government for directing the change, to criticize the opaque, apparently evidence-free process that produced the change, or to question whether the change was meant to fit with Trump's propaganda, that is, his claims of brilliant management of the pandemic. 

Trump Political Appointees Attempt to Intimidate CDC Staff to Manipulate Publications in the Morbidity and Mortality Weekly

White House Installed Pro-Trump Propagandist with No Health Care or Public Health Background as Head of Public Relations for DHHS

 The second case began in April, 2020.  Then Politico reported:

 The White House is installing Trump campaign veteran Michael Caputo in the health department’s top communications position

Caputo was given the title of Assistant Secretary for Public Affairs. He has an unlikely background to have been named head of public relations for the Department of Health and Human Services (DHHS). He has no apparent background in health care or public health. Also, Politico noted:

Caputo is an intense Trump loyalist whose recent book 'The Ukraine Hoax,' alleged a conspiracy behind Trump’s impeachment.

Furthermore

 Caputo is a longtime friend of Trump ally Roger Stone and former Trump campaign chairman Paul Manafort, both of whom were convicted of crimes in the last two years. 

Then CNN reported:

The new spokesman for the Department of Health and Human Services in a series of now-deleted tweets made racist and derogatory comments about Chinese people, said Democrats wanted the coronavirus to kill millions of people and accused the media of intentionally creating panic around the pandemic to hurt President Donald Trump.

In particular,

In a series of tweets on March 12, Caputo responded to a baseless conspiracy theory that the United States brought the coronavirus to Wuhan, China, by tweeting that 'millions of Chinese suck the blood out of rabid bats as an appetizer and eat the ass out of anteaters.'

 
CNN had many more graphic examples.  
 
Also, Mother Jones reported more about Caputo's involvement in Russia and Ukraine:
 
A longtime Republican operative who was ousted from a job on Trump’s 2016 campaign, Caputo recently worked to boost discredited claims alleging that Ukraine, not Russia, meddled in the 2016 election.
 
In particular, Caputo was alleged to have been involved in political dirty tricks on behalf of Trump in 2016:
 
In June 2018, the Washington Post reported that ... [Caputo] and Stone had met in 2016 with Henry Oknyansky, a Russian expat living in Florida, who wanted to sell damaging information about Hillary Clinton. Caputo, in text messages with Stone the Post obtained, referred to Oknyansky as 'the Russian.' Though no deal was reached, news of the meeting seemed to contradict claims both Stone and Caputo had made in testimony to the House Intelligence Committee. Both men denied any contact with Russians during the 2016 campaign.
 
Also, Caputo was alleged to have been involved in creating propaganda or disinformation about Ukraine's supposed intervention in the 2016 campaign, and Hunter Biden's actions there:
 
Last year, Caputo, along with other figures in Trump’s orbit, turned his focus to Ukraine. He says he travelled there last August to try to bolster the theory that Ukrainians interfered in 2016 election to help Clinton. He subsequently wrote a book, titled The Ukraine Hoax: How Decades of Corruption in the Former Soviet Republic Led to Trump’s Phony Impeachment, which pushes discredited allegations, including claims that former Vice President Joe Biden intervened in Ukrainian affairs to help his son, Hunter. Caputo produced a documentary offering similar allegations that aired in January on the rabidly pro-Trump One America News. Giuliani starred in a separate OAN series which pushed similar claims based his own trip to Ukraine.

 
Yet  despite Caputo's record as an unscrupulous political operator, and allegations that he was involved in peddling propaganda and disinformation, his appointment drew no outcry.

Assistant Secretary for Public Relations of DHHS Orchestrated Intimidation to Distort the Morbidity and Mortality Weekly Report

Somehow Caputo and the associates he brought to the DHHS managed to avoid much public notoriety for a few months.  Then on September 11, 2020 Politico reported that Caputo and his associates had been quietly busy.  Their apparent mission was to turn the respected CDC public health publication, the Morbidity and Mortality Weekly Report, into a vehicle for pro-Trump propaganda.  Politico noted that:

The CDC's Morbidity and Mortality Weekly Reports are authored by career scientists and serve as the main vehicle for the agency to inform doctors, researchers and the general public about how Covid-19 is spreading and who is at risk. Such reports have historically been published with little fanfare and no political interference, said several longtime health department officials, and have been viewed as a cornerstone of the nation's public health work for decades.

But since Michael Caputo, a former Trump campaign official with no medical or scientific background, was installed in April as the Health and Human Services department's new spokesperson, there have been substantial efforts to align the reports with Trump's statements, including the president's claims that fears about the outbreak are overstated, or stop the reports altogether.

In particular, Caputo et al tried to

retroactively change agency reports that they said wrongly inflated the risks of Covid-19 and should have made clear that Americans sickened by the virus may have been infected because of their own behavior

and

halt the release of some CDC reports, including delaying a report that addressed how doctors were prescribing hydroxychloroquine, the malaria drug favored by Trump as a coronavirus treatment despite scant evidence

To underscore that the effort was to promote Trump's political self-interest

an aide to Caputo berated CDC scientists for attempting to use the reports to 'hurt the President' in an Aug. 8 email sent to CDC Director Robert Redfield and other officials that was widely circulated inside the department and obtained by POLITICO. 'CDC to me appears to be writing hit pieces on the administration,' appointee Paul Alexander wrote, calling on Redfield to modify two already published reports

Alexander tried to gain control of the contents of the MMWR, calling

 on Redfield to halt all future MMWR reports until the agency modified its years-old publication process so he could personally review the entire report prior to publication, rather than a brief synopsis. Alexander, an assistant professor of health research at McMaster University near Toronto whom Caputo recruited this spring to be his scientific adviser, added that CDC needed to allow him to make line edits — and demanded an 'immediate stop' to the reports in the meantime.

Apparently CDC staffers resisted Caputo, Alexander et al, so that eventually contents untouched by their manipulations did become public.

One day after the Politico article, the New York Times  confirmed its essential findings

Current and former senior health officials with direct knowledge of phone calls, emails and other communication between the agencies said on Saturday that meddling from Washington was turning widely followed and otherwise apolitical guidance on infectious disease, the Morbidity and Mortality Weekly Reports, into a political loyalty test, with career scientists framed as adversaries of the administration.

The Times called Caputo's work a "bullying operation."  

The Washington Post also confirmed the Politico report after gaining access to emails sent by Alexander.

The Assistant Secretary's Actions Became Bizarre, and He Resigns Citing Mental Health Issues

As soon as the story of his attempts to "bully" the MMWR became public, Caputo's actions became more bizarre.  On September 14, 2020, the New York Times reported:

The top communications official at the powerful cabinet department in charge of combating the coronavirus made outlandish and false accusations on Sunday that career government scientists were engaging in 'sedition' in their handling of the pandemic and that left-wing hit squads were preparing for armed insurrection after the election.

Michael R. Caputo, the assistant secretary of public affairs at the Department of Health and Human Services, accused the Centers for Disease Control and Prevention of harboring a 'resistance unit' determined to undermine President Trump, even if that opposition bolsters the Covid-19 death toll.

Then he announced:

he personally could be in danger from opponents of the administration. 'If you carry guns, buy ammunition, ladies and gentlemen, because it’s going to be hard to get,' he urged his followers.

He went further, saying his physical health was in question, and his 'mental health has definitely failed.'

'I don’t like being alone in Washington,' Mr. Caputo said, describing 'shadows on the ceiling in my apartment, there alone, shadows are so long.'

 One day later Politico reported an announcement:

Today, the Department of Health and Human Services is announcing that HHS Assistant Secretary for Public Affairs Michael Caputo has decided to take a leave of absence to focus on his health and the well-being of his family

Alexander also left the agency 

Since Caputo's departure, Politico published an article detailing how he placed "his own loyalists and Trump veterans" into public relations positions at the DHHS. 

Also, the New York Times published an article detailing some of his efforts to bully CDC staff,

Mr. Caputo moved to punish the C.D.C.’s communications team for granting interviews to NPR and trying to help a CNN reporter reach him about a public relations campaign. Current and former C.D.C. officials called it a five-month campaign of bullying and intimidation.

For instance, after Mr. Caputo forwarded the critique of Dr. Schuchat to Dr. Redfield, C.D.C. officials became concerned when a member of the health department’s White House liaison office — Catherine Granito — called the agency to ask questions about Dr. Schuchat’s biography, leaving the impression that some in Washington could have been searching for ways to fire her.

In another instance, Mr. Caputo wrote to C.D.C. communications officials on July 15 to demand they turn over the name of the press officer who approved a series of interviews between NPR and a longtime C.D.C. epidemiologist, after the department in Washington had moved to take ownership of the agency’s pandemic data collection.

'I need to know who did it,' Mr. Caputo wrote. A day later, still without a reply, Mr. Caputo wrote back. 'I have not received a response to my email for 20 hours. This is unacceptable,' he said.

Efforts to Turn the MMWR Into Propaganda Criticized byAcademics in Public Health and Health Care, and the CEO of the Robert Wood Johnson Foundation

Per the Politico article above, Jennifer Kates, leader of the Kaiser Family Foundation's global health work

defended the CDC's process as rigorous and said that there was no reason for politically appointed officials to review the work of scientists.

Per the New York Times article above, Dr. William Schaffner, an infectious disease specialist at Vanderbilt University who sits on the external editorial board of the Morbidity and Mortality Weekly Report, said Caputo's operation 

undermines the credibility of not only the M.M.W.R. but of the C.D.C. And the C.D.C.’s credibility has been tarnished throughout Covid already

Per USA Today on September 13, 2020:

The interference is not just anti-science but disinformation intended to deceive the American public, said Dr. Eric Topol, a professor of molecular medicine at the Scripps Research Institute in La Jolla, California.

'This is outright egregious. It’s despicable,' Topol said, accusing Redfield and other leaders of allowing the agency to be hijacked by politics.

Also,

 On Twitter, Dr. Sherri Bucher, a global health researcher, wrote, 'There are no words to articulate how horrific this is. Trust & credibility, shattered, overnight. MMWR has been, for a long time, one of the most reliable, steadfast, scientific resources; unquestioned veracity, impeccable reputation for quality of data/analysis. No longer.

The Washington Post published an op-ed by Dr Erin Marcus, a professor of clinical medicine at the University of Miami Miller Medical School:

Caputo’s manipulation is appalling. If left unchecked, it could have disastrous consequences for the reputation and reliability of the CDC, which has already been battered by the U.S. response to covid-19. It could also prove devastating for medical practice in the United States more broadly.

In Scientific American, Dr Richard Besser, the CEO of the Robert Wood Johnson Foundation, wrote an op-ed entitled "We can't allow the CDC to be tainted by politics," noting:

 To meddle with, delay or politicize these [MMWR] reports would be a form of scientific blasphemy as well as a breach of public trust that could undermine the nation’s efforts to fight the coronavirus.

Summary

So to summarize, the White House put a pro-Trump political operative who had allegedly been involved in producing propaganda and disinformation in support of Trump to oversee all Department of Health and Human Services communications.  He and his hired cronies tried to bully and intimidate DHHS, particularly CDC staff, and to distort the contents of the renowned MMWR to support the Trump message.  Had these efforts succeeded they would have seriously impeded efforts to control the coronavirus pandemic by undermining the dissemination of scientific evidence needed for pandemic management and clinical care for affected patients.  

I found several academic public health and health care professionals willing to criticize Caputo and cronies' actions.  I found one leader of a prominent health care foundation willing to at least implicitly criticize them.  I found no one willing to hold accountable anyone at the "top" of the government who hired Caputo or encouraged his actions.  On this case, I could find no leader of a health care organization other than Dr Besser willing to say anything at all.   

Conclusions

Last month, we noted how disinformation about the coronavirus pandemic is being disseminated by the US president. 

Since then, two major efforts to use the CDC, the lead US public health organization, to support President Trump's political messaging, in effect, to function as a political propaganda outlet.  Individual US academic and practicing public health and health care professionals have been willing to decry these efforts, though not to directly hold Trump and his top lieutenants in the executive branch accountable.  In some cases, leaders of major medical organizations have been willing to state the principles that should have been upheld within the government.  

However, no chairpersons, deans, chancellors, vice-presidents for health affairs, university presidents; or journal editors, hospital executives, leaders of professional societies, executives of health care corporations, etc, etc were willing to publicly challenge Trump and his top collaborators.  Such leaders so far have also been unwilling to challenge Trump's efforts to spread disinformation.

To be charitable, such leaders may be to used to a kinder, gentler era to be able to fully comprehend that parts of the US government meant to be apolitical advocates for public welfare, such as the CDC, are being pushed to become part of an incipient Ministry of Propaganda.  



Fighting a deadly pandemic is hard enough.  It is gut wrenching that the fight is being subverted by political leaders spreading propaganda and disinformation.  It is sad that front line public health and health care professionals are hardly supported in their work by those who claim to lead them.  Where is the courage?  Where is the outrage?

"If not now, when?"

 

Friday, September 11, 2020

Tales From The Telly

1. Introduction. This post might just as easily be entitled "tales from the crypt," so far down the netherworld chute have American public health and medical workers been plunged. Nowadays whenever I speak to fellow physicians and tell them I've moved on from my own front line patient care, we exchange these utterances: they say "congratulations, I'm envious" and I say "my condolences." But the topic for today is more focal: telemedicine in the Age of Coronavirus.

Telemedicine, or "telemed," doesn't quite fit neatly into my ongoing series on why my dander's up. So for now let's set it aside and come back another time. It turns out that telemed—remote diagnosis and treatment using telecoms—is, like so many other innovations in health care, a two-edged sword. Let's look at it and see if we can come up with provisional answers to what, exactly, it means, beyond fear of face-to-face, to see its use soaring these days.

I've observed telemedicine now in a number of settings—lots of testimonials from colleagues, family, friends, and in just one instance myself as patient. Most of this is quite recent, for reasons we'll get to. I've never practiced it, never had time on my schedule to Zoom into some patient's bedroom. That's just an artifact of the timing. But I used to teach about it. And now it's arrived like gangbusters after languishing for decades in the ever-hopeful hearts of long standing organizations (here, here) devoted in part or in full to digital medicine.

The "why" for this onrush of telemedicine exposure is an easy one. In the Before Times, we had reimbursement problems that impeded it. All the other barriers, by, say 2010, were secondary. All our clocks now have a thick black line between BC and AD. Before Coronavirus versus After Donald.

Back in the BC, we can't get it paid for. Now, in the almost-AD: HHS rushes out new emergency regs, enabling telemed. With the pandemic, the new regs arrived just when providers, deprived of adequate PPE and in some cases a big chunk of salary, really needed the option. Whether they actually approved of it or not, different story. Necessity is the mother. All the rest is dross.

The above remarks set the stage. We just need to remind ourselves in passing: there's just not much scientific evidence for this technology's safety or efficacy. Rather, like so much else in digital medicine, telemed is probably here to stay because of one or another regulatory or epidemiologic crisis. Contrariwise, it's not an evidence-based imperative, at least not with respect to clinical results. For providers, of course, it may well mean survival, a different story.

So until we get more convincing science, here, for this blog's intrepid readers, are some narrative bits and bites to chew on: telemedicine, the good, the bad, and the ugly.

2. The Good. The single telemed session I undertook as a patient, reviewing some physiatric maneuvers, went rather well. So, too, did a family member's. When teaching about telemedicine I used to fret to think about its lack of touch. A cardiologist recently related some of his difficulties he'd had—the need to evaluate heart and lung sounds, to feel the liver—and how he recently almost lost a patient by relying on telemed. In that case, the common dreaded complaint of "I'm so tired" proved to stem from complete heart block. But this cardiologist didn't diagnosis his patient's CHB by telemed. He did it when he had the good sense to send that patient to the ER.

Conversely, I watched a vertigo patient properly and fully worked up, including appropriate neurologic testing. Vertigo is so often of the benign positional variety that this all made sense, with discussion of all the diagnostic and therapeutic maneuvers, the extensive taking of a history that can nail some diagnoses, and discussion of follow-up. There are lots of instances where such outcomes are possible. Physical therapy is another area where a session may go quite well.

Then, still in the "good" column, there's the public health benefit. An Associated Press release about telemedicine and coronavirus in Florida recently—this was late August—underscores the benefit. The AP release, available widely, e.g. here, didn't seem to get a lot of traction beyond its own republication. Maybe it was just drowned out by late summer vacation blues, gladiatorial politics, and whatever other Daily Outrage we're all lately subjected to.

In a relatively underserved area of Jacksonville, the site (or one site) of the GOP Convention days earlier, an aging public health nurse, like so many health workers faced with COVID-19, had a telemed session with a family physician, Dr. Cain. Both belonged to a minority community especially hard hit by the virus. Which is to say, hard hit by recent Florida politicians' methodical dismembering of the state's public health infrastructure. Privatization is one causative element of the systematic down-rating of public health in places like Florida. Ideology is undoubtedly another. Poor people's bodies are a favorite target of budget-cutters. They really don't matter, right? So those bodies get thrown under the bus. Always were.

Telemedicine can be a boon to the underserved, a patch on our deficits in social justice and public health. That was the case for Ms. Wilson, Dr. Cain's patient, who received assistance and did well. In the right hands—largely, I'd say, telemedicine offered by academic health centers (AHCs), but also in community hands such as Dr. Cain's—it can make a difference in narrowing the gap. Further, lest we view this as somehow second class, many patients in all socioeconomic categories prefer it—see the next section below—to going in and sitting around in waiting-rooms at either AHCs or community clinics.

3. The Bad. That's true even in the best of times. But as we know, right now we're not in those times.

On to the bad and the ugly. For the reader's consideration I submit a recent report (personal communication) from a colleague—a highly educated and sophisticated tech CEO—who'd enrolled as a patient in one of those "with six you get egg roll" deals with a telemedicine start-up. Right now a great number of telemedicine providers are based on free-standing start-ups: I know this because on a daily basis I receive at least one entreaty from such companies to throw my own hat in their ring. (Which was damned tempting by the way.) I've lost count, and I wonder whether there's any way to count up the entities that provide which kind of care. If there is, please add a comment below and tell me where that study's to be found.

Meantime, let's just put out there a typology—then let me how many of each you think there are.

  1. Academic centers' operations, now rampant, and generally fairly good (or as good as Zoom), in the AD time of coronavirus
  2. Dr. Cain's operation and other, similar, community-based ones (private/small group)
  3. Start-ups, which might or might not be conceived as extensions of physical docs-in-boxes
You tell me. Meantime, having talked to a lot of providers and patients who earn, or save, cash by participating in the doc-in-a-box style telemed shops, I'd like to tell my tech confrere's tale. Actually, let me let him tell it in his own words, substituting StartUp for the particular telemed company name.

I was overdue for my yearly physical, and since I had a subscription to StartUp, I decided to use the telehealth service for my physical.  I didn't have any major complaints, but I wanted to get some routine labs taken to make sure all was well.  I fired up the ... app and after giving a brief description of my concern and a few minute wait, I was virtually face to face with a doctor.  I've been on Propecia in the past, and have recently started it again during the COVID lockdown.  I knew my family physician often ordered a PSA test while I was on Propecia, so I thought it would be prudent to ask for the lab to be included in my blood work.  Things didn't go so well. 
Me:  I'm on Propecia, and I know my family doctor often ordered a PSA test in the past, can we include that? 
Doctor:  What's Propecia? 
Me: It's Finasteride. 
Doctor: Is that something your doctor prescribed? 
Me: Yes. 
Doctor [emphasis added here and below]: Well, they don't like us to order labs that require followup, so... 
Me: OK (I figured at this point it wasn't worth arguing the finer details of [StartUp] policy and I was reasonably sure the PSA would have been normal) 
Doctor: I'm ordering the labs, but sometimes they don't go through, so if there's a problem, just contact support and they'll sort things out.  Also, don't forget to follow up once you get the results. 
OK, so other than not knowing what Propecia is, not being able to order the PSA test and the fact that none of the tests might actually have been ordered, the call went pretty well. 
I made an appointment with Quest Diagnostics through the ... app for early the next morning to have the blood drawn.  After arriving at Quest and signing in, I was told there weren't any lab tests that had been requested for me.  I was prepared for this, and showed the receptionist the StartUp lab order PDF.  She looked at it and quickly said that they couldn't accept this as the order didn't include the doctor's name and she wouldn't know where to send the results.  I left, went back to the car, launched StartUp and requested another virtual consult.  After explaining to the doctor what Quest told me, he said it was strange but that he would re-request the labs. 
Armed with the new lab request, I went back to Quest, and spoke to the same receptionist.  She noted that it looked like someone "had done something" but there still weren't any lab tests to be found.  She also noted that their systems "weren't connected to anyone else".  At this point, I pushed back as I was fairly certain the lab tests were lurking in the Quest system and it was possible that the receptionist just didn't have experience or training with StartUp lab orders.  After some back and forth I was able to get her to enter the number provided with my lab order and was cleared to get the test.  As an added bonus, the Quest receptionist incorrectly told me that my insurance had been cancelled, only to later realize that she had entered my ID number incorrectly.- 
This was on a Friday, so I expected I would receive results early the following week.  On Tuesday I received a notification that my labs were available in the Quest portal.  I checked out the labs and then opened the StartUp app to initiate a follow up call to review the results.  Only one problem, according to StartUp the labs were still pending.  I sent a message to StartUp support and they said that normally results are available in the app as soon as the lab has them and that they would work with engineering to figure out what had happened.  Twenty Four hours later, there's still no word from engineering and the labs are still listed as pending in the app.  
I am lucky enough to have a distinguished physician as a friend who was kind enough to look over the labs and give me the all clear.  Without this connection, I would have been left wondering about the results and given that the StartUp doctor didn't seem familiar with Propecia (a common medication), I'm not sure I would have fully trusted their evaluation of the results.

It's no wonder that people who go to doc-in-a-box (or NP-in-a-box) sites typically do so for only the simplest and most straightforward complaints. And it's no wonder that the venture and hedge funds that capitalize these outfits do so in many cases while advertising they focus only on high-yield, low-risk diagnoses such as erectile dysfunction and contraception. Maybe the odd UTI or URI.

Oh, and colleagues who work for them tell me they exercise all sorts of mind-control, telling the providers what to say and what they can't say. Sadly, docs do this stuff (in category 3 above), often to moonlight and they just swallow their gall. Easy enough on the 'net to find out, however, exactly what they think about working for these outfits. But how many patients buy into it, as my colleague did, not knowing all this background?

In so many cases, therefore, it's all just another golden exercise in American ingenuity and lapping the cream. In no way is it, in its free-standing version, a response to the challenge of improving health care. Rather, it's the usual and sad response to improving investors' wallet contents.


4. Footnote: the Price of Admission. You can't do telemedicine without a good connection. But many who might most advantageously avail themselves of telemed consultation don't have that adequate connection. For those who'd like to read more about this conundrum, Brookings has just published a Techtank blog, by Visiting Fellow Tom Wheeler. He offers useful solutions in a piece entitled "broadband in red and blue," with some concrete and hopeful ways of redressing what's essentially yet another AD (After Drumpf) problem: the way the US has been closing the Digital Divide more assiduously for red than for blue states. The challenge, per Wheeler: "[t]here are almost three times as many Americans without a broadband subscription in blue urban areas than in red state rural areas."

People currently thinking about back-to-school issues, and kids' telelearning, probably aren't thinking quite as much about telemedicine, despite the striking parallel. But they should. Before they get sick.

The problems of telemedicine mirror those of the larger society, as does health equity mirroring societal equity. This will come as a surprise, no doubt, to precisely no one. Let's hope after November we get to putting the solutions, and the promises of telemedicine, into more socially just practice.

Sunday, August 30, 2020

President Trump and Surrogates Continue to Hold Campaign Events Enabling Spread of the Coronavirus: Had Enough Yet?

While the US continues to suffer from one of the worst outbreaks of the novel coronavirus pandemic to beset any developed nation (look here), national, state and local political leaders in the US who support President Trump have continued to hold events and otherwise behave in ways that seem designed to increase the spread of coronavirus. Multiple instances included leaders purposefully avoiding wearing face masks and social distancing in instance in which disease transmission was likely, eg, government meeting and political session, and engineering crowded events in which social distancing and wearing of face masks were rare (look here and here).



Three weeks since we last discussed this topic, as the US presidential race heats up, we have noted multiple instances in which President Trump and his campaign surrogates have again promoted multiple crowded, socially not distant events at which few attendees wore masks. At some of these events, the practices promoted by the organizers went against state or local laws or regulations.  And these practices are continuing to be associated with disease spread.

Listed in chronological order according to the date of the reporting:

Trump Campaign Events in Three States

As reported by the AP (via PBS) on August 19, 2020:

Iowa

During Pence’s Des Moines event, chairs arranged in small clusters six feet apart were quickly abandoned as many in the audience of about 200, few in masks, moved within a few inches of each other. Dozens crowded together afterward to get an autograph or nod from Pence.

Wisconsin

in Wisconsin on Monday, Trump absolved his audience of health precautions, along the way mocking the racial justice protests he has railed against for weeks.

In an aircraft hangar in Oshkosh, Trump flaunted violations of the state’s distancing and masking guidelines — recommendations also promoted by the federal Centers for Disease Control and Prevention — as he spoke to hundreds of supporters, most not wearing face coverings.

'This was supposed to be just a quick, little small gathering,' Trump said, joking that 'We’re supposed to have 50 people, right?'

'We’ll call it a peaceful protest, that way we can do whatever we want,' Trump added.

'This is like a rally,' Trump added, before telling supporters: 'I hereby grant you a pardon.'

Later in Wisconsin,

On Wednesday, Pence addressed a crowd at a metal fabricating pant in Darien, Wisconsin, where the crowd stood and sat close together, many people not wearing masks despite a statewide order requiring them indoors.

Arizona

At Tuesday’s similarly raucous rally in Yuma, Arizona, supporters sat on closely packed-in chairs and bleachers, and stood on a balcony as they chanted 'four more years!' While the hangar was open on one side overlooking Air Force One on the tarmac, it nonetheless felt stuffy inside in the stifling heat. Most in the crowd did wear official 'TRUMP' and 'MAGA' masks, though many did not.

To summarize, Trump campaign events were crowded and attended by people without face masks, and thus appeared designed to violate local rules about public health.  Trump himself mocked such rules and public health practices.

Republican National Convention Site, Charlotte, North Carolina

As reported by the Charlotte Observer on August 24, 2020:

Face masks were supposed to be worn at the Republican National Convention in Charlotte. In addition to North Carolina’s COVID-19 statewide mask mandate, RNC staff agreed to enforce the rule inside the convention center.

But on the floor of the RNC, strict coronavirus protocols quickly fell by the wayside Monday.

Social distancing was expected too — in addition to COVID-19 symptom screening and testing — to prevent a virus flareup as more than 300 delegates gathered at the Charlotte Convention Center Monday, in a dramatically scaled-down RNC to renominate President Donald Trump.

But many inside were seen not wearing masks and some attendees shook hands and huddled in tight-knit circles as the RNC recessed awaiting the arrival of Vice President Mike Pence. Among delegates and convention staff, some people did wear masks. Still others did not or were seen wearing face coverings ineffectively, such as having the mask slung below their chins.

Note that the management of the convention proceedings appeared to go against local public health rules..  Yet after local public health authorities reminded convention management of that, the problems continued.

Mecklenburg Public Health Director Gibbie Harris said Monday she contacted the RNC about the lack of masks and social distancing, observed not only by journalists inside the convention hall but also easily seen on live streams from the event.

'I have just shared concern about the lack of mask wearing and social distancing in the room at the RNC Roll Call Meeting with the RNC Convention staff,' Harris said in a statement Monday.

'I have been assured that they are working hard to address these issues. All attendees agreed to comply with the requirements prior to attending and were informed that these requirements would be enforced.'

Yet just a few hours later, delegates swiftly converged near the stage of the Richardson Ballroom as Trump concluded his remarks, holding up smartphones to snap a picture of their presidential nominee. Attendees, packed close to one another, danced the YMCA — with many still not wearing face coverings.

Further note that the Republican convention organizer's lax approach occurred at a time when transmission of coronavirus is a major concern in Charlotte.

The Charlotte area continues to grapple with the highest coronavirus case levels in North Carolina, though crucial trends — including hospitalizations and the test positivity rate — continue to improve. There have been 24,260 coronavirus cases and 282 related deaths among Mecklenburg residents as of Monday afternoon, according to state and local health officials said.

Thus it is not surprising that within days several convention attendees proved to be infected.  As reported by the Charlotte Observer on August 28, 2020:

Two attendees and two local support staff at the Republican National Convention in Charlotte tested positive for COVID-19, Mecklenburg County and GOP officials announced Friday.

The disclosures come after county health officials raised concerns about a lack of social distancing and mask wearing during the roll-call vote to renominate President Donald Trump for a second term on Monday — despite strict health protocols that were supposed to be followed. The GOP is defending the safety procedures it had in place.

Local health officials said the county instructed those who were infected to isolate immediately, and people who came in close contact with them should also quarantine themselves. A county spokeswoman did not respond to questions on whether the orders were followed.

To summarize, despite assurances that the event would promote best public health practices, the organizers allowed crowding and unmasked or inadequately masked attendance, even after public health officials had warned them about problems.  Probably due to the lack of public health preventive measures, attendees are already beginning to test positive for infection.


Republican National Convention Site, Washington DC

Melania Trump's Speech

As reported by CNN on August 26, 2020:

Those who attended first lady Melania Trump's speech in the White House Rose Garden that capped the second night of the Republican National Convention were not required to get tested for coronavirus, a person who attended the speech told CNN.

Despite that,

The vast majority of those attending did not wear masks, and the chairs provided for attendees did not appear to be placed six feet apart.

Trump's Nomination Acceptance Speech

According to the New York Times, August 28, 2020:

The chairs were packed in tightly on the White House lawn. Hundreds of people in the crowd had not been tested for the coronavirus upon attending.

The mostly maskless guests were seated cheek by jowl for hours....

Again, no masks, no social distancing, no observance of local public health rules.


Campaign Rally in Manchester, New Hampshire

As reported by NPR on August 28, 2020:

President Trump returned to New Hampshire Friday night, fresh off the Republican National Convention, for a rally at Manchester Airport.

For the hundreds of supporters in attendance, the atmosphere was that of a festival. Many wore Trump-themed clothing. Others wore T-shirts celebrating right-wing figures ranging from Fox News host Tucker Carlson to Brazilian President Jair Bolsonaro.

A minority wore masks, which are now required in New Hampshire at gatherings of more than 100 people. And many in the crowd jeered when an announcer on the PA system suggested they don them.

Again, no masks, no social distancing, and apparent public contempt for public health rules

Disease Spread Among Secret Service Agents Protecting Trump

Finally, the evidence that the Trump campaign is actually promoting the spread of COVID-19 is growing.  As reported by the Washington Post on August 28, 2020:

When President Trump gave a speech to a group of sheriffs in Tampa late last month, his decision to travel forced a large contingent of Secret Service agents to head to a state that was then battling one of the worst coronavirus surges in the nation.

Even before Air Force One touched down on July 31, the fallout was apparent: Five Secret Service agents already on the ground had to be replaced after one tested positive for the coronavirus and the others working in proximity were presumed to be infected, according to people familiar with the situation.

Then,

After the incident in Tampa in July, two agents who were assigned to stand guard at Trump’s private club in Bedminster, N.J., fell sick with coronavirus symptoms this month while the president golfed. It was his third trip there this summer.

In summary,

In the past two months, dozens of Secret Service agents who worked to ensure the security of the president and Vice President Pence at public events have been sickened or sidelined because they were in direct contact with infected people, according to multiple people familiar with the episodes, who spoke on the condition of anonymity to describe the incidents.

Trump's apparent disregard for the health of those who have sworn to protect him appears to be generating some unprecedented discontent.  A more rigorous program of coronavirus tests for agents was instituted:

after some discontent and anxiety percolated inside the agency earlier this summer, with agents and officers privately complaining that the White House and the Secret Service were not properly addressing the risks they faced on the road, according to people familiar with the concerns. Testing and protective equipment had been offered sparingly and inconsistently, some argued.

Even more pointedly,

this new virus that has killed nearly 180,000 Americans in eight months has prompted some to ask a new question: Should they be required to risk contracting a lethal disease — and infecting a loved one — to secure an event that does not follow health protocols?


Discussion

There is growing evidence that wearing face masks decreases the likelihood the wearer will transmit or contract the infection, and the likelihood that any such infection will be severe.  Keeping people physically separate, particularly by more than six feet, and particularly when they are indoors, also decreases transmission in either direction.

Nevertheless, after the Trump administration failed to effectively shield the US from the coronavirus pandemic, while peddling disinformation about the disease and its effects, the president continues to act in ways that actually promote further spread of the virus.  The perversity of his behavior is even being acknowledged by those sworn to protect him.  As reported by the Washington Post,

Never before has the Secret Service run up against a president so intent on putting himself first regardless of the costs, including to those around him,' said Ned Price, a national security expert and former CIA analyst.

While the Secret Service is having doubts, some Trump supporters deny the risks they are taking on his behalf.  Those who attend his campaign events, especially those who choose not to wear masks, have an elevated risk of becoming infected, and once infected, of transmitting infection to their friends and family.  Those who are already infected when they arrive at an event, even if asymptomatic, are at risk of spreading the disease to his other supporters.  Trump's careless, if not malevolent approach to public health at his campaign events is likely to hurt his own supporters before it hurts others.

Yet, perhaps rendered  stupid by Trump's propaganda and disinformation, they remain blissfully ignorant.  For example, as reported by NPR at the New Hampshire rally,

The COVID-19 pandemic was on the mind of many attendees. Timothy Parnell, an engineer who lives in Seabrook, said Democrats’ criticism of Trump’s handling of the coronavirus is 'absurd.'

'The only way the president could have done better is if he was psychic,' Parnell said. 'He took advice from the scientists; he asked for advice.'

Yet the evidence that Trump repeatedly disregarded, and often contradicted scientists' advice is clear.

Furthermore, as reported by the AP from a Pence event in Iowa,

Rob Mudd, who drove 120 miles from Cedar Falls to see Pence, was among those not wearing a mask. 'Is the disease real? Yes,' said Mudd, 53. 'So is the fear mongering.'

Likewise, Justin Chance, from suburban Des Moines, shook his head when asked why he, too, wore no mask. 'I just don’t believe all the hype,' said Chance, 55. 'I just don’t worry about it.'

Yet the US death rate for coronavirus this year has already exceeded 180,000.

Maybe his supporters are reassured about what Trump said in Oshkosh, “I hereby grant you a pardon.”   Of course, the coronavirus does not care if Trump gave someone "a pardon."  It could infect, and even kill such a person regardless.

Maybe the more Trump supporters fall ill, or see their friends and family members fall ill, the more they will doubt Trump's pretensions at royal pardons.  But that may take a long time, during which there may be a lot of disease and death.  Meanwhile, Trump will be able to do more and more damage to patients' and the public's health.

Instead of waiting, I hope my fellow professionals will step up now. It is time for us to tell every patient what they need to know to protect themselves from a deadly pandemic.  It is time for us to use every forum to reach the public with the message.  And it is surely time to call out the president and his supporters for their perverse and malevolent enabling of a deadly disease.

I know many health care professionals are afraid of appearing partisan.  It is not partisan to speak up for common sense public health measures to combat a deadly pandemic.  If there was ever a time for us health care professionals, especially those in the most senior and/or leadership positions to speak up, it is now.  Who will hear the call?

"If not now, when?"

Friday, August 21, 2020

Will US Health Care Leadership Challenge President Donald Trump's Propagation of Coronavirus Disinformation, a Major Source of the "Infodemic"?

Introduction: The Plight of Health Care Professionals Who Challenge the "Infodemic"

The coronavirus pandemic has been accompanied by a disinformation pandemic, sometimes called the "infodemic."  We have discussed how individual health care professionals trying to counter disinformation by educating patients and the public have encountered resistance, opposition and worse.  Here we discussed how 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."  Here we discussed how health care professionals who tried to counter disinformation online were subject to online challenges, insults and threats, and worse, how President Trump's campaign was organizing a cadre of "extremely pro-Trump" professionals who would parrot his messages, no matter how disinformative.



The Worsening Infodemic

Since then the disinformation problem has gotten much worse.  A recent study by Islam and colleages(1)

identified 2,311 reports of rumors, stigma, and conspiracy theories in 25 languages from 87 countries. Claims were related to illness, transmission and mortality (24%), control measures (21%), treatment and cure (19%), cause of disease including the origin (15%), violence (1%), and miscellaneous (20%). Of the 2,276 reports for which text ratings were available, 1,856 claims were false (82%).


So the challenge to health care professionals from disinformation has gotten much worse. On August 18, 2020, the New York Times reported

Doctors on the front lines of the global pandemic say they are fighting not just the coronavirus, but also increasingly combating a never-ending scourge of misinformation about the disease that is hurting patients.


The Times article included multiple anecdotes suggesting that the infodemic is directly harming patients:

An internist in New York treated a vomiting patient in May who drank a bleach mixture as part of a fake virus cure found on YouTube.

And in June a paramedic in Britain aided a clearly sick man who had refused to go to a hospital after reading misleading warnings about poor coronavirus treatment on social media.

Also,

Dr. Ryan Stanton, an emergency room physician in Kentucky, said a number of sick patients had waited until it was nearly too late to visit a hospital because they were convinced by what they had read online that Covid-19 was fake or 'no big deal.'

Similarly, the article by Islam et al noted estimates of the numbers of people who may have had adverse effects because of actions they took in response to disinformation: 800 dead and 5876 hospitalized world-wide after "consuming methanol as a cure for coronavirus"; "rumors have been the reported cause of 30 deaths in Turkey;" etc.

According to the Times article, health professionals who tried to challenge disinformation did not find it easy:

An emergency room doctor in Illinois was accused in April of profiting from naming coronavirus as the cause of a patient’s death, a rumor spreading online.

Also,

Some doctors say they face abuse when they participate in online discussions to correct the record.

And,

Dr. Mell, the physician in Illinois, encounters regular abuse from Facebook users when he has pushed back on false information.

Presumably efforts to combat disinformation should be informed by understanding of its sources.  The Times article briefly discussed physicians opinions of them. 

Before the pandemic, medical professionals had grown accustomed to dealing with patients misled by online information, a phenomenon they called Dr. Google. But in interviews, more than a dozen doctors and misinformation researchers in the United States and Europe said the volume related to the virus was like nothing they had seen before. They blamed leaders like President Trump for amplifying fringe theories, the social media platforms for not doing enough to stamp out false information and individuals for being too quick to believe what they see online.

A Major Source of the Infodemic: the US President and His Cronies

It would have been unthinkable a few years ago, but some physicians now are willing to state that a major source of dangerous health care disinformation is the current US president.



[Trump Chicago Hotel]


 In fact, the media has been replete with accounts of such disinformation propagated by President Trump.  Multiple  articles have cataloged examples of such disinformation.  The most recently updated were in published  in August, 2020, in the Washington Post, and the Atlantic.

Here is a summary of instances of disinformation that Mr Trump has peddled related to the coronavirus pandemic.  Sources are the two articles above or as noted.

Epidemiology, Diagnosis, Prognosis

The coronavirus is the same as influenza: "This is a flu.  This is like a flu." (from the Washington Post, March, 2020.)  However, coronavirus differs from the flu in its structure, epidemiology and clinical manifestations.

The coronavirus pandemic would spontaneously diminish or vanish, e.g., "disappear," "fade away," or "go away."  There is no rationale for this, and no trend in this direction in the US.

The pandemic is already going away, e.g., “Coronavirus numbers are looking MUCH better, going down almost everywhere,” and cases are “coming way down.”  The national case rate did decrease for a time, but then greatly increased, and now is considerably higher than it was a few months ago.

COVID-19 is not a severe disease, especially for children, e.g., children are "virtually immune," "99% of COVID-19 cases are 'totally harmless'" There is no evidence children are immune.  Cases in children are now rising.  The rate of significant morbidity or death is much higher than 1%.

Tests for coronavirus in the US are extremely accessible, e.g., "anybody that needs a test gets a test," "we're going up proportionally very rapidly," the US has done more testing "than all other countries combined."  There have been multiple reports of shortfalls in and inaccessibility of testing.

The US case rate is high because the US testing rate is so high: "There is a rise in Coronavirus cases because our testing is so massive and so good, far bigger and better than any other country." (from the Independent, July, 2020.)  By many measures, the US testing rate is lower than that of many other developed countries.

If testing stopped, then there would be no more cases, e.g. "If we stop testing right now, we'd have very few cases, if any." (from the Independent, June, 2020.)  This appears to be an instance of the logical fallacy of the appeal to ignorance, often characterized as "absence of evidence does not imply evidence of evidence" (see this from Logically Fallacious). 


Prevention, Management, Treatment

Hydroxychloroquine is safe and effective as a treatment or preventative drug, e.g., "I happen to be a believer in hydroxy.  I used it.  I had not problem,"  There is no good evidence that hydroxychloroquine is an effective treatment or preventative measure.  There is evidence that it has important and not rare adverse effects.

Bleaches or disinfectants could be administered internally for prevention or treatment  (from the New York Times, April, 2020.)  Doing so actually would be extremely dangerous, and possibly fatal. Note that there is reason to suspect that Trump's disinformation on this topic has harmed people. After he publicly discussed using bleach or disinfectant internally as a treatment for coronavirus, calls to poison control centers seemed to rise (from Vox, April, 2020.)  The article by Islam et al noted instances of patients harmed by ingesting disinfectant.

No Organized Challenges to Trump's Disinformation from Health Care Professionals

Donald Trump has extensively promoted disinformation about the coronavirus.  As US President, he commands a substantial "bully pulpit."  Essentially everything he says publicly is reported by US and foreign media.  He holds forth on Twitter daily, reaching millions of followers.  Thus his information is influential, and apparently dangerous.

Health care professionals have seen patients whose beliefs about the coronavirus pandemic are now apparently inspired by disinformation, including specific points pushed by Mr Trump.  These beliefs have led to dangerous actions, and at times adverse effects.  Professionals sworn to put their patients' welfare ahead of all other concerns are thus in a bind, needing to challenge the leader of the richest country in the world to persuade their patients to avoid dangerous choices.

While physicians on the front lines are now struggling with how to best deal with the disinformation influencing their patients coming from the highest office in the US, they have gotten little support from their leaders.  I found only a few instances of physicians in positions of leadership and influence willing to challenge President Trump.

The most direct challenge was found in an editorial in the British Medical Journal by two American authors, both academics at respected institutions, one a full professor in a global health institute.  The authors had the courage to entitle their article "Donald Trump: a political determinant of covid-19." (2)  They asserted that

After the US confirmed its first case of covid-19 on 22 January 2020, Trump responded with false reassurances, delayed federal action, and the denigration of science.

In particular, they were willing to state:

Trump’s anti-scientific pronouncements during covid-19 have been particularly perilous. On 28 February, he said that the coronavirus would soon disappear on its own 'like a miracle.' On 21 March, he promoted the anti-malarial drug hydroxychloroquine for 'use immediately' as a treatment, despite the lack of evidence for its effectiveness. His promotion triggered 'panic-buying, skyrocketing prices, and overdoses in malaria-prone regions in Africa and South Asia,' and led to shortages of the drug for those who need it to treat other conditions such as lupus, for which it has proved benefit. Rick Bright, the director of the US agency that oversees covid-19 vaccine development, says he was removed from his post because he questioned Trump’s promotion of hydroxychloroquine. On the day that the CDC advised the public to wear face masks, Trump said he would not wear one himself. On 23 April, Trump suggested that injecting disinfectant or bringing 'light inside the body' could cure covid-19, prompting experts to urgently warn the public against inhaling or ingesting bleach.

Beyond this moral clarity, I could find only one other instance of a senior academic physician directly challenging Trump, and that was only indirectly about Trump's enthusiasm for disinformation.  From the Independent, July, 2020:

A leading professor of medicine has called president Donald Trump 'unteachable' on the subject of masks and said that it indicates he is not competent to manage the response to the coronavirus pandemic.

In an appearance on CNN, Dr Jonathan Reiner, professor at the George Washington School of Medicine & Health Sciences, responded to the president’s latest remarks regarding the wearing of masks.

'He is unteachable and I can’t understand it. His failure to understand this simple public health measure, his reluctance to accept the advice of all of his public health experts, makes me wonder whether he is qualified now to manage this.'

I have so far found no other instances of leading academics, like professors, chairpersons, deans, chancellors, vice-presidents for health affairs, university presidents; or of journal editors, hospital executives, leaders of professional societies, executives of health care corporations, etc, etc who were willing to publicly challenge Trump's disinformation.  I have found no official statements from any of these institutions or organizations that challenge Trump's disinformation. 

At best, medical societies have put out statements reiterating the need to base policy about the pandemic on the best evidence.  For example, the American College of Physicians put out a statement that supported "the use of scientific expertise, based on the best available evidence, in the fight against COVID-19." However, these statements do not explain the context, that is, how the current president has denigrated scientific expertise and evidence as informative in efforts to manage the pandemic.

Fighting a deadly pandemic is hard enough.  It is gut wrenching that the fight is being subverted by political leaders spreading disinformation.  It is sad that front line clinicians are hardly supported by those who claim to lead them.  Where is the courage?  Where is the outrage?

"If not now, when?"


References

1.  Islam MS, Sarkar T, Khan et al. COVID-19-related infodemic and its impact on public health: a global social media analysis. Am J Trop Med Hyg 2020. Link here

2. Yamey G, Gonsalves G. Donald Trump: a political determinant of covid-19. Brit Med J 2020; ; 369 doi: https://doi.org/10.1136/bmj.m1643. Link here.











Sunday, August 09, 2020

Next Installment: How Can We Fight the Coronavirus Pandemic Under Political Leaders Who Enable the Spread of the Virus?

While the US continues to suffer from one of the worst outbreaks of the novel coronavirus pandemic to beset any developed nation, as we have discussed, President Trump and his administration have hindered pandemic management in the US and around the world. In particular, last month we noted what appeared to be a well developed pattern of behavior by the president and political leaders who support him in which they acted as if the were trying to enable the spread of the virus.  These instances included leaders purposefully avoiding wearing face masks and social distancing in instance in which disease transmission was likely, eg, government meeting and political session, and engineering crowded events in which social distancing and wearing of face masks were rare.





Only a month has past, but there have been too many new instances of political leaders acting as if they were actively trying to increase the spread of COVID-19 to ignore.  So we will again summarize new cases by category, and within categories, chronologically.

President Trump Acting Personally to Enable Viral Spread

Trump Attended Political Fundraiser Unmasked, Mingled in Crowd and Shook Hands

On this occasion, as is typical for him, the president avoided a mask and social distancing at the same time.  Per the Independent on July 21, 2020:

Video from an congressional candidate’s fundraiser in Washington shows Donald Trump mingling with a small crowd without a mask – even as he finally began wearing one in public after months of resistance.

Mr Trump appeared at a fundraiser for Madison Cawthorn, a young congressional candidate in North Carolina who defeated a Trump-backed contender in his recent primary – thereby breaking the president’s perfect endorsement record.

In Mr Cawthorn’s video of the fundraiser, held at the Trump International Hotel near the White House, he is enthusiastically greeted by various high-profile guests, including South Carolina senator Lindsey Graham – also unmasked – and the president’s attorney, Rudy Giuliani, who shakes his hand saying 'you can touch me'.

Mr Trump did not appear to be carrying a mask in either hand, and Mr Cawthorn himself was not wearing a mask either.

Trump, Unmasked, Invited Crowding at Various Somewhat Impromptu Events

Sometimes a Trump event starts with social distancing.  For example, per the Washington Post reporing on August 7, 2020, Trump attended an event at a:

facility [which] is larger than conference spaces in the White House, providing room for guests to spread out and safeguard against the coronavirus.

As the president spoke, he invited several guests, including Florida Gov. Ron DeSantis (R), to speak at a lectern set apart from his own to observe social distancing guidelines.

However, at the behest of Trump, social distancing soon vanished:

after his remarks, Trump invited a dozen people to crowd behind him shoulder-to-shoulder as he signed several executive actions and handed out ceremonial pens. Four wore face masks, while the others did not, including the president and four doctors in white medical smocks.

he article also noted several previous events at which Trump managed to omit masking and invite crowding in a somewhat impromptu manner:

On a trip to Tampa last week, Trump held an event on the airport tarmac in which he touted the endorsement of local sheriffs in front of more than 150 supporters, most of whom were clustered tightly and did not wear masks. At the White House this week, he invited 21 guests, including two children, to gather behind him as he signed a bipartisan bill on national parks.

Then,

On Thursday, Trump visited Ohio, where he wore a mask during a factory tour but also delivered remarks to dozens of supporters clustered at the airport.

Trump "Press Conference" at the Trump Organization's Bedminster, New Jersey Golf Club Attended by Paying Club Guests Sans Masks or Social Distancing

Most recently, the Washington Post reported on August 8, 2020:

Just before 7 p.m. Friday evening, members of President Trump's private golf club here began streaming into a gilded ballroom by the dozens. Some carried wineglasses — few wore masks.

The happy hour scene just steps from the golf course was orchestrated by Trump, who decided late Friday to hold an impromptu news conference and invite his club members to gather indoors in defiance of state restrictions aimed at slowing the spread of the novel coronavirus.

Then,

The pandemic, he told the room, 'is disappearing. It’s going to disappear.'

Many in the crowd behaved as if the pandemic had already vanished, forgoing guidelines on social distancing, face coverings and avoiding nonessential gatherings.
So by my count, President Trump held at least six events in the last month in which he did not wear a mask, most guests did not wear masks, and in which guests were crowded together.  All these circumstances favor transmission of the coronavirus, to Trump, and to everyone else there who failed to wear a mask while closer that six feet to other people. 


The Trump Administration, Family and Close Associates

Herman Cain, Prominent Trump Supporter and Former Presidential Candidate, Died of COVID-19 After Attending Packed Trump Rally in Tulsa Without a Mask

This is a tragic followup to a case we discussed last month.  The Trump campaign had organized and promoted a crowded campaign rally in Tulsa, Oklahoma over objections of local public health authorities and physicians.  The campaign actively worked to prevent social distancing and did not encourage masks.  Several campaign workers and Secret Service agents tested positive around the time of the rally, and prominent Trump supporter and former presidential candidate Herman Cain, who was photographed without a mask and crowded together with other at the rally, tested positive afterwards and was hospitalized.

On July 30, 2020, the Washington Post reported that Mr Cain passed away:

Herman Cain, the former pizza chain executive who sought the 2012 Republican presidential nomination, has died weeks after testing positive for the coronavirus.

A commentary in the New York Times noted that Mr Cain had personally scorned the public health measures meant to control the pandemic:

Mr. Cain was eager to display his disregard for the experts and their warnings. Before the Trump rally in Tulsa, which local public health officials had urged the campaign to postpone, Mr. Cain urged people to 'Ignore the outrage' and to defy 'the left-wing shaming!'

There is no record of whether Mr Cain later was outraged that he became a victim of the virus, and of Trump's campaign to minimize its risks.


Trump Supporters in the US Congress

Political leaders who support Trump also have been eager to show their disdain for measures meant to slow the spread of the pandemic.


Senator Ted Cruz (R-TX) Maskless on an Airplane

As reported by the Independent, July 13, 2020:

Texas senator Ted Cruz appeared to contravene an airline’s mandate on masks this weekend when he was pictured without one.

In a picture shared online on Sunday, Mr Cruz was onboard an American Airlines departure when he was seen unmasked.

The airline’s own mandate on masks says all passengers should wear one, unless when eating and drinking onboard.

Mr Cruz, who was pictured with a coffee in hand, was said to have 'not worn a mask once'.

'Captured today at 10:45am – Ted Cruz on a commercial flight, refusing to wear a mask,' wrote Twitter user Hosseh Enad with the picture.

He added: 'This was on an American Airlines flight — their policy clearly states that masks should be worn on the flight.'

Mr Enad said Mr Cruz had not been asked to wear one on Sunday, and was not seen masked.

Given the close quarters on commercial aircraft, social distancing may not always be possible, placing the emphasis on masks to decrease spread of the virus.  As noted above, Sen Cruz not also put himself at higher risk of contracting COVID-19, he increased the risk of passengers around him of contracting the disease from him.

Representative Louie Gohmert, Who Insisted on Attending Sessions Without a Mask, Tested Positive for COVID-19

Last month, we noted that Rep Gohmert (R-TX) often appeared at the House of Representatives without a mask and without maintaining social distancing.  On July 29, 2020, Politico reported:

Rep. Louie Gohmert — a Texas Republican who has been walking around the Capitol without a mask — has tested positive for the coronavirus, according to multiple sources.

Gohmert was scheduled to fly to Texas on Wednesday morning with President Donald Trump and tested positive in a pre-screen at the White House.

The article noted that Gohmert seemed to have ample opportunity to transmit the virus, for example:

Gohmert attended Tuesday's blockbuster House Judiciary Committee hearing with Attorney General William Barr in person, where lawmakers were seated at some distance from one another.

But footage from before the hearing shows Gohmert and Barr walking together in close contact, with neither wearing a mask. 

Trump Supporters in State Governments

 Republican State Legislators in Minnesota Refused to Wear Masks During Sessions

On July 13, the Minneapolis Star Tribune reported:

It was the closing hours of the last special session.... there was a stark contrast: Every Democrat entered the room with a face covering; but not one Republican wore a mask

Some particular examples:

For state Rep. Jeremy Munson, R-Lake Crystal, a state mandate would not change his decision not to wear a mask. At a recent groundbreaking event, he showed up without a mask. When one was offered, he refused it. Munson said a photo from the event captures everyone else — including City Council members and Republican Sen. Julie Rosen — in masks, while his face is bare.

'I just haven’t seen a need for it,' said Munson, maintaining that his focus is on washing his hands and social distancing.

The Senate Majority Leader Paul Gazelka

said he tries to be socially distant, but has not worn a mask at the Capitol and generally prefers not to use them.

His rationale for that, and for opposing any sort of legal mandate to wear a mask:

'People are tired of ... being micromanaged,' Gazelka said. 'It’s a sense of controlling your own destiny.'

Of course, failing to wear a mask could control the destiny of people nearby, who would be at increased risk should the person refusing to mask have coronavirus, even without symptoms.

Oklahoma Governor Kevin Stitt Got COVID-19 Infection After Scoffing at Pandemic Control Measures

Republican Governor Stitt, who had defiantly posted a picture of himself with his family at a crowded restaurant in March (look here), tested positive in July.  Per the New York Times, July 15, 2020:

Gov. Kevin Stitt of Oklahoma announced on Wednesday that he tested positive for the coronavirus, becoming the first governor in the United States known to have been infected during the pandemic.

But he

said that his own infection had not prompted him to second-guess his response to the virus, which has been less aggressive than in many other states, including some led by fellow Republicans. The governor has resisted issuing a statewide mask order, and continued to do so on Wednesday. He faced criticism early on in the outbreak, in March, when he posted a photo of himself with his children inside a crowded restaurant at a time when many people in the state were following social distancing protocols.

Gov Stitt apparently had continued to eschew masks right up to the moment he got the positive test, so he may well have spread the virus to other people

On Tuesday morning, hours before he received his test results, Mr. Stitt attended a special meeting of the state’s Land Office in a conference room at the State Capitol in Oklahoma City. He did not wear a mask.

Lt. Gov. Matt Pinnell, who serves in the governor’s cabinet as secretary of tourism and branding and who sat unmasked at a conference table across from Mr. Stitt at the Land Office meeting, said in a Facebook post that he was going to be tested after learning the news and was self-isolating at home.

Missouri Governor Mike Parson Derided "Dang Masks," Encouraged Maskless People to Crowd Together at Political Events

As reported by the Springfield (MO) News-Leader, July 18, 2020:

Missouri Gov. Mike Parson isn't always practicing what he and top state public health officials are preaching.

On July 10, a post on his official Twitter account instructed Missourians to social distance and wash their hands and added, 'If you can't social distance, wear a mask.'

The next day, his campaign posted photos of him mingling sans mask at a Missouri Cattlemen's Association steak fry in Sedalia, where he also lampooned the idea of mask mandates like those now in place in 28 other states.

'You don’t need government to tell you to wear a dang mask,' he said. 'If you want to wear a dang mask, wear a mask.'

Also,

At a ceremonial bill signing inside the Springfield Regional Police and Fire Training Center, a maskless Parson actually invited police officers and other dignitaries to gather behind him for photographs as he went about signing bill copies, and waved over more as time went on.

Utah Governor Gary Herbert Held Party at Governor's Mansion Sans Masks and Social Distancing

According to the Salt Lake City Tribune on July 23, 2020, on the day before a person who happened to work for the city Department of Public Health, walking by the Utah Governor's Mansion saw:

a harp sitting outside the stately residence. Illuminated by overhead string lights, caterers balanced trays of food and cleared away dirty dishes.

And,

The roughly 20 guests who were milling around the mansion lawn were dressed to the nines.... Only, some of them were lacking the trademark coronavirus-era accessory — a mask.

Also,

only half the partygoers were wearing the masks, meant to curb the spread of COVID-19. Some people appeared to have removed their face coverings to eat, he said, but others without masks were clustered in groups and chatting.

That pedestrian's husband took a photograph which

depicts at least one partygoer not wearing a face covering and another person whose mask was pulled down. Both appear to be standing in close proximity to other guests.

Note that Utah's Republican Governor had declined to issue a face-mask mandate at the time the party was held.

Summary

 As the US count of COVID-19 cases grows, now exceeding 5 million, while the death count grows  past 160,000, we continue to  see instances in which President Trump and his political supporters, including state governors and members of congress personally ignore common-sense, simple measures meant to better contain the pandemic.

There is growing evidence that wearing face masks decreases the likelihood the wearer will transmit or contract the infection, and the likelihood that any such infection will be severe.  Keeping people physically separate, particularly by more than six feet, and particularly when they are indoors, also decreases transmission in either direction.

Yet the leader of the US government, and many of his supporters in the US legislature and state governments continue to ostentatiously dismiss masks and social distancing, and to encourage others to do the same.  They continue to do this even as their ranks include more people who have caught the virus, some who have been symptomatic, and at least one who died.

Even after that death, per the New York Times

Even some of the harshest critics of Republican leadership said they did not think that Mr. Cain’s death would cause much reflection inside the party.

Evan McMullin, who ran against Mr. Trump as a third-party candidate in 2016, wrote on Twitter that Mr. Cain was 'the first senior casualty of the science denial Trump cult.'

In an interview, Mr. McMullin said he had little hope this was a wake-up call. 'I wish that was the case,' he said. 'Many voters who support the president live in a totally different, alternate information environment in which the news of Herman Cain’s death — his visit to the Trump rally, his decision to not wear a mask — won’t reach them.'

But as long as the political leadership remain unreached, not only will their personal actions continue to enable the spread of the coronavirus, they are unlikely to support effective policies to contain it.

Of course, such strongly partisan political leaders are not likely to change their thinking based on criticism from their political opponents. Yet most of the criticism they have faced has been clearly political.

Many health care professionals have been overwhelmed by the need at the front lines during the pandemic.  However, I have not heard a lot coming from those who have a bit more time to think, especially from the leaders of big health care institutions, directed at the political leaders who take the virus most casually.

I know many health care professionals are afraid of appearing partisan.  It is not partisan to speak up for common sense public health measures to combat a deadly pandemic.  If there was ever a time for us health care professionals, especially those in the most senior and/or leadership positions to speak up, it is now.  Who will hear the call?