The Ultimate Conflict of Interest: Trump Organization Revenue vs Lives Lost to Coronavirus

Introduction: Conflicts of Interest and the Trump Administration

We have been discussing the pervasiveness of conflicts of interest in health care for years.  Recently,  we have worried how conflicts of interest and corruption in health care could be combated under an administration with such severe conflicts of interest and corruption at the highest levels, most recently here.

President Trump and his family's conflicts of interest and alleged corruption centered on their ownership of the Trump Organization, a multi-national privately held hospitality and real estate business.  Since the inauguration, Trump personally has benefited from the Trump Organization's dealings with foreign, US federal and US state governments, grossly violating two clauses of the US Constitution.

These dealings raised major constitutional and ethical questions, and concerns about whether Trump administration policies were distorted to benefit his businesses, and hence his own fortune. However, our biggest concern was about how the conflicted and corrupt aura of his administration made it difficult to address conflicts of interest and corruption in health care.

Now, in the shadow of the coronavirus pandemic, it appears that Trump's conflicts of interest may be dangerously affecting his administration's public health policies and its ability to suppress the virus and save lives.


Social Distancing and Other Measures to Combat Coronavirus Damaging Trump Organization Finances

In the Washington Post on March 23, 2020, David Farenthold reported on the likely severe financial losses being incurred by the Trump Organization, whose biggest owner is President Trump

President Trump’s private business has shut down six of its top seven revenue-producing clubs and hotels because of restrictions meant to slow the spread of the novel coronavirus, potentially depriving Trump’s company of millions of dollars in revenue.

In particular,

he is also heavily invested in the hotel business, with 11 hotels around the world.

That business needs new people walking in the door every day, to eat and stay. And by keeping people away, the coronavirus has brought that industry its worst downturn in recent history.

'The data is bad. And we haven’t seen the worst of it yet,' said Jan Freitag, a senior vice president with the firm STR, which analyzes hotel industry data. He noted that the damage to the industry is being caused by the lockdowns and the fear of the virus. 'What we’re seeing here is a rapid descent that’s going to last. So it’s going to be a little bit of a worst-case combination of post-9/11 and [the financial crisis of] 2009.'

So far, the Trump Organization has closed hotels in Las Vegas; Doral, Fla.; Ireland; and Turnberry, Scotland — as well as the Mar-a-Lago Club in Florida and a golf club in Bedminster, N.J. Many of the clubs closed because they had to, under local orders. Others closed on their own, following strong guidance or recommendations from local officials.

Those are six of Trump’s top seven revenue-producing clubs and hotels, bringing in about $174 million total per year, according to Trump’s most recent financial disclosures. That works out to $478,000 per day — revenue that is likely to be sharply reduced with the clubs shuttered. The disclosures provide self-reported revenue figures but not profits.

Trump's personal financial concerns are compounded due to financing issues.

Three of Trump’s hotels — in Doral, Chicago and Washington — have outstanding loans from Deutsche Bank that originally totaled more than $300 million. Even before the coronavirus outbreak, all three reported lagging behind their peers in occupancy and revenue, struggles that the company’s representatives blamed, in one way or another, on Trump’s political rise.

[Trump Tower Chicago, which houses the Trump Hotel]

 While the latter two hotels are still open, they are not doing well.  For example, an article by Mr Farenthold and colleagues on March 20, 2020, noted that the Trump International Hotel in Washington, DC now has an occupancy of only 5%.  So the resulting sharp revenue drop raises the risk that the Trump Organization would default on its loans.

[Interior, Trump International Hotel, Washington, DC]



Hotel Closures Create Other Personal Problems for Trump

These financial threats to Trump may be compounded by threats to other benefits the Trump Organization properties have afforded him.  Some of these properties have been loci of political power.  In particular, the Trump International in Washington DC has been the place for Trump supporters to congregate, and for various interests, including corporate leadership and foreign governments to seek to influence Trump (see the voluminous "Tracking Corruption and Conflicts in the Trump Administration" report section of the Global Anti-Corruption blog for details.)

It is also very likely that the Trump Organization is also financed by shady Russian money.  As reported in Foreign Affairs in 2018,

according to several sources with knowledge of Trump’s business, foreign money played a large role in reviving his fortunes, in particular investment by wealthy people from Russia and the former Soviet republics. This conclusion is buttressed by a growing body of evidence amassed by news organizations, as well as what is reportedly being investigated by Special Counsel Robert Mueller and the Southern District of New York. It is a conclusion that even Trump’s eldest son, Donald Trump Jr., has appeared to confirm, saying in 2008—after the Trump Organization was prospering again—that 'Russians make up a pretty disproportionate cross-section of a lot of our assets.'

Trump’s former longtime architect, Alan Lapidus, echoed this view in an interview with FP this month. Lapidus said that based on what he knew from the internal workings of the organization, in the aftermath of Trump’s earlier financial troubles 'he could not get anybody in the United States to lend him anything. It was all coming out of Russia. His involvement with Russia was deeper than he’s acknowledged.'

So,

By the time he ran for president, Trump had been enmeshed in this mysterious overseas flow of capital—which various investigators believe could have included money launderers from Russia and former Soviet republics who bought up dozens of his condos—for a decade and a half. And Felix Sater was pitching Cohen on a Moscow deal as recently as mid-2016—as Trump was clinching the Republican nomination, according to a sentencing memo recently unveiled by the Mueller probe.

Furthermore, as Craig Unger wrote in the Washington Post in 2019,

for more than three decades, at least 13 people with known or alleged links to the Russian Mafia held the deeds to, lived in or ran criminal operations out of Trump Tower in New York or other Trump properties. I mean that many of them used Trump-branded real estate to launder vast amounts of money by buying multimillion-dollar condos through anonymous shell companies. I mean that the Bayrock Group, a real estate development company that was based in Trump Tower and had ties to the Kremlin, came up with a new business model to franchise Trump condos after he lost billions of dollars in his Atlantic City casino developments, and helped make him rich again.

Yet Trump’s relationship with the Russian underworld, a de facto state actor, has barely surfaced in the uproar surrounding Russia’s interference in the 2016 campaign.

Shady Russian operators, money launderers, the Russian mafia, and those tied to the Putin regime may not have much sympathy for those indebted to them who payment difficulties. Whatever the form of his Russian support, it might be that his waning financial fortunes have led to some quiet but severe pressure from overseas on the Trump Organization and Trump himself, further increasing his impetus to open up his hospitality properties, regardless of the costs and risks to others


The Conflict of Interest Illustrated and Some Dire Conclusions

As Farenthold wrote,

As he is trying to manage the pandemic from the White House, limiting its casualties as well as the economic fallout, his company is also navigating a major threat to the hospitality industry.

That threatens to pull Trump in opposite directions, because the strategies that many scientists believe will help lessen the public emergency — like strict, long-lasting restrictions on movement — could deepen the short-term problems of Trump’s private business, by keeping doors shut and customers away.

As he also wrote, at the same time that Trump is under personal financial and who knows what other pressure due to the closure of his hospitality properties,

Trump is considering easing restrictions on movement sooner than federal public health experts recommend, in the name of reducing the virus’s economic damage.

In a tweet late Sunday, Trump said the measures could be lifted as soon as March 30. 'WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF,' he wrote on Twitter.

Trump did not specify for whom the cure might be worse than the disease.  The obvious suspicion is that he is talking about the "cure's" effect on ... Donald Trump and his family.

This raises the strong and extremely worrisome concern that he is thinking of taking measures that may risk the lives of thousands or millions of people to preserve his wealth and personal power.  (Maybe he also is trying to save himself from some Russian retribution?)

That may be the most severe and dangerous health care conflict of interest we have ever seen in the US.

I, for one, do not trust Donald Trump to put the country's interests, and the lives of its citizens, ahead of his own personal and financial well-being.  As long as this horrendously conflicted man is running the country, we will be in doubt, and at grave risk.  

COVID-19: Could We Have Been More Ready?

We now see reports of how the US is short of either masks, gowns, doctors, hospital beds, ventilators, community health workers, tests, treatments, or some combination thereof, to manage the new COVID pandemic and the annual influenza season.  We see Congress hustling to adopt a funding package to catch up with the gaps.

I just saw, as an attending physician on a busy urban internal medicine hospital service, how that shortage potentially endangered mine and my colleagues lives, as well as that of my patients.  At first we were told to reuse our masks--there might be or would soon be a shortage.  Then we were told NOT UNDER ANY CIRCUMSTANCE to reuse them--we could infect patients by room-to-room transmission.  Then we ran short of masks and.....well you can guess what we were told.

All this got me to thinking about a project I was involved in nearly 15 years ago.  I was part of a national task force asked to develop a national public health and primary care response plan to respond to a theoretical (then presumed influenza) pandemic in the US.  We did, over a year-long series of scholarly and cordial meetings and document exchanges.  All the primary care disciplines lent representatives to the committee, organized by the Agency for Healthcare Research and Quality (then AHCPR).

As far as I can tell, our report, which would have required a significant cost outlay for workers and equipment which would sit idle until the pandemic arrived, was not adopted, and no funds were approved to beef up the already anemic public health infrastructure at that time, just post 911.  Even 911 was not enough to boost a response that, I suspect, national leaders saw as wasteful.

Wasteful... hmm. That means pockets would be emptier, balance sheets more toward the red, taxes higher, and stockholders' value down.  We needed to operate more like a business, cut waste, and increase efficiency.

But wait, that's managerialism right?  Increase shareholder value at all costs, even, in this case, human lives.  We've got a business--I mean public health infrastructure to run here.  No time for more idle firemen.

I wonder if anybody in power around 15 years ago remembers sitting on our plan, and regrets not adopting it?   This year, almost 60,000 have died from influenza, and we are waiting to see the death toll from COVID.  How much money is a life worth?

Wally R. Smith, MD

Guest Post: Coronavirus and the Finger of G-d

Health Care Renewal presents a guest post from Dr Michael Fine, a writer, community organizer, and family physician. He is the chief health strategist for the City of Central Falls, RI, and Senior Clinical and Population Health Services Officer for Blackstone Valley Community Health Care, Inc., and recipient of the Barbara Starfield Award, the John Cunningham Award, and the Austin T. Levy Award. He was director of the Rhode Island Department of Health, 2011–2015.  He is author of Abundance and Health Care Revolt


What Cheer!

So now Coronavirus is here.


Let me say up front what I’ve said before: for most of us, this will be a mild disease, and there is nothing to fear but fear itself. Still, we need to act and act fast if we are going to take good care of most people and protect our democracy.

And we have a choice. If we change a lot and change fast, we'll save the lives of a couple of hundred thousand more people, mostly people who are old or already sick. But to protect those people, we have to put the lives of young people, who are at some but minimal risk, on hold.


The lessons from China and Italy are clear. We can save lives, at least in the short run, by locking things down for three or four months. But if we are to be most effective, we have to do more than that. We have to create fever clinics and isolation hospitals. Convert existing hospitals to intensive care units. Build a health care system to take care of all Americans, and do that practically overnight. And find some way to support every American during this period, so no one is ignored or displaced during this period of extended hibernation.

To keep social peace, we need to fix what’s broken in our culture and fix it fast, otherwise people disadvantaged by our market economy won’t be able to stay home and stay quiet, and shouldn’t: many will risk more by staying home than they do from this virus. That means we need to make sure everyone has enough. Enough food and housing. Enough heat and water. Immediate access to health care when lots of people are sick. Enough internet and phone to stay connected. Enough money for us all to sustain ourselves during this period.

That means we wipe away all student loans and make college free for everyone, to pay it forward to the young people who we are asking to sacrifice now. That means we build a health care system that can care for everyone, the hell with what insurance card they carry, and that we do that overnight. And that means we take care of people before we take care of corporations. Which means wealth will shift from the rich, who have too much and have had too much for too long, to most people, who may have just enough but teeter on the edge unnecessarily. That means we do what we should have done long ago.

I have been thinking about the bankruptcy of our political culture for a long time, thinking about how we've let ourselves be polarized by people who take care of only themselves. At the time Merrick Garland’s nomination to the Supreme Court was illegally blocked, we needed a general strike. When the Russian involvement in the elections and mess about Ukraine was uncovered, we needed a national day of reflection, reconciliation and repentance, so that we might see ourselves and one another, and defend ourselves as one nation indivisible again.  This isn’t about Republicans or Democrats. Both parties have people of conscience in them. But both have become impotent, slaves to people with money, people who like to hear themselves talk and believe their own propaganda, people who are out only for themselves. While no one has been taking care of the business of democracy, which is what this country is about.

Coronavirus may do for us what we haven’t been able to do for ourselves. Now either we’ll change, or many more people than necessary will die.

Once upon a time, there would have been prophets in the streets, blowing trumpets and proclaiming the word of G-d, telling us to repent, to put on sack cloth and ashes.

[Prophet Jeremiah, Fuselli, Metropolitan Museum of Art]


Now we’ve got a virus and pundits on TV, telling us we need to change and change now. G-d, or nature, or time, whatever you want to call it, works in mysterious ways.

We can get through it by taking care of each other, sacrificing a little when necessary, talking to one another, and keeping our eyes on the prize.

Which is still democracy. Democracy remains a lousy form of government, but it's just better than all the others. Still a frightening, noisy culture. But the only culture that lets us live and breathe, which tolerates unshakable evil impulses up to a point, but also lets fly the angels of our better nature. Democracy turns the arc of history toward justice, despite where those with selfish and evil impulses want it to go.

Democracy works only if we reinvent it every day, and only when we remember to stand up for ourselves, each other and for justice. Unceasingly. Democracy is just not a spectator sport.
Coronavirus is a little scary, true. To control it best, we need to change ourselves, and make the changes we should have made, long ago. So perhaps, in Coronavirus, we are now seeing the finger of G-d in the world, because we change, and that gives me real hope.

There are signal fires on the ridge-tops and trumpets blowing in the streets. Now all we have to do is see what is right in front of us, hear what is all around us, and heed that callSpring is here early. Who would have thought?

Batten down the hatches. And pass the ammunition. Which turns out to be each other, once again.

The Mother of All Mission-Hostile Management: During the Coronavirus Pandemic Trump Shows He is the Enemy of the Public's Health

Introduction: Health Care Dysfunction

We have been talking about health care dysfunction for a very long time, starting with a publication in 2003: Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).  In that article, I postulated that US physicians were demoralized because their core values were under threat, and identified five concerns:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research studies

Since 2003 we have broadened our thinking about what constitutes and causes US (and more global) health care dysfunction. Early on we noticed a number of factors that seemed to enable increasing dysfunction, but were not much discussed.  These factors notably distorted how medical and health care decisions were made, leading to overuse of excessively expensive tests and treatments that provided minimal or no benefits to outweigh their harms.  The more we looked, the more complex this web of bad influences seemed.  Furthermore, some aspects of it seemed to grow in scope during the Trump administration (look here).

Mission-Hostile Management as a Cause of Health Care Dysfunction


We had found that health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values. Often business trained leaders put short-term revenue ahead of patients' or the public's health.  In addition, we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients' and the public's health, and even  corporate revenues. Then, we started seeing appointed government health care leaders who lacked medical, health care or public health background or expertise but also whose agenda also seemed to be overtly religious or ideological, without even a nod to patients' or the public' health (look here).

Today, the Trump administration is confronted with the threat of a global pandemic of a virus that can be lethal. 

[1918 influenza pandemic - Oakland, CA]


Unfortunately, the administration's response has exemplified many of the aspects of health care dysfunction we have discussed, particularly mission-hostile management. This is a situation in which mission-hostile management could be uniquely dangerous.  However, it seems to have brought out the worst tendencies of President Trump and his cronies in that regard.  Below are examples that came to light only in the last week, presented in chronological order.


Trump Administration Blocked Official Recommendation for Older People to Avoid Flying, Despite The Contagiousness of the Virus and Data That Seniors are More at Risk of Adverse Effects from It

Per the AP, March 7, 2020:

The White House overruled health officials who wanted to recommend that elderly and physically fragile Americans be advised not to fly on commercial airlines because of the new coronavirus, a federal official told The Associated Press.

The Centers for Disease Control and Prevention submitted the plan as a way of trying to control the virus, but White House officials ordered the air travel recommendation be removed, said the official who had direct knowledge of the plan.

Note that:

Dr. Peter Hotez, dean of tropical medicine at Baylor College of Medicine, last week warned U.S. lawmakers against minimizing the viruses risk for vulnerable people. During a Congressional hearing, he said the coronavirus 'is like the angel of death for older individuals.'

Some experts said they’ve been hoping for clearer and louder guidance from the government, to prod vulnerable people to take every possible step to avoid settings where they might more easily become infected.

'The clear message to people who fit into those categories is; ‘You ought to become a semi-hermit. You’ve got to really get serious in your personal life about social distancing, and in particular avoiding crowds of any kind,’' said Dr. William Schaffner, a Vanderbilt University expert on infectious diseases.

Nonetheless, there was no clear rationale for the administration to block the recommendation against flying.  However, at least

On Friday, the CDC quietly updated its website to tell older adults and people with severe medical conditions such as heart, lung or kidney disease to 'stay home as much as possible' and avoid crowds. It urges those people to 'take actions to reduce your risk of exposure,' but it doesn’t specifically address flying.

Trump Tried to Keep Passengers on Board Coronavirus Infected Cruise Ship to Reduce the Apparent Number of People in the US Affected by the Virus

Per the Independent, March 8, 2020:

A cruise ship on which at least 21 people are infected with coronavirus will dock in Carlifornia and unload its passengers – despite Donald Trump saying he wanted them to stay on board to keep the number of US cases down.

The Grand Princess is expected to arrive in Oakland on Monday. It has been anchored off San Francisco for several days.

So far 19 employees and two passengers have tested positive for Covid-19. Another 24 people tested negative and one case was inconclusive. There are about 3,500 passengers on board.

On Friday, Mr Trump said he wanted to keep passengers and crew on board so that US cases would not 'double'. He said: 'They would like to have the people come off. I'd rather have the people stay. But I'd go with them. I told them to make the final decision. I would rather – because I like the numbers being where they are. I don't need to have the numbers double because of one ship that wasn't our fault.'

Trump blocked disembarkation despite the inadequacy of medical care on board, and the lack of provisions available to keep the virus from spreading, especially to the crew.  So Trump appeared willing to sacrifice the health of those on board in a  simple-minded scheme to make the epidemic look less severe for his own political benefit.


Despite Public Health Advice to Avoid Large Crowds, Trump Promoted Safety of Large CPAC Conference, Which Was Shown to Have Included a Coronavirus Positive Attendee

After the conference, as reported by CNN on March 8, 2020:

When asked by reporters if he was worried about being exposed to coronavirus after he attended CPAC, Trump said, 'I'm not concerned at all.' Trump, who was speaking alongside Brazilian President Jair Bolsonaro ahead of their dinner at his Mar-a-Lago resort in Florida, also noted that the administration would not cancel any political rallies as the virus spreads.

'We'll have tremendous rallies. We're doing very well. We've done a fantastic job, with respect to that subject, on the virus,' Trump said.

Since then, multiple attendees, have self-quarantined, including fervent Trump supporters such as  Rep Gaetz (R-FL), Dep Collins (R-GA) , and incoming White House Chief of Staff, Rep Meadows (R-NC) (per the NY Times, March 9, 2020).  Thus Trump appeared to be willing to risk the health of Americans, including some of his strongest supporters, to give the appearance that his administration was controlling the epidemic.

Despite Public Health Advice to Avoid Crowds, Trump Defended Plans for a Large Rally

Similarly, from the Independent, March 11, 2020:

Despite his own administration advising people to avoid events with large crowds to help stop the spread of coronavirus, President Donald Trump has announced he’ll hold a campaign event in Wisconsin.

Mr Trump will attend a 'Catholics for Trump' event in Milwaukee, Wisconsin on 19 March.

The event is now apparently postponed, but Trump's promotion of it showed his disregard for the health of the people, including many of his most devoted supporters.


Trump Sought to Delay Testing for Coronavirus Due to Fear that Higher Numbers of Positive Cases Would Decrease His Chances of Re-Election

Per the Independent, March 13, 2020:

the US president is also reported to have been reluctant to launch a campaign of 'aggressive testing', which could have identified key outbreak areas.

'That’s partly because more testing might have led to more cases being discovered of coronavirus outbreak,' said Dan Diamond, a Politico health reporter who has been investigating the Trump administration’s response to the coronavirus outbreak.

Speaking to NPR, he added: 'The president had made clear – the lower the numbers on coronavirus, the better for the president, the better for his potential re-election this fall.'

Many public health experts felt that earlier aggressive testing could have possibly allowed containment of the virus.  Failure to do such testing in the political interest of the president again  appears to be an egregious example of mission-hostile management.

Trump Flouts CDC Recommendations for Social Distancing, Self-Quarantine

At an event at his own Mar-a-Lago resort, Trump had close contact with at least two individuals from Brazil who later tested positive for the coronavirus, hardly exemplifying CDC recommendations for social distancing.  Then he refused to self-quarantine.  Per the Washington Post, March 13, 2020:

Trump suggested the risk of exposure from a Brazilian official was low, even though the two had posed for a photo together. Trump said he had posed for so many photos, and shaken so many hands, that he did not remember the man.

Note that

Trump seemed to defy two basic practices that the rest of his government has been urging Americans to follow to prevent the spread of the virus. People who were exposed to an infected person are urged to quarantine themselves and seek testing. And everyone — exposed or not — should stop shaking hands.

Most public health experts believe that public health campaigns require leaders setting good examples.

Now more Mar-a-Lago guests have tested positive, per the New York Times, March 14, 2020:

four others at Mar-a-Lago that weekend have since tested positive, including three who accompanied President Jair Bolsonaro of Brazil for a dinner with Mr. Trump before Ms. Guilfoyle’s birthday party that Saturday night: Fabio Wajngarten, his press secretary, Nestor Forster, his top diplomat in Washington, and Nelsinho Trad, a senator.

By failing to set a good example in this case, Trump again showed disdain for the health of the people, particularly those who attend events at Mar-a-Lago, including  his supporters and the patrons of his business.

Discussion

We have discussed  cases in which top health care leadership took actions that ignored or directly challenged health care professionals' core values, that is, mission-ignorant or mission-hostile management.
 
 A major reason was the rise of  "generic managers." Increasingly, health care organizations, including hospitals, pharmaceutical companies, health insurance companies, government agencies, etc are now led by people with management training, but not necessarily with any training or background in medicine, biomedical research, epidemiology, public health, or health care policy. We began noting how such generic managers often prioritize short-term revenue over all other concerns, presumably based on the shareholder value dogma taught in business schools (look here).  Worse, generic managers may be ignorant of, misunderstand, or be frankly hostile to the core values of health care professionals. Finally, generic managers often are subject to perverse incentives that put short-term revenue and managers' self-interest ahead of core values.

In other words, health care is now in the grip of "managerialism," as characterized in   an article that in the June, 2015 issue of the Medical Journal of Australia (look here)(7) :
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals


We have identified breathtaking cases of mission-hostile management by managerialists leading health care organizations primarily to maximize current revenue and/or their own income and self-interest.  Some recent examples:
-  A proud teaching hospital ended up bankrupt after it was traded back and forth by for-profit hospital chains and private equity firms (look here).
- Hospitals offered better care to wealthier patients, and thus worse care to poorer one, or spent  money on achieving market dominance rather than quality patient care (look here and here)
- A pharmacy chain donated to a political organization supposedly to advocate for tax reform, but whose positions contradicted the chain's pledge of social responsibility (look here).
- A health care focused charity directed most of its revenue to a company owned by the charity's leaders (look here)
- Hospital management influenced timing of patient discharge to maximize revenue, regardless of the benefits to patients of shorter or longer stays (look here) etc, etc, etc
Here are more examples.

However, I cannot recall any modern examples of mission-hostile management which so grievously threatened the population of an entire country, nor any modern US examples of a national politician willing to so threaten the country's population for his own political purposes.  Even more astounding is his apparent disdain for the health and safety of his closest supporters and business patrons.

Our chances of survival in this now a global pandemic will remain low until we can replace this dangerous national leader.  Note that the chances of his supporters' and business patrons' may be even worse than those of the general public.   

How Threats to Health Care Professionals' Core Values Lead to Moral Injury

Introduction: Threats to Core Values

In the late 1990s, my colleagues and I started noting a rising tide of what we then called physician dissatisfaction.  One small clue was that physicians I met at meetings seemed to be responding to polite questions about their well-being with less enthusiastic responses.  In the early 2000s, publications begin appearing about health care professionals' dissatisfaction (1-3). 

To better understand what was causing this dissatisfaction, we interviewed doctors and health professionals, and found that US physicians feared their core values were under threat(4).   We postulated that several aspects of American health care dysfunction caused such threats, and set about trying to better characterize and understand them.  Since then, we have been discussing health care dysfunction and how it threatens core values on Health Care Renewal.

Health Care Professionals Whose Core Values are Threatened May be Morally Injured

We were focused on what produced threats to core values, but not so much on how these threats affected health care professionals, other than by producing dissatisfaction.

Meanwhile, others focused on that dissatisfaction, and then on health care professionals' burn-out, but not so much on its systemic causes.  In 2012, we noted the first report on burnout by Shanefelt et al(5), and we observed that the already voluminous literature on burnout often did not attend to the external forces and influences on physicians that are likely to be producing it. Instead, the literature often characterized burnout as a lack of health care professionals' resilience, or even the result of some sort of psychiatric disease affecting them.

However some physicians were trying to understand how health care professionals' angst derives from health care dysfunction.  In 2018, Dr Wendy Dean and Dr Simon Talbot wrote an article in StatNews entitled "Physicians' aren't 'burned out.' They're suffering from moral injury." They wrote:

Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. Even at the Mayo Clinic, which has been tracking, investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.

Rather than burnout, they suggested that physicians are suffering from moral injury:

The term 'moral injury' was first used to describe soldiers’ responses to their actions in war. It represents 'perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.' Journalist Diane Silver describes it as 'a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.'

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Moral injury is a consequence not of some sort of personal failing, or lack of self care.  It is the consequence of a bad system.  They cited some aspects of health care dysfunction, including

Financial considerations — of hospitals, health care systems, insurers, patients, and sometimes of the physician himself or herself — lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results — at times actively harming patients to avoid lawsuits.

 World War I - Battle of the Somme


Thus

Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting. Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of 'death by a thousand cuts.' Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.

Dean and Talbot noted that instead of addressing moral injury, large health care organizations seem to blame health care professionals for their own burnout, and hence make them the targets of interventions meant to improve burnout:

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses 'information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water' in response to emotional distress crises. Such teams provide the same support that first responders provide in disaster zones, but the 'disaster zones' where they work are the everyday operations in many of the country’s major medical centers. None of these measures is geared to change the institutional patterns that inflict moral injuries.

The Resonance of  Moral Injury

Dean and Talbot have continued to raise the alarm about moral injury.  They have expanded on their original writing by noting that health care organizations' focus on flaws of health care professionals as causes of burn out are a kind of "gaslighting"(6)

'Gaslighting' refers to the act of psychologically manipulating someone to question their own sanity, in order to gain some advantage. Intentional or not, it carries significant repercussions for its targets, which in this case may be clinicians in our struggling healthcare system.

The term comes from the 1944 film Gaslight, in which a woman's husband regularly dims and brightens the gaslights in their home while he sneaks around in the attic, searching for hidden valuables. When she asks why the gaslights flicker, he insists that they have not changed intensity and that she is only imagining it. The woman's husband invalidates her perceptions and leads her to doubt her sanity.

Scene from Gaslight with Charles Boyer and Ingrid Bergman

They asserted:

A similar phenomenon is happening today to clinicians regarding the distress they experience as a result of the double binds imposed by the competing allegiances inherent in our healthcare system.

Health care professionals, often blamed for their own burnout, found that the concept of moral injury resonated.  By mid 2019, Dr Dean, writing again in StatNews, wrote:

we have learned that the concept of moral injury resonates powerfully, not just with doctors, but with every kind of health care professional we’ve met, from nurses and social workers to hospital administrators, personal-care assistants, first responders, and others.

The concept of moral injury allows clinicians to express what the burnout label failed to describe: the agony of being constantly locked in double binds when every choice one makes yields a compromised outcome and when each decision contravenes the reason for years of sacrifice. All of us who work in health care share, at least in the abstract, a single mission: to promote health and take care of the ill and injured. That’s what we’re trained to do.

But the business of health care — the gigantic system of administrative machinery in which health care is delivered, documented, and reimbursed — keeps us from pursuing that mission without anguish or conflict. We do our best to put patients first but constantly watch the imperatives of business trump the imperative of healing.

By early 2020, the concept of moral injury appeared in the main stream media, that is, the Washington Post, in an article that agreed that moral injury

resonates with clinicians across the country. Since they penned an op-ed in the online health news site Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.

The article ended with this from an emergency department physician:

He said many people frame burnout as a character weakness, sending doctors messages like, 'Gee, Keith, you’ve just got to try harder and soldier on.' But [Dr Corl] said the term 'moral injury' correctly identifies that the problem lies with the system. 'The system is flawed,' he said. 'It’s grinding us. It’s grinding good docs and providers out of existence.'

Those further interested in understanding and addressing moral injury should see to the Fix Moral Injury website.


Discussion

In retrospect, it seems that Health Care Renewal has been trying to describe the causes of moral injury since 2004. Thus our work complements that of Dr Dean and Dr Talbot.

Our 2003 article(4) identified five aspects of health care dysfunction that threatened core values, and hence we now realize could cause moral injury:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research studies

Since then we have come upon many instances in which health care professionals' core values were under threat, likely generating moral injury.  We found cases in which top health care leadership took actions that ignored or directly challenged core values, that is, mission-ignorant or mission-hostile management.
 
 A major reason was the rise of  "generic managers." Increasingly, health care organizations, including hospitals, pharmaceutical companies, health insurance companies, government agencies, etc are now led by people with management training, but not necessarily with any training or background in medicine, biomedical research, epidemiology, public health, or health care policy. We began noting how such generic managers often prioritize short-term revenue over all other concerns, presumably based on the shareholder value dogma taught in business schools (look here).  Worse, generic managers may be ignorant of, misunderstand, or be frankly hostile to the core values of health care professionals. Finally, generic managers often are subject to perverse incentives that put short-term revenue and managers' self-interest ahead of core values.

In other words, health care is now in the grip of "managerialism," as characterized in   an article that in the June, 2015 issue of the Medical Journal of Australia (look here)(7) :
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals


We have identified breathtaking cases of mission-hostile management by managerialists leading health care organizations primarily to maximize current revenue and/or their own income and self-interest.  Some recent examples:
-  A proud teaching hospital ended up bankrupt after it was traded back and forth by for-profit hospital chains and private equity firms (look here).
- Hospitals offered better care to wealthier patients, and thus worse care to poorer one, or spent  money on achieving market dominance rather than quality patient care (look here and here)
- A pharmacy chain donated to a political organization supposedly to advocate for tax reform, but whose positions contradicted the chain's pledge of social responsibility (look here).
- A health care focused charity directed most of its revenue to a company owned by the charity's leaders (look here)
- Hospital management influenced timing of patient discharge to maximize revenue, regardless of the benefits to patients of shorter or longer stays (look here) etc, etc, etc
Here are more examples.

Dean and Talbot cited hospital systems and health insurance companies putting short-term revenue ahead of patient care as a cause of moral injury.  They also noted badly designed and implemented electronic health records and litigation risks as causes. But managerialism is rampant among health care organizations.

So we have identified shocking cases of leaders of various health care organizations who put self-interest ahead of the quality of care, or the integrity of health care education and research.  These organizations were not just hospitals and health insurance companies; but also academic medical centers, and medical schools; pharmaceutical, biotechnology and device companies; and lately, especially in the US, government and government agencies (look here).  (Also see our tag list for links to particular companies and organizations, eg, DHHS, Pfizer, UPMC, UnitedHealth, etc)

Organizational leaders enabled, directed or implemented actions like deceptive marketing and public relations, promotion of propaganda and disinformation,  manipulation and suppression of research, generation of conflicts of interest, and even crime and corrupt actions, including bribery and kickbacks, and fraud.  

And yet, despite these widespread actions generating moral injury, while health care professionals muttered under their breath about the behaviors of health care organizational leaders, there has been so little open discussion that it appears such discussion is taboo- we call this the anechoic effect.  Of course, failure to openly discuss the problem resulted in failure to craft any workable responses.

So appreciating that moral injury of health care professionals is a final common pathway of such extreme health care dysfunction adds even more urgency to our task.  To address health care dysfunction, we must address what health care professionals may see as severe problems, but which they seem afraid to talk about, much less challenge.  

As long as those with a vested interest in maintaining the current system can dismiss their critics as lacking resilience, in need of therapy, and just plain weak, their criticism will be blunted.  However, we must make those with such vested interests face the moral consequences of a dysfunctional system that has provided them with such personal advantages.


References

1. Haas JS. Physician discontent: a barometer of change and need for intervention. J Gen Intern Med 2001;16:496–7.

2. Shanafelt TD, Bradley KA, Wipf WE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358–67.

3. Steinbrook R. Nursing in the crossfire. N Engl J Med 2002;346:1757–66.

4. Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).

5.  Shanafelt TD, Boone S, Tan et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.  Arch Intern Med 2012; 172(18):1377-1385. doi:10.1001/archinternmed.2012.3199 (link here)

6. Dean W, Dean AC, Talbot SG. Why 'burnout' is the wrong term for physician suffering. Medscape - Jul 23, 2019. (link here)

7.  Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM.  The scourge of managerialism and the Royal Australasian College of Physicians.  Med J Aust 2015; 202: 519- 521.  Link here.