Saturday, March 14, 2020

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.


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.   

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