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?"

 

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'd say "congratulations, I'm envious." I'd 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 couldn'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.