Sunday, January 31, 2021

Logical Fallacies in Support of Propaganda and Disinformation

Health Care Renewal's original goal was to open discussion of US health care dysfunction.  We originally focused on issues discussed in my 2003 article (Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. Link here). These included ill-informed, incompetent, self-interested, conflicted or even corrupt leadership; and attacks on the scientific basis of medicine.  We soon found out that bad health leadership and attacks on science were facilitated by deceptive marketing, public relations, propaganda, and disinformation.  Furthermore, we then realized that logical fallacies were important tools used by deceptive marketers, propagandists, and disinformationists.

Introduction: Logical Fallacies

To help understand logical fallacies, we used two main sources.  One was the Nizkor project, a Holocaust educational resource, which contained a guide to logical fallacies (available here and here).  The impetus for publishing this guide was to counter the use of logical fallacies to push the agenda of holocaust deniers. Another was Logically Fallacious, a book by Bo Bennett PhD, and its accompanying website

Logically Fallacious defines logical fallacies thus:

Criteria for Logical Fallacies: 

It must be an error in reasoning not a factual error.

It must be commonly applied to an argument either in the form of the argument or in the interpretation of the argument. 

It must be deceptive in that it often fools the average adult.

Therefore, we will define a logical fallacy as a concept within argumentation that commonly leads to an error in reasoning due to the deceptive nature of its presentation. Logical fallacies can comprise fallacious arguments that contain one or more non-factual errors in their form or deceptive arguments that often lead to fallacious reasoning in their evaluation.

Our first semi-formal discussion of logical fallacies appeared in 2008. Its focus was how logical fallacies were used to support public relations/ propaganda about health care policy in support of the interests of pharmaceutical corporations. I confess it was rather personal.  The blog and I had come under written attack by a blogger who worked for a non-profit that was funded by and associated with the pharmaceutical industry.  The attacks featured "creative use of multiple logical fallacies."  My post attempted to analyze some examples.

Logical Fallacies in Health Care and Public Health

Since 2008 we published multiple posts about logical fallacies often featuring vivid examples. Logical fallacies were: used to obfuscate the role of an academic medical center in giving apparently preferential treatment to members of Japanese organized crime (Yakuza) (look here);  justify conflicts of interest affecting clinical researchers (look here, ); justify huge compensation given to managers of non-profit hospital systems (look here); justify a federal prosecutor who pursued unethical practices by health care corporations exiting the revolving door to become a defense attorney for such corporations (look here); justify a renowned academic medical center going into the contract research business (look here);  and justify use of a poor clinical research practice, an active run-in period before a randomized controlled trial (look here).

Then things got much wilder during the Trump years.  Early on, Trump and his enablers became known for a steady stream of propaganda and disinformation, often employing logical fallacies, and sometimes to support his health care or health policy ideas.  For example, by 2019, the Washington Post documented Trump's voluminous uses of the appeal to common belief fallacy to justify, among other things, his attacks on the Democrats health care agenda as a "disaster," and his boasts about a reform of the US Veterans Administration, reforms that actually preceded his time in office.

Then we heard about an unusual viral disease in China that quickly morphed into the COVID-19 pandemic.  Logical fallacies became a powerful tool for generating the onslaught of propaganda and disinformation about the pandemic.  The propaganda and disinformation came so fast and the pandemic situation was so unstable that I had trouble keeping up with it, other than documenting it on my Twitter feed.  However, once again logical fallacies were used by the disinformationists, eg, to justify decreases in coronavirus testing (look here); and to justify attacks against pandemic mitigation measures, such as mask wearing (look here).  

So now seems like a good time to catalog some of the logical fallacies that have most frequently or vividly been used in a health care or public health context to support deceptive marketing, propaganda, and disinformation to sell products and services, justify management behavior or misbehavior, or further leaders' self-interest.  The catalog is organized by the usual names of the cognitive fallacy arranged alphabetically.  Examples from the archive of Health Care Renewal of each fallacy will be provided.  Some will be from our early days, when logical fallacies were often used to support aspects of pharmaceutical/ biotechnology/ device company marketing and public relations practices, and to support public relations practices by hospital management and related groups.  Some will be more recent, and reflect the new (ab)normal, their widespread usage to generate propaganda and disinformation about the COVID-19 pandemic

Ad Hominem

There are several sub-types of the ad hominem fallacy. In particular, the circumstantial version is defined:

Suggesting that the person who is making the argument is biased or predisposed to take a particular stance, and therefore, the argument is necessarily invalid.

Example: Richard Epstein, a prominent market fundamentalist law professor, attacked critics of conflicts of interest affecting pharmaceutical marketing as those who "often treat the phrase 'market forces' as though it embodies the worst things in life," that is, as anti-capitalists (look here). 

Example: A physician decrying proposed restrictions on conflicts of interest in medicine called for leaders to "resist the temptation to join the separation witch hunt."  The implication is that people calling for more restrictions are witch hunters, that is embarking on a totally unreasonable and dangerous ideological crusade (look here). 

[Witch from The Lost King of Oz, Ruth Plunky Thompson, 1925]

Note that a person may be biased towards a certain point of view, and that bias could affect that person's arguments, but not necessarily.

The ad hominem tu quoque fallacy is defined:

Claiming the argument is flawed by pointing out that the one making the argument is not acting consistently with the claims of the argument.

Example: Since I worked on a project for and thus was paid as a consultant by Merck in 1997-9, it was implied my criticism of a pharmaceutical company in 2008 was hypocritical and therefore invalid (look here). 

Note that one's actions in one case do not necessarily affect one's arguments in another. 

Appeal to Authority

The appeal to authority is defined:  

Insisting that a claim is true simply because a valid authority or expert on the issue said it was true, without any other supporting evidence offered.

Example: An author tried to dismiss concerns about conflicts of interest affecting medical societies because physicians are so virtuous and responsible that conflicts could not possibly affect them (look here)  

Note that an authority may be more likely to make a valid argument, but there is no guarantee that all arguments made by an authority are valid.

Appeal to Common Belief

The appeal to common belief is defined:

 When the claim that most or many people in general or of a particular group accept a belief as true is presented as evidence for the claim.

Example: President Trump claimed that everyone knew that the Democratic health care policies were a "disaster," and that his reforms of the VA were extremely significant (although they were actually enacted during the previous administration (see the Washington Post in 2019). 

Just because many people believe something does not make it true.

Appeal to Common Practice 

The appeal to common practice has the following structure:

X is a common action.

Therefore, X is correct/moral/justified/reasonable etc 

Example: An author tried to dismiss concerns about conflicts of interest affecting physicians, particularly research physicians by saying publication bias "has been reported for more than 2 decades," implying that because it is common, worry is uncalled for (look here). 

Example: The CEO of a renowned academic medical center, formerly a high paid biotechnology executive, defended its venture into the contract research business by saying ""universities need to recognize this is how things are," and "the old way of doing things doesn't really work anymore." (Look here)

Just because some people do something does not mean what they do is justified, or based on truth.

Appeal to Fear

There are many kinds of appeals to emotion, generally defined as.

the general category of many fallacies that use emotion in place of reason in order to attempt to win the argument.  It is a type of manipulation used in place of valid logic.

The appeal to fear is one sub-type.  It is defined:

 When fear, not based on evidence or reason, is being used as the primary motivator to get others to accept an idea, proposition, or conclusion.

Example: A physician decrying proposed restrictions on conflicts of interest in medicine warned that "Those institutions that choose such inquisitional approaches will be blighted and suffer competitive disadvantages." The use of the emotionally charged word "blighted," in the absence of a clear argument that the blight would necessarily occur, made this an appeal to emotion, particularly fear (look here). 

Just because something is feared does not make it more likely.

Appeal to False Authority 

This is related to the appeal to authority, above.  The appeal to false authority is defined:

Using an alleged authority as evidence in your argument when the authority is not really an authority on the facts relevant to the argument.

Example: The CEO of a state hospital association justified the huge compensation given to local hospital system CEOs by quoting "management expert Peter Drucker" who asserted that hospital management is particularly difficult.  Note that she provided no evidence that Mr Drucker has any special expertise about health care (look here).  

Just because someone is said to be an expert in a particular field does not mean that person is an expert.  Just because a person is an expert does not make an argument based on that person's opinions right.

 Appeal to Ignorance

 This is also known as argument from ignorance.  Its definition is:

The assumption of a conclusion or fact based primarily on lack of evidence to the contrary.  Usually best described by, 'absence of evidence is not evidence of absence.'

Newer Example: President Trump called for a decrease in coronavirus testing apparently because he believes that diagnosing fewer cases would mean less actual disease: "Here's the bad part ... when you do testing to that extent, you're going to find more people; you're going to find more cases. So I said to my people, slow the testing down please." (look here and here). 

Newer Example: Governor Kristi Noem of South Dakota also claimed that there were more cases of coronavirus, and hence more hospitalizations for coronavirus in her state than other states because the state was testing at a higher rate (look here).  Thus she and the president seemed to equate diagnosis with disease, and were arguing that if there is less evidence of disease, there must be less actual disease.

Failure to see or detect something does not mean it does not exist.

Slippery Slope

The definition of the slippery slope is:

When a relatively insignificant first event is suggested to lead to a more significant event, which in turn leads to a more significant event, and so on, until some ultimate, significant event is reached, where the connection of each event is not only unwarranted but with each step it becomes more and more improbable.

Example: Richard Epstein, a prominent market fundamentalist law professor, attacked proposals of new restrictions on conflicts of interest affecting pharmaceutical marketing as leading to the prohibition of "the collaborative efforts that have long characterized standard practices [in research]." Yet none of the proposals he mentioned would have directly affected collaboration per se (look here).

Although things may appear to occur in sequence, a chain of causation may not be inevitable.

Special Pleading

The definition of special pleading is:

a fallacy in which a person applies standards, principles, rules, etc. to others while taking herself (or those she has a special interest in) to be exempt, without providing adequate justification for the exemption.

Example: An author attacked the credibility of a published critique of conflicts of interest affecting research sponsored by a particular drug company by saying that critique's authors had failed to completely disclose their alleged conflicts.  They were consultants to attorneys for plaintiffs who had sued the company.  Yet the author did not completely disclose his own conflicts in his article attacking the critiques, suggesting that he believed other people should have to fully disclose conflicts of interest, but he was exempt  (look here).

Straw Man

 [Scarecrow from Dorothy and the Wizard of Oz, L Frank Baum, 1908]

The definition of the straw man fallacy is:

when a person simply ignores a person's actual position and substitutes a distorted, exaggerated or misrepresented version of that position. 

Example: Because I had criticized manipulation and suppression of clinical research about particular drugs (SSRIs, Avandia, Vytorin), my critic implied "I suggested 'people should stop taking SSRIs, Avandia, and Vytorin.' He then added 'now I guess this should also apply to Zocor.'"  However, I had stated no such thing. (Look here)

Newer Example: A state Republican Chairman argued against pandemic mitigation members saying "We can’t live in a world where there’s never again a live, in-person concert or convention or gathering"  No one had credibly argued that pandemic mitigation meant that no such things would ever happen. (look here). 

Other Logical Fallacies Used to Support Propaganda or Disinformation

There are many other logical fallacies.  Some that have been used frequently lately by disinformationists in the political arena include:

- the abusive ad hominem fallacy: "Attacking the person making the argument, rather than the argument itself, when the attack on the person is completely irrelevant to the argument the person is making;" 

- cherry picking: "When only select evidence is presented in order to persuade the audience to accept a position, and evidence that would go against the position is withheld.

-the false dilemma: "When only two choices are presented yet more exist, or a spectrum of possible choices exists between two extremes.  False dilemmas are usually characterized by “either this or that” language"

- the red herring fallacy: "Attempting to redirect the argument to another issue to which the person doing the redirecting can better respond" 

Perusal of Logically Fallacious and the Nizkor project, as well as a number of other good sources, will reveal a catalog of fallacies and errors of reasoning, most of which are being used in contemporary political and sometimes specifically health care and public health related propaganda and disinformation.

Summary- Propaganda, Disinformation, and Logical Fallacies

As we noted recently, the coronavirus pandemic has been accompanied by a pandemic of disinformation, sometimes called the "infodemic."  In the US, while it would have seemed unthinkable up to 5 years ago, the biggest source of disinformation has been President Donald Trump (look here). Although Trump is now out of office, the barrage of coronavirus disinformation has continued apparently unabated, propagated by Trump's supporters (look here), foreign powers, eg, Russia (look here), and various anonymous internet-based trolls, bots, etc. The infodemic has likely had a major role in amplifying the pandemic by discouraging peoples' cooperation with pandemic control measures, and now generating vaccine hesitancy.  The result has likely been considerable morbidity and death.
If we hope to reduce suffering and death from the pandemic, we will need to confront the propaganda and disinformation that is driving it.

 Propaganda and disinformation operate through multiple mechanisms, including various forms of deception including manipulation and suppression of evidence; generation of specious arguments, including via the use of logical fallacies; and appeals to emotion and manipulation of human psychology.  Better understanding of logical fallacies will help us better counter propaganda and disinformation. 

Wednesday, January 06, 2021

Whoops, Dander Way Back Up: What's With the Vaccines?

Abbreviations used in this posting.

DIC: Disinformationist In Chief
DOPH: Department of Public Health; DOH: Department of Health
EHR: Electronic Health Record
ICC: Infection Control Committee
MAGA: Make America Great Again.
NDMA: National Defense Mobilization Act.
NIMBY: Not In My Back Yard
OMG: Oh My Gosh.
PH: Public Health
QR: the Quarterly Report
SCM: Supply Chain Management
PPE: Personal Protective Equipment
STM: Science, Technology and Medicine in US context. 
VA: Veterans Administration.
WH: the White House
WTF: What The Fig.


Time to Dive Into the COVID Territory. WTF: It's the Vaccines. 

OK, it's probably way past time for me to get away from this old "got my dander up" thing. Seems it gets up way too often anyway. Maybe this is the last one. Caution: it runs long. For a quick read, just take in the bullet lists.

Two topics I've stayed away from last year and this. One's the VA. I opined on the VA quite a bit around 2018-2019, as it got lost in MAGAville. Nothing last year or this. I still care deeply about it; once worked there. But it's stuck on a sort of ethical and political Möbius Strip. I find little truly new to say.

Then for the past year, the coronavirus, on which our chief blogger Dr. Poses has recently written most eloquently.

But OMG, just like everyone else I've been thinking about this slow motion viral train wreck of health policy pretty much non-stop. So belatedly allow me to weigh in on the most recent car to derail: the failure of vaccine delivery.

I anticipated everything else, along the lines of  Dr. Poses's above "don't say we didn't warn you" post. Just not this.

First car to derail was disinformation on the very gravity of the situation. That segment of this grotesque puzzle palace was confounded and distorted by the instant disinformation that's becoming the hallmark of our era. It's been discussed here in this blog. Go the search box and search on it.

The second car to derail was the endless dispute over public health protective policy—the absurd arguments over whether or not to mask or distance, whether "citizens should have to accept government interference"—and this was a not unanticipated failure of national leadership over PPE and all the other aspects of public health preparedness. Knew how the DIC had gutted PH planning. Saw that coming.

But not this. Didn't see this one. Didn't see this with the vaccines.

The third car to derail was over how to manage the explosion of patients. Again larded with disinformation, much of it from the DIC, Dr. Birx sitting there at the WH looking for a place to disappear into the floor. You could see that coming.

But not this.

The one car that never derailed, thanks to some extraordinary scientists we'll profile in the coming disinformation blog, was vaccine development. Didn't see that coming either, but in this case in a good way. This was the dog that didn't bark. Just worked. Tony Fauci, on whose NIH clinical service yours truly once worked for a short time, knows the story well. It's just not the story people ask him to tell.

(In an unusual collaborative effort, HCR's bloggers will soon take a longer collaborative shot at the science of this crisis in light of the parallel crisis of disinformation.)


Most Blew It. One Didn't.

But before that, and before today's story becomes staler than it already is, we interrupt this program to look at today's most egregious problem: getting vaccines into arms. It's getting reported, just not nearly enough. It's semi-anechoic, almost as though too diffuse for reporters to spend time on. So I will.

Diffuse, yes, this story. But you can get to those findings. When you do, they're not pretty.

As I said, this one I didn't see coming. Probably should have. This business of getting shots into arms, isn't just down to the DIC. He's now on his way out. But he's got a whole lot of local, state, and institutional henchmen and henchwomen. These people knew the challenges. They just sat back anyway and didn't plan. They played the competitive SCM game on vaccines, as they had on PPE. They cried poor. They decried, rightly so, the lack of guidance and funds from above.

But in this most life-and-death of situations, they blew it. They blew it through bureaucratic inertia and timidity and poor planning. They can't claim they needed to wait until the vaccine to "practice" the proper measures to get vaccines into arms, or lack of a model.

Because the model is there. It's called the State of Israel.

There are governors, mayors, hospital administrators and other managers, both here in the US and abroad who have a whole lot of 'splainin' to do. It's true, interestingly, in most but not all nations. (We'll come back to Israel.) So the US is not alone but that's cold comfort when we look at the history. A tiny bit of that history is as follows.
  • In STM, in the mid- to late-20th century, we had moon shots and such. Mostly government run but with a huge number of private contractors. There was coordination but admittedly benefited most of all Big Government and Big Industry.
  • We've had much more recent efforts at space exploration that morphed into true public-private collaborations. Still mostly Big Government and Big Industry. 
  • Preview of coming post: we've had barely-noticed efforts for over a quarter century to do the hard science. These efforts centered in publicly funded labs at non-profit institutions, and in a few quarters of the then-nascent biopharma industry. Without such efforts, results described in the next, fourth bullet would've never occurred. This quietly benefited every man, woman and child.
  • Now we have those public-private efforts since early 2020: newly visible, highly laudable, efforts to produce immunization protocols for COVID-19 at "Warp Speed." Yes, warp speed after 25 years of science. But nonetheless, remarkable. As pure science, but not as PH applied science.
  • What's been missing, throughout: attention to "the last six feet," to the mechanisms of cooperation and health care delivery that must, in a pandemic, supersede the usual habits of mind of managerial cultures, those focusing on the quarterly report, on the latest technology, and the high margin care centered in hospitals.
Putting a shot into an arm is neither high-tech nor high-margin. So the above final bullet is a bummer. It's a train wreck that was waiting to happen. And now it's happened. Now we have a way to abate the  pandemic, we're still letting it happen. Not only by allowing disinformationist anti-vaccinationism to go unopposed, but even more importantly by not getting shots into people's arms.

Sure, the professors of public health and medicine, seeking to exhibit appropriate gravitas and aequanimitas when approached by journalists and the talking-head media, will exclaim that all will get better fast. (There are exceptions: a few public health people have demonstrably got their dander up about this. Nowhere nearly enough, at least not publicly. Ranting doesn't get you promoted. It gets you fired.)

We can hope that quietly, behind the scenes, some of those same "we have to be patient" people are getting to the right places at the right time to actually make things happen.

It's an unnecessarily lugubrious process, and it's lamentable. I haven't actually yet found a medical colleague who disagrees.

How much should we care if that process is lacking in standardization from state to state, or country to country? That's one of the many paradoxes: dinging somebody else because there wasn't standardized guidance from above doesn't absolve institutions from failing to pull all the stops using their own criteria and protocols. It doesn't absolve them from flirting with all the media adulation over "look how diverse we are" or playing up the "hero" sobriquet, while putting too few doses in arms even in terms of available vaccine supply.

Right now, in the US, of available doses, those shipped to and received by organizations designated as vaccination sites, way under half of those doses are getting into arms. I get asked a lot: why aren't they? [The NY Times just published a piece rehearsing all this, here. What I write here is sort of a counterpoint to that Times piece.] You can guess the reasons I get as well as I can. Lack of staff (true); spoilage or sabotage (much in the news but de minimis); lack of guidelines (special pleading); on and on. So what if my people are getting one in three doses in arms, while that guy's people are only getting one in five in? Find your own local numbers. They're out there.

You won't like what you see.

OK, now let's talk details. Pause for a moment and consider how one nation got it right. If not pure gold standard and not a one-size-fits-all, a benchmark of sorts. Not because the Israeli PH folks are smarter. Or have better medicine or better vaccinology. Or more socialist. Or less capitalistic. Or more capitalistic. None of those is true. OK, maybe in part because they can bend capitalism differently, looking beyond the quarterly report.

Here's what Israel did. I've pulled this from multiple sources but found especially useful the recent article from the Jerusalem Post, on which I rely heavily. [And, now added post-publication, this important piece from Brookings.] The author lists nine reasons for success. None of them is: "we're just really smart."  My comparative comments follow each bolded claim.

1. Universal healthcare. "Community services are ubiquitous in Israel."

But wait! Even those in the US who do have insurance, and access to most services, can't get vaccinated and don't know when they will. The continuum-of-care clearly creates momentum. But people all over the US are busting their buns trying to participate. They're waiting for dozens of hours in snaking lines.
Seems we can reach out to individuals, but not to populations.

2. People trust their health funds. Trust and infrastructure didn't happen overnight in Israel.

But wait! Even those who trust their physicians—despite what you may have read, most Americans of all ethnicities, at least those with personal physiciansm do have that trust—can't get to the doses. The doses are being heavily guard-railed to protect those giving them against accusations of...what? Unfairness? Queue-jumping? Just being overwhelmed?

3. A focus on prevention.

OK, I buy this one. It would be hypocritical to criticize our margin-, QR-, and fractionated care-oriented health system and not buy the importance of the tilt-to-prevention effect.

4. Israel knows emergencies: “we know how to mobilize.”

But wait: didn't we used to know how to mobilize? Can you spell "NDMA"? Um, no. But maybe Uncle Joe can.

5. A lot of people work for the health funds  A clinic in every neighborhood. A big workforce.

But wait! Don't we have a huge medical workforce? I bet it's bigger per capita than Israel's. Don't we have a NDMA? In any case the actual OECD numbers tell a different story. Israel has a middling number of doctors (3.1) per thousand inhabitants, while the US has a slightly lower (2.6) number. For nurses, the other way around, our 11.9 to Israel's 5.0. The real story, therefore, no doubt resides in the way these personnel are actually deployed. (And for workforce redeployment, long lead times are admittedly needed, even with the right financial incentives.)
Fact is, nonetheless: the vaccine lines could have delivered far more doses per hour and arms per vial if managers had just temporarily redeployed personnel instead of making sure high-margin services didn't suffer at hospitals who got the vaccine. Managers do three things really well: protect the brand. Control the message. Amp the quarterly report. Non-profits, same as for-profits.

It's the NIMBY effect. "We can't run the {fill in the blank} if you take all our nurses." (I paraphrase.) But don't exaggerate. Take a few from each site, be fair, spread the pain, get shots in arms. We could've already done this.

6. Experience vaccinating a lot of people.

But wait! Like the guy on the exhibit-hall floor at the auto show, "yeah, we got that." Roll up a refrigerated truck, boys. Community-based delivery sites have largely if not entirely been left out. They shouldn't have. 

 “We run vaccination campaigns all the time,” [one nurse] said. “We do it every winter."

But wait! We do it too. Why aren't CVS and others already putting doses in arms right now? Money, you say? This really sounds like special pleading after the many billions spent on getting the vaccine developed. It's quite simply, even at the local and state levels, managerial incompetence and timidity. How else to explain that at fancy places like Stanford, interns, residents and respiratory therapists got the shaft while "orthopedic surgeons, nurses treating outpatients, and a dermatologist [were vaccinated]?" This absurdity was replicated all over the country. 

What a colossal piece of mismanagement. Maldistribution, non-planning, and waste. More on that in the final two sections of this posting.

7. Data and technology. "The health funds all work with computerized records that feed data securely...."

Wait, what!?! For decades, major legislation, in the military, at the VA, and for at least two decades in the civilian sector we've had enormous investment in digitizing records. Admittedly the EHR too has been far too fractionated, as InformaticsMD and others have written in this blog, as have others. But technology, or rather lack thereof, is not the reason we've blown it.

8. Communication. Israel "ran a widespread TV, radio and newspaper campaign encouraging people to take the vaccine...."

But wait: we just spent almost a billion dollars on media campaigns for one run-off election in one state. That would buy a whole lot of trucks carrying ultra-cold refrigerators. In the meantime the "commuication" goal is more about getting above the 70% uptake level than it is about getting shots into arms based on available doses. (New York State currently has an anemic but attractive such advertising effort, a start). It's not like we've got people in miles-long lines chickening out at the last minute. What's happening at the last minute is that, where they're allowed to queue up based on age, people over a certain age are getting turned away at the door after hours-long waits.

9. The spirit of the People of Israel. "[I]n the end, it comes down to the people...."

But wait: hogwash! There's nothing wrong with the American people, who're rapidly coming around to the realization this is a ticket back to their old lives. We'll have plenty more to say about anti-vaccinationism (are you listening Robert Kennedy?) in a coming blog. Meantime, one can only say hogwash: it's not the people. It's the leadership. Again, not just national but local and everything in-between.

Result: more than a million citizens vaccinated in Israel in the first two weeks. Compare that with, say, France, which as of this writing has vaccinated 2000 people despite having received somewhere in the range of 0.5-1.5M doses. (Personal correspondence; see also this link.)

It's not knowledge or know-how. It's a sense of community and, most of all, a history of organization. What do we have? Fractionation. Can't blame it on scale: "they're such a small country." There's an awful lot about our national government that works superlatively well, on a huge scale, even when intermittently under-funded, because there was a will to make it so. Social Security pulls it off. And being small and prosperous doesn't mean much, when US per capita spending in healthcare, top in the world is just about quadruple that OECD described with respect to Israel.

Fractionation is, now, literally, killing us. And our leaders, including locally, are the most fractionated of all.


Where Is Everyone Else? How's The World Doing?

Is there a will to combat this fractionation? I'm not convinced there is. But let's at least survey the ruins.

Since the US inaugurated its vaccination effort I conducted an e-mail survey of individuals whose interest and acuity I trust, in six countries including the US and in six states within the US. It was balanced for gender and ethnicity. All of these individuals are medical or public health professionals, including specialists in lung and infectious diseases; or they have experience in fields such as public health history or health administration. The uptake, i.e. response rate, was over ninety percent. Everything they told me has likely changed already, so where I can make it at all meaningful I provide only broad-stroke data. With that caveat in mind here are some of my findings.

The USA.

In the US, we're all over the map. But some data points stand out.
  • Comorbidities have been down-graded in importance. "Too complex." (I don't buy that.) Age has largely become a surrogate for comorbidity. I can actually argue this one both ways.

  • At least two physicians in my respondent group, one in California and one in Pennsylvania, are immunocompromised and have been denied even a place on the schedule. The given reason, interestingly, was not that immune status is unimportant. Rather, these physicians are community-based with no longer active hospital affiliations. So: no hospital to resort to for access to the jab. As of today, 1% of Californians have received immunization—unclear if this is a first injection or whole series. Hunch: the former.

  • In Tennessee, rightly we think, the elderly have been given opportunities to sign on and get early vaccination. The chosen cut-point was 75 and older. In some counties the schedules already run out to February, but at least folks can plan. One site to which 75 year old people were invited filled its schedule in two hours. Its county seat mayor "criticized the state for lack of a coordinated response or effective communication throughout the pandemic." Meanwhile this state is just full of contradictions: in one hospital, Saint Thomas Rutherford, it seems fully 60% of the medical staff is refusing the vaccine. Maybe this is why the powers-that-be are opening it up to non-immunocompromised, non-institutionalized elders. Also looks as though more responsibility has been already been given to CVS-like entities, e.g. Walgreens in Tennessee. Some sources say large pharmacy chains will play a larger part outside the crowded east coast.

  • (We know, admittedly if only from the media—no professional informants here—that Florida got a gubernatorial thumb-on-the-scale for its old folks. Whoops. They've been lining up and camping out overnight, then turned away. I'll try to update this if I get real numbers. Otherwise, it's just murky and a predictable if confusing result of the old GOP thumb-on-the-scale.)

  • In Colorado, the state university's health system and Kaiser shoulder a lot of the burden. Seniors aged 70 and higher are in a high category and either are being, or soon will be, lining up for the jab. Respondents in this state think 70+ year old citizens will be brought in somewhere around February—maybe. "Watch your social media." On the other hands, we're told by some informants on a conference call, health providers in Ohio are even worse off than those in Colorado. 

  • There appears to be even somewhat clarity or planning in two of the biggest states that on 4 November 2020 went blue, New York and Pennsylvania. I've not seen statistics for doses shipped, but the results seem abysmally haphazard for planning, prioritizing, or jabs-per-vial. The caveat is those data are so closely held, perhaps the health departments know. But no one I ask does.

  • Pennsylvania is particularly interesting. Per instructions from the state's Health Secretary, with one key exception the vaccine's distributors across the state are supposed to vaccinate health workers even if they are not associated with their specific hospital or system. Specifically there is to be a 10% set-aside for clinicians who do not have hospital affiliations. The key exception is Philadelphia, where there is a very large, very elaborate, very diverse and very managerial committee supposedly overseeing the distribution, negating the state's otherwise 10% set-aside.

    Informants in Philadelphia have seen no evidence that all this is working, with a Tower of Babel emerging instead. The state's website is full of highly bureaucratic and highly prescriptive language about what to do. But probably because they're simply overwhelmed, hospital officials, including MDs, seem to have given up on being proactive with communications or even answering e-mails. Unlike places like Massachusetts General and Stanford, many major department chairs in a preeminent institution are not yet vaccinated (personal communication). As of yesterday, 100k residents of Pennsylvania and New Jersey—very likely, I think, with New Jersey predominating per capita—since late December.

  • In any case, it's clear that in these states, where we're told only "frontline health workers and nursing home residents and staff are currently eligible," no one can really say that any of these words are true. It's a black hole. But with a combined population of over 21M for the above two states, the uptake is less than 5%. Hey, a lot better than California, if we can believe what's written above. (But these are all moving-target figures, so I'm not sure even I believe them.) It's not bad. But in densely populated mid-Atlantic states, it's still nowhere good enough. The numbers are too low and they're inequitable when even health workers and immunocompromised patients aren't getting vaccinated.

  • Back to New York for just a moment. In a cleverly crafted distro, the media-savvy governor, Andrew Cuomo, said three weeks ago that

    New York will begin vaccinating people with underlying health conditions as soon as late January, Gov. Andrew Cuomo said on Wednesday, as hundreds of thousands of vaccine doses are heading to the state in the coming weeks. The vaccination program is getting underway as the pandemic continues to surge in New York. The positive rate in the last day reached 6.21% out of 160,947 COVID-19 tests and 95 people died of the virus. There are now 6,097 people in the hospital due to COVID-19. But the vaccines are seen as the light at the end of the tunnel. New York is receiving nearly 170,000 doses of the COVID-19 vaccine from Pfizer and expects to receive 300,000 doses of a Moderna-manufactured vaccine in the coming weeks after its expected approval. Frontline health care workers and nursing home residents are scheduled to be vaccinated first. In the second phase, New Yorkers with underlying health conditions will be given the vaccine, which will be distributed by "regional hubs" led by health care networks on the local level. "It's a medical procedure," Cuomo said. "It will be handled by medical officials. There will be no political favoritism." New York's vaccination program will be conducted in multiple phases, with healthy adults and children going last. A vaccine program could run until September to reach a normal level of immunity in the country. The first non-clinical trial vaccines were administered this week in New York and the country. Plans for the second phase of the distribution program are due Jan. 1, Cuomo said. The goal, he added, is to make New York the first COVID-free state in the country.

    It's a week after January 1st. I find no evidence that this critical Phase 2 plan is anywhere in sight. Like Rachel Levine in Pennsylvania, lots of lofty "guiding principles," but awfully hard in any well-defined way to see the boots on the ground. And the bootprints are running in circles.

  • In Rhode Island the state's DOH is falling far short of its responsibilities in terms of communicating with clinicians. One expert, highly placed in the national firmament of Internal Medicine, notes that exactly the same problems noted above for Pennsylvania, with unequal access, obtain in lower New England, with physicians having to resort to Facebook to look for communications. He notes that

    The DOH has fallen short in its communication with the provider community on what they should expect - 'where' and "how" - even if the "when" is murky because of frequently-changing delivery numbers. "Soon" and "we're working on it" are not enough. Another unforced error, in my view, is the way they drew the distinction between physicians who are seeing COVID+ patients and those who are not ("high-risk" vs. "low-risk"). As a result, primary care physicians are in the 1d priority group, along with other types of workers, including "death professionals." In a high-prevalence environment and with a virus that has a long pre-symptomatic infectious phase as well as a high percentage of asymptomatic infections, drawing such lines misses the point that all of us who have face-to-face contact with patients are at increased risk (especially if they are breathing, with all due respect to the funeral directors). [Italics mine.]

    On the other hand, community clinicians can't be expected to do the planning. They run on shoestring budgets. So round and round it goes, the circle of blame-shifting and planning deficits continues, and few get to know what's going on in this part of New England. Wait: it sounds like the mid-Atlantic, a pattern appearing everywhere.


Maybe we shouldn't be surprised to hear things aren't much better in Europe. For those countries I don't cover, a good recent summary, from The Guardian, is here. There are a few surprises, though, the first being where it all started: Italy. But not in a good way.
  • Italy. Despite the vaunted construction of many design-forward, primrose-shaped (the COVID symbol in Italy) vaccine centers, distribution has been slow. One informant writes (my emphasis added) that

    [h]ere in Italy the policy is set by the ministry of health, then the organization/implementation is of each region. As of now, but things are no doubt going to be reset going ahead, the first to be treated are the retirement homes (guests + employees working in contact with the guests) and the personnel of the public hospitals (doctors nurses cleaning etc.), then will be treated the family doctors, the elders +80 and the individuals which are fragile (i.e. those who would be at higher risk if they get the virus). The discussion is ongoing if the +80 and the fragile will be reached by the family doctors who would treat them at home if needed. Then will be treated the doctors+nurses+.... of the private hospitals. Discussion is ongoing about when to treat the dentists (and, I assume other similar categories). I think that, if this all will not become a nightmare, which is quite likely to happen, it will be our turn around April-May. [Italics mine.]
    The government is organizing special vaccination gazebos which are being installed right now. Discussion is being raised about when to treat the inmates and it appears to be considered a priority because of the closed environment.
    I am asking myself what will be the approach about all those unable to decide for themselves. The individuals less than 16 won’t be treated for now (no vaccine exists yet here for them). As of now there is no obligation for anybody to get the treatment and as you may imagine there is a major discussion about this, at least for certain categories. In Italy there is in fact a substantial chunk of doctors-nurses-etc. refusing the treatment (from 10 to 30+%)....

    Another informant from the same region wrote me that "[w]e hear that after doctors, nurses, first line health workers, people working in nursing homes, we shall start with vulnerable and people over 80 years old," and on the same idea a WhatsApp message came through stating a typical Tuscan village's "casa famiglia" had been that day fully vaccinated.

    Why are the first- and hardest-hit in such continued difficulty? One informant writes that in Italy they have the "same questions here [as in US] about organization of this all (one of the problems here is of hiring new people, we seem to be late about that). We are very late with the organization, this is ridiculous, they had plenty of time to get organized!! Will see in the next weeks, they are working to overcome the problems. It will also depend from what is going to be the percentage of Pfizer, more difficult to handle. Also, it appears that there will be a shortage of vaccine, issue raised by Pfizer who urges the approval of other producers."

  • France. For the entire world, but especially the European countries, a chart available from Oxford University's superb Global Change Data Lab demonstrates how these countries' efforts start up, stall out and scud along the x-axis with no proper, Israeli-style organizational accelerants. Slide the slider and you will see. Missing from the dataset entirely is France, whose Health Ministry just announced "a possible inscription [registration]" program [italics mine] for "those wanting to get vaccinated." A Paris-based informant tells us in an e-mail that "[i]n France we will be vaccinated in another life." Such exclamations of course reflect frustration as much as anything else, but for France the numbers really do seem dismal: Pfizer doses expected to be received by the nation at large are as follows (in millions): by 12/30/2020, 1.16. By 01/06/2021, another 0.68. On or around 02/19/2021, another 1.60. Paltry.

  • UK. Sort of a special case, because PH authorities in the UK are sort of like their current leader and arguably a big chunk of his followers: all over the map, even more than in the now-recovering US. My one respondent so far gives few numbers but notes uneasiness over lack of evidence for all the sleight-of-hand tricks being announced to alter dosage amounts and scheduling. A quick look at the above Oxford site, however, tells some of the story numerically. (The "daily doses administered" graph, with time-scale slider, is especially informative.)  In the first three weeks of getting shots in arms, in the rolling 7-day average, Russia and Canada just slide along the bottom a nanometer above the horizontal axis; the UK scuds along, in parallel with them. somewhere just under 50k doses/day. That's less than one one-thousandth of the population. Onward to 2024! And that's with a National Health Service and an emphasis on primary care. Interestingly, the curve for the US, though nowhere nearly as impressive of that of Israel, does have a nice 45° slope, showing a zenith of about 350k doses per day. Oh, wait, if that levels off, it's again on-to-2024. (But we can rely on a continued uptick, right? Right?) 

  • Germany. I've received no response from German colleagues thus far. But the Oxford data puts Germany just above Croatia and below Canada. One plausible report from a day or two ago makes the following points based on data from the Robert Koch Institute. Just over a quarter million people have received COVID-19 vaccine in Germany as of January 4th, including more than 114,600 residents of nursing homes and around 123,100 medical staff. That's only a week a half into the effort. "Germany has registered nearly 1.8 million coronavirus cases and about 35,000 [deaths]. The German government has emphasized that vaccines would be in short supply at the beginning and that it was necessary to prioritize. Citizens over 80 years of age as well as staff and residents of old people's and nursing homes are among the first group to get inoculated. The first 1.3 million vaccine doses were delivered to Germany at the end of 2020. The government plans to distribute 670,000 vaccine doses every week from January 2021 onwards.

By now I suspect the reader will have concluded, as I have, that pandemonium reigns pretty much everywhere. With that one exception. For decision-making, fractionation and arbitrariness are the rule. Everything seems ad hoc. "Things will get better" is the only mantra in leaders—let's call them "leaders"—in efforts to sound hopeful by telling us "watch this space." The problem is that January 20th is two weeks away and Uncle Joe doesn't—can't—in any plausible scenario hit the ground running with this issue. It's almost as though every leader took their cue from the orange man in the WH. Wait it out and do as little planning—as little troop-muscling and -mustering—as possible. An at best limited defense: hand-sitting was too easy to do when the dollars weren't flowing from above.

It's a war. But we're not on a war footing. I know: military historians will tell us that at the beginning of wars there's actually been a huge amount of noise and inefficiency in systems of planning and execution. Every politician, in deciding on how draconian to be about enforcing social-preventive measures, had one eye on the health realities, another eye on their economic realities, and yet another (I know) on their own reelection. The social-prevention mistakes were in some sense unforced errors.

But what shall we say about the monumental error to duck local leadership on vaccine planning? We know that many may answer "without adequate budgets, what's the point?" I believe that's too facile. Both expert (clinical / PH) and non-expert (political) leadership needed to step up months ago and work together to put in place flexible, effective, adequately-staffed, vaccine-delivery plans. Even lack of precise knowledge of numbers-of-vials-expected come squarely under the "flexibility" umbrella.

That doses are being received and not distributed is inexcusable.

That doses are being denied, based on over-rigid or contrived local criteria, is inexcusable.

We could have done better. One country pulled it off. The rest of the developed world has also taken its eye off the ball. We're all playing hot-potato with this one, while people die. Forget the public-health system we wish we had. Even with the public health we have, we should have done better.