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?"

 

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

The Trump administration has written the book about how not to prepare for a pandemic, and how to mismanage the response once one occurs.  We have previously posted about how President Trump and his administration have hindered pandemic management in the US and around the world.  We have noted the President's support for such counter-productive policies as allowing vulnerable elderly people to fly, keeping passengers cooped up on cruise ships in which the virus was spreading, and reducing testing for the virus (in March).

Furthermore, early on we noted  instances in which the President personally promoted events at which viral spread was enabled: the CPAC conference, a large indoor event, some of whose attendees later tested positive; and a meeting at Mar-a-Lago that included officials from Brazil, some of whom later tested positive (again, in March).  Later, in May, Trump visited a factory which makes N95 masks but insisted on not wearing a mask himself, and several of his top officials, including the Secretary of Health and Human Services, followed his (bad) example and also eschewed masks.

A few such episodes could have been written off as merely particularly horrendous bungles.  However, the pattern is now so well established that it appears Trump and his followers are systematically trying to increase the spread of the virus. We have now cataloged numerous instances in which they seemed to do so. In some, there was evidence that such actions actually enabled viral spread.  I will list them by category, and within categories, chronologically.

President Trump Acting Personally to Enable Viral Spread

Trump Avoids Masks but not Close Personal Contact at Public Events

Public health experts, and the US Centers for Disease Control and Prevention (CDC) under Trump have suggested social distancing, avoiding close contact with others, and wearing masks as key measures all people can undertake to decrease viral spread.

Trump, instead has frequently sought close personal contact with others and has conspicuously avoided wearing a mask.  For example, Trump continued to shake hands with supporters, including some elderly (in Florida, March 11).  Trump continued to show up at events without a mask, usually accompanies by other administration officials who also were maskless: in Phoenix, at a mask factory, (May 5) apparently in violation of the company's policy (per the Washington Post); at another mask factory in Pennsylvanis (May 14); in the Rose Garden, accompanied by Secretary of DHHS Azar and Secretary of Defense Esper (May 15); and in a Ford manufacturing plant, violating company policy and state law (May 21).

By decreasing the number of people wearing masks and preventing social distancing at these events, Trump made it more likely that there would be virus transmission there.


While Trump Avoids Masks and Social Distancing at the White House, His Staffers Increasingly Test Positive

Similarly, Trump has deliberately tried to reduce the use of masks and social distancing in the White House and generally in his personal vicinity.  Again, this increased the likelihood of virus transmission.  On May 4, 2020, Yahoo News reported:

As the country copes with the coronavirus pandemic, millions of Americans are following social distancing guidelines from the White House coronavirus task force to slow the spread of the infection: staying 6 feet away from other people, avoiding large gatherings and wearing masks or cloth face coverings.

But inside the White House, many of these rules are not being observed. There are regularly large events with unmasked attendees in close quarters — including inside the Oval Office, where some people have been allowed to enter without wearing masks or taking tests for the virus.

Although some people have their temperatures checked,

Not everyone who goes inside the Oval Office, the president’s inner sanctum and one of the most secure spaces in the West Wing, is being tested. For both governors’ visits, a pack of pool reporters and cameramen were brought in. Though their temperatures were rechecked before they entered Trump’s office, the press pool, which stood feet away from the president, the governors and staff, were not given tests. And in the crowded confines of Oval Office press scrums, while Trump sits apart from most of the crowds, the 6-foot distancing rule is not observed, with reporters and top officials packed close together.

Another report by the Washington Post on May 8, 2020, emphasized that the lax approach at the White House was at the behest of Trump:

Several security officials with executive branch experience said in interviews Friday that the White House has taken a lax and risky approach that, in their view, reflected Trump’s consistent efforts to minimize the threat from the virus.

So,

Like Trump, most of his aides, including Pence and White House Chief of Staff Mark Meadows, have not worn face masks, and the president has huddled with guests at the White House for photo-ops that undermine the efforts at social distancing that do take place, such as seats placed more than six feet apart.

'This is a show of bravado. This is a show of ‘I got this. I’m in control,’ ' said one former security official familiar with White House security planning during past administrations.

'He’s tried to minimize this threat from day one. It’s the only way he can laugh in the face of this disease,' said this person, who like others spoke on the condition of anonymity to frankly address sensitive security matters.

Multiple anecdotes suggest that the White House is a permissive environment for transmission.  Various staffers have tested positive for coronavirus, suggesting that lax policies driven by Trump's aversion to masks were enabling spread.  First, on May 7, CNN reported:

A member of the US Navy who serves as one of President Donald Trump's personal valets has tested positive for coronavirus, CNN learned Thursday, raising concerns about the President's possible exposure to the virus.

The valets are members of an elite military unit dedicated to the White House and often work very close to the President and first family. Trump was upset when he was informed Wednesday that the valet had tested positive, a source told CNN, and the President was subsequently tested again by the White House physician.

The next day, Politico reported:

Katie Miller, a spokesperson for Vice President Mike Pence, has tested positive for coronavirus, according to two people with knowledge of Miller's diagnosis.

Miller's positive diagnosis for Covid-19 puts the potential threat of the infection squarely into the president’s inner circle. Miller serves as the vice president’s top spokesperson, traveling with him frequently and attending meetings by his side. She is also married to another top White House aide and senior adviser, Stephen Miller, who writes the majority of Trump’s speeches and spends copious amounts of time around the president, Jared Kushner and Ivanka Trump.

And on July 3, 2020, the New York Times reported:

Kimberly Guilfoyle, the girlfriend of President Trump’s eldest son and a top fund-raising official for the Trump re-election campaign, tested positive for the coronavirus on Friday before a Fourth of July event at Mount Rushmore, a person familiar with her condition said.

Ms. Guilfoyle traveled to South Dakota with Mr. Trump’s son Donald Trump Jr., in anticipation of attending a huge fireworks display where the president was set to speak.

So it is likely that despite some extraordinary measures to prevent infection in the White House, such as multiple temperature checks and copious use of rapid (but perhaps not very sensitive) tests for coronavirus, the President's insistence on avoiding masks and social distancing is allowing spread of the virus, even to staffers very close to the President.

Trump Scoffs at New Jersey Quarantine Regulations

As reported by NBC on June 24, 2020:

The White House said Wednesday that President Donald Trump will not change his plan to travel to New Jersey this weekend despite a new order by the governor requiring visitors who have been in states with high numbers of coronavirus cases to quarantine for 14 days.

'The president of the United States is not a civilian,' White House spokesman Judd Deere said when asked about Trump’s compliance with the quarantine order given his travel Tuesday to Arizona, which has seen a rise in the rate of its COVID-19 cases.

Again, Trump demonstrated his intentional disregard of standard, lawful public health measures meant to reduce the spread of coronavirus.


Trump's Tulsa Campaign Rally: No Masks or Social Distancing, Multiple Infections Documented

So far, the most vivid and elaborate demonstration of Trump's push to make the US safer for the coronavirus was provided by his campaign rally in  Tulsa, Oklahoma on June 20.  That location was one in which coronavirus cases were already climbing.  The rally went on despite Trump's and its organizers' apparent awareness of the dangers of it leading to worsening spread of the virus.

First, note that the campaign required that attendees sign a waiver to protect Trump and the organizers from liability.  As reported by CNN on June 12, 2020:

Attendees of President Donald Trump's upcoming rally in Tulsa, Oklahoma, must agree not to sue the campaign if they contract coronavirus.

Rallygoers are asked to RSVP to gain admission to the event and by registering, they must agree to a disclaimer that states they acknowledge the 'inherent risk of exposure to COVID-19 exists in any public place where people are present.'

'By attending the Rally, you and any guests voluntarily assume all risks related to exposure to COVID-19 and agree not to hold Donald J. Trump for President, Inc.; BOK Center; ASM Global; or any of their affiliates, directors, officers, employees, agents, contractors, or volunteers liable for any illness or injury,' the disclaimer reads.

The disclaimer proclaims that Trump and rally organizers were very aware that their event would likely lead to particular risk of spreading coronavirus.

Furthermore, local health authorities warned them about the risk, per Tulsa World on June 13, 2020:

Expressing concerns about COVID-19’s increasing spread, the Tulsa City-County Health Department’s director said he wishes the campaign rally for President Donald Trump at the BOK Center on June 20 would be pushed back to a later date.

In an interview with the Tulsa World on Saturday, Dr. Bruce Dart said Tulsa is seeing a 'significant increase in our case trends' that makes a large gathering like the rally dangerous for not only attendees, but the president himself.

Local health care professionals also added their warnings, as reported by Public Radio Tulsa on June 16, 2020:

Calling it a matter of public health, not politics, hundreds of health care providers have signed their names on a letter to Tulsa Mayor G.T. Bynum, calling on him to prevent President Trump's campaign rally planned for the BOK Center on Saturday.

'As our city and state COVID-19 numbers climb at a rate previously unseen, it is unthinkable that this is seen as a logical choice," reads the letter, dated June 14th and authored by Dr. Jabraan Pasha of the University of Oklahoma Medical Center in Tulsa. 'It has the potential to shake our cities [sic] infrastructure and stress our healthcare systems. It will undoubtedly cost lives.'

In case that was not enough, top public health experts on the President's own coronavirus task force also warned against the rally. As reported by NBC News on June 19, 2020:

Leading members of the coronavirus task force warned White House officials about the health risks of holding large-scale indoor campaign rallies and advised against such mass gatherings, according to two people familiar with the discussions.

Dr. Anthony Fauci, the nation's top infectious disease expert, and task force response coordinator Dr. Deborah Birx both vocalized concerns internally in the last week about the safety of holding a rally on Saturday with as many as 19,000 people in an enclosed arena in Tulsa, Oklahoma.

Their dismissal was blase:

But President Donald Trump and his campaign advisers are proceeding with the event, which is expected to draw tens of thousands inside and outside the venue who will neither be socially distant nor required to wear face coverings. They claim attendees 'assume a personal risk' and 'that is part of life.'

Again, this response indicates that the President and associates were well aware that what they were doing would likely spread the virus.

Yet there was one final warning before the event.  As CNN reported on the day of the rally, June 20, 2020:

Six staffers working on President Donald Trump's rally in Tulsa, Oklahoma, have tested positive for coronavirus, the Trump campaign said Saturday.

Nevertheless, the show would go on, but not before one extra effort by the Trump campaign to make sure there would be no social distancing at the event. As we found out in retrospect on June 27, 2020 via the Washington Post

In the hours before President Trump’s rally in Tulsa, his campaign directed the removal of thousands of 'Do Not Sit Here, Please!' stickers from seats in the arena that were intended to establish social distance between rallygoers, according to video and photos obtained by The Washington Post and a person familiar with the event.

The removal contradicted instructions from the management of the BOK Center, the 19,000-seat arena in downtown Tulsa where Trump held his rally on June 20.

The effects of the rally were discovered very quickly.  First two members of Trump's campaign team tested positive for coronavirus after the rally (CNBC, June 22, 2020).  Then it was the Secret Service's turn, per the Washington Post on June 24, 2020:

Dozens of Secret Service officers and agents who were on site for President Trump’s rally in Tulsa last week were ordered to self-quarantine after two of their colleagues tested positive for the novel coronavirus

The agents originally testing positive were part of the six staffers who tested positive listed above. How many other Secret Service agents may have been infected is not clear.

A Secret Service spokeswoman declined to comment on how many of its employees have tested positive or were quarantined, but said the Tulsa event has not affected the agency’s ability to do its job.

A few days later, a prominent Trump supporter who attended the rally fell ill, as reported by Politico on July 2, 2020:

Former presidential candidate Herman Cain announced on Thursday that he has been hospitalized with Covid-19, almost two weeks after attending President Donald Trump’s rally in Tulsa, Okla.

Cain was diagnosed with coronavirus on June 29, nine days after the president's rally, and his symptoms worsened and required hospitalization on July 1, according to a statement from his Twitter account.

'He spent the past night in a hospital and as of today, Thursday July 2, he is resting comfortably in an Atlanta-area hospital,' the statement read, adding that Cain did not need a respirator. 'There is no way of knowing for sure how or where Mr. Cain contracted the coronavirus.'

Cain, briefly a frontrunner in the 2012 GOP presidential primary, tweeted a picture on June 20 of himself and others at Trump’s indoor rally.

“Here’s just a few of the #BlackVoicesForTrump at tonight’s rally! Having a fantastic time!” the caption read. No one in the picture was wearing a mask.

Finally, the director of the Tulsa Public Health Department concluded that the rally likely made an important contribution to the surge of cases overall in Tulsa.  As reported by AP on July 8, 2020:

President Donald Trump’s campaign rally in Tulsa in late June that drew thousands of participants and large protests 'likely contributed' to a dramatic surge in new coronavirus cases, Tulsa City-County Health Department Director Dr. Bruce Dart said Wednesday.

Tulsa County reported 261 confirmed new cases on Monday, a one-day record high, and another 206 cases on Tuesday. By comparison, during the week before the June 20 Trump rally, there were 76 cases on Monday and 96 on Tuesday.

Although the health department’s policy is to not publicly identify individual settings where people may have contracted the virus, Dart said those large gatherings 'more than likely' contributed to the spike.

'In the past few days, we’ve seen almost 500 new cases, and we had several large events just over two weeks ago, so I guess we just connect the dots,' Dart said.

So despite multiple warnings from public health experts and health care professionals, Trump and his campaign held a intentionally maskless and socially compacted rally quickly followed by the spread of infection to staffers, at least one of his prominent supporters, and apparently a large but unknown number of the population of the city in which the rally was held.  Since then, Trump et al have held two large maskless and socially compacted events, one in an urban area with already a large surge in COVID-19, although it is too early to tally their effects.


The Trump Administration and Family

Ivanka Trump's Travels

Per the NY Times, April 16:

Ms. Trump herself has not followed the federal guidelines advising against discretionary travel, leaving Washington for another one of her family’s homes, even as she has publicly thanked people for self-quarantining.

In particular,

Ms. Trump and her husband, Jared Kushner, who is also a senior White House adviser, traveled with their three children to the Trump National Golf Club Bedminster in New Jersey

On Their Own, Top Administration Officials Avoid Masks and Have Others Take Them Off

Even when the President Trump is not present, his top officials have taken it upon themselves to prevent the use of masks and social distancing.  On May 8, 2020, the Washington Post reported that Defense Secretary Esper and Veterans Affairs Secretary Wilkie stood with several very elderly, and hence vulnerable to coronavirus, World War II veterans sans masks. On May 11, the Intercept reported that Vice President Pence attended an event without a mask, and that business executives in attendance were required to remove their own masks.  This occurred right after Pence was exposed to Katie Miller (see above), so soon after Pence entered quarantine.

How ICE Spread the Virus

Days ago, on July 10, 2020, the New York Times reported:

Even as lockdowns and other measures have been taken around the world to prevent the spread of the coronavirus, ICE has continued to detain people, move them from state to state and deport them.

An investigation by The New York Times in collaboration with The Marshall Project reveals how unsafe conditions and scattershot testing helped turn ICE into a domestic and global spreader of the virus — and how pressure from the Trump administration led countries to take in sick deportees.

The scope of the problem appears large:

So far, ICE has confirmed at least 3,000 coronavirus-positive detainees in its detention centers, though testing has been limited.

And,

So far, the governments of 11 countries have confirmed that deportees returned home with Covid-19.

So members of Trump's administration and family have also undermined public health measures meant to prevent the spread of the coronavirus, likely enabling infection in some affected people.

Trump Supporters in the US Congress

Trump's political supporters in the US Congress, and in state houses and legislatures have also enthusiastically followed his lead, promoting a maskless and not socially distanced life, despite increasing evidence that their efforts are leading to more people infected with coronavirus.

Republican Members of Congress Refuse Masks and Social Distancing

Republican members of the US House of Representatives have repeatedly refused to wear masks during their official duties while indoors and when close to other people.  On April 23, 2020, the NY Post reported:

Republican members of Congress were noticeably reluctant to wear masks on the House floor Thursday, sparking a sharp debate with Democrats, who readily accepted the federal guidance.

As lawmakers gathered for a morning debate on creating a coronavirus stimulus oversight committee, the GOP side of the chamber largely left their mouths and noses uncovered

The leadership provided the bad example, provoking mockery of masks as a pandemic prevention measure:

Minority Leader Kevin McCarthy (R-Calif.) and Minority Whip Steve Scalise (R-La.) arrived on the House floor without masks, as did many GOP peers.

'Nice mask!' a colleague told Scalise.

'Thanks! I wear it for Halloween, too!' the second-ranking Republican said, laughing uproariously.

Those who did not wear masks included Reps. Jack Bergman (R-Mich.), Andy Biggs (R-Ariz.), James Comer (R-Ky.), Louie Gohmert (R-Texas), Brett Guthrie (R-Ky.), Jody Hice (R-Ga.), David Kustoff (R-Tenn.), Michael McCaul (R-Texas), Tom McClintock (R-Calif.), Cathy McMorris Rodgers (R-Wash.) and Chip Roy (R-Texas).

Despite continuing exhortations from public health experts about wearing masks, House Republicans remained defiant.  As reported on May 28, 2020 by CNN:

A contingent of House Republicans continues to defy the recommendations of public health experts and Congress' top physician to wear face coverings to limit the spread of Covid-19, refusing to wear them on the floor of the chamber, in the hallways of the Capitol or when chatting with aides and colleagues -- even when they're unable to maintain a social distance.

Some of those anti-mask Republicans seem to have acquired coronavirus infections, suggesting that their deliberate avoidance of masks and social distancing has enabled the spread of the virus, even to those who advocated such defiance of public health orthodoxy.  As reported by USAToday on June 15, 2020:

South Carolina Republican Rep. Tom Rice announced Monday that he and his family contracted COVID-19, becoming the latest member of Congress to contract the deadly disease that has infected about 2.15 million Americans.

Rice, in a Facebook post to his constituents, said he and his family contracted the disease last week and were recovering. He joins seven other members of Congress who tested positive for the disease or who were diagnosed with a presumed case. But his case comes months after his colleagues' and comes as states push to reopen businesses and their economies.

And the defiance continues.  CNN reported on June 26, following up on a Congressman listed above whose state now experiencing a major surge in infections:

Texas Republican Rep. Louie Gohmert spends ample time on the House floor not wearing a mask, often talking with aides and lawmakers at length while not maintaining a social distance.

Asked why not, the 66-year-old Gohmert had an explanation that defied the science and the recommendations of leading public health experts.

'I don't have the coronavirus, turns out as of yesterday I've never had it. But if I get it, you'll never see me without a mask,' the conservative Texan told CNN Friday.

Told that health experts say that people who don't have symptoms may be carrying the virus and can unknowingly spread it to others, Gohmert responded: 'But I keep being tested and I don't have it. So I'm not afraid of you, but if I get it I'll wear a mask.'

Leading Republican Member of Congress to Hold Fundraising Event in Florida During Huge Virus Surge

I found one other example of a well known Congressman who seemed intent on holding an event that could risk further virus spread in a state already experiencing a major surge.  On July 7, 2020,Axios reported

House Minority Whip Steve Scalise’s PAC is inviting lobbyists to attend a four-day 'Summer Meeting' at Disney World's Polynesian Village in Florida, all but daring donors to swallow their concern about coronavirus and contribute $10,000 to his leadership PAC.

Why it matters: Scalise appears to be the first House lawmakers to host an in-person destination fundraiser since the severity of pandemic became clear. The invite for the 'Summer Meeting' for the Scalise Leadership Fund, obtained by Axios, makes no mention of COVID-19.

Trump Supporters in State Governments

Maskless Governors Went To Restaurants

Early on in the pandemic, despite evidence that crowded restaurants provided an ideal environment for virus propagation, one governor who supports Trump made a point of showing up in restaurants.

March 16, 2020, via the Independent:

[Republican] Oklahoma governor Kevin Stitt, has declared a state of emergency in response to the coronavirus outbreak just a day after he was slammed for tweeting a picture of his family at a crowded restaurant.

Two months later, two others made the restaurant scene, sometimes encouraged by Vice President Pence.

May 14, 2020, via the Arizona Republic

[Republican Governor Doug] Ducey’s office posted photos on social media of the governor stopping for lunch at Pita Jungle in Phoenix with a bipartisan group of legislators.

The get together was a show of support for the restaurant industry as eateries reopened dine-in service this week as the governor pulled back state restrictions in place because of the COVID-19 pandemic.

None of the politicians were wearing masks in the pictures. Restaurant staff appeared to be wearing masks.

The state’s own guidance for restaurants says eateries should develop standards for employees to wear masks around customers and coworkers.

May 20, 2020, via ABC News:

Vice President Mike Pence did something Wednesday that most Americans haven’t done in many weeks amid the coronavirus pandemic: He sat down for lunch at a burger joint.

The vice president held a photo op at Beth’s Burger Bar in Florida along with GOP Gov. Ron DeSantis to highlight efforts to allow restaurants in the state to begin reopening for limited, in-person service.

But,

Neither the vice president, nor Steele, nor DeSantis, or many others nearby, wore masks.

May 22, 2020 via the Atlanta Eater:

Photos posted to social media by WSB reporter Richard Elliott, AJC photojournalist John Spink, and AJC reporter Tamar Hallerman show Gov. Kemp and Vice President Pence speaking to the owners, staff, and diners at Star Cafe, and lunching on pulled pork and meatloaf paired with sweet tea.

But,

Despite the governor urging the public to face wear masks and to social distance during the ongoing COVID-19 health crisis, neither Gov. Kemp or the vice president — or most of their entourage — entered the restaurant wearing a mask or when conversing with people before dining, and social distancing seemed to be on the back-burner.

Note that since then Oklahoma, Florida, and Georgia have all experienced big coronavirus surges.


Pennsylvania Legislators Concealed COVID-19 Infection Acquired by One of Their Own

On May 28, 2020, the Washington Post reported:

Democratic state legislators in Pennsylvania accused their Republican counterparts Wednesday of keeping a GOP lawmaker’s positive coronavirus diagnosis under wraps for days, arguing the lack of transparency may have increased their risk of contracting the potentially deadly infection.

Republican state Rep. Andrew Lewis released a statement Wednesday revealing he received his positive test result on May 20 — a jarring announcement that rattled House Democrats who said they had no idea he had been sick or other GOP members had been told to self-quarantine due to possible exposure.

Lewis, whose last appearance at the state Capitol was on May 14, said he immediately went into isolation after testing positive and informed House officials about his condition.

In particular,

state Democrats were appalled that their Republican colleagues did not promptly inform them of Lewis’s positive test result or the subsequent self-quarantines of other GOP members, instead allowing them to potentially risk exposure by continuing to participate in person in voting sessions and House committee meetings. Several Democrats said Wednesday they only became aware of Lewis’s diagnosis from the media.

The connection between intentional behavior by the state legislators and their colleagues initially unknowing assumption of increased risk is clear.

After Refusing Masks and Social Distancing, Mississippi Legislators Acquiring Coronavirus Infections

On July 10, 2020, AP reported:

Packed elevators and crowded committee rooms. Legislators sitting shoulder-to-shoulder on the House and Senate floor. People standing close to each other and talking, sometimes leaning in to whisper, without a mask in sight.

Those were common scenes at the Mississippi Capitol in June — a month that saw a historic vote to remove the Confederate emblem from the state flag — and now at least 26 lawmakers have been diagnosed with the coronavirus in the biggest known outbreak in any state legislature in the nation.

That works out to about 1 in 7 Mississippi legislators.

Among those testing positive in the heavily Republican body are the GOP presiding officers, House Speaker Philip Gunn and Lt. Gov. Delbert Hosemann.

Again, there is a plausible connection between lack of masks and social distancing, and then rise in infections.  Note again that Mississippi has been also undergoing a major coronavirus surge.

Summary


We have thus seen an extensive array of examples in which President Trump, his administration, and his political supporters in the US Congress, state houses and state legislatures have deliberately undermined standard public health measures meant to reduce the spread of the coronavirus and better control the pandemic.  There are examples in which their defiance at least was temporally related to specific or general increases in infection.  These examples occurred before and during the latest and now most severe surge of the pandemic.  The examples occurred despite many, many warnings and cautions by public health and health care professionals, and protests by political opponents.

How can we explain this apparently perverse behavior?  Given its duration despite warnings and pushbacks, it is hard to attribute it to lack of knowledge, miscommunication, or error.  One can never dismiss the possibility of grotesque stupidity.

However, at this point, I cannot dismiss the likelihood of malevolence.  As Jurecic and Wittes postulated in the Atlantic back in March,

As the former Justice Department official Carrie Cordero declared on Twitter: 'To invert a @benjaminwittes formulation, the Trump administration #COVID19 response might be characterized as incompetence exacerbated by malevolence.'

It is an inversion in more ways than one. In the original formulation of the phrase—malevolence tempered by incompetence—the incompetence not only comes second, but it mitigates the malevolence. In Cordero’s rather apt reformulation, by contrast, the incompetence comes first, and the malevolence doesn’t mitigate it. It makes things worse.

So,

[Addressing] the malevolence. President Trump’s statements since the virus first appeared in the United States have been wholly untouched by concern for anything except blame avoidance.

Furthermore,

He barely bothers to express concern about public health, choosing instead to wax indignant about how the virus is affecting his public image. This has led to some scenes that might have been bleakly funny if not for the many lives at stake.

And as Greg Sargent wrote in the Washington Post on July 8,2020:

Not clueless and hapless.  Malevolent.

Once we dispense with the idea that Trump remains 'in denial,' we’re left with a few interpretations. The most charitable is that Trump continues to have principled disagreements with experts over these matters, but there are zero indications he has any substantively grounded views on them of any kind.

A far less charitable interpretation is that he’s merely indifferent to the catastrophic consequences that are resulting from these failures — and will continue to do so — and that he’s prioritizing nakedly self-interested political calculations over any such concerns.

Finally,

Central to getting this right is dispensing with the idea that Trump is a hapless, clueless actor rather than a deliberate and malevolent one.

If he is right, only then will be come up with a real solution for a malevolent and now life-threatening regime.

The Big Spin Out: 2020 Revolving Door Update

In  2020, cases of the revolving door accumulated quickly. 

The Old School Outgoing Revolving Door

Let us begin with cases of the old fashioned outgoing revolving door, that is, of people leaving leadership positions in governmental bodies which regulate health care or make health care policy, then soon obtaining jobs in the health care industry, particularly organizations which they previously regulated or were affected by the policies they made.

Dr Vindell Washington from National Coordinator for Health Care Information Technology to Alphabet

Per FierceHealthCare, January 7, 2020:

Alphabet, the parent company of Google and Verily Life Sciences, continues to bolster its ranks of healthcare experts with the latest hiring of Vindell Washington, M.D.

Verily Life Sciences hired Washington as its new chief clinical officer as part of its health platforms team, Verily Life Sciences representative Kathleen Parkes confirmed to FierceHealthcare Tuesday.

Washington served as the national coordinator for health IT from August 2016 to January 2017.

As one of the highest health IT policy leaders, Washington brings to Verily a deep understanding of the industry. He is an emergency medicine physician by training.

So he moved from a position with significant influence over government health IT policy to a big IT company involved in health care.  Admittedly though, this moves comes three years after he left the ONC.

Dr Kate Goodrich from Chief Medical Officer of the Center for Medicare and Medicaid Services (CMS) to Humana Inc

Per Louisville Business First, January 17, 2020:

Humana Inc. has hired away a key regulatory insider from the federal government.

Dr. Kate Goodrich will leave the chief medical officer role at Centers for Medicare & Medicaid Services in February. Politico reported Thursday Goodrich will become a senior vice president for the company.

CMS is the agency that oversees both Medicare and Medicaid, the government-backed health plans. Goodrich was also director of the Center for Clinical Standards and Quality, the CMS website states.

Note that Humana's business is heavily influenced by the actions of CMS.

Humana's core business is providing Medicare Advantage plans, a private version of the federal health plan for seniors. It has about 4.1 million members in Medicare Advantage plans, according to its latest financial disclosure.

The Medicare Advantage segment brought in about $37.1 billion of revenue in the nine months ended Sept. 30, 2019.

Mary Sumpter Lapinski from Government Affairs at Bristol-Myers-Squibb to Counselor to the Secretary of the Department of Health and Human Services (DHHS) for Public Health and Science, then to Vice President of Global Governance Affairs for Greenwich Biosciences


Note that in this case, someone recently reported as transiting the outgoing revolving door has also had in the past transited the incoming revolving door.

Per a Buzzfeed News article, January 24, 2020 (which also discussed the larger revolving door problems involving the pharmaceutical industry and the Trump administration):

Mary-Sumpter Lapinski, who worked in government affairs for Bristol-Myers Squibb from 2002–2007, served as a counselor to the health and human services secretary for public health and science. As of April 2019, Lapinski is the vice president of global government affairs for biopharmaceutical company Greenwich Biosciences.

Again, most recently she moved from a senior position in DHHS affecting public health and science to a biotech company.

Roxana Weil, Lead Toxicologist from the Center for Tobacco Products at the Food and Drug Administration (FDA) and Gabriel Muniz who inspected tobacco manufacturers for the FDA to Juul Labs Inc

Per Bloomberg (via the Detroit News, February 5, 2020):

Juul Labs Inc. has hired former Food and Drug Administration employees and is recruiting more researchers as it prepares for a crucial regulatory hurdle that will determine the future of the top U.S. e-cigarette maker.

So

Roxana Weil, formerly a lead toxicologist at the agency’s Center for Tobacco Products, joined Juul as principal scientific adviser in September. Gabriel Muniz, who worked in an FDA division that inspects tobacco manufacturers, joined Juul last month as a director of regulatory compliance.

Note that

The company and its peers must submit applications to the FDA by May 12 in order to continue selling their products. The deadline is a defining moment for the e-cigarette industry, which has been under fire following a surge in teen vaping and a lung-injury outbreak that sickened thousands and was later tied to THC.

For Juul, securing a swift clearance is critical. The company has seen its once-rich valuation drop since the broader vaping backlash began. Failing to win the FDA’s blessing could shut it out of a market it has dominated.

So they moved from regulating tobacco to a company essentially involved in selling tobacco analogues.  Note that the tobacco company Altria made a major investment in Juul (look here.)

The Au Courant Incoming Revolving Door

In the Trump era, many people have come through the incoming revolving door, that is, people with significant leadership positions in health care corporations or related groups have attained leadership positions in government agencies whose regulations or policies could affect their former employers.

There are two recent examples

Brad Smith, Chief Operating Officer of Anthem's Diversified Business Group to be Director, Center for Medicare and Medicaid Innovation (CMMI) at the DHHS

Per FierceHealthcare, January 6, 2020:

The Trump administration has selected Brad Smith to serve as the director of the Center for Medicare and Medicaid Innovation (CMMI), where he will oversee the creation and stewardship of value-based payment models.

Smith most recently was the chief operating officer of Anthem’s Diversified Business Group, a division of the insurance giant that includes provider services. He was also the co-founder and CEO of palliative care services company Aspire Health.

Anthem is a health insurer which provides Medicare supplements and Medicare Advantage programs, so its business is greatly affected by any changes in how Medicare or Medicaid makes payments.

Amanda Adkins, Executive for Cerner Corp, Now Running for the House of Representatives as a Republican

This could be called a running start that will likely lead through the incoming revolving door.

Per the  Kansas City Star, January 23, 2020:

Cerner executive Amanda Adkins has taken a leave of absence from the company to focus on her campaign to unseat Democratic Rep. Sharice Davids.

Adkins, a former Kansas Republican chair, launched her bid for Kansas’ 3rd congressional district in September, but initially planned to remain as Cerner’s vice president of strategic growth through the campaign.

But as of last week, according to a company spokeswoman, Adkins went on unpaid leave after from her role after 15 years with the health care IT giant.

Note that the Star article, unlike the others quoted above, provided at least a slightly detailed discussion of why this (potential) move poses a conflict of interest:

The Kansas City-based company is a major federal contractor with a $10 billion contract to design a new health care records system for the U.S. Department of Veterans Affairs. The new system is expected launch later this year.

Federal election rules prohibit federal contractors from giving directly to federal candidates. Craig Holman, a lobbyist for Public Citizen, a national group which advocates for tougher ethics standards, said Adkins’ unpaid leave protects Cerner from violating this rule.

But Holman said the fact that she can return from leave after the election still raises questions about a conflict of interest since she could end up on committees with oversight of the company’s contracts if elected to Congress.

'The conflict still persists,' Holman said in a phone call. 'The fact that she has not resigned and remains an employee of Cerner means that conflict of interest remains front and center.'

Summary

Sigh.  So while there is much discussion of corruption in high places, and its potential link to high crimes and misdemeanors, the revolving door quietly spins on well-oiled hinges, as it has for years, including many years before the current administration.  

So as we have repeatedly said,  most recently in October, 2019, ...

The revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door once again suggests how the revolving door may enable certain of those with private vested interests to have disproportionate influence on how the government works.  The country is increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

 The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.

Circular Logic - A Revolving Door Update

We have actually managed to go for three months without posting on the revolving door.

Since then, however, we have accumulated a sufficient number of relevant cases to post another round up.


The Old School Outgoing Revolving Door

Let us begin with cases of the old fashioned outgoing revolving door, that is, of people leaving leadership positions in governmental bodies which regulate health care or make health care policy, then soon obtaining jobs in the health care industry, particularly organizations which they previously regulated or were affected by the policies they made.

However, it is striking that many of the people recently reported as transiting the outgoing revolving door have also had in the past transited the incoming revolving door (see below).

Cynthia Ridgeway, From Department of Justice Prosecuting White Collar Crimes to Anthem

As reported on July 15, 2019 by Modern Healthcare:

Health insurer Anthem has hired Cynthia Ridgeway, a longtime attorney for the U.S. Justice Department, to be its corporate strategy director.

Ridgeway is first assistant U.S. attorney in the Southern District of Indiana. During her 15-year tenure at the U.S. attorney's office, she litigated high-profile white collar crimes

The brief report had no information about Ms Ridgeway's expected duties for Anthem.  It is possible, but not certain, that they could be relevant to her work in white collar crime investigations and prosecutions for the government.

Marilyn Tavenner, From Administrator of Center for Medicare and Medicaid Services (CMS) of the Department of Health and Human Services (DHHS) to America's Health Insurance Plans (AHIP) and Now to Blue Cross Blue Shield of Arizona

As in a July 23, 2019, PR release:

Marilyn Tavenner, R.N., the former Administrator for the Centers for Medicare and Medicaid Services (CMS) and past president and CEO of America's Health Insurance Plans (AHIP), officially joined the BCBSAZ board, which provides strategic oversight to the company.

Note that Blue Cross Blue Shield of Arizona is a non-profit corporation.

Further note that Ms Tavenner had quite an interesting past history of revolving door transits.  According to her Wikipedia page, she worked for for-profit hospital system Columbia/ HCA, now HCA, from 1981 to 2005, starting as a nurse, and rising to President of the Central Atlantic Division.  While there, she worked for CEO Rick Scott, on whose watch the company made a huge settlement for Medicare fraud (look here).  Scott was not charged, left the company, and then was elected to be Governor of and the Senator for Florida as a Republican.  Ms Tavenner then went on to be Secretary of Health and Human Resources for Virginia, and then CMS administrator from 2013-15.

So Ms Tavenner moved from a for-profit hospital company to running the government agency that operates  government health insurance programs, and thus greatly influences hospital revenues.  The agency also obviously greatly influences the insurance industry, whose major trade association she then went on to lead.  Now she will be part of the governance of a large, albeit non-profit insurance company.

Erik Paulsen, From the House of Representatives to the Board of Cardiovascular Systems

As reported by the St Paul Business Journal, July 25, 2019:

Former U.S. Rep. Erik Paulsen has joined the board of directors for St. Paul medical device company Cardiovascular Systems Inc.

Cardiovascular Systems (Nasdaq: CSII) touted Paulsen’s support for the medical device industry and involvement with federal health care and economic policy in its announcement Thursday.

As a member of Congress from 2009 to 2019 representing Minnesota’s Third District, which covers suburbs of Hennepin County, Paulsen was co-chair of the bipartisan House Medical Technology Caucus. He also served on the House Ways and Means Committee, which covers taxes and policies governing health care, economics and trade.

Thus Mr Paulsen went from having a leadership role in government relationships with medical technology, and "taxes and policies governing health care," to a role in governance of a health technology company.

Dr Scott Gottlieb, From Commissioner of the Food and Drug Administration (FDA) to Venture Capital and the Pfizer Board of Directors, and now the Board of Aetion

Dr Scott Gottlieb has frequently appeard in posts on Health Care Renewal.  Our last summary of his relevant transits to the revolving door, from July, 2019 noted:

Dr Scott Gottlieb, FDA Commisioner from 2017 to May, 2019,  had been no stranger to the revolving door.  Prior to assuming leadership of the FDA, he had relationships with multiple for-profit health care corporations, which drew wide notice when he was appointed to head the FDA in 2017, as we noted at that time here.  Also, Dr Gottlieb was clearly very comfortable with the pharmaceutical and biotechnology industries.  For example, in 2007-2008, we discussed many examples of Dr Gottlieb's strident promotion of the interests of these industries (look here, here, here and here).

Very quickly after leaving the FDA in 2019, Dr Gottlieb rejoined his old venture capital firm, New Enterprise Associates, as a full-time partner investing partner specializing in life sciences companies.

Then in June, 2019, he joined the board of Pfizer.

His latest move was reported on September 17, 2019 by Fierce Healthcare:

Former Food and Drug Administration (FDA) Commissioner Scott Gottlieb, M.D., has added another position to his roster of board and advisory roles since leaving the agency back in March.

He'll be joining healthcare technology company Aetion’s board of directors, the company announced Tuesday. The New York-based company offers real-world evidence and analytics to drug companies, payers, life sciences companies and regulatory agencies.

The company has an interesting array of financial backers:

Sanofi, Amgen, UCB, McKesson Ventures and Horizon Healthcare Services have all backed Aetion as strategic investors, according to the company.

It appears that Gottlieb's former role as leader of the FDA is highly relevant to the business of Pfizer, Aetion, and Aetion's "strategic investors." In particular, regarding Aetion:

Gottlieb will advise the company as it expands the reach and utility of the Aetion Evidence Platform, a scientifically validated tool to assess the safety, effectiveness and value of treatments using real-world evidence, the company said in a press release.

During his tenure, Gottlieb also pushed for the FDA’s use of real-world evidence, recognizing its potential to advance medical products and their development, Aetion said.

'The widespread adoption of real-world evidence to the development and application of new treatments will improve the precision of prescribing decisions and help make drug discovery far more efficient,' Gottlieb said in a statement.'“As a member of Aetion’s Board, I’m inspired by the opportunity to join the company’s efforts to bring RWE to the forefront of drug research and development.'

'Dr. Gottlieb has played a pivotal role in advancing the use of real-world evidence for regulatory decision-making. As a real-world evidence advocate and standard-setter, he’s an ideal partner in our work to help define RWE's role in the development, delivery, and payment of treatments,' Carolyn Magill, CEO of Aetion, said in a statement.

And regarding Pfizer and other pharmaceutical companies:

Aetion works with 12 of the top 20 biopharma firms in the world, along with leading payers.

We had discussed the conflicts of interest presented by Gottlieb's Pfizer board decision, which Senator Elizabeth Warren (D-MA) asserted "smacks of corrupion," here.

Matthew Whitaker, From Acting US Attorney General to Legal Advisor to a Marijuana and CBD Company

As reported on August 28, 2019 by Forbes:

Toronto-based CBD company Alternate Health Corp has hired Matthew Whitaker, former acting U.S. Attorney General, and his law firm Graves Garrett to serve as outside counsel.

Previously, he

served as Chief of Staff to then Attorney General Sessions from September 2017 to November 2018

Why was he selected?

'The legal environment surrounding CBD is rapidly evolving and it is essential that Alternate Health stays at the forefront of new government and FDA regulations,' he said. 'We believe his experience in government and the Department of Justice is a significant asset as we move forward.'

So Mr Whitaker, after taking a leading role in US government law enforcement, including enforcement of laws related to drugs like marijuana, would not be advising a foreign company trying to get favorable legal treatment from the government.

Rebecca Wood, from Chief Counsel at FDA to Leader of Food and Drug Practice at Sidley Austin

Ms Wood had been Chief Counsel at the FDA.

Recently reported by ProPublica (in a October 15, 2019 article to be discussed further below):

Wood now leads the food and drug practice at Sidley Austin, a powerful law and lobbying firm in Washington, where her colleagues lobby the FDA for various clients.

She is an example of

former Trump administration staffers who go back to K Street but don’t register as lobbyists — the Lobbying Disclosure Act only requires those who spend 20% or more of their time lobbying to register.

This still generates important conflicts of interest.

Wood said she 'advises clients on FDA-related issues and, in doing so, complies with all applicable ethics requirements.'

There is nothing illegal about returning to an old employer or being hired by a new one. Nor is there anything wrong with having colleagues who lobby the federal government. But the revolving door does present the possibility of conflicts of interests.

'The most important commodity in D.C. is information,' Hauser said. 'Former insiders have rare access to strategic intelligence, which is of significant value to corporate entities, and they can do so without registering as a lobbyist.'

Dr Karen DeSalvo, from Assistant Secretary of Health, DHHS and Office of the National Coordinator, to the University of Texas, now to Google as Chief Health Officer

As reported by Health Care Dive on October 18, 2019

Google has hired ex-Obama administration official Karen DeSalvo as its first chief health officer, further solidifying its investment in the $3.5 trillion industry by rounding out its healthcare team.

DeSalvo, a well-respected healthcare executive and public health expert, was the acting Assistant Secretary for Health at HHS and ran the Office of the National Coordinator, which manages the nation's health IT, under President Barack Obama. She has spent the past two years teaching at the University of Texas at Austin's Dell Medical School.

Note that there was a two year delay after Dr DeSalvo left the government until her hiring by Google.  This does apparently lessen the conflicts of interest generated.  However, many think 

The Au Courant Incoming Revolving Door

In the Trump era, many people have come through the incoming revolving door, that is, people with significant leadership positions in health care corporations or related groups have attained leadership positions in government agencies whose regulations or policies could affect their former employers.

On October 15, 2019, ProPublica published a striking article on people transiting the incoming revolving door from lobbying positions to leadership positions at government agencies whose regulations or policies could affect their lobbying clients.

Two of the people recently added to the ProPublica data base got major government health care leadership positions after working as lobbyists, and then returned to lobbying after ending their government "service."

By way of background:

At the halfway mark of President Donald Trump’s first term, his administration has hired a lobbyist for every 14 political appointments made, welcoming a total of 281 lobbyists on board, a ProPublica and Columbia Journalism Investigations analysis shows.

With a combination of weakened rules and loose enforcement easing the transition to government and back to K Street, Trump’s swamp is anything but drained. The number of lobbyists who have served in government jobs is four times more than the Obama administration had six years into office. And former lobbyists serving Trump are often involved in regulating the industries they worked for.

Even government watchdogs who’ve long monitored the revolving door say that its current scale is a major shift from previous administrations. It’s a 'staggering figure,' according to Virginia Canter, ethics chief counsel for the D.C.-based legal nonprofit Citizens for Responsibility and Ethics in Washington. 'It suggests that lobbyists see themselves as more effective in furthering their clients’ special interests from inside the government rather than from outside.'

Colin Roskey,  from Health Care Lobbying for Lincoln Policy Group to Deputy Secretary, DHHS, then back to Lobbying for Lincoln Policy Group

Per ProPublica:

Consider Colin Roskey. Days after leaving a two-decade career as what one former employer called the 'smartest' health care lobbyist, he joined the Department of Health and Human Services in January. As deputy secretary for legislation for mandatory health, he headed the portfolio that he tried to influence for most of his career.

HHS declined to reveal any recusals he signed while appointed. A spokesman said that “all employees are expected to abide by the ethics rules.”

Just days before joining HHS, Roskey listed among his clients major dialysis providers that receive federal payments through Medicare, including Fresenius Medical Care — an industry juggernaut, with more than 330,000 patients in thousands of dialysis clinics in the U.S. A third of the company’s billion-dollar revenue comes from Medicare. A recent revamp in the dialysis industry ordered by Trump, expected to shift millions of dollars from dialysis centers to cheaper home-based options, put Roskey’s office at the heart of regulating how much profit or loss some of his former clients will see in coming years. Roskey said in an interview that he recused himself from this matter.

Public records show that Roskey lobbied for at least 27 clients between January 2017 and December 2018 on an array of issues other than dialysis involving public health care programs, from prescription drugs to palliative care.

In early October, Roskey stepped out of government and went straight back to work for his old lobbying firm, Lincoln Policy Group, which specializes in health care policy. “Spending time at HHS will make [Roskey] even more valuable to our team — and we are so excited to have him back,” the lobbying firm announced in a statement.

Roskey said he had no knowledge of how the new kidney care regulations will be implemented.

After his monthslong stint with the Health Department, Roskey said he plans to lobby the legislative branch, which is not prohibited by the current ethics rules. 'While working with the government I gained knowledge and background, intellectually and professionally, and I intend to unapologetically utilize those skills for my employer and clients,' he said.

The conflicts of interest generated by the moves from and to the lobbying firm are are obviously significant.

Laura Kemper from Health Care Lobbyist to Deputy Assistant Secretary of DHHS, then to Lobbying as Vice-President for Governmental Affairs for Fresenius

We had previously discussed Ms Kemper's transit from lobbyist to government health care leader here.   From the ProPublica article,

Laura Kemper, [is] a former HHS senior official who, within days of leaving her post in March, was hired by Fresenius. Now vice president for government affairs, Kemper heads the company’s policy group.

According to lobbying records, she is listed among the in-house lobbyists who have visited Congress, the White House and HHS since March, pushing everything from reimbursement for dialysis services to home dialysis. The records show Fresenius shelled out more than $2.2 million for lobbying activities during the first half of the year.

Furthermore, ProPublica noted:

Her pass through the revolving door tests the boundaries of ethics rules. Indeed, Trump’s pledge prohibits staffers-turned-registered lobbyists from advocating for the special interests of their corporate bosses before the agencies where they used to work for at least five years. It also restricts former employees from behind-the-scenes lobbying with any senior federal official for the remainder of Trump’s presidency. Kemper signed that pledge.

Kemper declined to comment. In a statement, Fresenius said Kemper “has strictly followed her legal and ethical obligations and has not been involved in lobbying the administration or anything related to the Executive Order.” Disclosure forms filed by Fresenius “cite the general activity of a team and do not ascribe any particular lobbying activity,” according to its statement.

Recently, during an earnings call to investors, Fresenius CEO Rice Powell said that the company has talked to the 'appropriate people in Washington,' without naming any particular Fresenius or government staffer. “We are in the midst of commenting and asking questions” with HHS officials, he added.

As ProPublica has reported, political appointees who return to lobbying have found ways to tiptoe around ethics rules. Some register as lobbyists but limit their interactions to Congress, leaving colleagues to lobby the executive branch. Ethics restrictions don’t apply to congressional lobbying.

Summary

We have repeatedly said,  most recently in March, 2019, ...

The revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door once again suggests how the revolving door may enable certain of those with private vested interests to have disproportionate influence on how the government works.  The country is increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

 The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.