Showing posts with label free speech. Show all posts
Showing posts with label free speech. Show all posts

Saturday, April 25, 2020

At the "Reopen America" Protests, Vilifying Health Care Professionals to Protect the New Robber Barons

After the Trump administration's delayed and ineffectual efforts at containment failed (see relevant coverage here, here, here, here), the curve of exponentially increasing coronavirus cases and deaths may finally have started flattening due to social distancing.  The first responders, health care professionals and hospitals in the reddest zone, New York City, may be slightly less besieged.  But the pandemic is hardly over.

Vilifying Health Care Who Objected to Prematurely "Reopening" the Country

Nonetheless, supposedly popular protests, albeit very small, broke out calling for the end of onerous social distancing measures, ostensibly to let the economy recover.  President Trump then jumped in, suddenly called for the "liberation" of multiple states from these  measures. As the Washington Post reported on April 17, 2020

President Trump encouraged protesters in Minnesota, Michigan and Virginia who are defying social distancing orders to rally against the states’ safety measures intended to stop the coronavirus spread.

In back-to-back tweets Friday morning, Trump wrote: 'LIBERATE MINNESOTA' and then, 'LIBERATE MICHIGAN' and then, 'LIBERATE VIRGINIA, and save your great 2nd Amendment. It is under siege!'

It’s unclear why Trump seems to be siding with the protesters given that the states in question have imposed restrictions that follow the recommendations laid out by Trump’s White House coronavirus task force last month that go by the name 'The President’s Coronavirus Guidelines For America.'

When the guidelines were released, Trump urged all Americans to follow them for the sake of the country.

Never mind that prematurely ending pandemic suppression efforts would mainly liberate the virus to infect people at exponentially increasing rates.

The protests to "reopen" the states were met by small, peaceful counter-protests by health care professionals.  For their pains, they were vilified.

Four examples follow, in chronological order by the dates of the relevant reports:

Colorado

Per the Guardian, April 20, 2020

As protesters gathered outside the capitol steps and others assembled in their automobiles to ask the city to reopen for business, healthcare workers stood in the middle of the road in their scrubs. After having spent the last weeks treating Covid-19 patients, they staged their own demonstration: they wanted to remind the protesters of why the shutdown measures are important.

One protester in particular did not like it. She leaned out of her car window, wearing an American flag T-shirt, holding a placard that read 'land of the free'. Then, she yelled to the protester wearing scrubs: 'This is a free country. This is the land of the free. Go to China!'

She appeared to be expressing the view that closing down non-essential services in the US is equivalent to the actions of a communist state, as she continued: 'If you want communism, go to China. Now open up and go to work.'

Pennsylvania

Per the Pennsylvania Post, April 20, 2020

Armed with nothing but signs and science, half a dozen medical workers from across the state showed up near the capitol in Harrisburg on Monday to counter the message of hundreds of 'ReOpen PA' protesters calling for an end to coronavirus restrictions.

The small group of health care workers told people participating in the larger rally to go home to keep their loved ones safe. But they made their point from a distance.

However,

Anti-shut down protesters yelled at the nurses and physician assistants as they drove by. Some held up American or Gadsden flags to block the medical workers’ signs. Some angrily reminded the health care workers that they were lucky they were working.

'You have a job!' one protester screamed at Katrina Rectenwald, a 36-year-old registered nurse who works at a Pittsburgh hospital.

North Carolina

Per the Charlotte News-Observer, April 22, 2020

Tuesday morning, about 1,000 people converged on downtown Raleigh to protest in an effort to get Gov. Roy Cooper to reopen the state. North Carolina has been closed since March when he issued a stay-at-home order and closed schools and non-essential businesses due to the spread of the coronavirus.

[Amber] Brown, an oncology nurse practitioner, was there as the opposition.

Then

Brown arrived in Raleigh wearing a mask, goggles and a blue protective gown with the phrase 'Rally Together and Die Alone' written on it. As she maneuvered through the crowd of protesters, the hostility and heckling started when another counter-protester grabbed her arm and said, 'You’re with us.'

In front of the Legislative Building, other medical professionals dressed in scrubs, masks and lab coats awaited the ReOpen NC protesters. So Brown found a spot and stood there in a silent protest.

Protesters converged on her, first attacking her weight. Some called her a strain on the healthcare system, saying obesity kills more people than the coronavirus. But she stood strong.

'I didn’t say anything,' Brown said. 'I had a message, and I think it was pretty clear. I didn’t think I needed to say any words. When people are in a mob like that and they are angry and screaming, there is no reasoning with them. I wasn’t going to change their mind. I wasn’t there for them, I was there for my patients.'

She said she felt threatened. There were Raleigh police officers there, but Brown said there were not many counter-protesters. A dispute could have escalated quickly.

Arizona

Per the Arizona Republic, April 22, 2020

On Monday, [ICU nurse Lauren] Leander showed up at the Capitol, to serve as a counterweight to the hundreds of protesters demanding that Gov. Doug Ducey immediately reopen the economy.

To serve as a reminder that though jobs are at stake and that’s certainly important, so, too, are lives.

As The Republic’s Richard Ruelas described it, 'She would spend the next few hours standing silent, her facial expressions partly hidden behind her medical mask. Her body standing rigid in surgical scrubs.'

For that, she was insulted, scorned and generally screamed at by flag-waving protesters, some of whom carried signs about an overblown crisis and a 'pretend-demic'.

Note that not only was Ms Leander vilified at the protest, she was vilified on the internet by the Arizona State Republican Party Chairwoman

And, of course, by state GOP Chairwoman Kelli Ward, whose go-to response to anything with which she disagrees is to cry 'fake'.

Cue her Tuesday morning tweet, responding to nurses showing up to counter protests across the country: 'EVEN IF these 'spontaneously' appearing ppl at protests against govt overreach (sporting the same outfits, postures, & facial expressions) ARE involved in healthcare - when they appeared at rallies, they were actors playing parts. #Propaganda #FakeOutrage'

I’m guessing Leander, after a few 12-hour shifts working to save patients struck down by COVID-19, would tell you that her outrage at the prospect of reopening the state too soon is anything but fake.

In four states over a few days health care professionals were vilified by protesters calling for the premature "reopening" of the country.  A nurse was personally vilified by a local political notable, the state Chair of the Republican Party.  Why would people supposedly advocating for relaxing social distancing specifically to improve the economy and help working people and small businesses be so hostile to the health care professionals who would help them were they to get sick?

The answer appears to be that these protests were driven by political extremism more than worries about the economic misfortunes of working people and small businesses.

Trump and His Allies Had Previously Suggested the Acceptability of Attacking Health Care and Public Health Professionals

In the days leading up to these events, Trump and his enablers had pointed the ways towards the vilification health care and public health professionals.

Public Health Experts Who Created Statistical Models of the Pandemic Accused of Being Part of a "Deep-State" Plot

On March 27, 2020, the Washington Post published an article stating

In recent days, a growing contingent of Trump supporters have pushed the narrative that health experts are part of a deep-state plot to hurt Trump’s reelection efforts by damaging the economy and keeping the United States shut down as long as possible. Trump himself pushed this idea in the early days of the outbreak, calling warnings on coronavirus a kind of 'hoax' meant to undermine him.

Note that the notion of a "deep state" is a commonly heard conspiracy theory that members of the government bureaucracy are pursuing a independent agenda that includes a political vendetta against Trump and his followers. Trump then went on to validate the notion that the epidemiologists' models were "hoaxes"

On Thursday night, Trump cast doubt on experts’ projections on those as well. 'I have a feeling that a lot of the numbers that are being said in some areas are just bigger than they’re going to be,' Trump told Fox News host Sean Hannity in a phone interview. 'I don’t believe you need 40,000 or 30,000 ventilators. You know, you go into major hospitals, sometimes they’ll have two ventilators, and now all of a sudden they’re saying, ‘Can we order 30,000 ventilators?’'


Trump Accused Physicians Protesting the Lack of Personal Protective Equipment in Hospitals as  Seeking Media Fame

On April 11, the (UK) Independent reported that at his daily coronavirus press conference, Trump confronted CNN reporter Jim Acosta who had asked about physicians' complaints that they lacked sufficient testing and equipment, including personal protective equipment (PPE):

Acosta referred to doctors and other medical officials who have vented their frustrations about the dearth of essential equipment on CNN.

The president hit back: 'A lot of it is fake news.'

Acosta said: 'Doctors and medical officers come on our air and say ‘we don’t have enough tests, we don’t have enough masks’.'

Mr Trump chipped in: 'Well yeah, depending on your air they are always going to say that because otherwise, you are not going to put them on.'

Trump directly accused  health care professionals of lying about the lack of equipment and supplies merely to get media attention.  However, there are many easily found examples for all over the US about the inadequacy of such supplies and equipment.

So given this atmosphere, maybe it should not be a surprise that the "reopen" protests were also attended by political extremists.

The Extremists at the "Reopen" Protests


Presumably, the vilification of health professionals at the "reopen" protests had nothing to do with medicine and public health.  It was likely to be about political extremism, as exemplified by the participation of political extremists at the protests.  Reports suggested the involvement of several groups. 

The Proud Boys

The Anti-Defamation League describes the Proud Boys thus:

Misogynistic, Islamophobic, transphobic and anti-immigration. Some members espouse white supremacist and anti-Semitic ideologies and/or engage with white supremacist groups.

The  Guardian reported on April 17, 2020

Placards identified the Michigan Proud Boys as participants in the vehicle convoy.

The Proud Boys also showed up at the Colorado protest, according to Vice News, April 20, 2020:

Members of Proud Boys, a far-right street-fighting gang, were spotted at a protest in Denver over the weekend, and at last week's protest in Michigan where they were seen flashing the “OK” sign in photos with a Republican candidate for state office.

Finally, the Proud Boys showed up in Ohio, per the Cleveland Plain Dealer, April 21, 2020:

On Monday, at least one protestor at the Ohio Statehouse wore a Proud Boys T-shirt. The group is described as misogynistic and Islamophobic.

Michigan Liberty Militia

Again according to the Guardian:

Near the state house, local radio interviewed a man who identified himself as 'Phil Odinson'.

In fact the man is Phil Robinson, the prime mover in a group called the Michigan Liberty Militia, whose Facebook page features pictures of firearms, warnings of civil war, celebrations of Norse paganism and memes ultimately sourced from white nationalist groups like Patriot Front.

Ammon Bundy and Associates

Again via the Guardian, April 17, 2020, Bundy was tied to the Idaho protest, which

was also being promoted on a website dedicated to attacking [Idaho Governor] Little for his response to Covid-19. That website was set up by the Idaho businessman, pastor and one-time Republican state senate candidate, Diego Rodriguez.

Rodriguez launched the website at an Easter service held in defiance of the governor’s orders on Easter Sunday, which was also addressed by Ammon Bundy, the leader of the militia occupation of the Malheur national wildlife refuge in 2016 that become a rallying point for the anti-government right in the US.

Bundy has been holding similar gatherings for weeks in Emmett, Idaho, where he now lives. On Sunday, he repeated his opposition to the Idaho orders, writing on Facebook: 'We all have a duty to defend what is right and to make sure, that what God has given, man does not take away. Especially that great gift of agency, YES freedom!'

The Dorr Brothers' Gun Rights Groups

An article in the Washington Post on April 19, 2020 stated:

A trio of far-right, pro-gun provocateurs is behind some of the largest Facebook groups calling for anti-quarantine protests around the country, offering the latest illustration that some seemingly organic demonstrations are being engineered by a network of conservative activists.

The Facebook groups target Wisconsin, Ohio, Pennsylvania and New York, and they appear to be the work of Ben Dorr, the political director of a group called 'Minnesota Gun Rights,' and his siblings, Christopher and Aaron. By Sunday, the groups had roughly 200,000 members combined, and they continued to expand quickly, days after President Trump endorsed such protests by suggesting citizens should 'liberate' their states.

The Dorr brothers manage a slew of pro-gun groups across a wide range of states, from Iowa to Minnesota to New York, and seek primarily to discredit organizations like the National Rifle Association as being too compromising on gun safety. Minnesota Gun Rights, for instance, describes itself as the state’s 'no-compromise gun rights organization.'

In addition,

'Wisconsinites Against Excessive Quarantine' was created on Wednesday by Ben Dorr. His brother Christopher is the creator of 'Pennsylvanians Against Excessive Quarantine,' as well as 'Ohioans Against Excessive Quarantine.' A third brother, Aaron, is the creator of 'New Yorkers Against Excessive Quarantine.'

Various Unknown Anti-Semites

Per Channel 4 in Detroit on April 16, 2020 at the Michigan protest:

Nazi, swastika imagery used just days before Holocaust Remembrance Day


And,

The Jewish Community Relations Council of Detroit (AJC) has publicly condemned the behavior and signage of protestors that participated in 'Operation Gridlock' on Wednesday.

The Cleveland Plain Dealer reported on April 21, 2020:

A photo from Saturday’s stay-at-home protest at the Statehouse is gaining traction on Twitter for its anti-Semitic message.

The photograph captured two men in a minivan. One held a sign with an illustration of rodent with the Star of David on its side and the words 'The Real Plague.'

Participation by white supremacist, neo-Nazi, and extreme gun rights supporter at the "reopen" protests strongly suggests that these protests were more about extremist politics than working people and small businesses concerned mainly with maintaining their livelihoods.

The Plutocrats and Trump Donors Behind the "Reopen" Protests

Furthermore, numerous reports also suggested that the protests were products of political organizations tied to the Trump administration and some of its very rich donors which provided major funding and organizational help.




Michigan Conservative Coalition/ Michigan Trump Republicans

The Guardian reported on April 17, 2020 that the protest in Michigan:

was organized by the Michigan Conservative Coalition, which Michigan state corporate filings show has also operated under the name of Michigan Trump Republicans.

The Washington Post added on April 19, 2020:

Its founders are a Republican state lawmaker and his wife, Meshawn Maddock, who sits on the Trump campaign’s advisory board and is a prominent figure in the 'Women for Trump' coalition.

Michigan Freedom Fund

According to the Guardian, the Michigan protest:

was also heavily promoted by the Michigan Freedom Fund, a group linked to the Trump cabinet member Betsy DeVos.

The Washington Post (April 19) added that:

the Michigan Freedom Fund, ... is headed by Greg McNeilly, a longtime adviser to the DeVos family. He served as campaign manager for Dick DeVos, the husband of Education Secretary Betsy DeVos, when he ran unsuccessfully for governor of Michigan in 2006.


Idaho Freedom Foundation

Again, according to the Guardian April 17, 2020 article, the protest in Idaho

has been heavily promoted by the Idaho Freedom Foundation (IFF), which counts among its donors 'dark money' funds linked to the Koch brothers such as Donors Capital Fund, and Castle Rock, a foundation seeded with part of the fortune of Adolph Coors, the rightwing beer magnate.

Convention of States

The Washington Post reported on April 22, 2020:

The ads on Facebook sounded populist and passionate: 'The people are rising up against these insane shutdowns' they said. 'We’re fighting back to demand that our elected officials reopen America.'

But the posts, funded by an initiative called Convention of States, were not the product of a grass-roots uprising alone. Instead, they represented one salvo in a wide-ranging and well-financed conservative campaign to undermine restrictions that medical experts say are necessary to contain the coronavirus — but that protesters call overkill and whose economic fallout could damage President Trump’s political prospects.

A network of right-leaning individuals and groups, aided by nimble online outfits, has helped incubate the fervor erupting in state capitals across the country. The activism is often organic and the frustration deeply felt, but it is also being amplified, and in some cases coordinated, by longtime conservative activists, whose robust operations were initially set up with help from Republican megadonors.

The Convention of States project launched in 2015 with a high-dollar donation from the family foundation of Robert Mercer, a billionaire hedge fund manager and Republican patron. It boasts past support from two members of the Trump administration — Ken Cuccinelli, acting director of U.S. Citizenship and Immigration Services, and Ben Carson, secretary of housing and urban development.

Citizens for Self-Governance

The Washington Post also documented

Citizens for Self-Governance, [is] the parent organization of the Convention of States project.

A longtime associate of the conservative activist Koch family, [Convention of States board president Eric] O’Keefe helped manage David Koch’s 1980 bid for the White House when he served as the No. 2 on the Libertarian ticket.

Also,

In 2014, the year before it launched the Convention of States initiative, Citizens for Self-Governance received $500,000 from the Mercer Family Foundation, a donation Meckler said helped jump-start the campaign. Mercer declined to comment.

DonorsTrust

Furthermore, per the Washington Post April 22, 2020 article:

The Convention of States project, meanwhile, has received backing from DonorsTrust, a tax-exempt financial conduit for right-wing causes that does not disclose its contributors. The same fund has helped bankroll the Idaho Freedom Foundation, which is encouraging protests of a stay-at-home order imposed by the state’s Republican governor, Brad Little.

'Disobey Idaho,' say its Facebook ads, which use an image of the 'Join or Die' snake woodcut emblematic of the Revolutionary War and later adopted by the tea party movement.

Texas Public Policy Foundation

The April 22, 2020 Washington Post article also documented:

One of the most vocal groups opposing the lockdown in Texas is an Austin-based conservative think tank called the Texas Public Policy Foundation, which also hails the demonstrations nationwide.

'Some Americans are angry,' its director wrote in an op-ed promoted on Facebook and placed in the local media, telling readers in Texas about the achievements of protesters in Michigan.

The board vice chairman of the Texas Public Policy Foundation, oil executive Tim Dunn, is also a founding board member of the group promoting the Convention of States initiative. And the foundation’s former president, Brooke Rollins, now works as an assistant to Trump in the Office of American Innovation.

The Uihleins

On April 23, 2020, the Guardian reported:

One of Donald Trump’s most fervent billionaire donors is lobbying against strict stay-at-home rules in the election battleground state of Wisconsin, raising troubling new questions about how the president’s rightwing financial supporters may influence the US response to the pandemic.

Liz Uihlein, the billionaire behind Wisconsin’s Uline shipping and packaging company – who with her husband, Richard, has been dubbed the most 'powerful conservative couple you’ve never heard of' – is using her clout to try to force Wisconsin’s Democratic governor to relax stay-at-home rules, claiming that the crisis has been 'overhyped' by the media.

Her actions – from lobbying Republican legislators in the state to circulating a petition to employees to have the governor, Tony Evers, removed from office – come as two protests have been organized against the Democratic governor on Friday.


Note that:

Uihlein, who said she and her husband 'loved Trump' and is believed to have a net worth of about $4bn, laughed off suggestions that she might influence the president.

'You honestly think that money influences Donald Trump, are you kidding me?' she said.

But Uline, she and her husband’s privately held company, has already donated $1.5m to Trump’s Super Pac, America First Action, and $20m to other Republican groups so far in the 2020 election cycle. In the past, their donations topped $90m, according to the Center for Responsive Politics.

In summary, the "reopen" protests, ostensibly about protecting working people and small businesses from the economic effects of social distancing, were organized to an extent by a network of Trump cronies, including multiple people currently serving in the executive branch of the government, and were funded by plutocrats including the Koch brothers, beer magnate Adolph Coors, the Mercer family, oil executive Tim Dunn, and the Uihlein family.

Why Are the Plutocrats Promoting Protests Against Social Distancing?


Why are plutocrats  suddenly interested in public health, or worried about the plight of the little people who have lost their jobs or otherwise suffered from the economic dislocations due to the shutdown of much of the economy?  Why are such people willing to comport with extremists like the Proud Boys to do so?

The answer is not known, but there are some disturbing theories.

One formulation from columnist Will Bunch in the Philadelphia Inquirer

These right-wing groups certainly want to reelect Trump (and keep the wretched DeVos in her Education Department post) but what they’re really afraid of is that both the public-health catastrophe and the growing economic meltdown will lead to a political, economic or even social revolution in the United States that will threaten the status quo — i.e., them. The coronavirus has exposed the everyday disaster that is America’s employer-based health-care system and the broader fragility where millions were just one lost paycheck away from a miles-long line at a food bank. The conservative movement in America, therefore, will die a deserved and overdue death unless the oligarchs can change the political conversation around to your God-given right to buy plant seeds and Baskin-Robbins — and fast.

It’s also worth noting (and probably worthy of a separate column) that these billionaires and millionaires have zero moral qualms about working with some of the worst white-supremacists or neo-fascists in order to make sure a crowd turns out....

Another from Theda Skocpol, Professor of Government and Sociology at Harvard, interviewed by Sean Illing in Vox.  She first asserted that the "reopen" protests arose from:

combination of top-down influence from high-dollar organizations and some genuine energy at the grassroots level. But I also suspect this is mostly being pushed and promoted from above.

Prof Skocpol cited this example:

There’s FreedomWorks, a right-wing advocacy group that also helped turn the famous CNBC television rant into dozens of rallies across the country in February of 2009 — that was the origins of the Tea Party. The people at FreedomWorks are egging this anti-lockdown protest on and providing encouragement and models for these events and helping to select cities.

Now, that doesn’t mean FreedomWorks or any one person is in control of all this. But groups like this provide email lists, help organize activists around the country, and facilitate these things as much as they can. And of course Trump himself is using his social media feeds in the same way, which is just an amazing resource if you want to coordinate and target protests. So that’s what I mean when I say a lot of this is driven from the top down.

"The money quote" re the plutocrats' motivation:

For the elite conservative groups sponsoring this stuff behind the scenes, I think it’s driven by a firm belief that if Americans become used to trusting government and relying on social benefits from government, then that’s dangerous to the victory they think they have almost won in destroying the New Deal and the Great Society reforms in this country.

That is,

I think they see this pandemic and the government response to it as a potentially dangerous moment for their vision of the American economy and people’s place in it. They don’t want people to see how helpful government can be, they don’t want them to change their minds about the role of government in society. So this is a dangerous moment for their ideological worldview.

Summary

Health care professionals confronted with a pandemic of a potentially deadly disease want to be able to help patients as best they can, avoid if possible sacrificing their own health and lives, and promote the greater public health.  Many health care professionals are not very interested in health policy, much less politics.  But most are interested in education. Seeing people protest the very public health measures that may enable their survivial inspired health care professionals to try to educate the protesters about the risky tradeoffs that reopening the economy would entail.

However, their relatively innocent and public health spirited counter-protests landed them within a hornets' nest.  They found themselves not leading an educational dialog, but insulted, if not intimidated. 

The protests were not just about the economy, particularly protecting the livelihoods of working people and small businesspeople.  They were about an extremist political agenda, the power of the Trump administration, and likely about a long term project that had been "destroying the New Deal and Great Society reforms," that sought to restore the power of the Robber Barons and maintain a new gilded age.



Therefore, for us to get through this pandemic, we now have to confront the plutocrats who would rule us - even at the cost of sacrificing many of us.  This may be about educating the public.  However, it will also be about going up against some very rich and powerful people who saw the world within their grasp, and now may be seeing it fade away.  They will lash out to try to protect their money and power.  As some health care professionals discovered in the last few weeks, this will be a difficult, if not brutal and dangerous task.

But lives are hanging in the balance.  Courage!

Friday, February 28, 2020

The Virus This Time: Ill-Informed, Incompetent Leadership Enabling Suppression of Free Speech, Intimidation of Whistleblowers, Propaganda and Disinformation

Unfortunately, the rapid progression of coronavirus is providing a demonstration of the dysfunction, and worse, that can be produced by bad leadership in health care and public health.

Ill-Informed Leadership

During the Trump regime we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics.  We had not previously expected leaders of government to be personally knoweldgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

For example, in September, 2017, we noted a series of examples showing some basic ignorance of health policy, including fundamental confusion about the nature of health insurance. In August, 2018, we noted that Trump had long been an apologist for asbestos, which is known to cause asbestosis, lung cancer, and mesothelioma, claiming that those opposing use of asbestos were associated with organized crime, while more recently Trump's EPA seemed willing to relax regulation of asbestos, at a time when Russia seemed ready to become the major US supplier of it.

Now the Trump administration's leadership on the coronavirus epidemic seems similarly ill-informed.

Trump's Unjustified Optimism

As the epidemic has progressed, Trump has repeatedly made extremely rosy predictions without providing any factual basis for them.

StatNews reported on January 22, 2020:

'It's one person coming in from China," Trump said in Davos, Switzerland, during an appearance on CNBC.  'We have it under control.  It's going to be just fine.'

Meanwhile, the count of cases and fatalities was growing.

Later, per USA Today on February 11, 2010, at a rally President Trump

told the crowd that 'in theory' once the weather warms up Coronavirus, which he referred to as 'the virus,' will 'miraculously' go away. Trump did not offer any scientific explanation to back up his claim.

He continued in the vein on his trip to India, as reported by CNN on February 25, 2020:

'I think that's a problem that's going to go away,' Trump said during a trip to India, expressing confidence that the epidemic will not seriously harm the global economy.

This at best appears to be wishful thinking. 

While the count of cases and fatalities was rising, and more nations were reporting cases, as reported by CNN on February 28, 2020, Trump was hoping for an intervention from on high:

'It's going to disappear. One day it's like a miracle, it will disappear,' Trump said at the White House Thursday

Was he claiming direct communication from on high?

Nevertheless, remember that Trump should be easily be able to access very expert opinion and the latest data from the Centers for Disease Control and Prevention (CDC), US Food and Drug Administration (FDA), National Institutes of Health (NIH), and Department of Health and Human Services (DHHS).  However, if he add used this access, the effects on his thinking are not apparent. 

The Acting Secretary of the Department of Homeland Security (DHS) is Confused

As reported by the Washington Post on February 25, 2020, Acting Secretary of the DHS demonstrated confusion about some basic issues regarding coronavirus, although his agency is being tasked with many responsibilities in order to control the disease.

Appearing in front of a Senate appropriations subcommittee, Wolf was on the receiving end of a brutal line of questioning from Sen. John Neely Kennedy (R-La.). Throughout the exchange, Wolf struggled to produce basic facts and projections about the disease. Perhaps most strikingly, the hearing came at a time of heightened fears about the disease, with the stock market plunging over new estimates about its spread into the United States. It’s a moment in which you’d expect such things to be top of mind for someone in Wolf’s position.

Wolf got started on the wrong foot almost immediately, when Kennedy asked him how many cases of the coronavirus there were in the United States. Wolf stated there were 14 but was uncertain about how many cases had been repatriated back to the United States from cruise ships, placing the number at '20- or 30-some-odd.'

Asked how many DHS was anticipating, Wolf didn’t have an answer and suggested this was the Department of Health and Human Services’ territory. 'We do anticipate the number will grow; I don’t have an exact figure for you, though,' Wolf said.

'You’re head of Homeland Security, and your job is to keep us safe,' Kennedy responded, asking him again what the estimates might be. Wolf talked around the question, which led Kennedy to say, 'Don’t you think you ought to check on that, as the head of Homeland Security?'

Wolf also seemed confused about what was known about human-to-human virus transmission, the mortality of the virus versus that of influenza, the availability of respirators, and the likely time course of vaccine development

The Acting Deputy Secretary of the DHS Asked on Twitter How to Find Coronavirus Information Online

Again, despite his theoretical ability to get expert opinion and data from the CDC, FDA, NIH, DHHS etc, in an op-ed in the Washington Post on February 26, 2020, Max Boot noted:

Meanwhile, the acting deputy secretary, arch-nativist Ken Cuccinelli, took to Twitter to ask for the public’s help in accessing an online map from Johns Hopkins University tracking the virus’s spread. Imagine if the head of U.S. Strategic Command asked the public for helping in learning about nuclear weapons, and you start to comprehend the scale of the problem.

New Coronavirus Czar Mike Pence's Bizarre Beliefs About Science and Promotion of Sectarian-Based Health Care

President Trump named Vice President Mike Pence was named the "czar" of the effort to control coronavirus. Pence is a politician without background in medicine, biomedical research, health care, public health or epidemiology.  Worse than that, he has a record of professing bizarre beliefs about the relevant science.  As summarized by Newsweek on February 27, 2020,

'Time for a quick reality check,' Pence wrote in an op-ed back in 2000. 'Despite the hysteria from the political class and the media, smoking doesn't kill.'

He then went on to list smoking-related statistics: Two out of three smokers do not die from smoking-related illnesses. (False—it may be the opposite: two in three smokers die as a result.) Nine out of ten do not get lung cancer. (It makes it 15 to 30 times more likely you will.) But he did add 'smoking is not good for you' and suggested those 'reading this article through the blue haze of cigarette smoke' should quit.

The scientific consensus, as per the U.S. Centers for Disease Control (CDC): 'Smoking is the leading cause of preventable death.'

Pence also disputed the ability of condoms to protect against sexually transmitted disease, possibly because he espouses abstinence as a method of contraception, and refused to say whether he believes in evolution.

Furthermore, as we discussed here, Pence seems to be on a mission to align all of US health care with his extreme fundamentalist beliefs, regardless of the responsibility of government health care agencies to support the health of all Americans, regardless of their religious beliefs.  In particular, he allegedly engineered the appointment of people with similar sectarian beliefs to positions of responsibility in DHHS.

A person who is at best skeptical about some pretty well-established medical premises, and who espouses health care policies apparently mainly based on extreme religious beliefs for coronavirus "czar?" What could possibly go wrong?

Incompetent Leadership- President Trump's Word Salads about Coronavirus and Related Issues


Previously, we had discussed  ill-informed and incompetent leadership in terms of leaders who had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.

However, we began to note concerning examples suggesting that the top leader of the US executive branch, President Trump himself, could be cognitively impaired perhaps from a dementing, neurological or psychiatric disorder.

- In October, 2017, we first started cataloging pronouncements by President Trump on health care and related topics that started with a grossly cavlier attitude toward health policy (e.g., it is only about fixing somebody's back or their knee or something," and ended with word salad

As we were taught in medical school, word salads may be produced by patients with severe neurological or psychiatric disorders.

- In January, 2018, we discussed more examples of Trump's confused, incoherent comments on health care.

- In May, 2018, we noted attempts by Trump Organization functionaries to intimidate Trump's former personal physician, presumably to prevent him from revealing details of the president's medical history.

- In December, 2018, we cataloged Trump's counter-factual, and often severely incoherent pronouncements - basically more examples of word salad - about public health, health care and other topics, at times interspersed with claims of his high intelligence.

Now Trump has produced more word salad about coronavirus.  For example, as reported by Presswatchers on February 27, 2020:

This will end. This will end. You look at flu season. I said 26,000 people. I never heard of a number like that: 26,000 people, going up to 69,000 people, doctor, you told me before. 69,000 people die every year — from 20 to 69 — every year from the flu. Think of that. That’s incredible. So far, the results of all of this that everybody is reading about — and part of the thing is, you want to keep it the way it is, you don’t want to see panic, because there’s no reason to be panicked about it — but when I mentioned the flu, I asked the various doctors, “Is this just like flu?” Because people die from the flu. And this is very unusual. And it is a little bit different, but in some ways it’s easier and in some ways it’s a little bit tougher, but we have it so well under control, I mean, we really have done a very good job.

The video of this is below:




Another example from that press conference was reported by Esquire the same day.


Suppression of Free Speech by Scientists, Health Care Professionals, and the Media

While President Trump has been proclaiming the wonders of his handling of the coronavirus, his message has been contradicted by scientists and health care professionals working in his government.  So now he seems resolved to better "control the message," that is, to suppress the views of those who disagree with him, even if they are far more expert and better able to justify their views with facts.  As reported by the New York Times on February 28, 2020:

The White House moved on Thursday to tighten control of coronavirus messaging by government health officials and scientists, directing them to coordinate all statements and public appearances with the office of Vice President Mike Pence, according to several officials familiar with the new approach.

Furthermore,

The vice president’s move to control the messaging about coronavirus appeared to be aimed at preventing the kind of conflicting statements that have plagued the administration’s response. The latest instance occurred Thursday evening, when the president said that the virus could get worse or better in the days and weeks ahead, but that nobody knows, contradicting Dr. Anthony S. Fauci, one of the country’s leading experts on viruses and the director of the National Institute of Allergy and Infectious Disease. At the meeting with Mr. Pence on Thursday, Dr. Fauci described the seriousness of the public health threat facing Americans, saying that 'this virus has adapted extremely well to human species' and noting that it appeared to have a higher mortality rate than influenza.

'We are dealing with a serious virus,' Dr. Fauci said.

Dr. Fauci has told associates that the White House had instructed him not to say anything else without clearance.

IMHO, to best defend against an epidemic we need transparent communication about relevant facts and policies.  Suppressing expert opinion and data to make politicians look good could be disastrous for public health, and eventually disastrous for the politicians responsible.

The same is true about attempts to suppress reporting by the media.  Nonetheless, on February 26, 2020, CNN reported

the president has been blaming the media for this predicament, reverting to the same tactics that he has employed ever since taking office.

On Wednesday, in a widely-criticized tweet, he claimed that CNN and MSNBC 'are doing everything possible to make the Caronavirus look as bad as possible, including panicking markets, if possible.'

He misspelled coronavirus and the typo is still visible on his Twitter profile more than eight hours later.

CNN also explained why health care professionals are worried about Trump's repeated attempts to "control the message" about coronavirus

'When you learn you have a dangerous disease, you need to be able to trust your doctor. When entire populations face a dangerous public health crisis, they need to be able to trust their governments,' Dr. Leana S. Wen, a visiting professor at George Washington University's Milken Institute School of Public Health, wrote in a Washington Post op-ed last month.

That's a problem in this environment, where trust is in short supply. Multiple polls have shown that only one in three Americans believe he is honest and trustworthy.

The President's lies have given the public ample reason to distrust what he says -- and this has negatively affected perceptions of his administration as a whole.

'This president has lied about everything from trade deficits to Russian interference in US elections. He has disparaged experts at almost every opportunity,' said Daniel W. Drezner, professor of international politics at Tuft University's Fletcher School of Law and Diplomacy and author of the forthcoming book "The Toddler in Chief."

'At a time when people are looking to the federal government for reassurance,' Drezner said, 'he will be hard-pressed to provide any.'

Finally, on February 28, 2020, the New York Times reported that Trump surrogates on jumping on the media intimidation bandwagon:

Mick Mulvaney, the acting White House chief of staff, on Friday blamed the media for exaggerating the seriousness of coronavirus because 'they think this will bring down the president, that’s what this is all about.'

Intimidation of Whistleblowers


In the same vein, on February 28, 2020, the New York Times reported that a whistleblower charged DHHS with sending staff to meet quarantined Americans arriving from overseas without adequate preparation or equipment, and that the DHHS response was to attempt to intimidate the whistleblower:

In a narrative prepared for Congress, the whistle-blower painted a grim portrait of staff members who found themselves suddenly thrust into a federal effort to confront the coronavirus in the United States. The whistle-blower said their own health concerns were dismissed by senior administration officials as detrimental to staff 'morale.' They were 'admonished,' the complainant said, and 'accused of not being team players,” and had their “mental health and emotional stability questioned.'

After a phone call with health agency leaders to raise their fears about exposure to the virus, the staff members described a 'whitewashing' of the situation, characterizing the response as 'corrupt' and a 'cover-up,' according to the narrative, and telling the whistle-blower that senior officials had treated them as a 'nuisance' and did not want to hear their worries about health and safety.

Given Trump and cronies' attempts to control the message, how will we know when things are going wrong without whistleblowers?

Propagation of Propaganda and Disinformation

We just discussed how disinformation is distorting the conversation about and maybe the response to coronavirus.  Things are only getting worse.  the President and his allies continue to spread propaganda to make his administration look good and his perceived enemies look bad, regardless of the effect on the public's health.

On February 28, 2020, Politico reported:

President Donald Trump accused congressional Democrats early Friday morning of unfairly blaming the coronavirus’ threat to Americans on his administration, tying the global health epidemic even closer to domestic politics.

'So, the Coronavirus, which started in China and spread to various countries throughout the world, but very slowly in the U.S. because President Trump closed our border, and ended flights, VERY EARLY, is now being blamed, by the Do Nothing Democrats, to be the fault of ‘Trump,’' the president wrote on Twitter just after midnight.

In another message roughly half an hour later, Trump suggested Democratic lawmakers had been 'wasting time' on other legislative priorities and efforts to denigrate Republicans as the coronavirus outbreak proliferated.

'The Do Nothing Democrats were busy wasting time on the Immigration Hoax, & anything else they could do to make the Republican Party look bad, while I was busy calling early BORDER & FLIGHT closings, putting us way ahead in our battle with Coronavirus. Dems called it VERY wrong!' Trump wrote.

That post mirrored a similar tweet the president issued Thursday evening but later deleted, in which he charged that Democrats were “wasting their time on the Impeachment Hoax” as he sought to implement preventative measures to combat the coronavirus.

Neglecting a dangerous disease to fight perceived political enemies could ultimately leave all the humans involved worse off.

While the misinformation provided by Trump and his administration may be a product of their lack of knowledge and competence, it can directly hurt public health.  In StatNews on February 26, 2020, an opinion piece summarized some of the major misconceptions and lies promoted by the administration and explained their possible adverse effects.

'It’s really important for the U.S. government to be speaking with one common voice about these issues right now,' said Tom Inglesby, an infectious diseases physician and director of the Center for Health Security of the Johns Hopkins Bloomberg School of Public Health.

Without that, experts caution, the public will be left confused about their risks and what they can do to help curb the spread of the virus, such as staying home when sick.

Inglesby noted that health officials are working hard to prepare and plan for the spread of the virus within the U.S. But that work needs to be regularly and clearly communicated to the public — without conflicting statements from other officials.

'It will erode confidence in the effort if one part of the government says something in the beginning of the day, and another part of the government says something contradictory at the end of the day,' he said.

The specific examples of misinformation and lies the article used were:

Containment is ‘pretty close to airtight’ — Larry Kudlow, director of the National Economic Council, in an interview with CNBC Tuesday

The fatality rate is ‘similar to seasonal flu’ —Chad Wolf, acting secretary of the Department of Homeland Security, in testimony before Congress Tuesday

‘There’s a big difference between Ebola and coronavirus’ —Trump, in remarks in India Tuesday, when asked about decision to evacuate ill Americans from the Diamond Princess cruise ship, given his past criticism of the evacuation of an American health worker infected with Ebola

‘We’re very close to a vaccine’ —Trump, also in remarks in India

The virus might go ‘away in April, with the heat’ —Trump, speaking at a governor’s meeting earlier this month

Finally, just to ice this particular cake, Trump supporter and Trump's Medal of Freedom awardee is spreading some rank disinformation in support of his fearless leader.  On February 25, 2020, the Guardian reported,

The coronavirus outbreak is being 'weaponised' by the media to bring down Donald Trump when in fact it is simply a version of the 'common cold', the conservative radio host and presidential medal of freedom recipient Rush Limbaugh claimed on Monday.

His actual words were:

'It looks like the coronavirus is being weaponised as yet another element to bring down Donald Trump,' Limbaugh said on his Monday show. 'Now, I want to tell you the truth about the coronavirus. I’m dead right on this. The coronavirus is the common cold, folks.'

'The drive-by media hype of this thing as a pandemic, as the Andromeda strain, as, ‘Oh, my God, if you get it, you’re dead’ … I think the survival rate is 98%. Ninety-eight per cent of people get the coronavirus survive. It’s a respiratory system virus.'

That was complete nonsense, so

His comments were widely condemned: more than 80,000 people are known to have contracted the virus worldwide and 2,700 are known to have died. Authorities are struggling to cope in China, Iran, Italy and Tenerife.

That did not stop various pundits who regularly cheer for Trump on Fox News.  The Washington Post reported on February 28, 2020, that Sean Hannity, Tucker Carlson, Laura Ingraham, and Stuart Varney all joined the fray.

Summary

The Trump administration's response to the coronavirus seems more about their political fortunes, ideologies, and sectarian beliefs than about the health of the public.  If they do not change their ways, or the US does not change its leadership, it could be the death of at least some of us. Those in the US who uncritically support Trump should realize that viruses do not care about peoples' politics, so the Trump fans are just as much at risk as are the anti- and never-Trumpers.



Thursday, November 21, 2019

Health Care Dysfunction Makes it to the Presidential Debate


In last night's debate which included leading candidates from the Democratic Party for its presidential nomination, as reported by Mother Jones, Senator Bernie Sander (D-VT) said (per Mother Jones).
the current health care system is not only cruel, it is dysfunctional

The video is here.



So the concept of health care dysfunction has officially made it to the big time.

You Heard It Here First

What took so long?

We have been talking about health care dysfunction for a very long time, starting with a publication in 2003.

To better understand health care dysfunction, I interviewed doctors and health professionals, and published the results in Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).  In that article, I postulated that US physicians were demoralized because their core values were under threat, and identified five concerns:

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

After that my colleagues and I have tried to raise awareness of these and related issues, now mainly through the Health Care Renewal blog.  We also set up FIRM - the Foundation for Integrity and Responsibility in Medicine,  a US non-profit organization, to try to provide some financial support for the blog.

Health Care Dysfunction is Multi-Dimensional

Unfortunately, one sentence in a presidential debate hardly does justice to a huge and multi-faceted set of concerns.  

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

A brisk summary of these often complex issues follows.


 Threats to the Integrity of the Clinical Evidence Base

The clinical evidence has been increasingly affected by manipulation of research studies.  Such manipulation may benefit research sponsors, now often corporations who seek to sell products like drugs and devices and health care services.  Manipulation may be more likely when research is done by for-profit contract research organizations (CROs). When research manipulation failed to produce results to sponsors' liking, research studies could simply be suppressed or hidden.  The distorted research that was thus selectively produced was further enhanced by biased research dissemination, including ghost-written articles ghost-managed by for-profit medical education and communications companies (MECCs). Furthermore, manipulation and suppression of clinical research may be facilitated by health care professionals and academics conflicted by financial ties to research sponsors.

 Deceptive Marketing

The distorted evidence base was an ingredient that proved useful in deceptive marketing of health care products and services. Stealth marketing campaigns became ultimate examples of decpetive marketing.  Deceptive marketing was further enabled by the use of health care professionals paid as marketers by health care corporations, but disguised as unbiased key opinion leaders, another example of the perils of deliberate generation of  conflicts of interest affecting health care professionals and academics.

Distortion of Health Care Regulation and Policy Making

Similarly, promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or to the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.

More recently,  as we noted here, we became aware of efforts by foreign powers to spread such disinformation for political, not just financial gain, e.g., in April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak

Furthermore, companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement.  Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.

In the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers (look here).   We found multiple managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting - wait for it - big health care corporations, a staggering intensification of the problem of the revolving door.

Bad Leadership and Governance

Health care leadership was often ill-informed.  More and more people leading non-profit, for-profit and government have had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.  Lately, during the Trump administration, we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics look here).  We had not previously expected leaders of government to be personally knowledgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values. Often business trained leaders put short-term revenue ahead of patients' or the public's health.  In addition, we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients' and the public's health, and even  corporate revenues. Then, we started seeing appointed government health care leaders who lacked medical, health care or public health background or expertise but also whose agenda also seemed to be overtly religious or ideological, without even a nod to patients' or the public' health (look here).
 
Leaders of health care organizations increasingly have conflicts of interest.   Moreover, we have found numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.


In the Trump administration, corrupt leadership extends from the corporate world to the highest levels of the US government.  We discussed the voluminous reports of conflicts of interest and corruption affecting top leaders in the executive branch, up to and including the president and his family (look here).  One cannot expect effective enforcement of ethics rules and anti-corruption laws in such an environment

Abandonment of Health Care as a Calling

A US Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members, leading to the abandonment of traditional prohibitions on the commercial practice of medicine.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be "commercialized, nor treated as a commodity in trade."  After then, it ceased trying to maintain this prohibition. Doctors were pushed to be businesspeople, and to give making money the same priority as upholding their oaths. Meanwhile, hospitals and other organizations that provide medical care are increasingly run as for-profit organizations. The physicians and other health care professionals they hire are thus providing care as corporate employees, resulting in the rise of the corporate physician.  These health care professionals may befurther torn between their oaths, and the dictates of their corporate managers.

Perverse Incentives Put Money Ahead of Patients, Education and Research

We have extensively discussed the perverse incentives that seem to rule the leaders of health care. Financial incentives may be large enough to make leaders of health care organizations rich.  Incentives often prioritize financial results over patient care.  Some seem to originate from the shareholder value dogma promoted in business school, which de facto translates into putting current revenue ahead of all other considerations, including patient care, education and research (look here).

 Cult of Leadership

Health care CEOs tend now to be regarded as  exalted beings, blessed with brilliance, if not true "visionaries," deserving of ever increasing pay whatever their organizations' performance.  This pheonomenon has been termed "CEO disease" (see this post).  Afflicted leaders tend to be protected from reality by their sycophantic subordinates, and thus to believe their own propaganda.

Managerialism

Leadership of health care organizations by managers with no background in actual health care, public health, or biomedical science has been promoted by the doctrine of managerialism which holds that general management training is sufficient for leaders of  all organizations, regardless of their knowledge of the organizations' fundamental mission.

Impunity Enabling Corrupt Leadership

Most cases involving corruption in large health care organizations are resolved by legal settlements.  Such settlements may include fines paid by the corporations, but not by any individuals.  Such fines are usually small compared to the revenue generated by the corrupt behavior, and may be regarded as costs of doing business.  Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements.  The former were originally meant to give young, non-violent first offenders a second chance (look here).  However, in most instances in which corruption became public, are no negative consequences ensue for the leaders of the organizations on whose watch corrupt behavior occurred, or who may have enabled, authorized, or directed the behaviors.

Taboos

Some of the above topics rarely appeaedr in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant. We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  Those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.

However,in the Trump administration,  we began to also note examples of government officials attempting to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control (look here).



What a witches' brew, surely leading to a cruel and dysfunctional system.

Discussion

In 2017, we said that it was time to consider some of the real causes of health care dysfunction that true health care reform needs to address, no matter how much that distresses those who currently most personally profit from the status quo.

Furthermore, in 2019 we asserted that all the trends we have seen since 2017 are towards tremendous government dysfunction, some of it overtly malignant, and much of it likely enabling even worse health care dysfunction.

Now that health care dysfunction is in the headlines, we hope health care and public health professionals, patients, and all citizens will have a much more vigorous response to it.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways.  We do not have much time to act.

If not now, when?

If not us, who?  

Note (25 November, 2019): This post was re-posted by the Naked Capitalism blog here

Sunday, November 03, 2019

How Can We Promote Evidence-Based Medicine Under a Regime that Insists on Its Power to Say "2+2=5"?

Introduction: Evidence-Based Medicine

We have consistently advocated for Evidence-Based Medicine (EBM), which is about medical-decision making based on critical review of the best applicable evidence from clinical research informed by knowledge of biology and medicine, of the patient's biopsychosocial circumstances, the patient's values, and of ethics and morality. Since EBM depends on the availability of evidence from the best clinical research, we have advocated for the integrity of clinical research, and decried  manipulation of clinical research done to increase the likelihood that its results would please vested interests, and suppression of research whose results offended such vested interest, sometimes done when manipulation did not succeed in producing such pleasing results.

Addressing such threats to the evidence-based required challenging the role of large for-profit corporations, principally pharmaceutical, biotechnology, and device companies, in clinical research.  In doing so, we depended on support from other concerned health care professionals and scientists.  Sometimes, when manipulation and suppression crossed over the line to become fraud and deceptive marketing, government regulators and lawyers stepped in.  We have discussed numerous legal settlements involving penalties - admittedly, often less severe than we would have preferred  - on particular corporations.

So we have counted on governments having a shared interest in promoting the integrity of clinical research, and more broadly of clinical and public health science, and when necessary, acting to enforce such integrity.  

However, we have increasing reason to doubt these shared interests under the current US regime.



Administration Comfort with Suppression of Speech about Research

Consider episodes in which political appointees of the Trump regime seemed comfortable with the suppression of speech about medical, health care and public health research.

In 2016, we discussed several cases in which officials at the Department of Health and Human Services stifled responses to journalists about scientific issues.  In particular, employees of the Center for Disease Control (CDC) were told not to respond to any journalists' requests for information, even "simple data-related questions," in lieu of responses from agency public relations personnel.

In 2017, we discussed how President Trump's first Secretary of Health and Human Services, Dr Tom Price, had been involved in attempted suppression of the results of research about the drug Bildil at the behest of a previous campaign donor.

In addition, three recent episodes, one from August, 2019,  two more in late October, suggest that under Trump, open discussion of the science pertaining to health care and public health, and the pursuit of scientific truth in these areas have been increasingly subordinated to politics, and particularly to supporting the notion that the President is sole keeper of all truth. 

Silencing National Intstitute of Mental Health (NIMH) Scientists about the Relationship of Mental Health to Violence to Avoid Contradiction of a Trump Tweet


Per a Washington Post article from August 20, 2019, after mass shootings in El Paso, TX and Dayton, OH,

'Mental illness and hatred pull the trigger. Not the gun,' Trump said immediately after the shootings. In the following days, he reiterated that statement, arguing that the United States should reopen mental institutions shuttered decades ago as a way to address mass shootings.

But then,

federal health officials made sure no government experts might contradict him.

A Health and Human Services directive on Aug. 5 warned communication staffers not to post anything on social media related to mental health, violence and mass shootings without prior approval.

The particulars were as follows:

On Aug. 5, Trump was scheduled to speak following the weekend shootings. That morning, some HHS employees, including those at the National Institutes of Health, received an email asking those who contribute to official social media accounts to hold off on posts until 'we get the green light from HHS,'

Then,


some employees received another email from Renate Myles, an NIH spokeswoman. Social media posts could resume, the note said, butemployees were asked to 'please send any [social media] posts related to mental health, violence or other topics associated with mass shootings for review before posting.'

The second directive applied most directly to the National Institutes of Mental Health, where nearly all of the agency’s social media activities relate to mental health. It remains unclear how many people received that instruction, which was lifted by week’s end.

The administration's explanation was:

'It’s the department’s long-standing practice to not get ahead of the president’s remarks,' HHS spokeswoman Caitlin Oakley said. 'This allows the president to share his message first with the nation. Any suggestions that this was a formal policy put in place related to social media, or meant to stymie work on this issue, are factually inaccurate. These were staff-level discussions seeking to be sensitive and respectful to the victims and their families affected by tragedies of that weekend.'

However,

By contrast, two former senior health officials in the Obama administration said they did not recall ever receiving such a directive after a mass shooting.

Also,

In the days and months following the mass shooting at Sandy Hook Elementary School in Newtown, Conn., which killed 20 first-graders and six staff members, the National Institutes of Mental Health spoke extensively about mental illness and violence. 'The conversation has evolved, recognizing that violence most often associated with mental illness is suicide, and that most violence is unrelated to mental illness,' the NIMH director said at a meeting three months later. NIMH also hosted a special panel discussion, How Sandy Hook is Changing the Conversation,' during which mental health experts worked to dispel stereotypes that link mental illness to violence.

After this month’s shootings, however, NIMH and its director were largely silent on the shooting. The only mention on the official NIMH Twitter account was a retweet of the NIH account, directing those struggling with grief and emotional distress to the Substance Abuse and Mental Health Services Administration for counseling and support.

Furthermore,

An HHS employee who spoke on the condition of anonymity to describe internal discussions said he had 'no doubt this was meant to prevent anybody from making any statements that might contradict the president.'

The Post consulted one ethics expert:

'To say that scientists and experts who know the data and facts best are not allowed to speak — that’s very concerning,' said Dominic Sisti, a University of Pennsylvania professor who studies ethics in mental health and psychiatry.

Silencing the Director of the National Institute of Environmental Health Sciences (NIEHS)  and National Toxicology Program to Support Industries Favored by the Administration

The case had to do with the health risks posed by PFAS, industrial chemicals found in the environment.

Per an October 24, 2019 article in The Intercept, the background is:

the company that first developed both PFOA and PFOS and sold PFOA to DuPont for many years, still argues that the compounds do not cause health problems. In her testimony before the House Committee on Oversight and Reform in September, Denise Rutherford, 3M’s senior vice president of corporate affairs, said that 'the weight of scientific evidence has not established that PFOS, PFOA, or other PFAS cause adverse human health effects.' The company also requested that The Intercept remove the word “cause” in a recent article about PFAS. That request was denied.

However, Linda Birnbaum, recently retired director of the National Institute of Environmental Health Sciences and the National Toxicology Program, thought

'In my mind, PFAS cause health effects because you have the same kind of effects reported in multiple studies in multiple populations,' she said in a phone interview. Birnbaum pointed in particular to longitudinal studies, which follow populations’ exposures and health over time. 'You have longitudinal studies showing the same effects in multiple populations done by multiple investigators and you have animal models showing the same impact,' said Birnbaum. In addition, she pointed to studies that show the mechanism through which PFAS chemicals cause harm in people.

'That is pretty good evidence that PFAS or certain PFAS can cause health effects in people. It is not as strong for every effect, but there are quite a number of effects where they’re strong enough to say ‘caused,’' Birnbaum said. She pointed in particular to the relationship between the chemicals and immune response, kidney cancer, and cholesterol in humans, saying, 'That data is very clear.'

Dr Birnbaum had upset industry in the past, but in particular,

Her run-in with Republicans on the House Science Committee last year may have had the most severe consequences. Reps. Andy Biggs and Lamar Smith accused Birnbaum of lobbying based on an editorial in the journal PLOS Biology. In it, Birnbaum wrote that 'U.S. policy has not accounted for evidence that chemicals in widespread use can cause cancer and other chronic diseases, damage reproductive systems, and harm developing brains at low levels of exposure once believed to be harmless.' She called for more research on the risks posed by chemicals and noted that 'closing the gap between evidence and policy will require that engaged citizens — both scientists and non-scientists — work to ensure that our government officials pass health-protective policies based on the best available scientific evidence.'

Under the Trump administration, there were consequences:

'everything was scrutinized that I did. Everything I did required clearance. Even in my lab,' said Birnbaum. 'All of a sudden, everything had to go up at least to building 1,' she said, referring to the Bethesda building that serves as the administrative center for the National Institutes of Health. Birnbaum was also denied a salary increase after the incident and became aware that her job was at stake. 'I was told that they were trying to fire to me.'

Also,

Birnbaum was not allowed to use the word 'cause' when referring to the health effects from PFAS or other chemicals.

'I was banned from doing it'” said Birnbaum. 'I had to use ‘association’ all the time. If I was talking about human data or impacts on people, I had to always say there was an association with a laundry list of effects.' Birnbaum said this restriction 'was coming from the office of the deputy director. His job hinged on controlling me.'

Again, while there is room for debate about whether PFAS causes the problems, or are simply associated with the problems.  However, the accusation is not that there was debate within the government, but that Dr Birnbaum's government supervisor silenced her opinions about causation, whaterver the evidence on which she based them.

Silencing the Director of the Centers for Disease Control and Prevention (CDC) Climate and Health Program About "Climate Change"

On October 29, 2019, CBS News reported that Dr George Luber, Director of the CDC Climate and Health Program, had to stop talking about "climate change," particularly its health consequences,

In late 2016 Luber was organizing a climate change conference. Al Gore was to be the keynote speaker. But right after Donald Trump was elected president, Luber's boss called him in.

Luber recalled, 'I was told the optics are not good and that I needed to cancel it.'

Correspondent Mark Strassmann asked, 'Did he explain what the optics issue was?'

"That the meeting was happening three weeks after the inauguration."

'And that the White House would be unhappy?'

'Yeah,' Dr. Luber said.

America's new president had a dim view of Luber's science, referring to climate change as a hoax, 'created by and for the Chinese.'

Dr. Luber said his boss wanted something else: 'Just don't say 'climate change.' Can you call it 'extreme weather?' Can you call it something else?'

Strassmann said, 'You're saying that the Centers for Disease Control was suddenly afraid to use the term 'climate change'?'

'Yeah. Absolutely. I was told to use a different term,' he said.

CBS confronted Dr Patrick Breyesse, Dr Luber's manager, who essentially gave a non-denial denial:

He's the senior manager who Dr. Luber said ordered him to scuttle the science conference.

'It wasn't cancelled; we postponed it,' Dr. Breysse said.

'You didn't feel any pressure at all?' Strassmann asked.

'No.'

'Politically?'

"No."

That conference happened, but without CDC sponsorship.

Strassmann asked, 'Were any CDC employees ever told, 'Stop using the phrase 'climate change'?'

'Not to my knowledge,' Dr. Breysse replied, 'but we did discuss it.'

'That you change from 'climate change' to 'extreme weather,' because 'climate change' was more radioactive?'

'We talked about making the change, but we never made the change.'

Meanwhile, it appears that CDC leadership retaliated against Dr Luber,

In March 2018 the CDC revoked Dr. Luber's badge, phone and credentials. He was escorted off the property. The CDC moved to fire him. He faced more than 30 'troubling allegations,' from falsifying timecards to seeming hung over. Dr. Luber refuted all but one charge, and was allowed to stay.

However,

Dr. Luber still works at the CDC, but potentially faces up to a four-month suspension. He has to work from home, where he reviews scientific papers unrelated to climate change.

When asked about that, Dr Breyesse responded

'I can't talk about personnel matters, I'm sorry, Mark,' he responded.

'Has he been banned from the campus?'

'So, that's a personnel matter that I can't discuss.'

'Is the CDC retaliating against him?'

'I'm just not going to comment on that,' he said.

A Larger Pattern

To summarize, in the second half of 2019, we have seen three episodes of scientists/ health care professionals at the premier US government health and public health agencies silenced about relevant issues to apparently avoid contradicting Trump administration political goals and/or the pronouncements of the President himself.  There is reason to suspect that agency leaders punished or retaliated against the scientists and health professionals for speaking out.

These appear to be part of a larger pattern.  There have been a lot of similar episodes involving other kinds of science.  For example, there was the infamous case of government climate scientists attacked after they contradicted a Trump tweeted his erroneous take on the course of Hurricane Dorian.  As the New York Times reported on September 8, 2019:  

The Secretary of Commerce threatened to fire top employees at the federal scientific agency responsible for weather forecasts last Friday after the agency’s Birmingham office contradicted President Trump’s claim that Hurricane Dorian might hit Alabama, according to three people familiar with the discussion.

That threat led to an unusual, unsigned statement later that Friday by the agency, the National Oceanic and Atmospheric Administration, disavowing the National Weather Service’s position that Alabama was not at risk. The reversal caused widespread anger within the agency and drew accusations from the scientific community that the National Weather Service, which is part of NOAA, had been bent to political purposes.

After that episode, the National Task Force on Rule of Law and Democracy developed a report on government attaacks on the integrity and rigor of government research, as summarized in an op-ed in the Washington Post on October 3, 2019, entitled "Under Trump, the integrity of government research is in shambles." The authors wrote,

This isn’t the first time this administration has retaliated against scientists for doing their jobs. The Agriculture Department recently decided to relocate an entire staff of career economists from Washington to the Kansas City area after they published reports on the financial harms of Trump’s trade policies. The Interior Department moved a climate scientist to an accounting role after he stressed the dangers of climate change to Alaska’s Native communities. A recent tally by the Union of Concerned Scientists listed more than 120 attacks on science by the Trump administration.

The report called for a variety of legislative solutions, but these may be insufficient.

The pattern may be even larger.  In the Atlantic, Quinta Jurecic, the managing editor of Lawfare, wrote on September 11, 2019,

The saga of Dorian is a snapshot of Trump’s refusal to accept the reality of a world that looks any different from what he wants to be true, and a demonstration of how such an instinct in a leader is incompatible with the requirements of democracy.

Furthermore,

Trump’s behavior regarding Dorian is yet another example of his strained relationship with the truth, something that is at this point so routine as to be barely worth commenting on. In the language of the philosopher Harry Frankfurt, he is a 'bullshitter'—someone who does not so much lie in order to consciously obscure the truth as make statements without any thought or care to what the truth might be. Bullshit, Frankfurt argues, is careless, in that it requires no commitment to a stable universe of facts. And Trump’s falsehoods are careless insofar as he makes them without any regard for consistency or internal logic, but there is also a stubbornness to them. His bullshit is a way of insisting that the world take the shape he wants it to have, regardless of the facts on the ground.

Government by BS is not just a threat to science and scientific discussion.

Democracy, as Arendt writes, depends on the existence of a shared universe of mutually agreed-upon facts—like whether or not it is raining in Alabama. It also depends on the willingness of leaders to acknowledge that some things, including the weather, are beyond their control. That is not Donald Trump’s way. He is the strong man standing alone at the front of the crowd, who is strong only when there is no one there to tell him differently.

Trump seems to want to be like the Inner Party in Orwell's 1984. In Part III, Chapter 2, when Inner Party member O'Brien interrogates and tortures Winston Smith, he says:

reality is not external.  Reality exists in the human mind, and nowhere else.  Not in the individual mind, which can make mistakes, and in any case soon perishes: only in the mind of the Party, which is collective and immortal.  Whatever the Party holds to be truth, is truth.  It is impossible to see reality except by looking through the eyes of Party.  

So when O'Brien holds up his hand with four fingers extended, and Smith says he sees four fingers,

And if the Party says that it is not four but five - then how many?

The Party says the answer must be "five"

So the answer to the question posed by the title of this post is "we can't"

As long as we are led by a President who believes he has the power to make 2 + 2 equal "5," we will be unable to meaningfully promote clinical research integrity, much less evidence-based medicine.  Any progress will only come with a new President.