Threats to Democracy Round Up - Selected Topics, Late May, 2023

Influence of Hostile Foreign Powers

We have previously posted lots of words about the anechoic effect: the lack of echoes produced by seemingly important stories about health care dysfunction.  It seemed as if such stories were taboo, presumably because even discussing them was seen as a threat to the rich and powerful who increasingly run 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.   

 But as we discussed here, the major issues we discussed prior to 2015 gave way to a new normal with the advent of Trump as a presidential candidate and the MAGA movement as a major force in US politics.  In that 2020 discussion, we noted how the Trump administration acted 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).

Now it appears that the most striking example of the anechoic effect involves discussion of the underlying causes of the anti-democratic turn in the US that threatens the system that permits public discussion, and the possibility of reforming health care dysfunction among other issues.  We continue to see bits of evidence made public about how democracy is threatened by the influence of hostile foreign powers, especially Russia, on US politics, especially elections.  Yet the evidence produces few echoes.

Here are some of the more striking bits of evidence that appeared in just the last two weeks about Russia's malign influence on US democracy.

Russia's Malign Strategy and Tactics

-The April 2023 Indictment for Russian Election Interference and Threats to U.S. Democracy "The Kremlin’s Strategy: Exploiting far left and far right fringes; Exploiting the racial divide; Going local"
https://www.justsecurity.org/86424/the-april-2023-indictment-for-russian-election-interference-and-threats-to-u-s-democracy/

Racism as a National Security Threat "the one big thru-line from the Cold War to today in terms of the  most exploitable vulnerability Russia can weaponize against us:  America’s racial divisions"
https://open.substack.com/pub/asharangappa/p/class-15-racism-as-a-national-security

Evidence of widespread Russian election meddling in other countries: "Kemal Kilicdaroglu, main challenger of Turkish President Tayyip Erdogan,  said ... his party has concrete evidence of Russia's  responsibility for the release of 'deep fake' online content"
https://www.reuters.com/world/middle-east/erdogan-rival-says-has-evidence-russias-online-campaign-ahead-turkey-vote-2023-05-12/

Linkages of Trump and Supporters to Russia

 US Trumpists are increasingly part of a new global fascist axis: "far-right populism of Hungary’s prime minister is helping to inspire  U.S. Republicans' agenda for 2024, a game plan that targets  immigration, LGBTQ rights and... the war in Ukraine"
https://www.axios.com/2023/05/08/gop-hungary-connection-shaping-2024-campaign

Reminder that Trump "is Putin's puppet": He was "repeatedly asked by CNN host Kaitlan Collins if he backed Ukraine in its 15-month conflict with Vladimir Putin’s forces, and repeatedly dodged the question"
https://www.independent.co.uk/news/world/americas/us-politics/putin-ukraine-war-trump-cnn-b2336935.html

Follow the money: Trump Media got financing from Paxum Bank, which "promoted itself...as a way for video streamers of adult content  to coordinate financial transactions across international borders" and is owned by a sketchy Russian businessman
https://www.washingtonpost.com/technology/2023/05/13/trump-truth-social-loan-questions/

[Another Trump-Russia connection?] FBI agents raid condo unit owned by Russians at Trump Towers in Sunny Isles
https://www.miamiherald.com/news/local/article275358451.html

The FBI raided a condo in Trump Tower III in Sunny Isles Beach, FL because its "owner was being arrested... on  charges of illegally selling airplane parts to Russian airline  companies"  
https://www.yahoo.com/lifestyle/days-mysterious-fbi-raid-russians-225454222.html

Putting another Russian asset in the WH: In call to ReAwaken America rally, Trump said he would give Michael Flynn a WH position.  Flynn "entered, then withdrew, a guilty plea of making false statements to the F.B.I" and hung out with Putin in Russia
https://www.thedailybeast.com/trumps-call-in-to-michael-flynns-far-right-roadshow-is-red-meat-for-christian-nationalists

Reminder: "next to Putin at the head table, in the seat of honor, was an American.  Retired Lt. Gen. Michael Flynn, who would later become Donald Trump's  national security adviser"
https://www.nbcnews.com/news/world/guess-who-came-dinner-flynn-putin-n742696

Trump and Supporters' Techniques to Downplay their Connections to Russia: The Durham Investigation 

It was supposed to show how the investigation of Trump/Russia was a witch hunt.  It didn't

Not with a bang.... Trump fans hyped the Durham investigation. Trump fans will likely keep spinning it, but it "delivered underwhelming results... securing a guilty plea from a little-known FBI employee [and] ...losing ...2 criminal cases"
https://apnews.com/article/durham-trump-russia-probe-7e84f94ca9cf7905cbc5eddc108575b3

"Durham’s...report revealed little substantial new information  about the inquiry...failed to  produce the kinds of blockbuster revelations... that...Trump  and his allies suggested Mr. Durham would uncover"
https://www.nytimes.com/2023/05/15/us/politics/trump-russia-investigation-durham.html

"Durham...scolded the F.B.I. but failed to... uncover a politically motivated 'deep state' conspiracy.... charged no  high-level F.B.I. or intelligence official with a crime and acknowledged...Clinton’s 2016 presidential campaign did  nothing prosecutable"
https://www.nytimes.com/2023/05/17/us/politics/durham-report-trump-russia.html

Despite the failure of the Durham investigation to find any important misconduct much less "deep state" politicization of the Trump-Russia investigation, to Trump fans it  "was Watergate times 10, or 100"
https://www.nytimes.com/2023/05/16/us/politics/durham-report-conservative-reaction.html

Russia, Trump and the 2016 election "Russia tried to swing the 2016 election to Trump; FBI had reason to investigate a tip suggesting Trump campaign involvement; Trump campaign welcomed help from Russia:  ‘Steele dossier’ proved to be a red herring"  
https://www.washingtonpost.com/politics/2023/05/17/truth-about-russia-trump-2016-election/

Russian Propaganda and Disinformation

"hate crimes in America are often influenced by online chatter that's  increasingly linked to Russian sites or pro-Russian narratives on more  obscure parts of the internet. The Kremlin doesn't seem to mind"  
https://www.axios.com/2023/05/09/american-extremists-russian-sites-shootings

Conflicts of Interest, Corruption, Crime

Since 2015, we have asked (here) how the US (and the world) can possibly reduce health care corruption, a major cause of global health care dysfunction, under a thoroughly conflicted and corrupt Trump administration.  Since the end of that administration, Trump has campaigned to be president again.  Meanwhile, the evidence of his and his supporters' conflicts of interest, corruption, and criminality continue to grow.  Recent examples include:

Trump's Conflicts, Crimes, and Corruption

Jury finds Trump liable for sexual abuse, awards accuser $5M [When real, reasonable people get to review Trump's conduct while free of his intimidation and bluster they may tend to do so harshly]
https://www.sfgate.com/news/article/jury-to-start-deliberations-in-suit-accusing-18087335.php

"Trump admitted more directly than before on Wednesday that he knowingly  removed government records from the White House and claimed that he was  allowed to take anything he wanted with him as personal records" Confessing to a crime?  
https://www.nytimes.com/2023/05/11/us/politics/trump-documents-white-house.html

He just can't help himself: in his CNN Town Hall appearance, Trump appeared to defame E Jean Carroll again, just days after she won a lawsuit against him for his previous defamation
https://www.nytimes.com/2023/05/11/nyregion/e-jean-carroll-trump-defamation.html

[Even more accusations of sexual misconduct by Trump, even involving his own White House staff] Top aides reveal Trump’s alleged inappropriate conduct towards female staffers
https://www.independent.co.uk/news/world/americas/us-politics/donald-trump-white-house-aides-abuse-b2337881.html

Attacking the rule of law, eve obstruction of justice? - Trump fan politicians go after prosecutors who are investigating or otherwise legally pursuing Trump, including Manhattan DA Bragg, Special Counsel Smith, Fulton County GA DA Willis
https://www.theguardian.com/us-news/2023/may/17/donald-trump-republican-allies-prosecutors-investigations

There is apparently evidence that Trump knew he was committing a crime by walking off with classified presidential records despite his later claims that doing so was legal
https://www.independent.co.uk/news/world/americas/us-politics/trump-mar-a-lago-classified-documents-evidence-b2342010.html

The Conflicts, Crimes and Corruption of Trumpist and/or Far Right Politicians

[Noticing this glaring conflict of interest] Judge to order Wisconsin Elections Commission to reconsider fake elector complaint without the commissioner who joined the scheme
https://www.jsonline.com/story/news/politics/2023/05/08/wisconsin-elections-commission-must-reconsider-fake-elector-case/70195092007/

Are they all sleazy or criminal? Republican "Rep. Bryan Slaton resigned from the Texas House on Monday after an investigation determined that he had an inappropriate sexual relationship with a 19-year-old woman on his staff"  
https://www.chron.com/politics/article/bryan-slaton-pressure-resign-texas-house-18086307.php

TX rep Slaton "proposed banning children from attending drag shows to supposedly shield them from being groomed... resigned after he was found to have engaged in inappopriate sexual  conduct with a 19-year-old intern" Fake morality of the culture warriors
https://www.theguardian.com/us-news/2023/may/09/republican-drag-shows-danger-for-kids-resigns-misconduct-intern

[Again, are they all crooks?] Rep Santos [(R-NY) is accused of using illicit campaign contributions for personal expenses "indictment accusing him of wire fraud, money laundering,  stealing public funds and lying in federal disclosure forms"
https://www.nytimes.com/live/2023/05/10/nyregion/george-santos-charges-news/santos-had-been-under-investigation-for-his-campaign-finances-and-other-activities

Rep George Santos confesses to theft in Brazil to avoid prosecution
https://www.washingtonpost.com/world/2023/05/11/george-santos-brazil-case-theft/

Follow the money: "conservative operatives using sophisticated robocalls raised  millions of dollars from donors using pro-police and pro-veteran  messages....  nearly all the  money went to pay the firms making the calls and the operatives  themselves"
https://www.nytimes.com/interactive/2023/05/14/us/politics/scam-robocalls-donations-policing-veterans.html

[And now reports of sexual misconduct by Trump's lawyer Giuliani] Rudy Giuliani accused of sexual harassment by ex-employee
https://www.bbc.com/news/world-us-canada-65606131

[Are they all thugs, if not crooks?- Louisiana] GOP Rep Clay Higgins filmed shoving activist who questioned Lauren Boebert’s divorce
https://www.independent.co.uk/news/world/americas/us-politics/clay-higgins-shoved-activist-laren-boebert-b2341682.html

Propaganda, Disinformation, Deception

We used to write about propaganda and disinformation used to promote health care goods and services (stealth marketing campaigns), and advocate for policies favorable to private health care organizations (stealth health policy advocacy and stealth lobbying).  Some stealth marketing, lobbying and policy advocacy campaigns encompass not just propaganda, but disinformation.  For example, consider the health insurance company campaign to derail the Clinton administration's attempt at health reform as described by Wendell Potter in Deadly Spin (look here).  The tactics employed in that campaign included: use of front groups and third parties (useful idiots?); use of spies; distractions to make important issues anechoic; message discipline; and entrapment (double-think).

But back in the day, the notion of propaganda and disinformation as a real threat to health care, much less our democratic process and society as a whole, was pretty radical.  That was then.  By 2019 we were writing about a  a new (ab)normal that includes propaganda and disinformation in the service of hostile authoritarian foreign states meant to disrupt more democratic governments, whatever the cost in human health and lives.

 It is important to better understand the techniques of the propagandists and disinformationists, so:

Propagandists' and Disinformationists' Toolbox

Reflexive control "Using the name scholars have given to this area of research to  frame the debate baits Rufo’s opponents into arguing about what CRT is and isn’t, which... keeps the exact three words he wants (and  their attendant connotations) in circulation"  
https://open.substack.com/pub/asharangappa/p/erasing-memory

"How can we really engage in these conversations, when the tension is  there before you even pick up the book and open the topic?" [It's hard to  have a rational argument when fanatics are screaming at you]
https://www.axios.com/2023/05/04/us-history-test-results-civics-covid

The Flood the Zone with BS Technique:
[The old-time fast talking snake oil salesman in the internet age] Donald Trump steamrolls CNN’s town hall [It's easier to lie than to rebut a lie.  If someone lies very quickly, you can't respond in real time]
https://www.washingtonpost.com/opinions/2023/05/10/cnn-trump-town-hall-lies/

'"You can’t keep saying that all night long'....[so one]  can rebut him, correct him, interrupt him and otherwise battle with him  over every point, but that’s no match for ceaseless mendacity....'We don’t have time to fact-check every lie'"
https://www.washingtonpost.com/opinions/2023/05/10/cnn-trump-town-hall-lies/

It's the old Steve Bannon (and Russian) tactic: flood the zone with BS. "CNN hasn’t figured this thing out, and it’s a good bet its competitors have no better ideas" It's clear society needs a better solution to the flood the zone tactic.
https://www.washingtonpost.com/opinions/2023/05/10/cnn-trump-town-hall-lies/

"fear is weaponized even more than hate by leaders who seek to spark violence. Hate is often part of the equation...but fear is  almost always the key ingredient when people feel they must lash out to  defend themselves.
https://www.nytimes.com/2023/05/06/opinion/fear-speech-social-media.html

Ways to Combat Propaganda and Disinformation

Ending false equivalence in choice of editorial voices: "will the  newspaper raise the bar for those local or syndicated [supposedly conservative] voices — i.e.,  requiring the commentary to actually engage in a truthful semblance of a  given issue?
https://www.sltrib.com/opinion/commentary/2023/05/08/commentary-will-we-see-honest/

How the media can cover Trump better this time "Focus on 'the stakes' of the 2024 election, not 'the odds'; Explain Trump’s probable agenda;  Don’t make getting access to Republican politicians or projecting 'neutrality and 'objectivity' a main goal"
https://www.washingtonpost.com/opinions/2023/05/09/trump-2024-cnn-town-hall-media-coverage/

Christian Nationalism Threatens Health Care Professionals, Medicine, Health Care, and Public Health

Much of the "culture war" is about attacking particular patient groups (eg, transgender patients, women seeking abortions, needing birth control or care for such conditions as ectopic pregnancy and miscarriage) and the health care professionals who care for them, or about attacking public health professionals (eg, those involved in pandemic policy) or creating phony public health problems, eg, pornography.

Furthermore, while these attacks are often framed in a biomedical, health care or public health context, the motivation behind them seems to come from extreme sectarianism, particularly Christian nationalism.

Leaked data on right-wing physicians group shows its support of extreme sectarian religious beliefs, recruiting "doctors and medical school students seen as holding Christian views," returning US to a time when "evangelical Christian beliefs" were favored
https://www.wired.com/story/american-college-pediatricians-google-drive-leak/

The state's near-total abortion ban is forcing providers to leave the state "she had to tell a patient that her  pregnancy had a significant fetal abnormality.... her hands were tied. She  couldn’t offer any more care- they had to go elsewhere"
https://www.huffpost.com/entry/idaho-abortion-ban-crisis_n_6446c837e4b011a819c2f792

[Attempting intimidation for taking care of patients] Texas AG Ken Paxton probing Austin children’s hospital [but] "It’s not clear what law Paxton believes Dell Children’s has broken;  Texas does not currently have age limits on gender-affirming care"
https://www.texastribune.org/2023/05/05/ken-paxton-trans-care-investigation-dell-childrens/

Fearing legal repercussions, doctors in Texas say they are risking grave patient harm to comply with new abortion restrictions [abortion bans'  adverse effects:  Extreme sectarian based medicine hurts patients]  
https://www.newyorker.com/news/dispatch/in-the-post-roe-era-letting-pregnant-patients-get-sicker-by-design

Reminder that movement against abortion imposes extreme sectarian religious beliefs on those of other faiths: "Jewish law dating back to the Torah has established that abortion is not murder."
https://www.charlotteobserver.com/opinion/article275261916.html

Confluence of far-right politics and health care nonsense: After DeSantis' coup, New College will host Dr Scott Atlas as commencement speaker. He was a  member of the Trump administration who promoted herd immunity as solution to COVID
https://www.tampabay.com/news/education/2023/05/09/new-college-picks-trump-covid-adviser-scott-atlas-commencement-speaker/

[How sectarianism and superstition creeps into public health] Ladapo's wife who "studied traditional naturopathy, plant and herbal medicine, and shamanism" convinced Ladapo to go to  counseling that that caused him to believe he was following "God’s plan"  
https://www.orlandosentinel.com/2023/05/13/joseph-ladapo-says-anti-vaccine-crusade-was-gods-plan-it-cost-him-his-peers-trust-2/

[More threats to health care] Abortion Clinics Are Dealing with More Arson, Stalking, and Anthrax Threats Now-  Abortion providers feared they’d see an increase in harassment and threats if Roe v Wade was overturned. They were right.
https://www.vice.com/en/article/v7bday/rise-in-abortion-clinic-harassment-after-roe

[Turning sexual hangups into policy? Theocrats go after porn as a public health threat, and...] There’s ‘nothing more timid’ than a man watching porn, Josh Hawley says "There is no risk involved, no exposure to hardship or danger in the least" Promoting sex and relationships that are risky, difficult, dangerous?
https://www.kansascity.com/news/politics-government/article275458201.html

KS Republican county chair says LGBTQ friendly pastors "signed a contract with Satan," plans to "make it hostile to that group of people...small sliver of society...have them move elsewhere, that does a huge amount to shut this  down,”
https://themercury.com/news/republicans-revel-in-divine-plan-to-turn-kansas-into-conservative-sanctuary/article_4a9bbd54-a6fd-5d05-b06f-41785cf4eff6.html

Apparently afraid of prosecution under anti-abortion laws, doctors told patient threatened with a miscarriage "at high risk of life-threatening complications" they could do nothing.  Violating law requiring hospitals to treat patients in emergencies?
So anti-abortion laws make doctors damned if they do (abort pregnancy for patient facing high risk of severe complications) and damned if they don't (by failing to provide emergent care).
https://www.propublica.org/article/two-hospitals-denied-abortion-miscarrying-patient-breaking-federal-law

[More physicians driven away by bans on caring for patients demonized by sectarian extremists] Austin doctors who treated trans kids leaving Dell Children’s clinic after AG Paxton announces investigation
https://www.chron.com/news/houston-texas/article/talk-investigation-forces-tx-doctors-treat-trans-18098101.php

After quacky COVID herd immunity proponent and former Trump administration staffer Dr Scott Atlas invited to speak at DeSantis transformed New College commencement, students raise money to support alternative event
https://wusfnews.wusf.usf.edu/education/2023-05-10/with-former-trump-appointee-speaking-at-their-graduation-new-college-students-plan-alternative-commencement

Doctors forced out by laws restricting treatment of patients with pregnancy complications pushed by extreme sectarians: "Doctors... fleeing the state due to new abortion restrictions....[fearing] 'Being tried as a felon simply for saving someone’s life'"  
https://www.cnn.com/2023/05/13/us/idaho-abortion-doctors-drain

[Reminder: laws based on extreme sectarian religious views impose them on those of other faiths, and harm doctors and patients] Texas doctors depart as attorney general investigates hospital’s gender-affirming care
https://www.theguardian.com/us-news/2023/may/18/texas-hospital-inquiry-doctor-exodus

Follow the Money: Who Funds Attacks on Democracy

It's not just Russia and hostile foreign powers who threaten democracy behind the scenes.  Domestic greed is still a factor. 

Another example of how big national right-wing dark money came to small town to finance local school board candidates who wanted to ban books. We need to figure out who is paying for this, and what's in it for them  
https://www.bostonglobe.com/2023/05/06/nation/how-school-board-race-blue-state-illinois-became-nationally-funded-cage-match/

"Republicans...play this...game of supporting the  wealthy and big business behind the scenes... but making it appear...that they're on the side of the little person....going after the wokeness is a good way to do it...that's not  a bread and butter issue"
https://www.bbc.com/news/business-65428204

[One big corporation refuses to bow down to DeSantis' anti-woke threats.  Will others realize pumping money into extremists' political coffers is bad for business?] Disney Pulls Plug on $1 Billion Development in Florida
https://www.nytimes.com/2023/05/18/business/disney-ron-desantis-florida.html

 

 

Who Cares If Hunter Biden Owns a Laptop? Red Herrings and Reflexive Control

 Introduction: Propaganda and Disinformation in Health Care and Elsewhere

 We used to write about propaganda and disinformation used to promote health care goods and services (stealth marketing campaigns), and advocate for policies favorable to private health care organizations (stealth health policy advocacy and stealth lobbying).  Some stealth marketing, lobbying and policy advocacy campaigns encompass not just propaganda, but disinformation.  For example, consider the health insurance company campaign to derail the Clinton administration's attempt at health reform as described by Wendell Potter in Deadly Spin (look here).  The tactics employed in that campaign included: use of front groups and third parties (useful idiots?); use of spies; distractions to make important issues anechoic; message discipline; and entrapment (double-think).

But back in the day, the notion of propaganda and disinformation as a real threat to health care, much less our democratic process and society as a whole, was pretty radical.  That was then.  By 2019 we were writing about a  a new (ab)normal that includes propaganda and disinformation in the service of hostile authoritarian foreign states meant to disrupt more democratic governments, whatever the cost in human health and lives.

And in 2023, propaganda and disinformation are in the headlines all the time.  But it is still important for health care professionals and the public at large to appreciate the mechanisms of both, and how to mentally defend against them.  In 2023, despite the headlines, the propagandists and disinformationists are not slowing down.  So it's time to review how they operate again. Let me present a recent example that caught my eye.

Who Cares if Hunter Biden owned a Real Laptop?   

As Elon Musk's Twitter gets increasingly raucous, the propaganda and disinformation that appear therein has gotten back to basics, providing some stark examples of the techniques used.  For example, see this 5 word Tweet from Rep Elise Stefanik (R-NY), a Harvard educated Congresswoman who has become a prime booster of Trump. 

Hunter Biden’s laptop is real.

What could it mean? Is there a debate going on whether Hunter Biden (the son of President Biden) owns a laptop? Who would care?

Of course, it turns out that there is a very big controversy, promoted by people who support Trump, about whether some aspects of a laptop ostensibly once owned by Hunter Biden suggest that both Bidens are unethical, corrupt, or worse.  For example, Washington Post reporters tried to analyze the controversy and the various questions raised about the provenance of the allegedly incriminating data:

217 gigabytes of data provided to The Post on a portable hard drive by Republican activist Jack Maxey. He said the contents of the portable drive originated from Hunter Biden’s MacBook Pro, which Hunter reportedly dropped off at a computer repair shop in Wilmington, Del., in April 2019 and never reclaimed.

The vast majority of the data — and most of the nearly 129,000 emails it contained — could not be verified by either of the two security experts who reviewed the data for The Post. Neither found clear evidence of tampering in their examinations, but some of the records that might have helped verify contents were not available for analysis, they said. 

It's clear there was no clear chain of custody spanning Hunter Biden, the laptop, its hard drive, the data on that hard drive, and the data eventually given to the Washington Post.

Furthermore, the significance of this electronic data and the strengths of any arguments about the behavior of Hunter Biden, President Biden, or other people based on it are very unclear.

So what was the point of Rep Stefanik's stark statement (and many others like it)?

The Red Herring Logical Fallacy

One simple explanation is that Rep Stefanik et al were employing the Red Herring Logical Fallacy.  One definition of this fallacy is:

Attempting to redirect the argument to another issue to which the person doing the redirecting can better respond. While it is similar to the avoiding the issue fallacy, the red herring is a deliberate diversion of attention with the intention of trying to abandon the original argument.

So this is like the many other examples of the use of logical fallacies to advance self-serving arguments about health care, policy, or other issues that we have discussed. 

Reflexive Control

However, Rep Stefanik's 5 word assertion may actually be part of something more sophisticated.

It may be part of a larger strategy of reflexive control.  Discussions of reflexive control used to mainly appear in fairly esoteric places, eg in considerations of military and intelligence strategies, game theory, etc. Here is some background from the Georgetown Security Studies Review from 2017:

With confusion swirling around 'alternative facts,' the effects of disinformation and Russian meddling are just beginning to take hold. This phenomenon may be new to American politics, but it’s an old strategy in the Kremlin. To understand and combat the effects and goals of disinformation, we must understand the concept of reflexive control and how it fits into greater Russian strategy.

Reflexive control is a 'uniquely Russian' concept based on maskirovka, an old Soviet notion in which one 'conveys to an opponent specifically prepared information to incline him/her to voluntarily make the predetermined decision desired by the initiator of the action'. That is, reflexive control is a sustained campaign that feeds an opponent select information so that the opponent makes the decisions that one wants him/her to. Methods of reflexive control include spreading false information, leaking partial information at opportune moments, and projecting a different posture of oneself than what may actually be the case. The goal of reflexive control is to ‘control’ the ‘reflex’ of the opponent by creating a certain model of behavior in the system it seeks to control. The most fundamental way to do this is to locate the weak link in the system and exploit it through moral arguments, psychological tactics, or appeals to specific leaders’ character.

This concept has a long history in Russian military strategy, with the Soviet and Russian Armed Forces studying reflexive control at both the tactical and operational levels. Reflexive control has also long been taught at various Russian military schools and training programs, and is codified as Russian national security strategy in the Gerasimov Doctrine. Today, reflexive control is a key component in Russia’s idea of hybrid warfare.

 

Here is a useful summary from the PropWatch Project about how it's done:

 A messaging strategy of reflexive control conveys specially prepared information to an opponent to incline that opponent to voluntarily make the predetermined decision desired by the initiator of the action.' In other words, reflexive control is a way to get an opponent to willingly defeat himself. 

First introduced in the former Soviet Union by mathematician and psychologist Vladimir Lefebvre, reflexive control is a concept that has been perfected by Russia since the 1960's. A strategy of reflexive control can be reduced down to four basic components, also called the 4Ds:

Dismiss - to simply deny any involvement in a matter and discredit the accuser.
Distort - to warp, twist, or fabricate your own facts.
Distract - to introduce certain novel information into the mix or accuse your accuser of the same. 
Dismay - to play with emotions by using fear-mongering tactics.

Accusing one's political enemy of denying the existence of an object (a laptop) when the real questions are complicated ones about the truthfulness of evidence and the best way to interpret it seems to fit right in.

Conclusions

The problems of propaganda and disinformation in health care and policy no longer seem esoteric.  Instead they have become central problems of our time, and a clear challenge to our ideals of democratic government.  Without a functioning democracy, IMHO trying to make incremental changes in health policy to reduce health care dysfunction becomes an exercise in frustration, if not futility.

Health care professionals and the general public must better understand and learn to defend against both crude and sophisticated attempts to warp policy and politics, and corrupt democracy to prevent the onset of a new dark age.

We on Health Care Renewal  will continue to try to do our small part to defend against these dark arts.

Logical Fallacies in Support of Propaganda and Disinformation

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

Introduction: Logical Fallacies

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

Logically Fallacious defines logical fallacies thus:

Criteria for Logical Fallacies: 

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

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

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

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

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

Logical Fallacies in Health Care and Public Health

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

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

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

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

Ad Hominem

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

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

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

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

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

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

The ad hominem tu quoque fallacy is defined:

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

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

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

Appeal to Authority

The appeal to authority is defined:  

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

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

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

Appeal to Common Belief

The appeal to common belief is defined:

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

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

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

Appeal to Common Practice 

The appeal to common practice has the following structure:

X is a common action.

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

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

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

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

Appeal to Fear

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

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

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

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

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

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

Appeal to False Authority 

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

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

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

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

 Appeal to Ignorance

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

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

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

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

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

Slippery Slope

The definition of the slippery slope is:

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

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

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

Special Pleading

The definition of special pleading is:

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

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

Straw Man

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

The definition of the straw man fallacy is:

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

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

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

Other Logical Fallacies Used to Support Propaganda or Disinformation

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

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

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

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

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

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

Summary- Propaganda, Disinformation, and Logical Fallacies

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

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

President Trump and Surrogates Continue to Hold Campaign Events Enabling Spread of the Coronavirus: Had Enough Yet?

While the US continues to suffer from one of the worst outbreaks of the novel coronavirus pandemic to beset any developed nation (look here), national, state and local political leaders in the US who support President Trump have continued to hold events and otherwise behave in ways that seem designed to increase the spread of coronavirus. Multiple instances included leaders purposefully avoiding wearing face masks and social distancing in instance in which disease transmission was likely, eg, government meeting and political session, and engineering crowded events in which social distancing and wearing of face masks were rare (look here and here).

Three weeks since we last discussed this topic, as the US presidential race heats up, we have noted multiple instances in which President Trump and his campaign surrogates have again promoted multiple crowded, socially not distant events at which few attendees wore masks. At some of these events, the practices promoted by the organizers went against state or local laws or regulations.  And these practices are continuing to be associated with disease spread.

Listed in chronological order according to the date of the reporting:

Trump Campaign Events in Three States

As reported by the AP (via PBS) on August 19, 2020:

Iowa

During Pence’s Des Moines event, chairs arranged in small clusters six feet apart were quickly abandoned as many in the audience of about 200, few in masks, moved within a few inches of each other. Dozens crowded together afterward to get an autograph or nod from Pence.

Wisconsin

in Wisconsin on Monday, Trump absolved his audience of health precautions, along the way mocking the racial justice protests he has railed against for weeks.

In an aircraft hangar in Oshkosh, Trump flaunted violations of the state’s distancing and masking guidelines — recommendations also promoted by the federal Centers for Disease Control and Prevention — as he spoke to hundreds of supporters, most not wearing face coverings.

'This was supposed to be just a quick, little small gathering,' Trump said, joking that 'We’re supposed to have 50 people, right?'

'We’ll call it a peaceful protest, that way we can do whatever we want,' Trump added.

'This is like a rally,' Trump added, before telling supporters: 'I hereby grant you a pardon.'

Later in Wisconsin,

On Wednesday, Pence addressed a crowd at a metal fabricating pant in Darien, Wisconsin, where the crowd stood and sat close together, many people not wearing masks despite a statewide order requiring them indoors.

Arizona

At Tuesday’s similarly raucous rally in Yuma, Arizona, supporters sat on closely packed-in chairs and bleachers, and stood on a balcony as they chanted 'four more years!' While the hangar was open on one side overlooking Air Force One on the tarmac, it nonetheless felt stuffy inside in the stifling heat. Most in the crowd did wear official 'TRUMP' and 'MAGA' masks, though many did not.

To summarize, Trump campaign events were crowded and attended by people without face masks, and thus appeared designed to violate local rules about public health.  Trump himself mocked such rules and public health practices.

Republican National Convention Site, Charlotte, North Carolina

As reported by the Charlotte Observer on August 24, 2020:

Face masks were supposed to be worn at the Republican National Convention in Charlotte. In addition to North Carolina’s COVID-19 statewide mask mandate, RNC staff agreed to enforce the rule inside the convention center.

But on the floor of the RNC, strict coronavirus protocols quickly fell by the wayside Monday.

Social distancing was expected too — in addition to COVID-19 symptom screening and testing — to prevent a virus flareup as more than 300 delegates gathered at the Charlotte Convention Center Monday, in a dramatically scaled-down RNC to renominate President Donald Trump.

But many inside were seen not wearing masks and some attendees shook hands and huddled in tight-knit circles as the RNC recessed awaiting the arrival of Vice President Mike Pence. Among delegates and convention staff, some people did wear masks. Still others did not or were seen wearing face coverings ineffectively, such as having the mask slung below their chins.

Note that the management of the convention proceedings appeared to go against local public health rules..  Yet after local public health authorities reminded convention management of that, the problems continued.

Mecklenburg Public Health Director Gibbie Harris said Monday she contacted the RNC about the lack of masks and social distancing, observed not only by journalists inside the convention hall but also easily seen on live streams from the event.

'I have just shared concern about the lack of mask wearing and social distancing in the room at the RNC Roll Call Meeting with the RNC Convention staff,' Harris said in a statement Monday.

'I have been assured that they are working hard to address these issues. All attendees agreed to comply with the requirements prior to attending and were informed that these requirements would be enforced.'

Yet just a few hours later, delegates swiftly converged near the stage of the Richardson Ballroom as Trump concluded his remarks, holding up smartphones to snap a picture of their presidential nominee. Attendees, packed close to one another, danced the YMCA — with many still not wearing face coverings.

Further note that the Republican convention organizer's lax approach occurred at a time when transmission of coronavirus is a major concern in Charlotte.

The Charlotte area continues to grapple with the highest coronavirus case levels in North Carolina, though crucial trends — including hospitalizations and the test positivity rate — continue to improve. There have been 24,260 coronavirus cases and 282 related deaths among Mecklenburg residents as of Monday afternoon, according to state and local health officials said.

Thus it is not surprising that within days several convention attendees proved to be infected.  As reported by the Charlotte Observer on August 28, 2020:

Two attendees and two local support staff at the Republican National Convention in Charlotte tested positive for COVID-19, Mecklenburg County and GOP officials announced Friday.

The disclosures come after county health officials raised concerns about a lack of social distancing and mask wearing during the roll-call vote to renominate President Donald Trump for a second term on Monday — despite strict health protocols that were supposed to be followed. The GOP is defending the safety procedures it had in place.

Local health officials said the county instructed those who were infected to isolate immediately, and people who came in close contact with them should also quarantine themselves. A county spokeswoman did not respond to questions on whether the orders were followed.

To summarize, despite assurances that the event would promote best public health practices, the organizers allowed crowding and unmasked or inadequately masked attendance, even after public health officials had warned them about problems.  Probably due to the lack of public health preventive measures, attendees are already beginning to test positive for infection.


Republican National Convention Site, Washington DC

Melania Trump's Speech

As reported by CNN on August 26, 2020:

Those who attended first lady Melania Trump's speech in the White House Rose Garden that capped the second night of the Republican National Convention were not required to get tested for coronavirus, a person who attended the speech told CNN.

Despite that,

The vast majority of those attending did not wear masks, and the chairs provided for attendees did not appear to be placed six feet apart.

Trump's Nomination Acceptance Speech

According to the New York Times, August 28, 2020:

The chairs were packed in tightly on the White House lawn. Hundreds of people in the crowd had not been tested for the coronavirus upon attending.

The mostly maskless guests were seated cheek by jowl for hours....

Again, no masks, no social distancing, no observance of local public health rules.


Campaign Rally in Manchester, New Hampshire

As reported by NPR on August 28, 2020:

President Trump returned to New Hampshire Friday night, fresh off the Republican National Convention, for a rally at Manchester Airport.

For the hundreds of supporters in attendance, the atmosphere was that of a festival. Many wore Trump-themed clothing. Others wore T-shirts celebrating right-wing figures ranging from Fox News host Tucker Carlson to Brazilian President Jair Bolsonaro.

A minority wore masks, which are now required in New Hampshire at gatherings of more than 100 people. And many in the crowd jeered when an announcer on the PA system suggested they don them.

Again, no masks, no social distancing, and apparent public contempt for public health rules

Disease Spread Among Secret Service Agents Protecting Trump

Finally, the evidence that the Trump campaign is actually promoting the spread of COVID-19 is growing.  As reported by the Washington Post on August 28, 2020:

When President Trump gave a speech to a group of sheriffs in Tampa late last month, his decision to travel forced a large contingent of Secret Service agents to head to a state that was then battling one of the worst coronavirus surges in the nation.

Even before Air Force One touched down on July 31, the fallout was apparent: Five Secret Service agents already on the ground had to be replaced after one tested positive for the coronavirus and the others working in proximity were presumed to be infected, according to people familiar with the situation.

Then,

After the incident in Tampa in July, two agents who were assigned to stand guard at Trump’s private club in Bedminster, N.J., fell sick with coronavirus symptoms this month while the president golfed. It was his third trip there this summer.

In summary,

In the past two months, dozens of Secret Service agents who worked to ensure the security of the president and Vice President Pence at public events have been sickened or sidelined because they were in direct contact with infected people, according to multiple people familiar with the episodes, who spoke on the condition of anonymity to describe the incidents.

Trump's apparent disregard for the health of those who have sworn to protect him appears to be generating some unprecedented discontent.  A more rigorous program of coronavirus tests for agents was instituted:

after some discontent and anxiety percolated inside the agency earlier this summer, with agents and officers privately complaining that the White House and the Secret Service were not properly addressing the risks they faced on the road, according to people familiar with the concerns. Testing and protective equipment had been offered sparingly and inconsistently, some argued.

Even more pointedly,

this new virus that has killed nearly 180,000 Americans in eight months has prompted some to ask a new question: Should they be required to risk contracting a lethal disease — and infecting a loved one — to secure an event that does not follow health protocols?

Discussion

There is growing evidence that wearing face masks decreases the likelihood the wearer will transmit or contract the infection, and the likelihood that any such infection will be severe.  Keeping people physically separate, particularly by more than six feet, and particularly when they are indoors, also decreases transmission in either direction.

Nevertheless, after the Trump administration failed to effectively shield the US from the coronavirus pandemic, while peddling disinformation about the disease and its effects, the president continues to act in ways that actually promote further spread of the virus.  The perversity of his behavior is even being acknowledged by those sworn to protect him.  As reported by the Washington Post,

Never before has the Secret Service run up against a president so intent on putting himself first regardless of the costs, including to those around him,' said Ned Price, a national security expert and former CIA analyst.

While the Secret Service is having doubts, some Trump supporters deny the risks they are taking on his behalf.  Those who attend his campaign events, especially those who choose not to wear masks, have an elevated risk of becoming infected, and once infected, of transmitting infection to their friends and family.  Those who are already infected when they arrive at an event, even if asymptomatic, are at risk of spreading the disease to his other supporters.  Trump's careless, if not malevolent approach to public health at his campaign events is likely to hurt his own supporters before it hurts others.

Yet, perhaps rendered  stupid by Trump's propaganda and disinformation, they remain blissfully ignorant.  For example, as reported by NPR at the New Hampshire rally,

The COVID-19 pandemic was on the mind of many attendees. Timothy Parnell, an engineer who lives in Seabrook, said Democrats’ criticism of Trump’s handling of the coronavirus is 'absurd.'

'The only way the president could have done better is if he was psychic,' Parnell said. 'He took advice from the scientists; he asked for advice.'

Yet the evidence that Trump repeatedly disregarded, and often contradicted scientists' advice is clear.

Furthermore, as reported by the AP from a Pence event in Iowa,

Rob Mudd, who drove 120 miles from Cedar Falls to see Pence, was among those not wearing a mask. 'Is the disease real? Yes,' said Mudd, 53. 'So is the fear mongering.'

Likewise, Justin Chance, from suburban Des Moines, shook his head when asked why he, too, wore no mask. 'I just don’t believe all the hype,' said Chance, 55. 'I just don’t worry about it.'

Yet the US death rate for coronavirus this year has already exceeded 180,000.

Maybe his supporters are reassured about what Trump said in Oshkosh, “I hereby grant you a pardon.”   Of course, the coronavirus does not care if Trump gave someone "a pardon."  It could infect, and even kill such a person regardless.

Maybe the more Trump supporters fall ill, or see their friends and family members fall ill, the more they will doubt Trump's pretensions at royal pardons.  But that may take a long time, during which there may be a lot of disease and death.  Meanwhile, Trump will be able to do more and more damage to patients' and the public's health.

Instead of waiting, I hope my fellow professionals will step up now. It is time for us to tell every patient what they need to know to protect themselves from a deadly pandemic.  It is time for us to use every forum to reach the public with the message.  And it is surely time to call out the president and his supporters for their perverse and malevolent enabling of a deadly disease.

I know many health care professionals are afraid of appearing partisan.  It is not partisan to speak up for common sense public health measures to combat a deadly pandemic.  If there was ever a time for us health care professionals, especially those in the most senior and/or leadership positions to speak up, it is now.  Who will hear the call?

"If not now, when?"

Do Cry for Those in Arizona: What Happens When Politicians Disregard Health Care and Public Health Professionals During a Pandemic

Introduction: Health Care Professionals Vilified After They Caution Against Premature Reopening During the Pandemic

As we discussed in April, 2020, after the curve of the coronavirus pandemic began to flatten in the first heavily affected areas in the northeast US, supposedly popular protests, broke out calling for the end of onerous social distancing measures, ostensibly to let the economy recover.  President Trump then jumped in, calling for the "liberation" of multiple states from these  measures.

Trump wrote: 'LIBERATE MINNESOTA' and then, 'LIBERATE MICHIGAN' and then, 'LIBERATE VIRGINIA, and save your great 2nd Amendment. It is under siege!'

As these protests multiplied, health care professionals responded by staging counter-protests to warn people about the danger of premature "reopening."  For their pains, they were often vilified.  In particular, we noted that one brave ICU nurse silently stood at the capitol of Arizona.

'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'.

The state Republican chairwoman even accused her of one of the "actors playing parts."

In that and a later post we noted how these "reopening" protests were egged on by right-wing politicians, including President Trump himself; infiltrated by extreme right-wing groups, including armed militias; accompanied by threats of death and violence to counter-protesters and anyone preaching restraint; and organized and funded by right-wing political organizations, often allied with Trump, and often funded by plutocrats.  It was unclear whether more than a small minority of the protesters were truly concerned about the economic costs of delaying reopening.  Rather, they seemed mainly about pushing a political agenda which had little to do with public health or health care.

Was this any way to make health care and public health policy?  Nonetheless, these protests, which were orders of magnitude smaller than those which later broke out after the death of George Floyd, and pressure from Trump et al seemed to induce Republican state leaders to reopen early and quickly.

Now the health care professionals' warning are shown to be valid.  Consider the case of Arizona.

Health Care Professionals Inundated as Coronavirus Surges

As documented by the Washington Post on June 25, 2020:

Arizona has emerged as an epicenter of the early summer coronavirus crisis as the outbreak has expanded, flaring across new parts of the country and, notably, infecting more young people.

Maricopa County, which includes Phoenix, is recording as many as 2,000 cases a day, 'eclipsing the New York City boroughs even on their worst days,' warned a Wednesday brief by disease trackers at Children’s Hospital of Philadelphia, which observed, 'Arizona has lost control of the epidemic.'

This came after Arizona became the poster child for early and quick reopening. "The state’s cases began rising dramatically about May 25, 10 days after Ducey allowed the state’s stay-at-home order to expire...." said a local public health expert.

The Republican Governor seemed to be reacting directly to Trump's push to "liberate" states:

Trump, who was urging governors to jump-start their economies, was coming to Arizona to tour a Honeywell plant and to convene a discussion about issues facing Native Americans.

The day before the president’s visit, Ducey announced plans to accelerate the reopening of his state’s economy, lifting restrictions on salons and barbershops and allowing restaurants to resume dine-in service. A chart displaying the number of new cases, which did not show the 14-day decline recommended by White House guidelines, 'really doesn’t tell you much,' Ducey said at his May 4 news conference.

In the Washington Post's summary:

At critical junctures, blunders by top officials undermined faith in the data purportedly driving decision-making, according to experts monitoring Arizona’s response. And when forbearance was most required, as the state began to reopen despite continued community transmission, an abrupt and uniform approach — without transparent benchmarks or latitude for stricken areas to hold back — led large parts of the public to believe the pandemic was over.

Stories coming out of Arizona are starting to resemble those that came out of New York at its peak of pandemic induced misery.  On June 24, 2020, the Arizona Republic published a vivid anecdote of yet another person who scoffed at the virus, and then became ill.

Jimmy Flores, 30, met up with his close friends at the bars in Scottsdale on a Saturday night in June.

'This bar was super packed. I was kind of concerned because I was like, man, everyone's tight, they have limited cups. Some people were sharing drinks, it was weird,' said Flores, who also shared drinks with his friends at a bar in north Scottsdale that night.

He ended up hospitalized for over a week. He "was discharged home Monday, but breathing is still a challenge and he is taking multiple medications."  He started posting about his case on Facebook, but his friends thought he was being "political."  Now he says, "I really care about people not going through this and that they have to take this seriously because it really hurts."

[Old Town, Scottsdale in happier times]


And the New York Times published an op-ed on June 26, 2020 from an emergency department physician sadly mirroring the tales of despair coming out of New York only a few months ago. 

Patients are evaluated, stabilized and admitted to an inpatient medical team. But many admitted patients remain in the emergency department, 'boarding' while awaiting transfer to the hospital wards because there are no more intensive-care beds available in the hospital or there is insufficient staff to care for them in the beds that are available.

Because of that, far fewer emergency department beds are available for people with non-Covid-19 health conditions and medical emergencies. So sick people wait for an emergency department bed to become available. The surge in cases night after night shows no sign of slowing and it is terrifying.

The media has reported how few hospital beds are available in the state. But even if we had enough beds, it wouldn’t matter if our staff wasn’t physically and emotionally well enough to attend to the people occupying those beds. Many hospital systems have chosen to furlough staff and tighten belts even as health care teams were beginning to feel the psychological strain of the pandemic. Physicians are a small part of our clinical care teams. We are profoundly limited in what we can do without the support of nurses, paramedics, emergency and intensive-care technicians, respiratory therapists, radiology technicians, environmental services workers, social workers, case managers, unit coordinators, clinical pharmacists and others.

Health care workers are exhausted. Staffing shortages and increasing fatigue are the new normal for emergency departments, intensive-care units and Covid-19 units, and across hospital wards. Staffing levels are being set with an emphasis on 'productivity' as determined by financial calculations rather than clinical severity or the complex needs of our patients and the community we serve.

Finally,

Emergency medical and critical-care team members are canaries in the coal mine. When we are understaffed and overworked, when there is no staff to triage patients, when more and more patients are piling up at the emergency department door, the system breaks down, then people break down. You can borrow ventilators (until you can’t) and make more personal protective equipment (we hope). You cannot magically produce more nurses, respiratory therapists, physicians or other professionals.

And things are getting worse every single day.  The Arizona Republic reported June 28, 2020:

Arizona cases of COVID-19, the disease caused by the new coronavirus, increased by more than 3,850 cases on Sunday — the highest number of cases in a single day, according to data released by the Arizona Department of Health Services.

Arizona's total identified cases rose to 73,908 on Sunday with 1,588 known deaths, according to the most recent state figures. That's an increase of 3,857 confirmed cases, or 5.5%, since Saturday.

Inpatients with suspected or confirmed COVID-19 and ventilator and ICU bed use again hit record highs Saturday, while emergency department visits dropped from Thursday's record of 1,249, according to the daily report from the Arizona Department of Health Services.

As of Saturday, 85% of current inpatient beds and 87% of ICU beds were in use for COVID-19 and other patients.

But it did not have to happen.  Had Arizona's political leadership paid attention to the message of one brave ICU nurse back in April, or numerous messages from other health care and public health professionals, had they resisted President Trump's constant exhortations that the economy comes first, and that coronavirus is not a big problem, the pandemic would likely have been better controlled in Arizona, and elsewhere, than is actually the case.

 So do cry for those in Arizona.

Summary


Traditionally, political leaders have trusted health policy experts, and health care and public health professionals to help them make health policy.  In the past, political leaders listened to such experts and professionals when planning for epidemics and pandemics, and addressing new health and public health emergencies.

However, in our new (ab)normal, many political leaders follow the lead of the current president, Donald Trump, and his party.  They seem unworried that the president has a record of peddling lies and disinformation (look here), and has a record of conflicts of interest and corruption goes far beyond any conceivable precedent (look here). They accept Trump's multiple assurances that the coronavirus pandemic is either a hoax, or "fake news," or inconsequential, or fading away (look here).  They shrug when Trump scoffs at public health measures meant to slow viral spread, such as face masks (look here).  They put extreme politics, ideology, and sectarianism (look here) ahead of science, logic, and the warnings of experts.

So, health care professionals trying to uphold their mission to put patients' and the public's health first have stumbled into a political conflict far beyond anything we have seen in our lifetimes.  Upholding the mission is proving to be difficult, unpleasant, and now dangerous.  The danger is not just from the virus, but from our fellow humans putting their politics and ideology ahead of all else.  That does not make the mission any less important.  Innocent lives are still hanging in the balance.

We could retreat in fear from the powerful opposition we have stirred up.  That would allow complete politicization of the management of the coronavirus pandemic, doubtless leading to even more disease and death (and ironically, even worse economic disruption).  Retreating would betray our patients and make a mockery of our mission.  Or we could persist.  What will it be?

"And if not now, when?"

ADDENDUM (30 June, 2020) - This was re-posted by the Naked Capitalism blog here.