Addressing threats to health care's core values, especially those stemming from concentration and abuse of power - and now larger threats to the democracy needed to advance health and welfare. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.
Introduction: Conflicts of Interest and the Trump Administration
We have been discussing the pervasiveness of conflicts of interest in health care for years. Recently, we have worried how conflicts of interest and corruption in health care could be combated under an administration with such severe conflicts of interest and corruption at the highest levels, most recently here.
President Trump and his family's conflicts of interest and alleged corruption centered on their ownership of the Trump Organization, a multi-national privately held hospitality and real estate business. Since the inauguration, Trump personally has benefited from the Trump Organization's dealings with foreign, US federal and US state governments, grossly violating two clauses of the US Constitution.
These dealings raised major constitutional and ethical questions, and concerns about whether Trump administration policies were distorted to benefit his businesses, and hence his own fortune. However, our biggest concern was about how the conflicted and corrupt aura of his administration made it difficult to address conflicts of interest and corruption in health care.
Now, in the shadow of the coronavirus pandemic, it appears that Trump's conflicts of interest may be dangerously affecting his administration's public health policies and its ability to suppress the virus and save lives.
Social Distancing and Other Measures to Combat Coronavirus Damaging Trump Organization Finances
In the Washington Post on March 23, 2020, David Farenthold reported on the likely severe financial losses being incurred by the Trump Organization, whose biggest owner is President Trump
President Trump’s private business has shut down six of its top seven revenue-producing clubs and hotels because of restrictions meant to slow the spread of the novel coronavirus, potentially depriving Trump’s company of millions of dollars in revenue.
In particular,
he is also heavily invested in the hotel business, with 11 hotels around the world.
That business needs new people walking in the door every day, to eat and stay. And by keeping people away, the coronavirus has brought that industry its worst downturn in recent history.
'The data is bad. And we haven’t seen the worst of it yet,' said Jan Freitag, a senior vice president with the firm STR, which analyzes hotel industry data. He noted that the damage to the industry is being caused by the lockdowns and the fear of the virus. 'What we’re seeing here is a rapid descent that’s going to last. So it’s going to be a little bit of a worst-case combination of post-9/11 and [the financial crisis of] 2009.'
So far, the Trump Organization has closed hotels in Las Vegas; Doral, Fla.; Ireland; and Turnberry, Scotland — as well as the Mar-a-Lago Club in Florida and a golf club in Bedminster, N.J. Many of the clubs closed because they had to, under local orders. Others closed on their own, following strong guidance or recommendations from local officials.
Those are six of Trump’s top seven revenue-producing clubs and hotels, bringing in about $174 million total per year, according to Trump’s most recent financial disclosures. That works out to $478,000 per day — revenue that is likely to be sharply reduced with the clubs shuttered. The disclosures provide self-reported revenue figures but not profits.
Trump's personal financial concerns are compounded due to financing issues.
Three of Trump’s hotels — in Doral, Chicago and Washington — have outstanding loans from Deutsche Bank that originally totaled more than $300 million. Even before the coronavirus outbreak, all three reported lagging behind their peers in occupancy and revenue, struggles that the company’s representatives blamed, in one way or another, on Trump’s political rise.
[Trump Tower Chicago, which houses the Trump Hotel]
While the latter two hotels are still open, they are not doing well. For example, an article by Mr Farenthold and colleagues on March 20, 2020, noted that the Trump International Hotel in Washington, DC now has an occupancy of only 5%. So the resulting sharp revenue drop raises the risk that the Trump Organization would default on its loans.
[Interior, Trump International Hotel, Washington, DC]
Hotel Closures Create Other Personal Problems for Trump
These financial threats to Trump may be compounded by threats to other benefits the Trump Organization properties have afforded him. Some of these properties have been loci of political power. In particular, the Trump International in Washington DC has been the place for Trump supporters to congregate, and for various interests, including corporate leadership and foreign governments to seek to influence Trump (see the voluminous "Tracking Corruption and Conflicts in the Trump Administration" report section of the Global Anti-Corruption blog for details.)
according to several sources with knowledge of Trump’s business, foreign money played a large role in reviving his fortunes, in particular investment by wealthy people from Russia and the former Soviet republics. This conclusion is buttressed by a growing body of evidence amassed by news organizations, as well as what is reportedly being investigated by Special Counsel Robert Mueller and the Southern District of New York. It is a conclusion that even Trump’s eldest son, Donald Trump Jr., has appeared to confirm, saying in 2008—after the Trump Organization was prospering again—that 'Russians make up a pretty disproportionate cross-section of a lot of our assets.'
Trump’s former longtime architect, Alan Lapidus, echoed this view in an interview with FP this month. Lapidus said that based on what he knew from the internal workings of the organization, in the aftermath of Trump’s earlier financial troubles 'he could not get anybody in the United States to lend him anything. It was all coming out of Russia. His involvement with Russia was deeper than he’s acknowledged.'
So,
By the time he ran for president, Trump had been enmeshed in this mysterious overseas flow of capital—which various investigators believe could have included money launderers from Russia and former Soviet republics who bought up dozens of his condos—for a decade and a half. And Felix Sater was pitching Cohen on a Moscow deal as recently as mid-2016—as Trump was clinching the Republican nomination, according to a sentencing memo recently unveiled by the Mueller probe.
for more than three decades, at least 13 people with known or alleged links to the Russian Mafia held the deeds to, lived in or ran criminal operations out of Trump Tower in New York or other Trump properties. I mean that many of them used Trump-branded real estate to launder vast amounts of money by buying multimillion-dollar condos through anonymous shell companies. I mean that the Bayrock Group, a real estate development company that was based in Trump Tower and had ties to the Kremlin, came up with a new business model to franchise Trump condos after he lost billions of dollars in his Atlantic City casino developments, and helped make him rich again.
Yet Trump’s relationship with the Russian underworld, a de facto state actor, has barely surfaced in the uproar surrounding Russia’s interference in the 2016 campaign.
Shady Russian operators, money launderers, the Russian mafia, and those tied to the Putin regime may not have much sympathy for those indebted to them who payment difficulties. Whatever the form of his Russian support, it might be that his waning financial fortunes have led to some quiet but severe pressure from overseas on the Trump Organization and Trump himself, further increasing his impetus to open up his hospitality properties, regardless of the costs and risks to others
The Conflict of Interest Illustrated and Some Dire Conclusions
As Farenthold wrote,
As he is trying to manage the pandemic from the White House, limiting its casualties as well as the economic fallout, his company is also navigating a major threat to the hospitality industry.
That threatens to pull Trump in opposite directions, because the strategies that many scientists believe will help lessen the public emergency — like strict, long-lasting restrictions on movement — could deepen the short-term problems of Trump’s private business, by keeping doors shut and customers away.
As he also wrote, at the same time that Trump is under personal financial and who knows what other pressure due to the closure of his hospitality properties,
Trump is considering easing restrictions on movement sooner than federal public health experts recommend, in the name of reducing the virus’s economic damage.
In a tweet late Sunday, Trump said the measures could be lifted as soon as March 30. 'WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF,' he wrote on Twitter.
Trump did not specify for whom the cure might be worse than the disease. The obvious suspicion is that he is talking about the "cure's" effect on ... Donald Trump and his family.
This raises the strong and extremely worrisome concern that he is thinking of taking measures that may risk the lives of thousands or millions of people to preserve his wealth and personal power. (Maybe he also is trying to save himself from some Russian retribution?)
That may be the most severe and dangerous health care conflict of interest we have ever seen in the US.
I, for one, do not trust Donald Trump to put the country's interests, and the lives of its citizens, ahead of his own personal and financial well-being. As long as this horrendously conflicted man is running the country, we will be in doubt, and at grave risk.
We now see reports of how the US is short of either masks, gowns, doctors, hospital beds, ventilators, community health workers, tests, treatments, or some combination thereof, to manage the new COVID pandemic and the annual influenza season. We see Congress hustling to adopt a funding package to catch up with the gaps.
I just saw, as an attending physician on a busy urban internal medicine hospital service, how that shortage potentially endangered mine and my colleagues lives, as well as that of my patients. At first we were told to reuse our masks--there might be or would soon be a shortage. Then we were told NOT UNDER ANY CIRCUMSTANCE to reuse them--we could infect patients by room-to-room transmission. Then we ran short of masks and.....well you can guess what we were told.
All this got me to thinking about a project I was involved in nearly 15 years ago. I was part of a national task force asked to develop a national public health and primary care response plan to respond to a theoretical (then presumed influenza) pandemic in the US. We did, over a year-long series of scholarly and cordial meetings and document exchanges. All the primary care disciplines lent representatives to the committee, organized by the Agency for Healthcare Research and Quality (then AHCPR).
As far as I can tell, our report, which would have required a significant cost outlay for workers and equipment which would sit idle until the pandemic arrived, was not adopted, and no funds were approved to beef up the already anemic public health infrastructure at that time, just post 911. Even 911 was not enough to boost a response that, I suspect, national leaders saw as wasteful.
Wasteful... hmm. That means pockets would be emptier, balance sheets more toward the red, taxes higher, and stockholders' value down. We needed to operate more like a business, cut waste, and increase efficiency.
But wait, that's managerialism right? Increase shareholder value at all costs, even, in this case, human lives. We've got a business--I mean public health infrastructure to run here. No time for more idle firemen.
I wonder if anybody in power around 15 years ago remembers sitting on our plan, and regrets not adopting it? This year, almost 60,000 have died from influenza, and we are waiting to see the death toll from COVID. How much money is a life worth?
Health Care Renewal presents a guest post from Dr Michael Fine, a
writer, community organizer, and family physician. He is the chief
health strategist for the City of Central Falls, RI, and Senior Clinical
and Population Health Services Officer for Blackstone Valley Community
Health Care, Inc., and recipient of the Barbara Starfield Award, the
John Cunningham Award, and the Austin T. Levy Award. He was director of
the Rhode Island Department of Health, 2011–2015. He is author of Abundance and Health Care Revolt
What Cheer!
So now Coronavirus is here.
Let
me say up front what I’ve said before: for most of us, this will be a
mild disease, and there is nothing to fear but fear itself. Still, we
need to act and act fast if we are going to take good care of most
people and protect our democracy.
And
we have a choice. If we change a lot and change fast, we'll save the
lives of a couple of hundred thousand more people, mostly people who are
old or already sick. But to protect those people, we have to put the
lives of young people, who are at some but minimal risk, on hold.
The
lessons from China and Italy are clear. We can save lives, at least in
the short run, by locking things down for three or four months. But if
we are to be most effective, we have to do more than that. We have to
create fever clinics and isolation hospitals. Convert existing hospitals
to intensive care units. Build a health care system to take care of all
Americans, and do that practically overnight. And find some way to
support every American during this period, so no one is ignored or
displaced during this period of extended hibernation.
To
keep social peace, we need to fix what’s broken in our culture and fix
it fast, otherwise people disadvantaged by our market economy won’t be
able to stay home and stay quiet, and shouldn’t: many will risk more by
staying home than they do from this virus. That means we need to make
sure everyone has enough. Enough food and housing. Enough heat and
water. Immediate access to health care when lots of people are sick.
Enough internet and phone to stay connected. Enough money for us all to
sustain ourselves during this period.
That
means we wipe away all student loans and make college free for
everyone, to pay it forward to the young people who we are asking to
sacrifice now. That means we build a health care system that can care
for everyone, the hell with what insurance card they carry, and that we
do that overnight. And that means we take care of people before we take
care of corporations. Which means wealth will shift from the rich, who
have too much and have had too much for too long, to most people, who
may have just enough but teeter on the edge unnecessarily. That means we
do what we should have done long ago.
I
have been thinking about the bankruptcy of our political culture for a
long time, thinking about how we've let ourselves be polarized by people
who take care of only themselves. At the time Merrick Garland’s
nomination to the Supreme Court was illegally blocked, we needed a
general strike. When the Russian involvement in the elections and mess
about Ukraine was uncovered, we needed a national day of reflection,
reconciliation and repentance, so that we might see ourselves and one
another, and defend ourselves as one nation indivisible again. This
isn’t about Republicans or Democrats. Both parties have people of
conscience in them. But both have become impotent, slaves to people with
money, people who like to hear themselves talk and believe their own
propaganda, people who are out only for themselves. While no one has
been taking care of the business of democracy, which is what this
country is about.
Coronavirus
may do for us what we haven’t been able to do for ourselves. Now either
we’ll change, or many more people than necessary will die.
Once
upon a time, there would have been prophets in the streets, blowing
trumpets and proclaiming the word of G-d, telling us to repent, to put
on sack cloth and ashes.
[Prophet Jeremiah, Fuselli, Metropolitan Museum of Art]
Now
we’ve got a virus and pundits on TV, telling us we need to change and
change now. G-d, or nature, or time, whatever you want to call it, works
in mysterious ways.
We
can get through it by taking care of each other, sacrificing a little
when necessary, talking to one another, and keeping our eyes on the
prize.
Which
is still democracy. Democracy remains a lousy form of government, but
it's just better than all the others. Still a frightening, noisy
culture. But the only culture that lets us live and breathe, which
tolerates unshakable evil impulses up to a point, but also lets fly the
angels of our better nature. Democracy turns the arc of history toward
justice, despite where those with selfish and evil impulses want it to
go.
Democracy
works only if we reinvent it every day, and only when we remember to
stand up for ourselves, each other and for justice. Unceasingly.
Democracy is just not a spectator sport.
Coronavirus
is a little scary, true. To control it best, we need to change
ourselves, and make the changes we should have made, long ago. So
perhaps, in Coronavirus, we are now seeing the finger of G-d in the
world, because we change, and that gives me real hope.
There
are signal fires on the ridge-tops and trumpets blowing in the streets.
Now all we have to do is see what is right in front of us, hear what is
all around us, and heed that callSpring is here early. Who would have thought?
Batten down the hatches. And pass the ammunition. Which turns out to be each other, once again.
We have been talking about health care dysfunction for a very long time, starting with a publication in 2003: 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 studies
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 (look here).
Mission-Hostile Management as a Cause of Health Care Dysfunction
We had found that 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).
Today, the Trump administration is confronted with the threat of a
global pandemic of a virus that can be lethal.
[1918 influenza pandemic - Oakland, CA]
Unfortunately, the
administration's response has exemplified many of the aspects of health
care dysfunction we have discussed, particularly mission-hostile management. This is a situation in which mission-hostile management could be uniquely dangerous. However, it seems to have brought out the worst tendencies of President Trump and his cronies in that regard. Below are examples that came to light only in the last week, presented in chronological order.
Trump Administration Blocked Official Recommendation for Older People to Avoid
Flying, Despite The Contagiousness of the Virus and Data That Seniors
are More at Risk of Adverse Effects from It
The
White House overruled health officials who wanted to recommend that
elderly and physically fragile Americans be advised not to fly on
commercial airlines because of the new coronavirus, a federal official
told The Associated Press.
The Centers for Disease
Control and Prevention submitted the plan as a way of trying to control
the virus, but White House officials ordered the air travel
recommendation be removed, said the official who had direct knowledge of
the plan.
Note that:
Dr. Peter Hotez, dean of tropical medicine at Baylor College of Medicine, last week warned U.S. lawmakers against minimizing the viruses risk for vulnerable people. During a Congressional hearing, he said the coronavirus 'is like the angel of death for older individuals.'
Some experts said they’ve been hoping for clearer and louder guidance from the government, to prod vulnerable people to take every possible step to avoid settings where they might more easily become infected.
'The clear message to people who fit into those categories is; ‘You ought to become a semi-hermit. You’ve got to really get serious in your personal life about social distancing, and in particular avoiding crowds of any kind,’' said Dr. William Schaffner, a Vanderbilt University expert on infectious diseases.
Nonetheless, there was no clear rationale for the administration to block the recommendation against flying. However, at least
On Friday, the CDC
quietly updated its website to tell older adults and people with severe
medical conditions such as heart, lung or kidney disease to 'stay home
as much as possible' and avoid crowds. It urges those people to 'take
actions to reduce your risk of exposure,' but it doesn’t specifically
address flying.
Trump Tried to Keep Passengers on Board Coronavirus Infected Cruise Ship to Reduce the Apparent Number of People in the US Affected by the Virus
A cruise ship on which at least 21 people are infected with coronavirus will dock in Carlifornia and unload its passengers – despite Donald Trump saying he wanted them to stay on board to keep the number of US cases down.
The Grand Princess is expected to arrive in Oakland on Monday. It has been anchored off San Francisco for several days.
So far 19 employees and two passengers have tested positive for Covid-19. Another 24 people tested negative and one case was inconclusive. There are about 3,500 passengers on board.
On Friday, Mr Trump said he wanted to keep passengers and crew on board so that US cases would not 'double'.
He said: 'They would like to have the people come off. I'd rather have the people stay. But I'd go with them. I told them to make the final decision. I would rather – because I like the numbers being where they are. I don't need to have the numbers double because of one ship that wasn't our fault.'
Trump blocked disembarkation despite the inadequacy of medical care on board, and the lack of provisions available to keep the virus from spreading, especially to the crew. So Trump appeared willing to sacrifice the health of those on board in a simple-minded scheme to make the epidemic look less severe for his own political benefit.
Despite Public Health Advice to Avoid Large Crowds, Trump Promoted Safety of Large CPAC Conference, Which Was Shown to Have Included a Coronavirus Positive Attendee
When
asked by reporters if he was worried about being exposed to coronavirus
after he attended CPAC, Trump said, 'I'm not concerned at all.'
Trump, who was speaking alongside Brazilian President Jair Bolsonaro
ahead of their dinner at his Mar-a-Lago resort in Florida, also noted
that the administration would not cancel any political rallies as the
virus spreads.
'We'll have tremendous rallies. We're
doing very well. We've done a fantastic job, with respect to that
subject, on the virus,' Trump said.
Since then,
multiple attendees, have self-quarantined, including fervent Trump
supporters such as Rep Gaetz (R-FL), Dep Collins (R-GA) , and incoming
White House Chief of Staff, Rep Meadows (R-NC) (per the NY Times, March 9, 2020). Thus Trump appeared to be willing to risk the health of Americans, including some of his strongest supporters, to give the appearance that his administration was controlling the epidemic.
Despite Public Health Advice to Avoid Crowds, Trump Defended Plans for a Large Rally
Despite his own administration advising people to avoid events with large crowds to help stop the spread of coronavirus, President Donald Trump has announced he’ll hold a campaign event in Wisconsin.
Mr Trump will attend a 'Catholics for Trump' event in Milwaukee, Wisconsin on 19 March.
The event is now apparently postponed, but Trump's promotion of it showed his disregard for the health of the people, including many of his most devoted supporters.
Trump Sought to Delay Testing for Coronavirus Due to Fear that Higher Numbers of Positive Cases Would Decrease His Chances of Re-Election
the US president is also reported to have been reluctant to launch a campaign of 'aggressive testing', which could have identified key outbreak areas.
'That’s partly because more testing might have led to more cases being discovered of coronavirus outbreak,' said Dan Diamond, a Politico health reporter who has been investigating the Trump administration’s response to the coronavirus outbreak.
Speaking to NPR, he added: 'The president had made clear – the lower the numbers on coronavirus, the better for the president, the better for his potential re-election this fall.'
Many public health experts felt that earlier aggressive testing could have possibly allowed containment of the virus. Failure to do such testing in the political interest of the president again appears to be an egregious example of mission-hostile management.
Trump Flouts CDC Recommendations for Social Distancing, Self-Quarantine
At an event at his own Mar-a-Lago resort, Trump had close contact with at least two individuals from Brazil who later tested positive for the coronavirus, hardly exemplifying CDC recommendations for social distancing. Then he refused to self-quarantine. Per the Washington Post, March 13, 2020:
Trump suggested the risk of exposure from a Brazilian official was low, even though the two had posed for a photo together. Trump said he had posed for so many photos, and shaken so many hands, that he did not remember the man.
Note that
Trump seemed to defy two basic practices that the rest of his government has been urging Americans to follow to prevent the spread of the virus. People who were exposed to an infected person are urged to quarantine themselves and seek testing. And everyone — exposed or not — should stop shaking hands.
Most public health experts believe that public health campaigns require leaders setting good examples.
four others at Mar-a-Lago that weekend have since tested positive, including three who accompanied President Jair Bolsonaro of Brazil for a dinner with Mr. Trump before Ms. Guilfoyle’s birthday party that Saturday night: Fabio Wajngarten, his press secretary, Nestor Forster, his top diplomat in Washington, and Nelsinho Trad, a senator.
By failing to set a good example in this case, Trump again showed disdain for the health of the people, particularly those who attend events at Mar-a-Lago, including his supporters and the patrons of his business.
Discussion
We have discussed cases in which top health care leadership took actions that ignored or
directly challenged health care professionals' core values, that is, mission-ignorant or mission-hostile management.
A major reason was the rise of "generic managers." Increasingly, health care organizations,
including hospitals, pharmaceutical companies, health insurance
companies, government agencies, etc are now led by people with
management training, but not necessarily with any training or background
in medicine, biomedical research, epidemiology, public health, or
health care policy. We began noting how such generic managers
often prioritize short-term revenue over all other concerns, presumably
based on the shareholder value dogma taught in business schools (look here).
Worse, generic managers may be ignorant of, misunderstand, or be
frankly hostile to the core values of health care professionals. Finally, generic managers often are subject to perverse incentives that put short-term revenue and managers' self-interest ahead of core values.
In other words, health care is now in the grip of "managerialism," as characterized in an article that in the June, 2015 issue of the Medical
Journal of Australia (look here)(7) :
- businesses of all types are now largely run by generic managers,
trained in management but not necessarily knowledgeable about the
details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals
We have identified breathtaking cases of mission-hostile management by
managerialists leading health care organizations primarily to maximize
current revenue and/or their own income and self-interest. Some recent
examples:
- A proud teaching hospital ended up bankrupt after it was traded back and forth by for-profit hospital chains and private equity firms (look here).
- Hospitals offered better care to wealthier patients, and thus worse
care to poorer one, or spent money on achieving market dominance rather
than quality patient care (look here and here)
- A pharmacy chain donated to a political organization supposedly to
advocate for tax reform, but whose positions contradicted the chain's
pledge of social responsibility (look here).
- A health care focused charity directed most of its revenue to a company owned by the charity's leaders (look here)
- Hospital management influenced timing of patient discharge to maximize
revenue, regardless of the benefits to patients of shorter or longer
stays (look here) etc, etc, etc Here are more examples.
However, I cannot recall any modern examples of mission-hostile management which so grievously threatened the population of an entire country, nor any modern US examples of a national politician willing to so threaten the country's population for his own political purposes. Even more astounding is his apparent disdain for the health and safety of his closest supporters and business patrons.
Our chances of survival in this now a global pandemic will remain low until we can replace this dangerous national leader. Note that the chances of his supporters' and business patrons' may be even worse than those of the general public.
In the late 1990s, my colleagues and I started noting a rising tide of what we then called physician dissatisfaction. One small clue was that physicians I met at meetings seemed to be responding to polite questions about their well-being with less enthusiastic responses. In the early 2000s, publications begin appearing about health care professionals' dissatisfaction (1-3).
To better understand what was causing this dissatisfaction, we interviewed doctors and health
professionals, and found that US physicians feared their core values were under threat(4). We postulated that several aspects of American health care dysfunction caused such threats, and set about trying to better characterize and understand them. Since then, we have been discussing health care dysfunction and how it threatens core values on Health Care Renewal.
Health Care Professionals Whose Core Values are Threatened May be Morally Injured
We were focused on what produced threats to core values, but not so much on how these threats affected health care professionals, other than by producing dissatisfaction.
Meanwhile, others focused on that dissatisfaction, and then on health care professionals' burn-out, but not so much on its systemic causes. In 2012, we noted the first report on burnout by Shanefelt et al(5), and we
observed that the already voluminous literature on burnout often did not
attend to the external forces and influences on physicians that
are likely to be producing it. Instead, the literature often characterized burnout as a lack of health care professionals' resilience, or even the result of some
sort of psychiatric disease affecting them.
However some physicians were trying to understand how health care professionals' angst derives from health care dysfunction. In 2018, Dr Wendy Dean and Dr Simon Talbot wrote an article in StatNews entitled "Physicians' aren't 'burned out.' They're suffering from moral injury." They wrote:
Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one
of these. But the concept of burnout resonates poorly with physicians:
it suggests a failure of resourcefulness and resilience, traits that
most physicians have finely honed during decades of intense training and
demanding work. Even at the Mayo Clinic, which has been tracking,
investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.
Rather than burnout, they suggested that physicians are suffering from moral injury:
The term 'moral injury' was first used
to describe soldiers’ responses to their actions in war. It represents 'perpetrating, failing to prevent, bearing witness to, or learning about
acts that transgress deeply held moral beliefs and expectations.'
Journalist Diane Silver describes it as 'a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.'
The moral injury of health care is not the offense of killing another
human in the context of war. It is being unable to provide high-quality
care and healing in the context of health care.
Moral injury is a consequence not of some sort of personal failing, or lack of self care. It is the consequence of a bad system. They cited some aspects of health care dysfunction, including
Financial considerations — of hospitals, health care systems, insurers, patients, and sometimes of the physician himself or herself — lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results — at times actively harming patients to avoid lawsuits.
World War I - Battle of the Somme
Thus
Navigating an ethical path among such intensely competing drivers is
emotionally and morally exhausting. Continually being caught between the
Hippocratic oath, a decade of training, and the realities of making a
profit from people at their sickest and most vulnerable is an untenable
and unreasonable demand. Routinely experiencing the suffering, anguish,
and loss of being unable to deliver the care that patients need is
deeply painful. These routine, incessant betrayals of patient care and
trust are examples of 'death by a thousand cuts.' Any one of them,
delivered alone, might heal. But repeated on a daily basis, they
coalesce into the moral injury of health care.
Dean and Talbot noted that instead of addressing moral injury, large health care organizations seem to blame health care professionals for their own burnout, and hence make them the targets of interventions meant to improve burnout:
The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses 'information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water' in response to emotional distress crises. Such teams provide the same support that first responders provide in disaster zones, but the 'disaster zones' where they work are the everyday operations in many of the country’s major medical centers. None of these measures is geared to change the institutional patterns that inflict moral injuries.
The Resonance of Moral Injury
Dean and Talbot have continued to raise the alarm about moral injury. They have expanded on their original writing by noting that health care organizations' focus on flaws of health care professionals as causes of burn out are a kind of "gaslighting"(6)
'Gaslighting' refers to the act of psychologically manipulating someone to question their own sanity, in order to gain some advantage. Intentional or not, it carries significant repercussions for its targets, which in this case may be clinicians in our struggling healthcare system.
The term comes from the 1944 film Gaslight, in which a woman's husband regularly dims and brightens the gaslights in their home while he sneaks around in the attic, searching for hidden valuables. When she asks why the gaslights flicker, he insists that they have not changed intensity and that she is only imagining it. The woman's husband invalidates her perceptions and leads her to doubt her sanity.
Scene from Gaslight with Charles Boyer and Ingrid Bergman
They asserted:
A similar phenomenon is happening today to clinicians regarding the distress they experience as a result of the double binds imposed by the competing allegiances inherent in our healthcare system.
Health care professionals, often blamed for their own burnout, found that the concept of moral injury resonated. By mid 2019, Dr Dean, writing again in StatNews, wrote:
we have learned that the concept of moral injury resonates powerfully, not just with doctors, but with every kind of health care professional we’ve met, from nurses and social workers to hospital administrators, personal-care assistants, first responders, and others.
The concept of moral injury allows clinicians to express what the burnout label failed to describe: the agony of being constantly locked in double binds when every choice one makes yields a compromised outcome and when each decision contravenes the reason for years of sacrifice. All of us who work in health care share, at least in the abstract, a single mission: to promote health and take care of the ill and injured. That’s what we’re trained to do.
But the business of health care — the gigantic system of administrative machinery in which health care is delivered, documented, and reimbursed — keeps us from pursuing that mission without anguish or conflict. We do our best to put patients first but constantly watch the imperatives of business trump the imperative of healing.
By early 2020, the concept of moral injury appeared in the main stream media, that is, the Washington Post, in an article that agreed that moral injury
resonates with clinicians across the country. Since they penned an op-ed in the online health news site Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.
The article ended with this from an emergency department physician:
He said many people frame burnout as a character weakness, sending doctors messages like, 'Gee, Keith, you’ve just got to try harder and soldier on.' But [Dr Corl] said the term 'moral injury' correctly identifies that the problem lies with the system. 'The system is flawed,' he said. 'It’s grinding us. It’s grinding good docs and providers out of existence.'
Those further interested in understanding and addressing moral injury should see to the Fix Moral Injury website.
Discussion
In retrospect, it seems that Health Care Renewal has been trying to describe the causes of moral injury since 2004. Thus our work complements that of Dr Dean and Dr Talbot.
Our 2003 article(4) identified five aspects of health care dysfunction that threatened core values, and hence we now realize could cause moral injury:
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 studies
Since
then we have come upon many instances in which health care
professionals' core values were under threat, likely generating moral injury. We found
cases in which top health care leadership took actions that ignored or
directly challenged core values, that is, mission-ignorant or mission-hostile management.
A major reason was the rise of "generic managers." Increasingly, health care organizations,
including hospitals, pharmaceutical companies, health insurance
companies, government agencies, etc are now led by people with
management training, but not necessarily with any training or background
in medicine, biomedical research, epidemiology, public health, or
health care policy. We began noting how such generic managers
often prioritize short-term revenue over all other concerns, presumably
based on the shareholder value dogma taught in business schools (look here).
Worse, generic managers may be ignorant of, misunderstand, or be
frankly hostile to the core values of health care professionals. Finally, generic managers often are subject to perverse incentives that put short-term revenue and managers' self-interest ahead of core values.
In other words, health care is now in the grip of "managerialism," as characterized in an article that in the June, 2015 issue of the Medical
Journal of Australia (look here)(7) :
- businesses of all types are now largely run by generic managers,
trained in management but not necessarily knowledgeable about the
details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals
We have identified breathtaking cases of mission-hostile management by managerialists leading health care organizations primarily to maximize current revenue and/or their own income and self-interest. Some recent examples:
- A proud teaching hospital ended up bankrupt after it was traded back and forth by for-profit hospital chains and private equity firms (look here).
- Hospitals offered better care to wealthier patients, and thus worse care to poorer one, or spent money on achieving market dominance rather than quality patient care (look here and here)
- A pharmacy chain donated to a political organization supposedly to advocate for tax reform, but whose positions contradicted the chain's pledge of social responsibility (look here).
- A health care focused charity directed most of its revenue to a company owned by the charity's leaders (look here)
- Hospital management influenced timing of patient discharge to maximize revenue, regardless of the benefits to patients of shorter or longer stays (look here) etc, etc, etc Here are more examples.
Dean and Talbot cited hospital systems and health insurance companies
putting short-term revenue ahead of patient care as a cause of moral
injury. They also noted badly designed and implemented electronic
health records and litigation risks as causes. But managerialism is
rampant among health care organizations.
And yet, despite these widespread actions generating moral injury, while health care professionals muttered under their breath about the
behaviors of health care organizational leaders, there has been so little open
discussion that it appears such discussion is taboo- we call this the anechoic effect. Of course, failure to openly discuss the problem resulted in failure to craft any workable responses.
So appreciating that moral injury of health care professionals is a final common pathway of such extreme health care dysfunction adds even more urgency to our task. To address health care dysfunction, we must address what health care professionals may see as severe problems, but which they seem afraid to talk about, much less challenge.
As long as those with a vested interest in maintaining the current system can dismiss their critics as lacking resilience, in need of therapy, and just plain weak, their criticism will be blunted. However, we must make those with such vested interests face the moral consequences of a dysfunctional system that has provided them with such personal advantages.
References
1. Haas JS. Physician discontent: a barometer of change and need for intervention. J Gen Intern Med 2001;16:496–7.
2. Shanafelt TD, Bradley KA, Wipf WE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358–67.
3. Steinbrook R. Nursing in the crossfire. N Engl J Med 2002;346:1757–66.
4. Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14(2): 123-130. (link here).
5. Shanafelt TD, Boone S, Tan et al.
Burnout and satisfaction with work-life balance among US physicians
relative to the general US population. Arch Intern Med 2012; 172(18):1377-1385. doi:10.1001/archinternmed.2012.3199 (link here)
6. Dean W, Dean AC, Talbot SG. Why 'burnout' is the wrong term for physician suffering. Medscape - Jul 23, 2019. (link here)
7. Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM. The scourge of
managerialism and the Royal Australasian College of Physicians. Med J
Aust 2015; 202: 519- 521. Link here.
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.
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.
'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
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.
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.
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 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.'
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.
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.
Introduction: Propaganda and Disinformation in Health Care
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).
In fact, towards the end of its existence, the USSR sponsored a disinformation campaign which spread the notion that HIV was a bio-weapon invented by a US laboratory (look here). Although false ideas associated with that campaign persisted for years, the risk that health care disinformation would be used by hostile state actors seemed to die off as the cold war ended.
But now we have 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. For an example look here at how starting around 2015 Russia was spreading disinformation about measles and measles vaccination over the internet, using new technology like bots.
Now they seem to be doing it again, this time about coronavirus.
As China attempts to contain the spread of a new coronavirus that has left more than 100 people dead, rumors and disinformation have spread amid the scramble for answers.
Some of the speculation has centered on a virology institute in Wuhan, the city where the outbreak began. One fringe theory holds that the disaster could be the accidental result of biological weapons research.
The story started circulating in right-wing media:
The British newspaper Daily Mail was among the first to suggest the possibility of a link between the newly spreading virus and the Wuhan National Biosafety Laboratory, reporting last week that the lab, which opened in 2014 and is part of the Wuhan Institute of Virology, had been the subject of safety concerns in the past.
A separate article published by the Washington Times, a conservative newspaper in Washington, took the theories a step further, suggesting in a headline that the 'Coronavirus may have originated in lab linked to China’s biowarfare program' and pointing to the Wuhan Institute of Virology.
So,
Despite little public evidence, the theory has spread widely on social media, to conspiracy theory websites and in some international news outlets.
Yet there was no good evidence to support this theory.
'Based on the virus genome and properties there is no indication whatsoever that it was an engineered virus,' said Richard Ebright, a professor of chemical biology at Rutgers University.
Also,
Milton Leitenberg, an expert on chemical weapons at the University of Maryland, said he and other analysts around the world had discussed the possibility that weapons development at the Wuhan lab could have led to the coronavirus outbreak in a private email chain but that no one had found convincing evidence to support the theory.
A popular pro-Trump website has released the personal information of a scientist from Wuhan, China, falsely accusing them of creating the coronavirus as a bioweapon, in a plot it said is the real-life version of the video game Resident Evil.
On Wednesday, far-right news site Zero Hedge claimed without evidence that a scientist at the Wuhan Institute of Virology created the strain of the virus that has led the World Health Organization to declare a global health emergency.
Note that
Zero Hedge, which describes itself as a financial blog, has more than 50,000 followers on Facebook and more than 670,000 followers on Twitter and is run by Daniel Ivandjiiski, a Bulgarian-born, US-based, former investment banker, who writes the majority of the posts published by the pseudonym Tyler Durden. The site regularly amplifies conspiracy theories from anonymous message board 4chan and writes frequently about the deep state, doomsday prep, bitcoin speculation, and New Age pseudoscience.
Furthermore,
The new focus on the scientist is the culmination of several conspiracy theories that have gained traction since the beginning of the outbreak early in January. One version of the hoax began in Facebook Groups run by supporters of the pro-Trump QAnon movement and the anti-vax community, where users claimed the outbreak was a population control plot by former Microsoft CEO Bill Gates.
The Zero Hedge take has been propagated widely:
The Zero Hedge article has been posted on Twitter over 10,000 times and shared close 2,000 times on Facebook in the last 24 hours.
And,
The rumors and lies are also being spread across 4chan. A user linked to the Zero Hedge article in a 4chan thread titled, 'All hail [the scientist], creator of Corona-Chan.' In another 4chan thread, users claimed the scientist had created a mutant superbug.
The hoaxes surrounding the coronavirus have become so prevalent that 'uncensored' subreddits about the outbreak are being created for users on Reddit who want to share the theories.
In summary, an unsubstantiated theory about the coronavirus, one that could both increase public anxiety, if not panic, and stir up hostility between China and the US, started circulating in right-wing, including extremist, web-sites and media, and soon bled into the larger social media. But why? Cui bono? Who could benefit from this?
Using Disinformation and Extreme Ideology to Sell Dubious Products
One answer appear to be people selling quack products.
A New York Times article on February 6, 2020 focused on World Health Organization (WHO) efforts to fight disinformation about coronavirus (see below). It included the opinions of "Andrew Pattison, manager of digital solutions at the W.H.O." He suggested:
Medical misinformation on the virus has been driven by ideologues who distrust science and proven measures like vaccines, and by profiteers who scare up internet traffic with zany tales and try to capitalize on that traffic by selling 'cures' or other health and wellness products.
'There are self-appointed experts, people working from anecdote, or making up wild claims to get traffic or notoriety,' said Mr. Pattison of the W.H.O.
Furthermore,
Sarah E. Kreps, a professor of government at Cornell University, considers the people deliberately spreading distortions to be practitioners of 'algorithmic capitalism,' in which people scare up traffic and sell against it.
Examples abound. Infowars, the far right website that purveys conspiracy theories and fake news, and others are now banned on several leading social media sites but are still advertising pseudoscientific remedies directly through their own shops. An early distortion of the coronavirus news appeared in an Infowars video on Jan. 22 — claiming that the virus could be part of some man-made plot to thin the population.
'The globalists and the deep state have declared war on humanity,' a host on the video said. 'They hate human life. This is why they kill babies.'
Next to the box in which the video appears is an advertisement for an immune gargle product that, the ad claims, 'is designed to support your immune system like no other,' and that is 'scientifically proven.'
However, the Mayo Clinic reports that the ingredient mentioned in the product, colloidal silver, has not been proved safe or effective in treating disease. And even the Infowars shop where the product is listed reads at the bottom: 'This product is not intended to diagnose, treat, cure or prevent any disease.'
Whether these disinformationists are primarily cynical businesspeople hiding behind extreme ideology, or extreme ideologists who found a way to profit from these beliefs, or both is not clear.
The Russian Connection
Furthermore, it appears that once again the Russians are involved, demonstrating their updated disinformation techniques that take advantage of the internet and social media.
On February 14, 2020, an article in Foreign Policy discussed Russian involvement in disinformation about coronavirus:
The overarching theme of the stories that appear across the Russian media, from fringe websites to prime-time television, is that the virus is the product of U.S. labs, intended to kneecap China’s economic development. Some articles have flirted with the idea that Bill Gates or Kremlin nemesis George Soros might have had a hand in the outbreak.
Note that:
Right now, the main audience is largely domestic, with a sprinkling of conspiratorial reports across the different language services of Sputnik, the more tabloid of Russia’s international broadcasters. The conspiracy theories haven’t featured prominently on English-language Russian government-backed international broadcasters such as RT and Sputnik, however, according to Bret Schafer, a fellow at the German Marshall Fund’s Alliance for Securing Democracy who studies disinformation. While these channels have historically played around the edges of conspiracy theories, 'they still want that veneer of being a legit international broadcaster,' Schafer said.
The Russian disinformation did not appear to be focused on the escaped Chinese bio-weapon theory, but that particular theory might not be the point.
The Russian messaging fits a now well-established pattern in that it doesn’t look to persuade audiences of a single alternative truth. That would take effort, planning, and persuasion. Modern-day Russian propaganda has instead been described by the Rand Corp. as a 'firehose of falsehood,' a steady stream of underdeveloped, sometimes contradictory conspiracy theories intended to exhaust and confuse viewers, making them question the very notion of objective truth itself.
State department officials tasked with combatting Russian disinformation told the AFP false personas were being used on Twitter, Facebook and Instagram to advance Russian talking points in multiple languages.
'Russia’s intent is to sow discord and undermine US institutions and alliances from within, including through covert and coercive malign influence campaigns,' said Philip Reeker, acting assistant secretary of state for Europe and Eurasia.
'By spreading disinformation about coronavirus, Russian malign actors are once again choosing to threaten public safety by distracting from the global health response,' he said.
Some accounts have falsely claimed the US is waging “economic war on China” and that the virus is a biological weapon manufactured by the CIA.
Furthermore,
Several thousand online accounts – previously identified for airing Russian-backed messages on major events such as the war in Syria, the Yellow Vest protests in France and Chile’s mass demonstrations – are posting “near identical” messages about the coronavirus, according to a report prepared for the state department’s Global Engagement Center and seen by the AFP.
The accounts are run by humans, not bots, and post at similar times in English, Spanish, Italian, German and French. They can be linked back to Russian proxies, or carry messages similar to Russian-backed outlets such as RT and Sputnik, the report said.
'In this case, we were able to see their full disinformation ecosystem in effect, including state TV, proxy websites and thousands of false social media personas all pushing the same themes, said Lea Gabrielle, head of the Global Engagement Center, which is tasked with tracking and exposing propaganda and disinformation.
This is now looking like a big-time Russian disinformation effort aimed at further destabilizing the west,
A state official said Russian operatives appeared to have been given 'carte blanche' to attack the US.
'Whether or not a particular theme is being directed at the highest levels doesn’t matter,' the official said. 'It’s the fact that they have freelance ability to operate in this space to do whatever damage they can, which could have seismic implications.'
All from the same folks who are trying to meddle in the upcoming election, in favor of their preferred candidate, President Trump (look here).
A Prominent US Senator Helps Propagate Disinformation
During the early phases of the measles disinformation campaign, we noted that in February, 2015, the New York Times discussed the strange inability of some then Republican candidates for the presidency to discuss the issue clearly.
Now a Senator Tom Cotton (R-AK) is adding to the confusion about coronavirus. The New York Times reported on February 17, 2020 (updated February 18):
Speaking on Fox News, Senator Tom Cotton, Republican of Arkansas, raised the possibility that the virus had originated in a high-security biochemical lab in Wuhan, the Chinese city at the center of the outbreak.
'We don’t have evidence that this disease originated there,' the senator said, 'but because of China’s duplicity and dishonesty from the beginning, we need to at least ask the question to see what the evidence says, and China right now is not giving evidence on that question at all.'
Note that he raised doubts while suggesting the plausibility of the escaped Chinese bio-weapon theory, but did not dwell on the evidence. Instead, the Times noted he seemed to complain about the lack of relevant evidence:
Speaking to the Fox News anchor Maria Bartiromo, Mr. Cotton suggested that a dearth of information about the coronavirus’s origins was raising more questions than answers.
'We don’t know where it originated, and we have to get to the bottom of that,' he said on the program 'Sunday Morning Futures.'
But there is nothing to suggest that he used his position as a US Senator to learn more about what facts are currently known, and what public health experts currently think. Surely organizations like the CDC and WHO could have helped him with that before he jumped into the discussion. It would also have been possible for him to access the US State Department's information about the Russian coronavirus disinformation campaign and about the possible malign effects of further spreading disinformation about this new disease. But no, Sen Cotton appeared to be attending to other sources, like these mentioned in the Times article:
Last month, Mr. [Steve] Bannon [former Trump campaign manager in his 2016 campaign, former owner of Breitbart News] invited Bill Gertz, a Washington Times reporter, to be a guest on the inaugural episode of his radio show 'War Room: Pandemic,' a spinoff of his 'War Room: Impeachment,' which defended Mr. Trump during the Senate impeachment trial.
'Bill Gertz had an amazing piece in The Washington Times about the biological labs that happen to be in Wuhan,' Mr. Bannon said on his Jan. 25 show. Mr. Gertz appeared on another show several days later to continue putting forward the bioweapons theory.
Fox News has also dabbled in the theory, in one article drawing a connection between a 1980s thriller by Dean Koontz that 'predicted coronavirus.' The book is about a Chinese military lab that creates a biological weapon.
In addition, although the NYT article suggested that Sen Cotton then attempted to "walk back" his original statements, on January 19, 2020, Fox News reported he had reiterated it:
Sen. Tom Cotton, R-Ark. stood by his earlier suggestion that the deadly coronavirus may have originated in a high-security biochemical lab in Wuhan, China, telling 'The Story' Tuesday that we 'need to be open to all possibilities' in exploring the origins of the outbreak that has sickened more than 75,000 people around the world.
When host Martha MacCallum pressed the Senator on his startling and unverified claim, Cotton cited a study published by Chinese scientists in The Lancet, which he called a 'respected international science journal.'
'I'm suggesting we need to be open to all possibilities and we need to demand that China open up and be transparent so a team of international experts can figure out exactly where this virus originated,' Cotton said.
He also brought up the 'questions' surrounding the biosafety level 4 'super laboratory' in Wuhan, the city where the virus is believed to have originated.
In epidemiology, it may be wise not to dismiss even theories that appear far-fetched, at least in the initial phases of an investigation, but there should be some effort to assess the plausibility of the competing hypotheses. Again, notice that a US Senator with no obvious public health or epidemiological expertise was continuing to talk off-the-cuff about a major public health issue, sans any reference to the sorts of expertise and evidence he could easily access.
Discussion
The problem of disinformation about medicine, health care, and public health only seems to be getting worse. It appears to be fueled in part by the good old fashioned profit motive, but often focused on the profits from useless, possibly harmful pseudo-remedies. It may be justified, or actually generated by extreme ideologies, all of which so far seem to be on the far-right end of the political spectrum. Particularly disquieting is the proclivity, at least in the US, for politicians of a certain stripe to not merely downplay it, but aid in its dissemination, meanwhile ignoring all the possible resources available to them that could supply some evidence and rational assessment of same.
One small cause for hope are the growing efforts to combat it. For example, as discussed in the New York Times, the WHO is now actively trying to combat the "infodemic" of coronavirus disinformation.
Clearly, health care professionals should be doing their part in fighting disinformation and active measures that seek to distort medicine, health care and public health. National and local health departments, and agencies such as the CDC and FDA in the US all should be joining the WHO and the US State Department in fighting current disinformation campaigns, and preparing for future ones. Needless to say, politicians regardless of political philosophy should be supporting these efforts, should base their remarks on evidence and logic, and certainly should not be helping the spread of disinformation.
Yet, as Chris Cilllizza wrote for CNN re Sen Cotton's dissemination of coronavirus disinformation, we are living
in a sort of post-truth world, one if not created, then pushed by President Donald Trump. Trump's candidacy was born in a conspiracy theory (former President Barack Obama wasn't actually born in the United States) and he has embraced any number of conspiracy theories in his days as President. (Millions of illegal votes were cast in the 2016 election, Obama ordered the phones at Trump Tower wiretapped, etc.)
Trump has mainstreamed conspiracy theories and convinced lots and lots of people they are true with much the same tactic Cotton used on Sunday, which amounts to this: I am not saying this is true, I am just saying people are talking about it and we owe it to ourselves to ask the question.
But simply because Trump has made this sort of stuff commonplace doesn't mean it's OK. It isn't. After all, there's a difference between a random post on some Reddit message board and a US senator spinning conspiracy theories on national TV. Or at least, there should be.
However Trump, and maybe Cotton too, seem to benefit from the barrage of disinformation and active measures emanating from Russia. We just heard that the US intelligence community says Russia is once again using active measures to influence the upcoming US election - on behalf of Trump (look here). It is also hard to ignore that Sen Cotton is a big fan of US President Donald Trump (look here) as is Trump of him.
So, it may be too much to expect them to change their ways. Instead, we may need to change our political leadership, and charge our political operating system to make it less vulnerable to hacking by hostile foreign nations, like Russia.
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