Health Care Reform Articles - March 3, 2020

Too many tests, too little time: Doctors say they face ‘moral injury’ because of a business model that interferes with patient care

by Melissa Bailey - Washington Post - February 1, 2020

All those tests? They turned out to be unnecessary, but left the patient with over $1,000 in extra charges. The excessive testing, Corl said, stemmed from a model of emergency care that forces doctors to practice “fast and loose medicine.” Patients get a battery of tests before a doctor even has time to hear their story or give them a proper exam.
“We’re just shotgunning,” Corl said.
The shingles case is one of hundreds of examples that have led to his burnout with emergency medicine. What’s driving that fatigue and exasperation, he argued, is something deeper — a sense of what he called “moral injury.” 
Corl, 42 and now an assistant professor of medicine at Brown University, is among a growing number of physicians, nurses, social workers and other clinicians who are using the phrase “moral injury” to describe their inner struggles at work.
The term comes from war: It was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”
Psychiatrist Wendy Dean and surgeon Simon Talbot were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.
That idea 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.
Burnout has long been identified as a major problem facing medicine: 4 in 10 physicians report feelings of burnout, according to a 2019 Medscape report. And the physician suicide rate is more than double that of the general population.
Dean said she and Talbot have given two dozen talks on moral injury. “The response from each place has been consistent and surprising: ‘This is the language we’ve been looking for for the last 20 years.’ ”
Dean said that response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, endless clicking on electronic health records.
Those barriers can be particularly intense in emergency medicine.
Corl said he has been especially frustrated by a model of emergency medicine called “provider-in-triage.” It aims to improve efficiency but, he said, prioritizes speed at the cost of quality care.
In this system, a patient who shows up to an ER is seen by a doctor in a triage area for a rapid exam lasting less than two minutes. In theory, a doctor in triage can more quickly identify patients’ ailments and get a head start on solving them. The patient is usually wearing street clothes and sitting in a chair.
These brief encounters may be good for business. They reduce the “door to doc” time — how long it takes to see a doctor — that hospitals sometimes boast about on billboards and websites. They enable hospitals to charge a facility fee much earlier, the minute a patient sees a doctor. And they reduce the number of people who leave the ER, frustrated or angry, without “being seen,” which is another quality measure.
But “the real priority is speed and money and not our patients’ care,” Corl said. “That makes it tough for doctors who know they could be doing better for their patients.”
Dean said people often frame burnout as a personal failing. Doctors get the message: “If you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help.” But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians’ control.
Emergency physician Angela Jarman sees similar challenges in California, including ER overcrowding and bureaucratic hurdles to discharging patients. As a result, she said, she must treat patients in the hallways, with noise, bright lights and a lack of privacy — a recipe for ­hospital-acquired delirium.
“Hallway medicine is such a [big] part of emergency medicine these days,” said Jarman, 35, an assistant professor of emergency medicine at University of California at Davis. Patients are “literally stuck in the hallway. Everyone’s walking by. I know it must be embarrassing and dehumanizing.”
For example, when an older patient breaks an arm and cannot be released to their own care at home, they may stay in the ER for days to await evaluation from a physical therapist and approval to transfer to rehab or a nursing home, she said. Meanwhile, the patient gets bumped into a bed in the hallway to make room for new patients who keep streaming in the door.
Being responsible for discharging patients who are stuck in the hallway is “so frustrating,” Jarman said. “That’s not what I’m good at. That’s not what I’m trained to do.” 
Jarman said many emergency physicians she knows work part time to curtail burnout. “I love emergency medicine, but a lot of what we do these days is not emergency medicine,” she said. “I definitely don’t think I’ll make it 30 years.”
Also at UC-Davis, Nick Sawyer, an assistant professor of emergency medicine, has been working with medical students to analyze systemic problems. Among those they have identified: patients stuck in the ER for up to 1,000 hours while awaiting transfer to a psychiatric facility; patients who are not initially suicidal, but become suicidal while awaiting mental health care; patients who rely on the ER for primary care.
Sawyer, 38, said he has suffered moral injury from treating patients like this one: A woman had a large kidney stone and a “huge amount of pain” but could not get approval for surgery because the stone was not infected and therefore her case wasn’t deemed an “emergency” by her insurance plan.
“The health system is not set up to help patients. It’s set up to make money,” he said.
The best way to approach this problem, he said, is to help future generations of doctors understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”
How to measure doctor experiences among physicians is far from clear.
Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of “moral distress” for 25 years, said there isn’t a base of research for moral injury among clinicians as there is for moral distress, which happens when someone feels responsible for addressing a moral problem but is not able to follow through as they feel they should.
But “what both of these terms signify is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven’t in the past,” Rushton said.
Dean grew interested in moral injury from personal experience. After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.
Dean and Talbot created in 2018 a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.
Their work is attracting praise from a range of clinicians.
In Cumberland County, Pa., Mary Franco, who is now 65, retired early from her job as a nurse practitioner after a large corporation bought out the small private practice she worked in. She said she saw “a dramatic shift” in the culture there after the change, where “revenue became all-important.” The company cut in half the time for each patient’s annual exam, she said, down to 20 minutes. She spent much of that time clicking through electronic health records, she said, instead of looking the patient in the face. “I felt I short-shrifted them,” she said.
In southern Maine, social worker Jamie Leavitt said moral injury led her to take a mental health break from work last year. She said she loves social work, but “I couldn’t offer the care I wanted to because of time restrictions.” One of her tasks was to connect patients with mental health services, but because of insurance restrictions and a lack of quality care providers, she said, “often my job was impossible to do.” 
In Chambersburg, Pa., physician Tate Kauffman left primary care for urgent care because he found himself spending half of each visit doing administrative tasks unrelated to a patient’s ailment — and spending nights and weekends slogging through paperwork required by insurers.
“There was a grieving process, leaving primary care,” he said. “It’s not that I don’t like the job. I don’t like what the job has become today.”
Corl said he was so fed up with the provider-in-triage model of emergency medicine that he moved his ER clinical work to smaller, community hospitals that don’t use that method.
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 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.”
https://www.washingtonpost.com/health/too-many-tests-too-little-time-doctors-say-they-face-moral-injury-because-of-a-business-model-that-interferes-with-patient-care/2020/01/31/c00e9d58-3d3a-11ea-8872-5df698785a4e_story.html

Physicians aren’t ‘burning out.’ They’re suffering from moral injury

By Simon G. Talbot and Wendy Dean - STAT - July 26, 2018

Physicians on the front lines of health care today are sometimes described as going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury.
Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.
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.
We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.
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.
Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury.

Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.

In an increasingly business-oriented and profit-driven health care environment, physicians must consider a multitude of factors other than their patients’ best interests when deciding on treatment. 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.
Patient satisfaction scores and provider rating and review sites can give patients more information about choosing a physician, a hospital, or a health care system. But they can also silence physicians from providing necessary but unwelcome advice to patients, and can lead to over-treatment to keep some patients satisfied. Business practices may drive providers to refer patients within their own systems, even knowing that doing so will delay care or that their equipment or staffing is sub-optimal.
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.
Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already. Many physicians contemplate leaving heath care altogether, but most do not for a variety of reasons: little cross-training for alternative careers, debt, and a commitment to their calling. And so they stay — wounded, disengaged, and increasingly hopeless.
In order to ensure that compassionate, engaged, highly skilled physicians are leading patient care, executives in the health care system must recognize and then acknowledge that this is not physician burnout. Physicians are the canaries in the health care coalmine, and they are killing themselves at alarming rates (twice that of active duty military members) signaling something is desperately wrong with the system.
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.
What we need is leadership willing to acknowledge the human costs and moral injury of multiple competing allegiances. We need leadership that has the courage to confront and minimize those competing demands. Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based, and financially responsible decisions. Top-down authoritarian mandates on medical practice are degrading and ultimately ineffective.
We need leaders who recognize that caring for their physicians results in thoughtful, compassionate care for patients, which ultimately is good business. Senior doctors whose knowledge and skills transcend the next business cycle should be treated with loyalty and not as a replaceable, depreciating asset.
We also need patients to ask what is best for their care and then to demand that their insurer or hospital or health care system provide it — the digital mammogram, the experienced surgeon, the timely transfer, the visit without the distraction of the electronic health record — without the best interest of the business entity (insurer, hospital, health care system, or physician) overriding what is best for the patient.
A truly free market of insurers and providers, one without financial obligations being pushed to providers, would allow for self-regulation and patient-driven care. These goals should be aimed at creating a win-win where the wellness of patients correlates with the wellness of providers. In this way we can avoid the ongoing moral injury associated with the business of health care.
Simon G. Talbot, M.D., is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School. Wendy Dean, M.D., is a psychiatrist, vice president of business development, and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine.
https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/ 

Worries about medical bills and lost pay may hamper coronavirus efforts in the United States

by Amy Goldstein - Washington Post - March 3, 2020

The race to curb the spread of the new coronavirus could be thwarted by Americans fearful of big medical bills if they get tested, low-income workers who lose pay if they take time off when sick, and similar dilemmas that leave the United States more vulnerable to the epidemic than countries with universal health coverage and sturdier safety nets.

As the test for the virus becomes more widely available, health-care experts predict that some people with flu-like illnesses — or those who may have been exposed — will avoid finding out whether they have been infected because they are uninsured or have health plans that saddle them with much of the cost of their care.
Making sure the right people get tested — and keeping them away from others if they are infected — is crucial to help diminish the virus’s spread within communities as it pops up in a growing number of states.
Now that federal health officials have ironed out initial problems with the test itself and enabled more labs to take part in the hunt for infection, this work of testing and quarantining is the essential second stage. Yet the government has not yet begun to tell Americans where to go for testing, and neither public nor private insurers are changing their rules to buffer people from testing-related charges.
Some preparations recommended by the Centers for Disease Control and Prevention are incompatible with the way benefits work. Officials have urged people to keep an adequate supply of their routine medicines in case they end up quarantined. But insurance companies seldom permit refills until a patient is nearly out of pills. The agency also urges people with respiratory illnesses to stay home from work. But with no federal sick leave requirements, some experts predict the virus will spread more rapidly.
For an international, fast-spreading epidemic, the nation’s health-care system and many workers’ benefits are “certainly not optimally designed,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.
Federal funds cover the cost of the coronavirus test itself when it is run in federal, state or local public health laboratories. But that changes as academic and commercial labs get involved. In neither case does the government buffer people from bills for visiting a doctor’s office, urgent care center or emergency room, though nearly half of the 160 million Americans with insurance through their jobs have health plans with high deductibles.
“Deductibles are designed to make people think twice about going to the doctor if they are feeling sick,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation, a health-research organization. “In a potential pandemic, the last thing you want people to do is thinking twice about going to the doctor.”
America’s Health Insurance Plans, the industry’s main trade group, has issued guidance called “Keeping Americans Safe from Coronavirus.” The statement says insurers are “carefully monitoring the system” and working with the CDC to share information.
But it does not urge insurance companies to eliminate out-of-pocket costs for the tests or for visits to doctors or clinics for respiratory illnesses, saying that health plans may want to determine “whether policy changes are needed to ensure that people get essential care.”
Thomas Inglesby, director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, said eliminating the financial disincentive to get tested “needs to be at the top of the list” of problems that federal health officials tackle.
Inglesby said that other countries, including Western democracies with government-financed health-care systems, have not been fully publicizing their testing strategies. But he said, “Countries where patients could get large bills for diagnostic testing will have additional challenges identifying people.”
Even before the test was widely available in the United States, a few instances of people ending up with large, coronavirus-related medical bills have lit up Twitter.
In one case, a 29-year-old Miami engineer, Osmel Martinez Azcue, had been in China for work, returned home briefly, then flew to Italy for another quick assignment. By the time he arrived home on Jan. 27, he said in an interview, he had spent a miserable, feverish night in the Lisbon airport, popping ibuprofen as he waited for a connecting flight.
His mother, who lives in his apartment building, started researching the coronavirus and convinced him that he needed a test.
He thought it was probably the flu, but the next morning, he called an urgent care center, which told him that only two hospitals in town could help him.
He went immediately to Miami’s public hospital, Jackson Memorial, where emergency room workers, already alerted, said they rushed him into a quarantine room. A nurse in protective gear quizzed him about his travels, and a doctor told him he needed a CT scan, Azcue said.
He knew the inexpensive insurance he had switched to in the fall requires him to pay $5,000 upfront, so he asked the doctor to first give him a routine flu test, and, if it was positive for influenza, to send him home.
Less than two hours after he arrived, he left the hospital with a flu diagnosis and a Tamiflu prescription.
On Valentine’s Day, a bill arrived from National General Insurance that upset Azcue so much that he did not take his longtime girlfriend out to celebrate. It said he owed $3,270.75 unless he sent the insurer three months of records to prove that the flu had not been a preexisting medical condition. After his story appeared in the Miami Herald, the insurer withdrew the records demands late last week, saying he would owe $1,400.
Said Hopkins’s Inglesby: “It is in the public interest for us to have free testing available for people — not just the test itself but the process of getting tested.”
So far, doctors are not getting a lot of calls from worried patients, said Robert McLean, president of the American College of Physicians — the professional association of internists — and medical director of a 400-doctor medical group in southern Connecticut affiliated with the Yale New Haven Health System.
The health system has designed protocols so that “if someone is sick with a cough, everyone gets asked whether they have been to China” or other outbreak sites. “If there is any of that stuff, it gets triaged to a doctor for a phone call.”
But Scott Becker, chief executive of the Association of Public Health Laboratories, said he was thinking about the health system’s capacity the other night, when his wife wasn’t feeling well after work with what turned out to be the flu. They went to an urgent care clinic in suburban Maryland that was crowded.
“I’m thinking, this place is busy, and it’s a one-and-a-half-hour wait now. And we don’t have community spread here. What’s going to happen? We are going to quickly overwhelm clinics,” he said.
Meanwhile, Georgetown’s Corlette said work-related worries may also deter people from taking time off to get a test or staying home if they are sick. She noted that nearly one-third of all workers — and more than two-thirds of all low-income workers — do not get paid sick days.
“Workers who serve our food, take care of our elderly, take care of our kids, change our sheets — that’s a thing that should be keeping people up at night,” she said.

 

https://www.washingtonpost.com/health/worries-about-medical-bills-and-lost-pay-may-hamper-coronavirus-efforts-in-the-united-states/2020/03/02/75825be0-5c9c-11ea-9055-5fa12981bbbf_story.html 

 

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

by Healthcare Renewal blog - February 28, 2020 

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

Ill-Informed Leadership

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

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

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

Trump's Unjustified Optimism

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

StatNews reported on January 22, 2020:

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

Meanwhile, the count of cases and fatalities was growing.

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

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

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

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

This at best appears to be wishful thinking. 

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

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

Was he claiming direct communication from on high?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

The video of this is below:




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


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

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

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

Furthermore,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Intimidation of Whistleblowers


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

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

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

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

Propagation of Propaganda and Disinformation

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

On February 28, 2020, Politico reported:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

His actual words were:

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

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

That was complete nonsense, so

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

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

Summary

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

http://hcrenewal.blogspot.com/ 

 

Saturday, February 22, 2020

Rising Tide of Disinformation about Coronavirus: the Roles of Ideologues, Quacks, Russians, and US Politicians

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.

Disinformation About Coronavirus

On January 29, 2020, the Washington Post reported on a new disinformation campaign:

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.

Then the bioweapon theory started appearing on more extreme sites.  BuzzFeed reported on January 31, 2020:

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.

On February 22, 2020, the Guardian provided considerably more detail, and now it is coming from official US State Department sources:

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.

http://hcrenewal.blogspot.com/

 

The 2020 elections are being driven by health care. That’s good news for Democrats.

by Catherine Rampell - Washington Post - March 3, 2020

Between coronavirus and Obamacare sabotage, the 2020 presidential race is shaping up to be yet another election driven by health care. Which might deliver another coveted victory to Democrats.
Not because Democrats have done a lot right but, rather, because Republicans keep doing everything wrong.
Ahead of the 2018 midterms, Democrats had an undeniable advantage on health care. Polls consistently showed it as a top campaign issue, and nearly half of political ads in federal races mentioned it. Republicans had just spent the previous year trying to repeal the Affordable Care Act, and voters had finally figured out what they stood to lose: protections for preexisting conditions, the Medicaid expansion and other popular provisions.

After eight years of playing defense on health care, Democrats were at last on offense. The public saw Democrats as protectors of Obamacare and awarded the party control of the House.
But Democrats being Democrats, they soon squandered their advantage.
Almost immediately, Democrats launched a divisive debate over how to improve the current system. Some on the far left demanded that Democrats commit to abolishing private health insurance, which would involve taking employer-based plans away from some 180 million Americans who might be averse to giving them up. The amount of blowback after Obamacare canceled objectively bad insurance plans for just a few million Americans suggests how toxic a single-payer-or-bust purity test could be.
Democrats had put themselves back on defense and had somehow turned an issue that should have been an unalloyed advantage into a political liability.
Luckily for them, Republican incompetence and heartlessness have again come to Democrats’ rescue.
In the years since the GOP tried and failed (and tried, and failed) to repeal Obamacare legislatively, Republicans continued a sort of backdoor sabotage of the law.
They’ve made numerous subtle changes, such as expanding the availability of junk insurance plans that look like a good deal until you get sick and realize the plans don’t cover necessary care. They cut funds for marketing campaigns that alert people about open enrollment periods. They added (probably illegal) Medicaid work requirements and announced a plan to convert part of Medicaid into block grants.
Just last month, the administration implemented an immigration rule that has frightened and confused families into disenrolling U.S.-citizen children from Medicaid and the Children’s Health Insurance Program.
Many of these changes have largely flown under the political radar. But the prospect of a public health crisis has drawn more attention to the holes in our health-care system — including those that may have predated President Trump but have widened under his leadership.
 For instance, the rise in uninsured rates since 2016 — a direct result of the GOP’s Obamacare sabotage — takes on new salience. Stories of Americans stuck with big bills for coronavirus testing and hospital stays are likely to discourage people who are uninsured or underinsured from getting screened and treated.
The Trump administration has made plenty of other unforced errors on health policy, many of which are directly related to its handling of the coronavirus epidemic or otherwise laid bare by it.
The president has made clear that he cares more about threats to the stock market than those to public health and has spread misinformation about the risks for both. Trump and his underlings have attacked government experts, including scientists and doctors. And the government’s coronavirus response team is being overseen by a vice president notorious for bungling a previous public health crisis.
Even before concerns about a global pandemic, voters were saying that, once again, health care would be their top issue in the coming election. If these developments weren’t enough to convince voters they can’t trust Republicans on health care, perhaps some news that broke Monday will: The Supreme Court said it would hear another case challenging the constitutionality of the Affordable Care Act.
The case will be heard in the court’s next term — possibly before the November election — and the Trump administration still says it wants the law struck down. It also still doesn’t have a replacement plan if the court were to acquiesce. This, too, represents not only terrible policy but also terrible politics.
Republicans suggest it is somehow improper or unpatriotic for critics to point out the administration’s failures in its handling of coronavirus. They say Democrats should stop trying to capitalize on Republican health-policy screw-ups. To that Democrats should simply reply, as Republicans have in the past: Well, then stop screwing up.
https://www.washingtonpost.com/opinions/the-2020-elections-are-being-driven-by-health-care-thats-good-news-for-democrats/2020/03/02/d216852c-5ccc-11ea-b014-4fafa866bb81_story.html

Warren, Unlike Sanders, Makes the Medicare Math Add Up

His plan comes up comes up $12.5 trillion short, while hers spares the middle class a tax increase.

by Simon Johnson - Wall Street Journal - March 2, 2020

 

Bernie Sanders released an updated plan last week to pay for Medicare for All. The plan is light on details, but leaves the senator at least $12.5 trillion short of covering the cost of his health-care proposal over 10 years. It calls for some tax increases on working families, but the real burden may be much higher than advertised: Mr. Sanders may have to raise taxes on American workers by 16 percentage points or more to avoid multitrillion-dollar deficits. Fortunately, Elizabeth Warren’s financing plan for Medicare for All offers a better alternative.
Mr. Sanders’s blueprint identifies $17.5 trillion in new federal revenue over the next 10 years, sourced to new or higher taxes on workers and corporations, among other changes to the code. Mr. Sanders bases his calculations on a study by Yale researchers published recently in the Lancet, which found that his plan would reduce national health spending from $52 trillion over a decade to $47 trillion. Mr. Sanders claims he will redirect the current projected $30 trillion in federal, state and local health-care spending over the next decade to Medicare for All. Thus, he says he only needs $17 trillion to fill the gap.
There are three problems with his math. First, the Yale study didn’t account for the cost of Mr. Sanders’s long-term care program—estimated at around $2.5 trillion. Second, the study assumed reimbursement cuts to hospitals that Mr. Sanders hasn’t explicitly endorsed. Third, Mr. Sanders’s $30 trillion in projected federal spending includes funding for the National Institutes of Health, the Centers for Disease Control and Prevention and more. This money can’t be spent on Medicare for All unless it is zeroed out from these vital public-health agencies.
Most analyses have found that the Sanders Medicare for All proposal would require around $30 trillion in new federal spending over a decade. That leaves Mr. Sanders $12.5 trillion short of what he needs to cover the cost of his plan.
How could Mr. Sanders fill the gap? His plan includes two proposals that affect middle-class families. One is a 4% “income-based premium” on workers, which excludes the first $29,000 in income for a family of four. This “premium” would be an additional tax on income above the exclusion floor, and presumably even less income would be excluded for single workers or those without children. The senator says this tax will generate $4 trillion over 10 years. To make up the $12.5 trillion shortfall, that tax would need to be roughly four times as large—the equivalent of a tax increase of 16% of income.
Mr. Sanders’s second proposal is a 7.5% payroll tax paid by employers that exempts the first $1 million of a company’s payroll. Mr. Sanders estimates this would generate $5.2 trillion over 10 years. To generate the missing $12.5 trillion, that payroll tax rate would need to reach roughly 26.5%. And while the employer receives the bill, higher payroll taxes are mostly passed on to workers in lower wages, reduced hours or both.
Mr. Sanders could raise taxes on the wealthy and big corporations. But he already plans to do that: His financing for Medicare for All and other plans includes a wealth tax, a substantial corporate tax increase, a financial-transactions tax, an increase in the top personal tax rate, and a capital-gains tax increase. There isn’t room to squeeze trillions in additional revenue out of these sources.
Mr. Sanders is adamant that total costs for middle-class families will go down, because new taxes will be less than what families save on health-care costs. This is plausible in the aggregate at certain income levels. But it is implausible that every middle-class family will come out ahead—especially if the plan is fully paid for in taxes.
The plan Ms. Warren released in October addresses these vulnerabilities. Unlike Mr. Sanders’s plan, it commits to specific reimbursement rates for health-care providers—roughly 110% of current Medicare rates. Her plan brings the overall cost of Medicare for All down to $20.5 trillion over 10 years, according to an analysis I did with Donald Berwick, who ran the Centers for Medicare and Medicaid Services under President Obama. Ms. Warren’s plan doesn’t raise taxes on the middle class. Every business that pays for employee health insurance today will pay less for each employee during the transition.
As Democrats choose a nominee, they should consider which candidate’s Medicare for All financing plan is best for working families and provides the most appealing general election message.
Mr. Johnson is a professor of entrepreneurship at the MIT Sloan School of Management and an informal adviser to Elizabeth Warren’s campaign.
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