Trump’s COVID-19 Case Exposes Inequalities in the Healthcare System

Early Friday morning (October 2, 2020) President Trump announced through Twitter that he had tested positive for COVID-19 (aka SARS-CoV-2). Later Friday afternoon he was whisked away by helicopter for a 10-minute ride to Walter Reed National Military Medical Center (WRNMMC, formerly Bethesda Naval Medical Center) which is across the street from the National Institutes of Health campus in Bethesda. There he received REGN-COV2, a combination of two monoclonal antibodies (REGN10933 and REGN10987) directed against the spike protein of the COVID-19 virus. In addition, he received a dose of remdesivir (an antiviral drug) as well as zinc, vitamin D, famotidine (Pepcid®), melatonin and aspirin. As of Saturday morning, Trump has done well by all accounts.

All the therapies administered to Trump are unproven but have some evidence supporting their use against COVID-19. The Trump administration issued an emergency use authorization for remdesivir earlier this year after the drug showed moderate effectiveness in improving outcomes for patients who were hospitalized with the coronavirus (1). REGN-COV2 is now in Phase 3 clinical trials, is still experimental and has not received emergency use approval from the FDA. However, it had sufficient evidence for President Trump to receive the drug in response to a compassionate use request to the manufacturer (2). There is also some evidence that the other ancillary therapies might be useful therapies against COVID-19 (3-7).

What these therapies have in common is that the available scientific evidence of their efficacy was funded, at least in part, by the US government, most prominently the FDA’s Coronavirus Treatment Acceleration Program (CTAP) (8). The US government has spent several billion dollars on COVID-19 therapies including $450 million on REGN-COV2 and at least $75 million for remdesivir (9,10). The success of the program is remarkable in light of the disbanding of the National Security Council pandemic unit which had predicted the disaster we are now enduring (11). The ingenuity of the scientific community is truly amazing when motivated by billions of dollars. Those Americans who actually pay taxes should be proud of their government officials for making such successful investments on their behalf.

President Trump’s care is in contrast to my own or the general public. I recently became ill with increasing shortness of breath, orthopnea and a nonproductive cough but no fever. Because I have a history of diastolic dysfunction, I had assumed this was heart failure. As a physician who has many friends in the medical community, I am privileged to be able to call my cardiologist who saw me later that day. The general public might well have had to accept his next available appointment which was over 3 months or go to an emergency room. After 2 days, and 5 trips to a free-standing radiology center and 2 trips to a laboratory testing site, it became clear that I had left lower pneumonia by chest-x-ray and a normal brain naturetic peptide. Later that day I went to a free-standing clinic and had a rapid COVID-19 test which was negative. Because my presentation was atypical for bacterial pneumonia, I called my pulmonary physician who also saw me later that day. He ordered a coccioidomycosis serology and a COVID-19 test by PCR. The former because of the high possibility of Valley Fever which can cause up to a third of community-acquired pneumonias in Arizona and the latter because of the poor sensitivity of the rapid COVID-19 antibody test (12,13). However, I was not able to schedule the collection of the nasal swab or blood for 10 days at a free-standing laboratory. This seems excessively long and my pulmonologist decided against empirical treatment for Valley Fever because of a potential drug interaction with one of my heart medications (dofetilide).

President Trump often brags that the US has the greatest healthcare system in the world and for him it is. Although he repeatedly touted ineffective therapies for COVID-19 such as hydroxychloroquine, bleach and light and belittled those who wore masks, when he got sick only scientifically based therapy was used despite the expense (14). The general public probably does not have President Trump’s or my access to physicians. Donald Trump, the White House staff, and some professional athletes are getting daily COVID-19 tests but the rest of us taxpayers are forced to wait 10 days to get a nasal swab and a blood sample drawn.

USA Today is now reporting that President Trump had earned capital gains from Regeneron Pharmaceuticals and Gilead Sciences, the manufacturers of REGN-COV2 and remdesivir (15). According to a 2017 financial disclosure form filed with the U.S. Office of Government Ethics in June 2017, Trump had a capital gain of $50,001 to $100,000 for Regeneron Pharmaceuticals and $100,001 to $1 million for Gilead. Trump’s subsequent disclosure forms, including his 2020 form signed July 31, did not list Regeneron or Gilead. Ostensibly, he, other family members and close associates sold their stocks to avoid any apparent conflict of interest.

Based on previous experience, I remain skeptical that therapies developed and distributed by our tax monies will really be free. Will the clever businessmen who run drug companies take money from the US government for product development and then bill a hefty sum for their product? Will the rush to develop a vaccine before the November elections put expediency over safety? Some vaccines rushed to market such as the polio vaccine of 1955 or the swine flu vaccine of 1976 resulted in serious side effects in some recipients (16). As Trump is so fond of saying, “We will have to wait and see”.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. FDA. COVID-19 Update: FDA Broadens Emergency Use Authorization for Veklury (remdesivir) to Include All Hospitalized Patients for Treatment of COVID-19. August 28, 2020. Available at: https://www.fda.gov/news-events/press-announcements/covid-19-update-fda-broadens-emergency-use-authorization-veklury-remdesivir-include-all-hospitalized#:~:text=Today%2C%20as%20part%20of%20its,laboratory%2Dconfirmed%20COVID%2D19%2C (accessed 10/3/20).
2. Farr C, Stankiewicz K. Here’s everything we know about the unapproved antibody drug Trump took to combat coronavirus. CNBC. October 2, 2020. Available at: https://www.cnbc.com/2020/10/02/what-we-know-about-regeneron-antibody-drug-trump-took-to-combat-coronavirus.html (accessed 10/3/20).
3. Arentz S, Yang G, Goldenberg J, et al. Clinical significance summary: Preliminary results of a rapid review of zinc for the prevention and treatment of SARS-CoV-2 and other acute viral respiratory infections [published online ahead of print, 2020 Aug 1]. Adv Integr Med. 2020;10.1016/j.aimed.2020.07.009. [CrossRef] [PubMed]
4. Entrenas Castillo M, Entrenas Costa LM, Vaquero Barrios JM, Alcalá Díaz JF, López Miranda J, Bouillon R, Quesada Gomez JM. "Effect of calcifediol treatment and best available therapy versus best available therapy on intensive care unit admission and mortality among patients hospitalized for COVID-19: A pilot randomized clinical study". J Steroid Biochem Mol Biol. 2020 Oct;203:105751. [CrossRef] [PubMed]
5. Freedberg DE, Conigliaro J, Wang TC, Tracey KJ, Callahan MV, Abrams JA; Famotidine Research Group. Famotidine Use Is Associated With Improved Clinical Outcomes in Hospitalized COVID-19 Patients: A Propensity Score Matched Retrospective Cohort Study. Gastroenterology. 2020 Sep;159(3):1129-1131.e3. [CrossRef] [PubMed]
6. Zhang R, Wang X, Ni L, et al. COVID-19: Melatonin as a potential adjuvant treatment. Life Sci. 2020;250:117583. [CrossRef] [PubMed]
7. Mohamed-Hussein AAR, Aly KME, Ibrahim MAA. Should aspirin be used for prophylaxis of COVID-19-induced coagulopathy? Med Hypotheses. 2020 Jun 8;144:109975. [CrossRef] [PubMed]
8. FDA. Coronavirus Treatment Acceleration Program (CTAP). Available at: https://www.fda.gov/drugs/coronavirus-covid-19-drugs/coronavirus-treatment-acceleration-program-ctap (accessed 10/3/20).
9. Loftus P, Walker J.  U.S. Commits $2 Billion for Covid-19 Vaccine, Drug Supplies. Wall Street Journal. July 7, 2020. Available at: https://www.wsj.com/articles/u-s-commits-2-billion-for-covid-19-vaccine-drug-supplies-11594132175 (accessed 10/3/20).
10. Public Citizen. The Public Already Has Paid for Remdesivir. Available at: https://www.citizen.org/news/the-public-already-has-paid-for-remdesivir/ (accessed 10/3/20).
11. Riechmann D. Trump disbanded NSC pandemic unit that experts had praised. AP News. March 14, 2020. Available at: https://apnews.com/article/ce014d94b64e98b7203b873e56f80e9a (accessed 10/3/20).
12. Valdivia L, Nix D, Wright M, Lindberg E, Fagan T, Lieberman D, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia. Emerg Infect Dis. 2006;12(6):958-62. [CrossRef] [Pubmed]
13. Guglielmi G. Fast coronavirus tests: what they can and can't do. Nature. 2020 Sep;585(7826):496-498. [CrossRef] [PubMed]
14. Robbins RA. Lack of natural scientific ability. Southwest J Pulm Crit Care. 2020;21(1):15-22. [CrossRef]
15. Tyko K. Trump COVID-19 treatment: President had stakes in Regeneron and Gilead, makers of antibody cocktail, Remdesivir. USA Today. October 3, 2020. Available at: https://www.usatoday.com/story/money/2020/10/03/trump-walter-reed-treatment-president-regeneron-gilead-remdesivir/3610111001/ (accessed 10/3/20).
16. Trogen B, Oshinsky D, Caplan A. Adverse Consequences of Rushing a SARS-CoV-2 Vaccine: Implications for Public Trust. JAMA. 2020 Jun 23;323(24):2460-2461. [CrossRef] [PubMed]

Cite as: Robbins RA. Trump’s COVID-19 Case Exposes Inequalities in the Healthcare System. Southwest J Pulm Crit Care. 2020;21(4):82-5. doi: https://doi.org/10.13175/swjpcc055-20 PDF 

Lack of Natural Scientific Ability

Back in March President Trump suggested he would have thrived in another profession, medical expert (1). Despite no training or experience, Trump boasted “I like this stuff. I really get it”. Citing a “great, super-genius uncle” who taught at MIT, Trump professed that it must run in the family genes. Trump went on to say “People are really surprised I understand this stuff … Maybe I have a natural ability.”

This was followed by a series of White House briefings where Trump and members of his White House Coronavirus Task Force spoke on the COVID-19 pandemic. Trump tried to dominate these conferences and repeatedly lied about the coronavirus pandemic and the country’s preparation for this once-in-a-generation crisis. Below is a partial list of 35 of the biggest lies about the COVID-19 pandemic he’s told as the nation endures a public-health and economic calamity are in Table 1 (2). 

Table 1. Partial list of Trump lies regarding the COVID-19 pandemic (2).

Date	Trump claim	Truth
2/7/20	The coronavirus would weaken “when we get into April, in the warmer weather—that has a very negative effect on that, and that type of a virus.”	Respiratory viruses can be seasonal, but the COVID-19 can be transmitted in ALL AREAS, including areas with hot and humid weather and is clearly not diminishing.
2/27/20	The outbreak would be temporary: “It’s going to disappear. One day it’s like a miracle—it will disappear.”	Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, warned days later that he was concerned that “as the next week or two or three go by, we’re going to see a lot more community-related cases.”
Multiple times	The claim: If the economic shutdown continues, deaths by suicide “definitely would be in far greater numbers than the numbers that we’re talking about” for COVID-19 deaths.	The number of people who died by suicide in the US in 2017 was roughly 47,000, nowhere near the COVID-19 deaths now at about 147,000 (3).
Multiple times	“Coronavirus numbers are looking MUCH better, going down almost everywhere,” and cases are “coming way down.”	Most states now have rising COVID-19 cases, hospitalizations and deaths (3).
7/2/20	The pandemic is “getting under control.”	Most states now have rising COVID-19 cases, hospitalizations and deaths (3). It is not under control.
7/4/20	“99%” of COVID-19 cases are “totally harmless.”	The evidence shows that the virus “can make you seriously ill” even if it doesn’t kill you
7/6/20	“We now have the lowest Fatality (Mortality) Rate in the World.”	The U.S. has neither the lowest mortality rate nor the lowest case-fatality rate (3).
3/4/20	“The Obama administration made a decision on [laboratory] testing that turned out to be very detrimental to what we’re doing.”	The Trump White House rolled back Food and Drug Administration regulations that limited the kind of laboratory tests states could run and how they could conduct them.
3/13/20	The Obama White House’s response to the H1N1 pandemic was “a full scale disaster, with thousands dying, and nothing meaningful done to fix the testing problem, until now.”	Barack Obama declared a public-health emergency two weeks after the first U.S. cases of H1N1 were reported, in California. Trump declared a national emergency more than seven weeks after the first domestic COVID-19 case was reported, in Washington State. While testing is a problem now, it wasn’t back in 2009. The challenge then was vaccine development: Production was delayed and the vaccine wasn’t distributed until the outbreak was already waning.
Multiple times	The Trump White House “inherited” a “broken,” “bad,” and “obsolete” test for the coronavirus.	The novel coronavirus did not exist in humans during the Obama administration.
Multiple times	The Obama administration left Trump “bare” and “empty” shelves of medical supplies in the national strategic stockpile.	The stockpile’s former director said in 2019, before the coronavirus pandemic, that it was well-equipped. The outbreak has since eaten away at its reserves.
5/10/20	Trump attacked “Joe Biden’s handling of the H1N1 Swine Flu.”	Biden was not responsible for the federal government’s response to the H1N1 outbreak.
3/6/20 & 5/11/20	“Anybody that needs a test, gets a test. We—they’re there. They have the tests. And the tests are beautiful” and “If somebody wants to be tested right now, they’ll be able to be tested.”	Trump made these two claims two months apart, but the truth is still the same: The U.S. does not have enough testing.
3/24 & 3/25/20	The United States has outpaced South Korea’s COVID-19 testing: “We’re going up proportionally very rapidly,” Trump said during a Fox News town hall.	When the president made this claim, testing in the U.S. was severely lagging behind that in South Korea. As of March 25, South Korea had conducted about five times as many tests as a proportion of its population relative to the United States.
5/11/20	America has “developed a testing capacity unmatched and unrivaled anywhere in the world, and it’s not even close.”	The United States is still not testing enough people and is lagging behind the testing and tracing capabilities that other countries have developed.
Multiple times	“Cases are going up in the U.S. because we are testing far more than any other country.”	COVID-19 cases are not rising because of “our big-number testing.” Outside the Northeast, the share of tests conducted that come back positive is increasing, with the sharpest spike happening in southern states. In some states, such as Arizona and Florida, the number of new cases being reported is outpacing any increase in the states’ testing ability. And as states set new daily case records and report increasing hospitalizations, all signs point to a worsening crisis.
3/11/20	The United States would suspend “all travel from Europe, except the United Kingdom, for the next 30 days.”	The travel restriction would not apply to U.S. citizens, legal permanent residents, or their families returning from Europe.
3/12/20	All U.S. citizens arriving from Europe would be subject to medical screening, COVID-19 testing, and quarantine if necessary. “If an American is coming back or anybody is coming back, we’re testing,” Trump said. “We have a tremendous testing setup where people coming in have to be tested … We’re not putting them on planes if it shows positive, but if they do come here, we’re quarantining.”	Testing was already severely limited in the United States at the time Trump made this claim. It was not true that all Americans returning to the country are being tested, nor that anyone is being forced to quarantine.
3/31/20	“We stopped all of Europe” with a travel ban. “We started with certain parts of Italy, and then all of Italy. Then we saw Spain. Then I said, ‘Stop Europe; let’s stop Europe. We have to stop them from coming here.’”	The travel ban applied to the Schengen Area, as well as the United Kingdom and Ireland, and not all of Europe as he claimed.
Multiple times	“Everybody thought I was wrong” about implementing restrictions on travelers from China, and “most people felt they should not close it down—that we shouldn’t close down to China.”	The travel ban was the “uniform” recommendation of the Department of Health and Human Services.
Multiple times	travel restrictions on China were a “ban” that closed up the “entire” United States and “kept China out.”	Nearly 40,000 people traveled from China to the United States from February 2, when Trump’s travel restrictions went into effect, to April 4.
3/17/20	I’ve always known this is a real—this is a pandemic. I felt it was a pandemic long before it was called a pandemic … I’ve always viewed it as very serious.”	Trump has repeatedly downplayed the significance of COVID-19 as outbreaks began stateside. From calling criticism of his handling of the virus a “hoax,” to comparing the coronavirus to a common flu, to worrying about letting sick Americans off cruise ships because they would increase the number of confirmed cases, Trump has used his public statements to send mixed messages and sow doubt about the outbreak’s seriousness.
3/26/20	This kind of pandemic “was something nobody thought could happen … Nobody would have ever thought a thing like this could have happened.”	Experts both inside and outside the federal government sounded the alarm many times in the past decade about the potential for a devastating global pandemic.
3/2/20	Pharmaceutical companies are going “to have vaccines, I think, relatively soon.”	The president’s own experts told him during a White House meeting with pharmaceutical leaders earlier that same day that a vaccine could take a year to 18 months to develop.
3/19/20	Trump said the FDA had approved the antimalarial drug chloroquine to treat COVID-19. “Normally the FDA would take a long time to approve something like that, and it’s—it was approved very, very quickly and it’s now approved by prescription,” he said.	FDA Commissioner Stephen Hahn quickly clarified that the drug still had to be tested in a clinical setting.
3/23/20	Trump suggested in a briefing on April 23 that his medical experts should research the use of powerful light and injected disinfectants to treat COVID-19.	Trump walked this statement back the next day, saying he was being “sarcastic”.
5/8/20	The coronavirus is “going to go away without a vaccine … and we’re not going to see it again, hopefully, after a period of time.”	Tony Fauci has said that until there is “a scientifically sound, safe, and effective vaccine” the pandemic will not be over.
Multiple times	Taking hydroxychloroquine to treat COVID-19 is safe. “You’re not going to get sick or die,” Trump said on one occasion. “It doesn’t hurt people,” he commented on another.	Trump’s own FDA has warned against taking the antimalarial drug with or without the antibiotic azithromycin, which Trump has also promoted.
5/9/20	“One bad” study from the Department of Veterans Affairs that found no benefit among veterans who took hydroxychloroquine to treat COVID-19 was run by “people that aren’t big Trump fans.” The study “was a Trump-enemy statement.”	There’s no evidence that the study was a political plot orchestrated by Trump opponents, and it reached similar conclusions as other observational reports. The VA study was led by independent researchers from the University of Virginia and the University of South Carolina with a grant from the National Institutes of Health.
3/20/20	Trump twice said during a task-force briefing that he had invoked the Defense Production Act (DPA), a Korean War–era law that enables the federal government to order private industry to produce certain items and materials for national use. He also said the federal government was already using its authority under the law: “We have a lot of people working very hard to do ventilators and various other things.”	Federal Emergency Management Agency Administrator Peter Gaynor told CNN on March 22 that the president has not actually used the DPA to order private companies to produce anything. Shortly after that, Trump backtracked, saying that he had not compelled private companies to take action. Then, on March 24, Gaynor told CNN that FEMA plans to use the DPA to allocate 60,000 test kits. Trump tweeted afterward that the DPA would not be used.
3/21/20	Automobile companies that have volunteered to manufacture medical equipment, such as ventilators, are “making them right now.”	Ford and General Motors, which Trump mentioned at a task-force briefing the same day, announced earlier in March that they had halted all factory production in North America and were likely months away from beginning production of ventilators.
3/24/20	Governor Andrew Cuomo of New York passed on an opportunity to purchase 16,000 ventilators at a low cost in 2015, Trump said during the Fox News town hall.	Trump seems to have gleaned this claim from a Gateway Pundit article. There is no evidence that Cuomo was offered the ventilators or turned any offer down.
3/29/20	Trump “didn’t say” that governors do not need all the medical equipment they are requesting from the federal government. And he “didn’t say” that governors should be more appreciative of the help.	Trump told Fox News’ Sean Hannity on Thursday, March 26, that “a lot of equipment’s being asked for that I don’t think they’ll need,” referring to requests from the governors of Michigan, New York, and Washington. He also said, during a Friday, March 27, task-force briefing, that he wanted state leaders “to be appreciative … We’ve done a great job.”
3/29 and 3/30/20	Hospitals are reporting an artificially inflated need for masks and equipment, items that might be “going out the back door,” Trump said on two separate days. He also said he was not talking about hoarding: “I think maybe it’s worse than hoarding.”	There is no evidence to show that hospitals are maliciously hoarding or inflating their need for masks and personal protective equipment when reporting shortages in supplies.
4/14/20	Asked about his past praise of China and its transparency, Trump said that he hadn’t “talk[ed] about China’s transparency.”	Trump lauded the country in tweets he sent in late January and early February. In one, he highlighted the Chinese government’s “transparency” about the coronavirus outbreak.
3/29/20	WHO ignored “credible reports” of the coronavirus’s spread in Wuhan, the Chinese city that first reported the new virus, including those published in The Lancet medical journal in December.	The Lancet said it did not publish such reports in December. Its first reports on the virus’s spread in Wuhan were published on January 24.

Trump eventually stopped the news briefings in face of their declining popularity and public trust and being outshone by Tony Fauci MD, director of National Institute of Allergy and Infectious Disease. Fauci is best known as an expert virologist for his handling of the Acquired Immunodeficiency Disease Syndrome (AIDS). He has faithfully served his patients, the American people, through six presidential administrations, providing sound, science‐based guidance. However, he has been wrong. Two examples are not recommending masks early in the COVID-19 pandemic and stating that few COVID-19 patients were asymptomatic (4). However, both were based on the best available scientific evidence of the time which turned out to be wrong. In neither instance was Fauci’s honesty questioned and, in both instances, Fauci self-corrected those errors.

The strained relationship between the White House and Fauci has been apparent for months. Trump was visibly annoyed when Fauci spoke at news briefings (5). In April Trump retweeted a call to fire Fauci during early criticism of Trump’s mishandling of the COVID-19 pandemic (6). He has attempted to silence Fauci’s inconvenient scientific voice from testifying before Congress and giving TV interviews (7). More recently, he has tried an old tactic of having aides and underlings attack opponents and then evaluating how it plays with the public. If it goes well Trump repeats it, but if it does not, he says the aide was acting on his own. The White House let their top economic advisor, Peter Navarro, attack Fauci in an USA Today op-ed (8). Last Sunday, White House scientific advisor Brett Girori MD tried to undermine Fauci last Sunday on Meet the Press saying Fauci only looks at the COVID-19 pandemic from “a very narrow public health point of view”; doesn’t “have the whole national interest in mind’; and repeated the White House opposition to Fauci’s call for states experiencing COVID-19 surges to pause their reopening processes (9).

The attacks against Fauci were apparently unsuccessful. Referring to the White House attacks, Fauci remained calm saying, “I cannot figure out in my wildest dreams why they would want to do that” (10). New polling from Quinnipiac University found that 65% of voters trust the information Fauci is providing about the coronavirus while only 30% trust the information provided by Trump (11). In the face of the polls favorable to Fauci, the White House is now distancing itself from Navarro saying he went rogue failing to obtain proper clearance for his op-ed (12).

In a closely related event, the Trump Administration has mandated that hospitals sidestep the Centers for Disease Control and Prevention and send critical information about COVID-19 hospitalizations and equipment to a different federal database (13). From the start of the pandemic, the CDC has collected data on COVID-19 hospitalizations, availability of intensive care beds and personal protective equipment. The change sparked concerns that the administration was hobbling the ability of the nation's public health agency to gather and analyze crucial data in the midst of a pandemic. It further allows data to be manipulated, altered or spun for political purposes. The decision raises serious questions about the credibility, transparency, and availability of data needed by public health officials, researchers, and physician leaders to advance science-based and data-driven decision-making. The White House has lied enough to show they cannot be trusted with data needed for responses to the COVID-19 pandemic such as reopening.

The scientific data is what it is. It has no philosophy, no politics, and is often not what we want it to be. During this pandemic which is the most catastrophic public health disaster since the “Spanish Flu” of 1918, we need scientific leadership to ensure that the data is driving our responses and not being driven by a political agenda. Leaders like Tony Fauci are needed for this pandemic. Others who attempt to undermine Fauci for their own nefarious political purposes will hopefully be ignored by the public. Nonscientific wags who claim scientific abilities they do not have do not really get it. They will likely lead us towards a cataclysmic catastrophe that could be diminished with sensible decisions made on the basis of science rather than politics.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Nakamura D. ‘Maybe I have a natural ability’: Trump plays medical expert on coronavirus by second-guessing the professionals. Washington Post. March 6, 2020. Available at:  https://www.washingtonpost.com/politics/maybe-i-have-a-natural-ability-trump-plays-medical-expert-on-coronavirus-by-second-guessing-the-professionals/2020/03/06/3ee0574c-5ffb-11ea-9055-5fa12981bbbf_story.html (accessed 7/17/20).
2. Paz C. All the president’s lies about the coronavirus. The Atlantic. July 13, 2020. https://www.theatlantic.com/politics/archive/2020/07/trumps-lies-about-coronavirus/608647/ (accessed 7/17/20).
3. Coronavirus Resource Center. Johns Hopkins University. Available at: https://coronavirus.jhu.edu/ (accessed 7/17/20).
4. Panetta G. Fauci says he doesn't regret telling Americans not to wear masks at the beginning of the pandemic. Business Insider. Jul 16, 2020. Available at: https://www.businessinsider.com/fauci-doesnt-regret-advising-against-masks-early-in-pandemic-2020-7 (accessed 7/17/20).
5. Lahut J. Trump is reportedly getting frustrated with Dr. Fauci's 'blunt approach' during White House press conferences. Business Insider. Mar 23, 2020. Available at: https://www.businessinsider.com/trump-reportedly-growing-frustrated-with-dr-faucis-blunt-approach-2020-3 (accessed 7/17/20).
6. Brewster J. Trump retweets call to fire Fauci after he criticized U.S. response to virus. April 13, 2020. Available at: https://www.forbes.com/sites/jackbrewster/2020/04/13/trump-retweets-call-to-fire-fauci-after-he-criticized-us-response-to-virus/#47860ca451d6 (accessed 7/17/20).
7. Pramuk J. White House blocks Fauci from testifying at House coronavirus hearing. CNBC. May 1, 2020. Available at: https://www.cnbc.com/2020/05/01/anthony-fauci-blocked-from-testifying-at-house-coronavirus-hearing.html (accessed 7/17/20).
8. Navarro P. Anthony Fauci has been wrong about everything I have interacted with him on. USA Today. July 14, 2020. Available at: https://www.usatoday.com/story/opinion/todaysdebate/2020/07/14/anthony-fauci-wrong-with-me-peter-navarro-editorials-debates/5439374002/ (accessed 7/17/20).
9. Meet the Press. July 12, 2020. https://www.nbcnews.com/meet-the-press/video/adm-brett-grior-dr-fauci-is-not-100-percent-right-about-covid-19-response-87536197610 (accessed 7/17/20).
10. Nicholas P, Yong E. 1.        Fauci: ‘Bizarre’ White House Behavior Only Hurts the President. July 15, 2020. Available at: https://www.theatlantic.com/politics/archive/2020/07/trump-fauci-coronavirus-pandemic-oppo/614224/ (accessed 7/17/20).
11. Stelter B. New poll reaffirms that most Americans don't trust the President, but they do trust Dr. Fauci. CNN Business. July 16, 2020. Available at: https://www.cnn.com/2020/07/15/media/poll-trump-fauci-reliable-sources/index.html (accessed 7/17/20).
12. Samuels B. White House distances itself from Navarro op-ed bashing Fauci. The Hill. 07/15/20. Available at: https://thehill.com/homenews/administration/507406-white-house-distances-itself-from-navarro-op-ed-bashing-fauci (accessed 7/17/20).
13. Huang P, Simmons-Duffin S.  White House strips CDC of data collection role for COVID-19 hospitalizations. NPR. July 15, 2020. https://www.npr.org/sections/health-shots/2020/07/15/891351706/white-house-strips-cdc-of-data-collection-role-for-covid-19-hospitalizations (accessed 7/17/20).

Cite as: Robbins RA. Lack of natural scientific ability. Southwest J Pulm Crit Care. 2020;21(1):15-22. doi: https://doi.org/10.13175/swjpcc044-20 PDF 

Seven Words You Can Never Say at HHS

The recent announcement of the seven words you can never say at Health & Human Services (HHS) reminded me of the late George Carlin’s routine, “Seven Words You Can Never Say on Television” (1). Policy analysts at the Centers for Disease Control (CDC) in Atlanta were told of the list of forbidden words at a meeting last Thursday, December 14, with senior CDC officials who oversee the budget, according to an analyst who took part in the 90-minute briefing (2). The forbidden words are "vulnerable," "entitlement," "diversity," "transgender," "fetus," "evidence-based" and "science-based." In some instances, the analysts were given alternative phrases. Instead of “science-based” or “evidence-based,” the suggested phrase is “CDC bases its recommendations on science in consideration with community standards and wishes,” the person said. In other cases, no replacement words were immediately offered.

This is the latest attempt by government departments to distort fact. As an example, The New York Department of Education tried a similar tactic in 2012 (3). Among the words were dinosaur, birthday, and Halloween. Some of the reasons given were that dinosaurs suggest evolution which creationists might not like; Halloween was targeted because it suggests paganism; and birthday because it isn’t celebrated by Jehovah’s Witnesses; The Bush administration waged a similar war on climate change (4). That war has been extended by the Trump Administration as part of their war on any science that the Trump administration does not like (5). Science that does not fit Trump’s agenda or ideology is insulted or called “fake news”. Climate change is fact and not a hoax dreamed up the Chinese as Trump has claimed (6).

Mr. Carlin is not alive to make fun of the latest war on free speech but perhaps others will take up Carlin’s calling. Seven words they might suggest be banned include stupid, moron, fool, clown, weird, dumb and incompetent-all frequently used by President Trump on Twitter (7). The CDC is a scientific organization. Appointing unqualified politicians to head scientific organizations to carry out a political agenda is like mixing oil and water. No matter how times you say it, the water will not float on top of the oil. Science relies on a precise vocabulary and is not Republican or Democrat, conservative or liberal, or right or left. In my view, those that banned these words made an indirect attack on fact and should be “ashamed” (7).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Carlin G. 7 words you can never say on television. Available at: https://www.youtube.com/watch?v=kyBH5oNQOS0 (accessed 12/18/17).
2. Sun LH, Eilperin J. Words banned at multiple HHS agencies include ‘diversity’ and ‘vulnerable’. Washington Post. December 16, 2017. Available at: https://www.washingtonpost.com/national/health-science/words-banned-at-multiple-hhs-agencies-include-diversity-and-vulnerable/2017/12/16/9fa09250-e29d-11e7-8679-a9728984779c_story.html?utm_term=.c983e2f2af81 (accessed 12/18/17).
3. CBS News New York. War on words: NYC dept. of education wants 50 ‘forbidden’ words banned from standardized tests. March 26, 2012. Available at: http://newyork.cbslocal.com/2012/03/26/war-on-words-nyc-dept-of-education-wants-50-forbidden-words-removed-from-standardized-tests/ (accessed 12/18/17).
4. Union of Concerned Scientists. Scientific integrity in policy making. September, 2005. Available at: https://www.ucsusa.org/our-work/center-science-and-democracy/promoting-scientific-integrity/reports-scientific-integrity.html#.Wjf0TFWnGUk (accessed 12/18/17).
5. Editorial Board. President Trump’s war on science. New York Times. September 9, 2017. Available at: https://www.nytimes.com/2017/09/09/opinion/sunday/trump-epa-pruitt-science.html (12/18/17).
6. Marcin T. What has Trump said about global warming? Eight quotes on climate change as he announces Paris agreement decision. Newsweek. June 1, 2017. Available at: http://www.newsweek.com/what-has-trump-said-about-global-warming-quotes-climate-change-paris-agreement-618898 (accessed 12/18/17).
7. Lee JC, Quealy K. The 394 people, places and things Donald Trump has insulted on twitter: a complete list. New York Times. November 17, 2017. Available at: https://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html (accessed 12/18/17).

Cite as: Robbins RA. Seven words you can never say at HHS. Southwest J Pulm Crit Care. 2017;15(6):294-5. doi: https://doi.org/10.13175/swjpcc154-17 PDF 

Fake News in Healthcare

An article in the National Review by Pascal-Emmanuel Gobry points out that there is considerable waste in healthcare spending (1). He blames much of this on two entitlements-Medicare and employer-sponsored health insurance. He also lays much of the blame on doctors. “Doctors are the biggest villains in American health care. ... As with public-school teachers, we should be able to recognize that a profession as a whole can be pathological even as many individual members are perfectly good actors, and even if many of them are heroes. And just like public-school teachers, the medical profession as a whole puts its own interests ahead of those of the citizens it claims to be dedicated to serve.”

Who is Pascal-Emmanuel Gobry and how could he say something so nasty about teachers and my profession? A quick internet search revealed that Mr. Gobry is a fellow at the Ethics & Public Policy Center, a conservative Washington, D.C.-based think tank and advocacy group (2). According to his biography, Gobry writes about religion, culture, politics, economics, business, and technology, but not health care. He is a columnist at The Week, a contributor at Forbes, a blogger at the Patheos Catholic and his writing has appeared in the Wall Street Journal, The Atlantic, and The Daily Beast amongst others. He holds a Master of Science in management from HEC Paris (Hautes études commerciales de Paris, a quite prestigious business school) and lives in Paris.

To make his point on waste, Mr. Gobry comments on Atul Gawande’s 2007 New Yorker “exposé on the Herculean efforts by a handful of scientists to get intensive-care physicians to implement a basic hygiene measures checklist so as to stop hospital-borne diseases” (3). He goes on to quote the Centers for Disease Control that hospital-borne diseases kill about 100,000 people per year, that the checklist was of no cost to the doctors, and its scientific rationale was unquestionable. “Doctors still resisted it with all their might because they found it mildly inconvenient; perhaps they found it even less acceptable that anybody might tell them how to do their jobs”. I showed this article to one of my former pulmonary/critical care fellows who has been in practice about 10 years. He commented, “Another guy who doesn’t practice medicine or know what he’s talking about.”

Gobry is referring to the Institute of Healthcare Improvement (IHI) central line associated blood stream infection (CLABSI) guidelines. These include hand washing, sterile gloves, sterile gown, wearing of a cap, full body drape, chlorhexidine, and not using femoral sites for insertion. In our intensive care units only chlorhexidine usage was associated with a decline in CLABSI (4). Every ICU I have practiced in has emphasized handwashing and demanded use of sterile gloves, gowns and drapes. The remaining guidelines are not supported by good evidence.

Gobry also claims that a computer is better at diagnosis than most physicians. He claims that the evidence is “pretty robust at this point, and the profession resists it tooth and nail. In a few years, we’ll be able to know how many unnecessary deaths this led to, but the number will have lots of zeroes”. However, in the only direct comparison of diagnostic accuracy, physicians vastly outperformed computer algorithms (84.3% vs. 51.2%) (5).

Journalists like Gobry are writing melodramatic articles about medicine and often getting it wrong. In this case he sensationalized Gawande’s article and misquoted the evidence for both the IHI guidelines and computer diagnosis.

There’s a TV commercial about an actor playing a doctor. Gobry is a business journalist attempting to play a doctor at the National Review. My former fellow is right. Gobry is a guy who does not know what he is talking about. Unfortunately, his writings can affect public policy and influence politicians who know even less. As President Trump said, “Nobody knew that health care could be so complicated” (6).

I am a doctor playing a journalist at the Southwest Journal of Pulmonary and Critical Care. Our articles may not be as sensational as Gobry’s, but we stick to what we know-pulmonary, critical care and sleep medicine. I think we usually get it right. President Trump has railed against “fake news”, most recently on Lou Dobbs Tonight (7). Journalists like Gobry contribute to fake news by being deliberately obtuse, appealing to emotions, name-calling, and omitting or distorting facts. As physicians, we have been denigrated by journalists like Gobry and others who make outrageous claims for their own purposes. It is the responsibility of physicians to challenge those like Gobry who get it wrong.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Gobry P-E. The most wasteful health spending is also the most popular. National Review. October 25, 2017. Available at: http://www.nationalreview.com/article/453088/health-care-spending-wasteful-popular (accessed 10/25/17).
2. Ethics & Public Policy Center. Pascal-Emmanuel Gobry. https://eppc.org/author/pascal-emmanuel-gobry/ (accessed 10/25/17).
3. Gawande A. The Checklist. The New Yorker. December 10, 2007. Available at: https://www.newyorker.com/magazine/2007/12/10/the-checklist (accessed 10/25/17).
4. Hurley J, Garciaorr R, Luedy H, et al. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73. Available at: http://www.swjpcc.com/critical-care/2012/5/10/correlation-of-compliance-with-central-line-associated-blood.html. 
5. Semigran HL, Levine DM, Nundy S, Mehrotra A. Comparison of Physician and Computer Diagnostic Accuracy. JAMA Intern Med. 2016 Dec 1;176(12):1860-1861. [CrossRef] [PubMed]
6. Howell T Jr. Trump: 'Nobody Knew That Health Care Could Be So Complicated'. Fox News. February 27, 2017. Available at: http://nation.foxnews.com/2017/02/27/trump-nobody-knew-health-care-could-be-so-complicated (accessed 10/25/17).
7. Trump DJ. Lou Dobbs Tonight. October 25, 2017. Available at: http://video.foxbusiness.com/v/5624925494001/?#sp=show-clips (accessed 10/26/17).

Cite as: Robbins RA. Fake news in healthcare. Southwest J Pulm Crit Care. 2017;15(4):171-3. doi: https://doi.org/10.13175/swjpcc132-17 PDF 

EMR Fines Test Trump Administration’s Opposition to Bureaucracy

Earlier this week the Health and Human Services Office of Inspector General (OIG) released an audit report on $6.1 billion paid to 250,000 clinicians in the incentive program for meaningful use of electronic medical records (EMRs) (1). A random sample of 100 clinicians who had received at least one incentive payment revealed that 14 of them who had had not met all meaningful use requirements as they had attested (Table 1) (1,2).

Table 1. Meaningful use deficiencies identified in 14 of 100 clinicians.

• Six clinicians couldn't provide a mandatory analysis of security risks;
• Four clinicians couldn't prove that they had generated at least one list of patients-another requirement -who had the same condition;
• Three clinicians could not provide patient encounter data to document that they had met various meaningful use measures;
• One clinician had 90-days' worth of patient encounter data when a year's worth was needed;
• One clinician did not use certified EHR technology as much as required.

The OIG recommended that the Center for Medicare and Medicaid Services recover the $291,222 paid to the clinicians in the sample group and extrapolated the recovery to $729 million from the remaining clinicians based on this random sample. This is about 13% of the incentives paid to clinicians for the CMS EMR program. The decision to carry out the recommendation will ultimately fall to a US Department of Health and Human Services (HHS) secretary, Tom Price MD, who has opposed government programs that created regulatory hassles for physicians.

"We would protest if they went through with this," said Robert Tennant, director of health information technology policy at the Medical Group Management Association (MGMA). "Going after folks who tried to meet arbitrary government requirements, who made a good faith effort, isn't fair” (2). Tennant said that this complexity, made worse by evolving requirements, helps explain the deficiencies listed in the OIG audit. "I'm not surprised some providers found it daunting to keep up with the changes," he said. The requirement for a security risk analysis is a problem, Tennant noted, because CMS hasn't given clinicians sufficient guidance on how to meet the requirements. "This is a real stumbling block for smaller practices," he said. "They're not security experts, they're clinicians" (2). American College of Physicians Vice President of Governmental Affairs and Medical Practice Shari Erickson said that clinicians who originally attested to meaningful use lacked clear, specific guidance on what documentation they needed for each requirement (2).

CMS incentivized using EMRs because many clinicians were reluctant to initiate EMRs in their practices because of cost and efficiency considerations. Average costs to initiate an EMR were $163r,765 for a single practitioner and $233,298 for a practice with five physicians (3). Reimbursement under the EMR program was about $65,000 per provider (4). Furthermore, there was an 8% decrease in productivity after EMR initiation (3). In other words, if physicians wanted to see Medicare/Medicaid patients they were asked to use EMRs that cost them money and made them work harder.

The violations identified in the OIG audit seem fairly minor and are the type of trivial violations that the lawyers and bureaucrats seem to delight in identifying and excessively penalizing clinicians. In contrast, large health care organizations seem to go unpunished for more egregious violations. Witness the lack of action against Banner Healthcare for compromising 3.7 million medical records in 2016 (5). The average cost of data breach has been estimated at $398 per compromised record (2). Extrapolating, Banner should be fined nearly $1.5 billion.

Medicine is likely the most regulated industry in the US. Several of my colleagues have complained that the regulation seems more directed at them and not at the hospitals and insurance companies that seem to create most of the increase in cost and the violations. Some of the more paranoid clinicians viewed the EMR as nothing more than a tactic to gain further control of their practice and viewed Hillary Clinton as someone who would continue the onslaught on clinicians. These fines for EMR noncompliance are the first true test for the Trump administration in the area of healthcare regulation. Many of my colleagues are watching Trump and Price to see if their opposition to bureaucracy was merely lip service or has some backbone. 

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Levinson DR. Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements. Department of Health and Human Services. Office of the Inspector General. June 2017. Available at: https://oig.hhs.gov/oas/reports/region5/51400047.pdf (accessed 6/15/17).
2. Lowes R. Proposal to take back EHR bonuses galls med societies. Medscape. June 13, 2017. Available at: http://www.medscape.com/viewarticle/881563?nlid=115819_4502&src=wnl_dne_170615_mscpedit&uac=9273DT&impID=1368453&faf=1 (accessed 6/15/17). 6
3. Fleming NS, Aponte P, Ballard DJ, Becker E, Collinsworth A, Culler S, Kudyakov R, McCorkle R, Chang D. Exploring financial and non-financial costs and benefits of health information technology: the impact of an ambulatory electronic health record on financial and workflow in primary care practices and costs of implementation. The Agency for Healthcare Research and Quality (AHRQ). 2011. Available at: https://healthit.ahrq.gov/sites/default/files/docs/publication/R03HS018220-01Flemingfinalreport2011.pdf (accessed 6/15/17).
4. Hayes TO. Are electronic medical records worth the costs of implementation?American Action Forum. August 6, 2015. Available at: https://www.americanactionforum.org/research/are-electronic-medical-records-worth-the-costs-of-implementation/ (accessed 6/15/17).
5. Robbins RA. Banner hacked-3.7 million at risk. Southwest J Pulm Crit Care. 2016;13(2):80-1. [CrossRef]

Cite as: Robbins RA. EMR fines test Trump administration's opposition to bureaucracy. Southwest J Pulm Crit Care. 2017;14(6):312-4. doi: https://doi.org/10.13175/swjpcc079-17 PDF