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Coronavirus & Systems Fragility

What this health crisis may reveal about the American way of practicing medicine and treating public health
Senior man sick with corona virus

Here’s a link to an unrolled Twitter thread by former USAID official Jeremy Konyndyk. It begins:

Later in the thread:

Read the whole thread. His basic point is that the US Government did not want to see data that would indicate community transmission, so it didn’t look for that. What do you think? I’m especially interested in what medical professionals in this blog’s readership have to say.

I received this e-mail from Wyoming Doc a couple of days ago, and have his permission to post it:

I have just learned of the first Coronavirus Death in the USA. It is now getting real.

I would point you to the following links — I am seeing myself — but to a greater degree hearing about rather concerning things happening in our hospitals across the country.
The first is this video:


The second is this website I showed you the other day:


I would start first with a little background. I have been a physician now for almost 30 years. It has been a career spanning the very end of the “Marcus Welby” era, and then piece by piece the complete dismantling of the medical profession by the insurance companies and now “non-profit” corporations. When I was young, the leadership structure in the hospitals was completely and utterly controlled by three groups: the physicians, the nurses, and in the case of Catholic hospitals, the church and the nuns, or in non-Catholic hospitals, philanthropic community leaders.

The focus at the time was mostly on taking care of the most patients the best that could be done in a compassionate way with the resources available. And believe it or not, in my opinion, the care that was given in that time was far superior than what is going on now. The leaders of the hospitals were community leaders, and so was the medical and the nursing staff. To put it succinctly: they cared about their neighbors. Many, many nights while on call I would see the nuns right along side the nurses and physicians working themselves to death to take care of sick patients. These hospitals were never in debt — the resources and the donations coming in were used for the expenses going out. There were no four-star mahogany and marble lobbies. There were no 2 million dollar annual salaries for the hospital CEOs. There were no non-profit corporate boards extracting every bit of wealth from the patients to maintain multimillion dollar salaries for the board members and the middle managers.

When I was a young medical student, a very old professor taught a course in medical ethics. In one of his most pressing lectures, he discussed the fact that the goals and ideals of medicine and public health were a complete 180 degrees from the wants and desires of a free market. He added that every time combining public health/medicine and free markets had been tried in history it ended in tears — usually bankrupting the society. It was his fervent desire that we not allow this to happen to the profession as we entered its ranks, and to keep an eye out for this at all times.

Well, as everyone knows by now, his worst fears have been realized. Many, probably not most, members of my profession — especially the procedure-based specialists and surgeons — in the past 10-15 years have completely lost sight of the public well-being. Their sights are now on lucre. The one desire for many of them has been how to make more money more quickly. They have been aided and abetted by the governing agencies and Boards of all the various medical specialties. These national leadership organizations have made all the activities of being a physician so onerous and the billing so difficult that the vast majority of physicians have no choice but to become employees of these mega-corporations. The physicians have made a deal to take a back seat to these “businessmen” to keep the cash coming. The leadership of our hospital systems are no longer physicians, nurses, nuns, and philanthropists. Nope –it is all MBA all the time. Even the physicians who are nominally in charge — ie the ubiquitous Chief Medical Officers of the corporations — do not get considered for the jobs unless they have an MBA after their name. And the credentialing of the leadership teams are just absolutely ridiculous. Look at the websites of your local hospital and its leadership. It is usual to see things like this:  John Doe, MD MBA FACP PhD FACC. The non-MD credentialing is even more hilarious — I have no idea what 95% of these abbreviations mean — but they have to puff themselves up anyway. The hubris and the arrogance would be hilarious, but now the crisis is upon us.

About 10-15 years ago, the change began in earnest. One by one, the physicians in charge were replaced with MBA bureaucrats. The usual committee structure in the hospital — “Pharmacy & Therapeutics”, “Patient Care Committee” etc — had their physicians, nurses and pharmacists replaced with bureaucrats. Some of these bureaucrats were MDs and RNs — the paycheck was awesome —and they turned their backs on their duties and their colleagues and patients on the ground to keep the cash coming. I even lived to see the day when one of my hospitals fired the MD and RN leadership of the Medical Ethics Committee and replaced them with an MBA.

Suddenly, the only ethical thing to do was whatever was needed to maximize cash flow. And any MD or RN who did not like it? Well, you’re fired — see you later. We began to completely corporatize medical care. Advertisements and billboards everywhere, customer service feedback surveys flowing in the mail, the list is endless. Public health concerns began to be confined strictly to things that would boost revenue: colonoscopies, mammograms, labs, vaccinations, bone density studies, etc. Things that have no revenue flow — like mental health issues, opioid abuse, elder care — well, who cares about that? Very soon, the hospitals began to merge into gigantic corporations and then they began to collude to control the health care costs in the community. Our health care systems in all our big cities are gigantic monopolies. This despite the fact that this kind of behaviour is illegal under federal statutes. And please note: this is why insurance costs are so enormously high in this country — and getting higher every year. Obamacare did NOTHING to stop this; it actually in many ways has made it much easier to pull off.

Because of this situation and for many other reasons, I decided to make a change in my life a few years ago. I have now moved to a very small hospital in rural America. In my life now, the corporate board has now been replaced by a board elected by the taxpayers: they are truly leaders of the community and do everything in the spirit of what the people need and are counting on from their hospital. The hospital is led by an MD — and there are administrators — but they too are members of the community. There is an obvious care about the community and its needs. I have spoken to colleagues across the country this week — some big hospitals have done nothing at all to prepare for the crisis. It is no surprise to me that people in all levels at my current hospital have gone to enormous lengths to make sure everyone here is ready to go. I feel like I have stepped back in time twenty years. It is a very good feeling.

In the big city, I had become very accustomed to going to important meetings in the hospitals — all controlled by the business leadership now — and no medical facts or issues being discussed at all. Anything medical is distilled down to number crunching, revenue cycles, and “profit centers.” Never a word is said about medical facts, public health, impact on patients, or morality like it used to be — at least most of the time. Anyone who voices dissent is ostracized, and finds themselves disinvited and even dismissed from employment.

So the Youtube video is old hat to me. The people in charge of these critical things in our world often look like Barbie and Ken. They are cool cucumbers. They know all about branding, deceptive advertising, maximizing revenue, hiding truths, sucking up. But when actually asked questions that are critical to the issue at hand — they often know nothing. And because they know nothing, nothing gets done. I have seen it many times before and am sure I will see it again. I read commentary online that people were shocked by that DHS Chief’s answers to questions. I am not shocked — I am very accustomed to it. Please note: our entire corporate health care system at the local hospital level in the big cities is now under the control of people just like him. They are looking for every way they can to defuse this crisis with calming advertising, words, pleasantries, smiles, and soothing statements. I am sure that they are also looking for any way they can profit financially from it as well. All I can say is: Good Luck.

A case in point was the following interaction I was told about yesterday by an old student of mine who is now a fellow at a major medical center on the East Coast. I heard the same exact recollection of the story from someone else in the room.

This was a meeting with the upper administration of the hospital system and heads of departments and multiple physicians and nurses. It occurred between the CEO and a DOC who is older and near retirement and who is an infectious disease specialist. The discussion about the current crisis went something like this:

CEO: I am not sure that we need to be preparing like this – this is obviously overblown – and is really going to damage our budget projections. The HHS seems to think this is going to go away in the spring anyway.
DOC: Why in God’s name would you want it to go away in the spring?
CEO: (chuckling) What the hell are you talking about? We all want this thing to go away as soon as possible.
DOC – Historically, when pandemics are spread by aerosol droplets,  and are as infectious as this one seems to be, they may recede in the spring — but then come back in the fall with horrific fury. Remember the last one — the Spanish Flu? The first wave was nothing, but the second and third waves turned the planet into a funeral home.
CEO: Oh for God’s sake – don’t you get it? That will give us time to get a vaccine — we will not need to worry about it in October.
DOC: A vaccine? you must be kidding. It is never a good idea to rush a vaccine. Remember the first polio vaccine was rushed to market. It did not work and actually harmed many children. Remember the swine flu vaccine in the 1970s? It was not properly tested. Very few died from the swine flu. Hundreds and thousands were maimed or killed by Guillain Barré Syndrome because of it. And I doubt that half of our population would be even willing to take it. You do not understand.

CEO: Oh I understand way more than you obviously do. There is already an antiviral — we will have that as well.

DOC: Really? Again, not really fully tested. And have you looked at the cost? Even a conservative estimate at the dosing they are using it would be $5000 a day. What is that going to do to your budget projections when you have 100 people in here in the hospital on that drug? Do we even have enough in the country for a sudden mass need? I do not know.

And then CEO looked DOC in the eye and just moved on to something else.

And DOC found out later that he would no longer be welcome at any of these meetings.

Please know this: viruses are not Republicans, they are not Democrats. Viruses are not going to respond to advertising, sweet words, or revenue cycles. They are going to accomplish their mission, and that alone. There may be things we are able to do, but we will need all the medical wisdom in the world focusing on our country as a whole and our local communities. That is just not happening to the extent it should be. We are going to fight this one with business school principles.

I again pray all the time that this virus will burn out — that it will stop, that it will not get worse. I pray that God will have mercy and allow this to be a close call. But I am afraid that we have let our society crumble in so many ways –not just medicine — that it is going to take a punch in the face to get our attention. This coronavirus may very well be the brass knuckles.

A follow-up e-mail from him:

This has been one of the most harrowing weeks in my career. The patients are really wigged out. Multiple times this week,  I have seen patients with a cough or fever — and we cannot ID a pathogen. That has caused a constant boogeyman to be sitting on my shoulder: fear. I can see the fear in my staff’s eyes, and then on Friday, a  nurse suddenly after lunch developed a 101 fever and a bad cough — again no pathogens. I have a feeling this is happening in many other places in this country.

We have no way to test these people. I can offer little if any hope. I am telling them to stay at home, and I can see the horror in their eyes. I am now at the same level of those physicians in Milano 700 years ago –

So when I get this kind of soul crushing fear in my life, I always call one of my elder family members. My parents and grandparents are all gone now. The only one left is my 92 year old Auntie Marina. She lived through hell in Greece during the Nazi occupation and immediately thereafter. She is an amazing woman. And this is what she said to me.

“My dear, I was there when your parents handed your life and everything you are over to God. I was right on the front row. He has been preparing you every day of your life since you were a baby for the duties that you must now perform. Be brave, and sturdy, and do everything in His name. He will surround you with courage — and fear not, if he decides this is your time to go, you will be welcomed by all the saints and angels. But here in our house, we are going to be lifting you up in prayer, multiple times a day. And I am certain that your parents are looking down and are very very proud of you.”

I am a member of my community and my church. I cannot leave my post — and I would ask that you pray for me and my staff for the bravery to continue on. I know that is a lot of drama,  but we are really having fear here on the front lines. I would ask that you keep all the health care workers in America in your prayers right now.

In further conversation, the doctor said that we should be thinking about a world in which a large number of health care workers can’t come to work because they are in quarantine or sick with the virus. We are looking at this problem right now.

He also recommends that people follow the coronavirus Reddit, which he says is well-moderated, and a source of solid information: https://www.reddit.com/r/Coronavirus/