Father Greed: Vanishing Ventilators and Free Enterprise Public Health.

Posted on | April 1, 2020 | 2 Comments

Mike Magee

If you wanted to sum up President Trump’s two key messages this week, they would be: 1) A lot of people are going to die, and 2) Thank God for free enterprise public health.

On both counts, he is on thin ground. Numbers of deaths could far exceed the 240,000 he apparently now finds acceptable. And…not unrelated, Father Greed has firm control over America’s Medical Industrial Complex, paralyzing the critical supply chain with deception and profiteering.

Case in point (outlined in detail in a ProPublica March 30th exclusive investigation), the “disappearing Federal ventilator.”

Here are the basic facts:

1. In 2006, HHS established a special office (BARDA – Biomedical Advanced Research and Development Authority) to manage material preparedness for a medical disaster. The agency’s top priority – stockpiling ventilators. By 2008, they set a goal of the large scale purchase of a functional, but not elaborate, ventilator for $2000.
2. They signed a contract with Newport Medical Instruments for $6.4 million in September, 2010. By May, 2012, the machine was still on the drawing board, and the company was purchased by Covidien, an Irish medical device corporation. Covidien began to raise enough foot-dragging issues to bump up the BARDA offer by $2 million.  But before lifting a finger, they were sold to Medtronic which mailed in designs and then said thank you very much, but goodbye in 2015.
3. BARDA picked up the pieces and in 2015 signed a $13.8 million contract with a small Pennsylvania manufacturer, Respironics, a subsidiary of Dutch technology manufacturer, Royal Philips, N.V.
4. In 2019,  they received a green light  to create 10,000 “low-cost, portable, easy-to-use ventilators” at a cost of $3,280 per unit. The machine was called the Trilogy Evo Universal.
5. Instead, the Pennsylvania company geared up their assembly line to produce a high-priced commercial model selling originally at a list price of $12,495, and now for $17,154.

With not a single Respironics ventilator in the federal stockpile, who are buying from the “Make America Great Again” Murrysville, Pennsylvania plant?  The government of Madrid bought 10 for $11,000 each last month. Budapest, Hungary has a few as well.

Two other points of interest:

1. In 2016, Respironics paid a $35 million fine for kickpacks to medical suppliers who bought their equipment.
2. Jared to the Rescue: Respironics is currently negotiating with Jared Kushner to build 43,000 of the more complicated (and expensive) version of the Trilogy Evo Universal.

If successful, look for a Rose Garden appearance of the Philips Respironic CEO at the next afternoon episode of Trump’s Great  American Catastrophe (airs every day , 5:30PM – 7:00PM).

A Health System Disconnected and Conflicted in an Un-united United States.

Posted on | March 31, 2020 | 2 Comments

Mike Magee

Governors like Andrew Cuomo of New York have discovered the price for inefficiency and conflicts of interest in the face of the Covid-19 epidemic. As he said yesterday, “No one hospital has the resources to handle this. There has to be a totally different operating paradigm where all those different hospitals operate as one system.”

Our system is marked by extreme variability, a nation of health care have’s and have-not’s. Yet even when we Americans acknowledge the absurdity of our convoluted system of third-party payers, and the pretzel positions our politicians weave in and out of as they try to justify it, reform it, then un-reform it, many still find solace in telling themselves, “Well, we still have the best health care in the world.” 

This crisis in a matter of weeks has revealed the limitations of a conflicted network built on short-term profiteering and entrepreneurial adventurism. Here are a few early learnings:

1. There is no national system – not for health, not for disaster.
2. The buck stops nowhere. Since there is no plan, and no point of central control, there is no one in charge.
3. “1000 points of light” doesn’t cover the absence of “good government.”
4. There is no national inventory stockpile because there is no national health plan. When Obama (post-Ebola) constructed centralized disaster planning to try to umbrella this weakness, Trump rapidly disbanded it to erase the Obama name and play to conservative partisans.
5. “Just in time inventory management” boosts profit margins, but leaves all vulnerable to shortages during a crisis.
6. Extreme care delivery segmentation – confronting a disaster scenario – fails for all, not just the poor and disadvantaged.
7. There is no tradition nor apparatus for sharing of human or material health resources in America.
8. What is shared and heavily coordinated are the federal government relations lobbying plans and strategies of the national associations that constitute the Medical Industrial Complex in America including insurers, pharmaceuticals, hospitals, and medical organizations.

The United States is un-united when it comes to public health policy and responses to this crisis. For example, only 32 states, 80 counties, 17 cities, the District of Columbia and Puerto Rico are currently being urged to stay home. For the others, their  citizens (and the virus) continue to wander around.

Our President is unrepentant. Yesterday, for the second day in a row, he paraded corporate leaders of “the greatest health system in the world” in front of the cameras on the White House lawn. At the March 29^th conference, Trump proudly introduced middleman pharmaceutical distribution CEO Michael Kaufman of Cardinal Health, for mutual admiration. Without a hint of irony, or acknowledgement of the cloud currently overhanging his company for their central role in creating the opioid epidemic, Kaufman proudly proclaimed, “We have really seen government agencies working with industry like no time before.”

Though many will die, as even the President now admits, we will survive as a nation. But hopefully, with a new leader, the first order of business will be to create a rational and universal health care system capable of protecting and securing the health of all Americans. Because, as we are tragically realizing, there is no “united states” without a safe, secure and reliable health care system.

Is There a Genetic Pre-disposition to die of Covid-19?

Posted on | March 30, 2020 | 3 Comments

Mike Magee

As Donald Trump learned when he was forced finally to declare bankruptcy on his Atlantic City Trump Taj Mahal Casino, and as our second President, John Adams, said: “Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.” Thus, without apology and as wide-eyed with faux-surprise and “Who knew?” bewilderment as ever, Trump was forced to acknowledge that continued denial on his part could result in over two million deaths.

In contrast, a number of brilliant scientists from around the world have been questioning their original assumptions that Covid-19 was primarily a threat to those over 70, immunocompromised or with existing co-morbid conditions. The reason for their uneasiness is the observation that some younger adults (and recently a child under age 1) who appeared healthy in every way, have become very, very sick – and in a significant number of cases, died from the virus. And as scientists do, they asked, “Why?”

As Science magazine reported this week, “COVID-19, caused by the new pandemic coronavirus, is strangely—and tragically—selective….Researchers are now gearing up to scour the patients’ genomes for DNA variations that explain this mystery.”

What are the genetic suspects so far.

1. The cell surface protein angiotensin-converting enzyme 2 (ACE2): A variant of the gene controlling this protein can make it easier for the virus to penetrate respiratory cell walls.

 2. The human leukocyte antigen genes: These genes control the bodies immune response to viruses and bacteria.

The researchers around the world are just getting started, but they aren’t starting from scratch. There are enormous genomic databanks already in existence seeded by volunteer DNA donations, and funded by private institutes and governments around the world. These include:

Geneticist Andrea Ganna of the University of Helsinki’s Institute for Molecular Medicine Finland (FIMM), with funding from U.S. based Broad Institute, which has created the COVID-19 Host Genetics Initiative and is pooling a group of DNA databases worldwide. Their goal is to cross-match those who have become severely ill or died from the disease against the genomes of those who have not, hunting for genetic vulnerabilities.

FinnGen, has collected DNA samples and health data for 5% of the 5 million–person Finnish population

The Icahn School of Medicine at Mount Sinai is contributing its 50,000-participant biobank.

The UK Biobank, with DNA data on 500,000 participants, has announced it is adding COVID-19 health data.

deCODE Genetics, with testing in broad use in Iceland, has genome and health data on half of Iceland’s 364,000 inhabitants, and is now adding new coronavirus results.

Harvard University’s Personal Genome Project, which has recruited people willing to share their full genome for research, received 600 positive responses in 48 hours when they sent questionnaires to participants, asking about their COVID-19 status.

11 Italian hospitals have signaled their intent to give ethics approval to a University of Seina genetics team to collect DNA samples from willing Covid-19 patients.

Pediatrics researcher Jean-Laurent Casanova at the Rockefeller University is tapping into their global network, and collecting DNA samples on Covid-19 pediatric ICU patients. 

Two weeks ago, President Trump declared “I don’t take responsibility at all.” He has spent the last fourteen days shifting blame and setting state governors and his political rivals up for a fall. Fine, we get it.

But it’s important for you to know that he is an outlier. Many, including frontline nurses and doctors and caring professionals are stepping up – and researchers around the world are doing their best as well.

We can’t waste any time and energy right now on this President. Use your prayers and blessings and support for those who really care about our future.

Work, Love, Courage – in Abundance.

Posted on | March 27, 2020 | 2 Comments

Mike Magee

This morning I listened to an interview of the President of Mass. General Hospital, Dr. Peter Slavin, as he outlined the reality of Covid-19 and the challenges faced by his nurses, doctors and health professionals during this crisis. In his words, I found pride in having been part of the caring professions whose lives center around three critical themes: work, love, courage.

Forty-seven years have passed since I received my medical degree, but not one year has passed in which I was not proud to have chosen this life. My biases are strong and well known by now. Covix-19 has only reinforced them

The world is a better place today for having developed and supported strong, enduring patient-caregiver relationships. This is not simply a function of the nuts and bolts of health services that this relationship provides, in full vision and especially under duress. But also for those things it has reliably delivered over many decades around the world, quietly below the radar screen.

The first of these, as a collective, is the management and processing of a population’s fear and worry, which, absent the efforts of nurses, doctors and caring professionals, would accumulate in our society to destabilizing effect.

The second is a subtle and rational reinforcement of important societal bonds. The importance of this second contribution was best highlighted by the great Cardinal Bernardin, who shortly before he died said to several thousand AMA physicians, “There are four words in the English language that have common English roots. They are heal, health, whole and holy. I tell you this today to remind each of you that to heal in a modern world you must provide health; and to provide health you must keep the individual, the family, the community, and society whole. And if you can do all that, why that is a holy thing.”

The third mostly invisible contribution is hopefulness; a quiet confidence that most problems can be managed, most mysteries solved, and that, absent a cure today, there remains hope for a discovery tomorrow aralen. That deep-seated optimism, embodied in individuals whom you trust, have confidence in, and believe in, is transferable, and helps create a reservoir of good will, a belief that life is worth living, that risks are worth taking, that loving and being loved is possible, that dreaming, imagining, purchasing a home, getting married, having children are all worth the effort.

As these caring relationships have become threatened by Covid-19, stable civil societies are noticing the difference. This situation is made worse by predatory leaders, who leverage lies and fear as a currency to control a population in order to reinforce existing and past power silos, and who attempt to segregate us one from another to maintain the status quo. They not only draw down the reservoir of good will locally and globally, but compromise caring professionals medium and long term success.

I am older now, but still have a voice. I am not inside the hospital any longer, but I am inside the hearts and minds of every nurse and doctor and health professional who willingly place themselves in harms way for each of us. They have the courage to rise, the willingness to work, the hearts to love. They are honest and true.

The Trump Easter Celebration – Resurrecting The Economy?

Posted on | March 25, 2020 | 2 Comments

Mike Magee

New York Times columnist, Thomas Friedman, was sufficiently disturbed by President Trump’s suggestion that our nation needlessly sacrifice American lives to protect the American economy with a quick return to work by Easter, that he turned to his old friend, Michael Sandel, legendary political philosopher at Harvard for reassurance.

As many of us do, Sandel saw the problem as systemic. As he put it, “In a highly individualistic society like ours, we don’t do solidarity very well.”

Channeling my own messaging from CODE BLUE: Inside the Medical Industrial Complex, he continued, “Our lack of preparedness for the pandemic reveals the lack of solidarity in our social and political life, especially in our inadequate system of public health and lack of universal access to health care.”

Friedman is not the first columnist to be unnerved by American culture. Back in November of 2017, David Brooks wrote a column titled “Our Elites Still Don’t Get It.” In it, he states, “Trump is constantly making friend/enemy distinctions …creating toxic communities based on in-group/out-group rivalry.” Of course, back then, Brooks could not have imagined how far down that road we would travel.

Sandel sees a pathway back to sanity he calls the “common good.” What does that mean, asked Friedman. “The common good is about how we live together in community. It’s about the ethical ideals we strive for together, the benefits and burdens we share, the sacrifices we make for one another. It’s about the lessons we learn from one another about how to live a good and decent life.”

In Sandel’s eyes, the course Trump is suggesting amounts to an Easter celebration that allows the Economy rather than Christ to rise from the dead. He says, “The strategy of contending with the pandemic by allowing the virus to run its course as quickly as possible in hopes of hastening ‘herd immunity’ is a callous approach reminiscent of social Darwinism — the idea of the survival of the fittest. It allows the contagion to spike, intensive care units to be overrun, the most vulnerable to die, but with the goal of jump-starting the economy sooner rather than later.”

In 2017, David Brooks wrote, “The first step in launching our own revival is understanding that the problem is down in the roots.” Sandel believed that rot at the roots reflects markets out of control. “Markets are useful instruments for organizing productive activity. But unless we want to let the market rewrite the norms that govern social institutions, we need a public debate about the moral limits of markets.”

President Trump would do well to read Michael Sandel’s “Justice: What’s the Right Thing To Do?” In it, he says, “the Gross National Product does not allow for the health of our children, the quality of their education or the joy of their play. It does not include the beauty of our poetry or the strength of our marriages, the intelligence of our public debate or the integrity of our public officials. It measures neither our wit nor our courage, neither our wisdom nor our learning, neither our compassion nor our devotion to our country. It measures everything, in short, except that which makes life worthwhile. And it can tell us everything about America except why we are proud to be Americans.”

Confronting Presidential Out-ertia.

Posted on | March 23, 2020 | 6 Comments

Mike Magee

“All change of matter has an external cause. (Every body remains in its state of rest or motion in the same direction and with the same velocity, if not compelled by an external cause to forsake this state.) … This mechanical law can only be called the law of inertia (lex inertiæ) Immanuel Kant, 1786

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In the March 23, 2020 COVID-19 Washington Press Briefing, President Trump signaled his active intent to break through his self-imposed inertia and embrace opening markets while closing out American lives. In the process he has taken inertia and morphed its evil twin, out-ertia. What should medical leaders like Tony Fauci do now?

____________________________________________________________________________

Inertia describes the tendency for physical objects and human beings to resist change. If you want something to move, or to stop moving, or to shift direction, you must apply force whether through gravity, friction, or contact.

Isaac Newton defined inertia as his first law of his Laws of Motion in 1687 in his Philosophiae Naturalis Principia Mathematica. But the word “inertia” was first introduced in scholarly fashion 60 years earlier by Johannes Kepler in his Epitome Astronomiae Copernicanae, deriving the word from the Latin word for “idleness” or “laziness.”

The phrases “dig in your heels” or ‘denial and routine were her two best friends” reflect human tendency to embrace existing habits and ideas. Most of the time, this proves harmless and with some patience evolves with time. But in moments of great environmental change, whether by global warming or COVID-19, inertia can prove to be dangerous and fatal.

This truth is magnified by those in power. Indecision and poor judgement are a deadly combination. It matters little whether the man in control fails to recognize change or fails to react to it – the outcome is the same.

History tells us that failures of inertia are more commonly exhibited by those directly involved at the center of a crisis. They readily exhibit a bias toward the status quo, hanging by a thread to the old ways. Clarity often arrives first through witnesses on the periphery with greater perspective.

Breaking the rules requires mental courage. This is especially true at the beginning. After the first push, there is momentum. But it has to be a real push, not a feign, nor a wink and a nod. Gentle corrections of Presidential fabrications, false promises, and misdirections are not a course changing push. You’d have to say, “If you lie one more time in my presence, I will walk off the stage and quit.”

Dr. Fauci needs to insure his availability to the public to speak truth to power. That’s the only way to confront Presidential out-ertia. Trump has signaled his intent. There is no “hidden agenda.” It is present and clear, and there is no Presidential regret. Time for Medicine, Nursing, and all Health Professionals to rise to or fall from the challenge.

David Brooks on COVID-19 Response: Beware of Dread.

Posted on | March 17, 2020 | 5 Comments

Mike Magee

On March 12th, New York Times columnist David Brooks indulged in a moment of existential reflection when he wrote, “Frank Snowden, the Yale historian who wrote ‘Epidemics and Society,’ argues that pandemics hold up a mirror to society and force us to ask basic questions: What is possible imminent death trying to tell us? Where is God in all this? What’s our responsibility to one another?”

Three days later, he discarded metaphysics and just couldn’t take it anymore. On PBS News, he let loose with this:
“I feel a deep sense of anger that our government has responded so badly. Frankly, this is what happens when you elect a sociopath as president, who doesn’t care, (and) who’s treated this whole thing for the past month as if it’s about him.”

Likely Snowden’s book with its crushing insights put Brooks over the edge. Here are a few nuggets from a recent New Yorker interview of the author:

Historically, epidemics have “shaped politics, crushed revolutions, and entrenched racial and economic discrimination.”

“Epidemic diseases are not random events that afflict societies capriciously and without warning. On the contrary, every society produces its own specific vulnerabilities … it’s structure, its standard of living, and its political priorities.”

Epidemics are a category of disease that seem to hold up the mirror to human beings as to who we really are.”

“Epidemics also, as we’re seeing now, have tremendous effects on social and political stability. They’ve determined the outcomes of wars, and they also are likely to be part of the start of wars sometimes.”

“The way we respond very much depends on our values, our commitments, and our sense of being part of the human race.”

“The health of the most vulnerable people among us is a determining factor for the health of all of us.”

“To have officials in the White House saying, ‘Oh, its nothing more than a common cold, we’ve got it under control,’ when they have nothing under control, as far as I can see, and they’ve put people in charge who don’t even believe in science.”

Even as David Brooks awoke, Republican leaders have slept on, or offered weak bromides like Marco Rubio’s plea that we not “spend all our time taking political shots”, as if Susan Collins was right when she said President Trump had “learned his lesson.” No, he hasn’t.

His words – serious one day, flippant the next – mean nothing.  Actions – only verifiable actions – count now. They must be real, rational, and responsible. And so is David Brooks warning, “Dread overwhelms the normal bonds of human affection.”

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