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The World Leadership Trophy: The Winner's Prize in the Virus-Killer Race Print
Written by <a href="index.php?option=com_comprofiler&task=userProfile&user=42475"><span class="small">Dilip Hiro, TomDispatch</span></a>   
Monday, 27 April 2020 08:27

Hiro writes: "Historically, in hyper-crises, local and global systems can change fundamentally."

Chinese president Xi Jinping. (photo: EFE)
Chinese president Xi Jinping. (photo: EFE)


The World Leadership Trophy: The Winner's Prize in the Virus-Killer Race

By Dilip Hiro, TomDispatch

27 April 20

 


It was the wars I noticed first and, in those years, made the heart of TomDispatch’s coverage. You know, the ones that went under the label of “the war on terror,” that never were won and only seemed to expand exponentially across the Greater Middle East and Africa. Those were the conflicts that somehow lacked progress, no matter how often Americans “thanked” the troops for their endless efforts, no matter how much money -- and there was always ever more of it -- poured into the Pentagon and the national security state. In other words, the world’s richest, most powerful country with a military budget that left the next seven militaries combined in the dust, just couldn’t do it -- not any way, not anywhere. Trillions of dollars were squandered against ill-armed groups of extremist irregulars who wielded deadly roadside bombs made for approximately the price of a pizza. In the previous century, the U.S. had similarly been unable to win two distant wars, one on the Korean peninsula and one in Vietnam. It had, however, stopped fighting in Korea, leaving behind a split peninsula and a never-ending truce. It had (finally) stopped in Vietnam, too, withdrawing in defeat. And keep in mind that, in those Cold War years of American global dominance, there were numerous places where Washington got exactly what it thought it wanted, however disastrously for the locals, from Guatemala to Iran to Chile.

But no longer. Its twenty-first-century wars could have been considered pandemic ones, even before Covid-19 appeared on the scene. They killed many (including Americans and lots of foreign civilians) and spread like wildfire. And to give him credit, Donald Trump grasped the reality of all this, however intuitively, long before, in the presidential campaign of 2016 (and in his presidency), he derided this country’s “ridiculous, Endless Wars.” In this country’s inability to win abroad, he sensed a strange helplessness, hopelessness; in a word, decline.

Cannily enough, only days after Mitt Romney lost his presidential race to Barack Obama in 2012, Trump moved to trademark “Make America Great Again,” an old tagline from the Reagan era, for a future run of his own. MAGA would, of course, become his slogan of choice in 2015-2016. As I realized at the time, in a moment when other American politicians felt obliged to call this country the most “indispensable,” “exceptional,” and “greatest” one on this or any other planet, that “again” in Trump’s slogan officially made him the first declinist presidential candidate in our history.

As those wars -- now true pandemic ones -- go on and the U.S. military and the military-industrial complex still get ever more money for ever less results amid the greatest accumulation of disease and death on earth, that sense of decline has become part and parcel of our world, though it’s seldom directly discussed in this country. Fortunately, today, TomDispatch regular Dilip Hiro is back with a pandemic chronology, as he says, “from hell,” one that is also distinctly a chronology of American decline. When this decline is over, who knows what kind of planet we’ll find ourselves on?

-Tom Engelhardt, TomDispatch


istorically, in hyper-crises, local and global systems can change fundamentally. Before the coronavirus pandemic hit first China and then the rest of the globe, the question of whether the American imperial era might be faltering was already on the table, amid that country's endless wars and with the world’s most capricious leader. When humanity emerges from this devastating crisis of disease, dislocation, and impoverishment, not to mention the fracturing of a global economic system created by Washington but increasingly powered by Beijing on a climate-stressed planet, the question will be: Has the Chinese dragon pushed the American eagle down to a secondary position?

To assess that question objectively in this unsettled moment, it’s necessary to examine on a day-to-day basis how the two contemporary superpowers handled the Covid-19 crisis, and ask the question: Who has proved better at combating the deadliest disease of modern times, President Donald Trump or President Xi Jinping? It’s chastening to note that whereas China under Xi has suppressed the latest coronavirus at the human cost of three lives per million population, the U.S. under Trump is still struggling to overpower it, having already sacrificed 145 of every million Americans.

In the afterglow of Trump’s December 16, 2019, touting of a partial trade deal with China (after a lengthy trade war), a Sino-American exchange took place. George Gao, director of the Chinese Centers for Disease Control and Prevention (CCDC), spoke with his American counterpart, Robert Redfield, on January 3rd, alerting him to the arrival of an as-yet-unidentified, pneumonia-inducing virus in the city of Wuhan (news of which the Chinese government would for crucial days withhold domestically). Redfield then briefed Secretary of Health and Human Services Alex Azar on that conversation.

Ever since, the trajectories of the policies followed by Beijing and Washington have diverged by 180 degrees. Mind you, the potential prize for the winner of the contest for killer of the super-virus is the World Leadership Trophy.

Attacked by a Virulent Virus, China Fights Back

China’s National Health Commission (NHC), which had dispatched a team of experts to Wuhan on December 31st, informed the World Health Organization (WHO) that cases of pneumonia of an unknown sort had been detected in that city, linked to human exposure at a 1,000-stall wholesale seafood market, selling fish and other animals, dead and alive. With that, the Chinese scientists faced two separate challenges: to isolate the pathogen causing the disease in order to set out its genome sequencing and to determine whether or not there was human-to-human transmission of the virus.

On January 3rd, the NHC centralized all testing related to the mysterious disease and, two days later, in conjunction with experts in infectious diseases caused by pathogens that jump from animals to humans, completed the sequencing of the genome of the virus. It became accessible worldwide that January 7th. And on January 10th and 11th, the WHO issued guidance notices to all its member states about collecting samples from any patients who might show symptoms of the disease, listing stringent precautions to avoid the risk of human-to-human transmission.

On January 14th, Maria Van Kerkhove, acting head of the WHO's emerging diseases unit, offered a mixed message on the situation. She told reporters that there had, so far, been only the most limited kinds of human transmission between family members in China. Nonetheless, she added, the possibility of wider human-to-human transmission should not be regarded as “surprising” given the similarity of the new virus to the ones in the earlier SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome) outbreaks. However, Reuters and China’s Xinhua News Agency also quoted her as saying that there had been only the most limited human-to-human transmission of the new coronavirus so far, mainly among small clusters of family members and that “it is very clear right now that we have no sustained human-to-human transmission.”

On January 16th, scientists at the German Center for Infection Research in Berlin developed a new laboratory test to detect the novel coronavirus. This offered the possibility of diagnosing suspected cases quickly. The WHO publicized it as a guideline for diagnostic detection. The leaders of many countries adopted it, but not President Trump who, in America First-style, demanded a test produced by U.S. scientists. Only on February 29th, however, would the Food and Drug Administration allow laboratories and hospitals to conduct their own Covid-19 tests to speed up the process. That was four weeks after the WHO had started distributing its effective test globally.

On January 19th that China’s National Health Commission confirmed human-to-human transmission of the novel coronavirus. On that day, it publicly confirmed the first cases of person-to-person transmission. Headed by a cabinet minister, the NHC classified the novel coronavirus as a category B infectious disease under the country’s 1989 Law on Prevention and Control of Infectious Diseases (revised in 2004 and 2013). This law allows the upgrading of an infectious disease to category A subject to the decision of the cabinet. Under that classification, medical institutions are authorized to treat patients in isolation in designated places and take necessary preventive measures to discover and deal with their close contacts.

On January 20th, after chairing a cabinet meeting, Premier Li Keqiang first spoke of the necessity of controlling a coronavirus epidemic, demanding that all Communist Party and government units address the situation. While endorsing Li’s call, President Xi Jinping stressed “the importance of informing the public to safeguard social stability.” As one high-level Communist Party committee typically stated in a posting on WeChat, “Whoever deliberately delays or conceals reporting for the sake of their own interests will be forever nailed to history’s pillar of shame.”

All this happened on the eve of the week-long Chinese New Year holiday, a time when hundreds of millions of people return to their homes for celebrations. On January 22nd, three days before the New Year, the authorities suspended all rail and air links out of Wuhan.

The next day, the central government imposed a complete lockdown on that bustling city of 11 million and other large urban centers in the province of Hubei. Residents were forbidden to leave their homes, while food and other supplies were to be delivered by neighborhood committees. This set a precedent for similar measures in other cities, as in the coming weeks many areas across China imposed such “closed management” situations on communities. Up to 760 million people were subjected to travel curbs of one sort or another, while the economy was reduced to 40%-50% of its normal capacity.

During a meeting with WHO Director General Tedros Adhanom Ghebreyesus in Beijing on January 29th, President Xi assured him that he had personally overseen and directed the response to the viral outbreak and the prevention and control measures that went with it. On January 30th, with the novel coronavirus having spread to 17 countries including the United States, the World Health Organization declared the outbreak a “global health emergency.” On February 11th, it labeled the disease caused by the latest coronavirus, which can culminate in death-inducing pneumonia, Covid-19.

Meanwhile, in Trumpland...

On January 29th, President Trump officially inaugurated a task force led by Health and Human Services Secretary Alex Azar to monitor, contain, and mitigate the spread of the coronavirus while also keeping Americans informed on the matter.

Azar and the Centers for Disease Control Prevention’s Robert Redfield had already been involved in protecting Americans from the deadly virus. On January 7th, Redfield had established the CDC’s Covid-19 Incident Management System and, on the 21st, he activated its emergency response structure. On that very day, the first lab-confirmed coronavirus case was reported in Olympia, Washington. (Earlier ones would later be detected.) The president noted the news with a tweet: “It’s one person coming in from China and we have it under control. It’s going to be just fine.”

Inside the White House, Trump’s national trade adviser, Peter Navarro addressed a warning memo to the National Security Council stating that the present “lack of protection elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans.” He estimated that such a pandemic could kill half-a-million people and deliver a $5.7 trillion hit to the economy.

Two days later, in response to these developments, all Trump did was ban the arrival of non-US citizens who had recently traveled to China. From then on, he repeatedly touted this as evidence that he had acted early. Azar’s plan to set up surveillance in five cities at the cost of $100 million fell through when, on February 21st, Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, told reporters that problems with the kits to test for Covid-19 were still unresolved.

In the absence of meaningful testing, the number of cases in the U.S. looked small. “The coronavirus is very much under control in the USA,” Trump tweeted on the 24th. “CDC & World Health [Organization] have been working hard and very smart. Stock Market starting to look very good to me!” He ignored Navarro’s memo of the previous day and its warning that “there is an increasing probability of a full-blown Covid-19 pandemic that could infect as many as 100 million Americans, with a loss of life of as many as 1-2 million souls.”

Instead, on February 25th, at a news conference in New Delhi during his trip to India, the president haughtily claimed that a vaccine for Covid-19 would soon be available. “Now they have it, they have studied it, they know very much, in fact, we’re very close to a vaccine,” he said confidently.

That same day, in a CDC briefing in Washington, Nancy Messonnier described the situation this way: “Ultimately, we expect we will see [the infected] community spread in this country... [and] disruption to everyday life may be severe. But these are things that people need to start thinking about now.” That led to a staggering 1,031 point fall in the Dow Jones Industrial Average, which infuriated Trump. He promptly urged Larry Kudlow, director of the National Economic Council, to go on television and preach confidence. Accordingly, Kudlow told CNBC, “We have contained this. I won’t say airtight, but it’s pretty close to airtight.”

On his return to Washington on February 26th, Trump replaced Azar as the head of the coronavirus task force with Vice President Mike Pence, and charged him with disseminating positive messages in order to steady a jittery stock market. The next day, the grievance-laden president complained that the media were doing all they could “to make the Caronavirus [sic] look as bad as possible, including panicking markets, if possible.”

Meanwhile, Back in the Middle Kingdom

On February 10th, Chinese President Xi visited a hospital in Beijing where he held a video call with health workers in Wuhan. Coverage of it and his temperature being taken by a doctor filled the front page of the official newspaper, the People’s Daily. By then, Communist Party chiefs in Wuhan and Hubei province had been “replaced” because of their poor initial response to the coronavirus.

In Wuhan, an extra 60,000 hospital beds for Covid-19 patients were created within a month by converting 16 exhibition halls and sports venues into field hospitals and constructing two brand new hospitals as well. On February 23rd, Xi teleconferenced with 170,000 local officials, describing the pandemic as the hardest public-health emergency to contain since the founding of the People's Republic. He noted that the situation remained grim and complex, while Hubei Province and significant parts of the rest of the country (as well as the economy) had been shut down.

The highest priority was given to the production of personal protective equipment. According to an official March 6th press briefing, production of protective clothing had jumped from less than 20,000 pieces daily to 500,000 pieces daily. The output of specialist N95 masks shot up eightfold to 1.6 million and ordinary masks totaled 100 million.

During a trip to Wuhan four days later, Xi praised front-line medical workers, military officers, soldiers, community workers, police officers, officials, and volunteers fighting the pandemic, as well as patients and residents in the locked-down city. The epidemic had by then caused 3,000 deaths. On March 9th, however, daily new cases in Wuhan had already dropped to 19 from thousands a day a month earlier. All the makeshift hospitals were closed. Nonetheless, Xi warned that prevention-and-control work required constant vigilance.

When 114 countries reported coronavirus cases to the World Health Organization on March 11th, it declared the Covid-19 outbreak a global pandemic.

By mid-March, the Chinese government and the Jack Ma Foundation, part of the giant corporate conglomerate Alibaba Group, had sent doctors and medical supplies to Belgium, Cambodia, France, Iran, Iraq, Italy, the Philippines, Serbia, Spain, and the United States. The foundation announced that it would ship “20,000 testing kits, 100,000 masks and 1,000 protective suits and face shields” to every country in Africa and added that Ethiopia’s Prime Minister, Abiy Ahmed, would “take the lead in managing the logistics and distribution of these supplies to other African countries.”

Of the 89 countries that, by March 26th, had received emergency assistance from China to fight the pandemic, 28 were in Asia, 16 in Europe, 26 in Africa, nine in the Americas, and 10 in the South Pacific. Such medical supplies mainly included testing kits, masks, protective suits, thermometer guns, and ventilators. China also invited officials and experts from more than 100 countries to a video conference on Covid-19, while President Xi conducted 26 telephone conversations with 22 foreign leaders, including French President Emmanuel Macron, Saudi King Salman bin Abdul Aziz, Spanish King Felipe VI, Italian Prime Minister Giuseppe Conte, and Donald Trump.

Trump Wakes Up

On March 13th, President Trump declared a national emergency, pledging to dramatically speed up coronavirus testing (which he disastrously failed to do). By then, he had chalked up a remarkable series of false claims and outright lies about the fast-spreading disease. Typically, on a visit to CDC headquarters in Atlanta, Georgia, on March 6th, he had boasted of his “natural ability” to understand the subject of epidemiology.

On March 13th, he falsely announced that a Google website was being developed to help people find places to get Covid-19 tests, something Google’s officials turned out to know nothing about. The next day, he lined up executives from Walmart, Target, CVS, Walgreens, LabCorp, Quest Diagnostics, and Roche Diagnostics, insisting that they would help expedite testing to stop the quick-spreading virus. In fact, little happened and the nation began to shut down. Public schools closed, sports leagues postponed or cut off their seasons, people began working from home in large numbers (as others by the millions simply lost their jobs), and supplies of hand sanitizer, disinfectant wipes, and toilet paper disappeared from store shelves. A month on, very few of the president’s promises had materialized, while the disease had spread dramatically and deaths had begun to soar.

Asked about the shortage of testing kits and sites, which has left America lagging far behind South Korea and other countries in dealing with the still-spreading virus, Trump couldn’t have been clearer. “I don’t take responsibility at all,” he said. And yet, locked into his “Make America Great Again” bubble, until March 6th he blocked an offer from the Jack Ma Foundation to send 500,000 testing kits and one million masks to the U.S. to be distributed by the CDC.

By heeding the WHO’s battle cry of “test, test, test,” South Korea had managed to avoid the kinds of lockdowns implemented by China, many Western European countries, and some American cities. In a desperate phone call to President Moon Jae-in on March 24th, Trump begged him to rush test kits to the United States. In response, Jeong Eun-kyeong, director of the South Korean equivalent of the CDC, agreed, but only at a level that would not diminish his own country’s testing capacity.

Soon after the arrival of 1,000 Chinese ventilators at John F. Kennedy International Airport on April 4th, much to the relief of a grateful Governor Andrew Cuomo, a tweet from Trump read, “USA STRONG!” His boast, however, sounded hollow, given the grim news that, between February 12th and March 11th, the Dow Jones index had dropped around 8,000 points from its historic peak, as national unemployment tripled from a low of 3.5% (with more to come).

To counter this, on April 9th, the Federal Reserve released business lending and other programs worth $2.3 trillion to steady a fast-sinking economy. It had already injected $500 billion dollars into the financial system in March, with plans for a further $1.5 trillion to come.

By March 27th, as the U.S. had gained the global status of number one in coronavirus cases, the president also signed into law the $2.2 trillion Coronavirus Preparedness and Response Supplemental Appropriations Act, passed almost unanimously by Congress, to rush federal assistance to workers and businesses. It included the payment of $1,200 to most taxpayers; enhanced unemployment benefits; a $500 billion lending program for large companies, cities, and states; and a $367 billion fund for small businesses.

Despite all this, the country’s gross domestic product is expected to fall by at least 10.8% in the second quarter of 2020. China’s GDP contraction of 6.8% in the first quarter of the year was a historic drop. However, at 5.9%, the jobless rate in urban areas in March 2020 was down by 0.3% from the previous month.

Passing on the World Leadership Trophy?

The question that many experts on geopolitics are now pondering is this: Have their responses to Covid-19 shifted the balance of power between China and the U.S. in a way that will matter in a post-coronavirus world? Watching the chaos of Trump’s daily press conferences and his administration’s failure to stop the virus effectively proved an alarming reminder that rational people can plan for anything -- except an irrational American president. After all, under his watch 746,459 Americans had contracted Covid-19, and 39,651 had died by mid-April. The comparable figures for China were 82,747 cases and 4,632 deaths.

Nathalie Tocci, an adviser to the European Union’s foreign affairs chief, recently offered a pertinent historical parallel to consider. She cited the 1956 Suez crisis -- Britain’s unsuccessful, if conspiratorial, alliance with France and Israel to militarily topple the nationalist regime of Egypt’s President Gamal Abdul Nasser. It is now considered the sunset moment for Britain’s imperial power. In the present context, she speculated that the Covid-19 pandemic may prove to be a “Suez moment” for the United States.

Ignoring the warnings of scientists and public health experts, President Trump threatens to disastrously extend his coronavirus chronology from hell into an increasingly painful future by “reopening” the country too soon. By so doing, he will only accelerate the day when the World Leadership Trophy, held by America since 1946, is handed to the People’s Republic of China.



Dilip Hiro, a TomDispatch regular, is the author of After Empire: The Birth of a Multipolar World among many other books. His latest book is Cold War in the Islamic World: Saudi Arabia, Iran and the Struggle for Supremacy (Oxford University Press).

Follow TomDispatch on Twitter and join us on Facebook. Check out the newest Dispatch Books, John Feffer’s new dystopian novel (the second in the Splinterlands series) Frostlands, Beverly Gologorsky's novel Every Body Has a Story, and Tom Engelhardt's A Nation Unmade by War, as well as Alfred McCoy's In the Shadows of the American Century: The Rise and Decline of U.S. Global Power and John Dower's The Violent American Century: War and Terror Since World War II.

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The Pandemic Could Put Your Doctor Out of Business Print
Written by <a href="index.php?option=com_comprofiler&task=userProfile&user=54144"><span class="small">Daniel Horn, The Washington Post</span></a>   
Monday, 27 April 2020 08:27

Excerpt: "Primary-care practices were barely eking by. If patients stay away too long, they'll crumble."

Pediatrician Greg Gulbransen makes a telemedicine call with a patient at his practice in Oyster Bay, N.Y., this month. Insurers don't always cover such telehealth work. (photo: Lucas Jackson/Reuters)
Pediatrician Greg Gulbransen makes a telemedicine call with a patient at his practice in Oyster Bay, N.Y., this month. Insurers don't always cover such telehealth work. (photo: Lucas Jackson/Reuters)


The Pandemic Could Put Your Doctor Out of Business

By Daniel Horn, The Washington Post

27 April 20


Primary-care practices were barely eking by. If patients stay away too long, they’ll crumble.

ome coronavirus patients experience a mild fever or never know they were infected. Others crash quickly and unpredictably, five to 12 days after developing symptoms; every doctor on the front lines has been humbled by a patient who is fine in the morning and on a ventilator in the afternoon. To combat this problem, primary-care teams at my hospital are trying something new: calling patients on Days 2, 5 and 8 after we’ve diagnosed them with covid-19 and instructed them to self-isolate at home. We’re looking for signs of an impending crash. We’re also reaching out to our frailest patients and giving them instructions about what to do if they contract the virus.

I made 30 such calls last week to people living alone, struggling with food insecurity or grappling with mental health issues. These were some of the most meaningful conversations of my career. Our primary-care teams have undoubtedly saved many lives with the telephone surveillance, which takes about 30 percent of our doctors’ time and nearly all of our nurses’ time. Primary-care practices across the country are deploying similar programs.

We’re also doing it, apparently, for peanuts. Covid-19 has led to a revolution in telemedicine, but insurance companies will pay only for services that directly replace in-person visits. Our frequent calls don’t do that; a patient wouldn’t come back two days later just to check in. At the same time, our core pre-covid work has evaporated. We ask patients not to come in for preventive or chronic care, for both their safety and — to preserve our protective gear — ours.

That won’t stop us, of course; the heroism I see every day has nothing to do with remuneration. But the pandemic, to say nothing of the looming backlog of deferred medical care, will not retreat quickly, and it doesn’t help patients if primary-care providers go out of business.

I’m lucky to work for a well-funded, nonprofit hospital system, where expensive advanced testing and difficult procedures like bone marrow and heart transplants help subsidize the money-losing work my primary-care peers do to sustain the health of our communities. But these are unsure times even at Mass General: We project a 50 percent loss in patient-care volume over three to four months, which will have a major impact on the $1.2 billion annual revenue our 2,900 physicians bring in. We hope that our infrastructure and assets will help us weather the storm.

Most primary-care doctors in our country don’t have this support system. America began this pandemic with a national primary-care shortage, and without help, they now face existential peril.

Most doctors get paid for each in-person service they provide. In Massachusetts, where I practice, Medicare reimburses us $130 for an annual checkup and $121 for a follow-up visit. Any work done in between those visits does not generate revenue. This model is called fee-for-service, and it was a disaster for primary care long before the coronavirus swept the country.

So much of health care has rapidly changed during this pandemic, but the payment model has not. As a result, while many doctors are performing heroic acts of service, the health-care system nationally is facing a 55 to 70 percent decrease in revenue, thanks to the sudden absence of in-person visits. Nearly half of medical practices say they’ve had to furlough staff, and 22 percent have made permanent layoffs. Those numbers will grow.

At my hospital, we’re fortunate: Officials say we’ll face no salary cuts, changes to our benefits or forced furloughs for at least eight weeks. That’s helpful: This is a time to focus on caring for our patients. And it’s been a wonder to watch. In our respiratory illness clinic, primary-care doctors like me now work alongside orthopedic surgeons and gynecologic oncologists, despite the fact that treating influenza-like illness is way outside their comfort zone. We’ve deployed new delivery models (part of a three-year strategic plan) in just three weeks: Paramedics provide mobile health care at home; intensive care unit clinicians help manage ventilators in community hospitals via video. These changes will remain after the coronavirus is gone.

But a reckoning is coming. If it was a stand-alone business, a high-functioning primary-care network like mine would operate at a net loss of 20 to 30 percent a year, or an average annual cost of $150,000 per physician, according to our internal modeling. That’s partly because we employ diabetes educators, geriatric case managers, social workers and addiction-recovery coaches — health professionals who are essential to the well-being of our patients but whose work is not reimbursed by insurers. We hire those professionals and pay them ourselves.

At a big hospital system, this works, because profit margins elsewhere offset our losses, and our work on population health is seen as central to the mission. But thanks to the pandemic, orthopedic surgeons, dermatologists and gastroenterologists have stopped performing 60 to 80 percent of their hip replacements, biopsies and colonoscopies, according to preliminary volume reports here. These specialists are now working side by side with us on the hospital floor to care for the exploding numbers of coronavirus patients.

Things are even more dire elsewhere. Half of all family medicine physicians work in small practices that aren’t cross-subsidized by other lucrative specialties. Instead, they rely on high volumes and minor procedures. Under normal circumstances, I might see 15 adults per day, while they see 20. At Northampton Area Pediatrics, a 40-year-old primary-care clinic in western Massachusetts, volume has plummeted during the pandemic. “What was a day typically spent seeing upwards of 30-plus kids became seeing anywhere from 8 to 15 children on telemedicine,” says pediatrician Ryan Kearney, who works there. His bosses applied for, but did not receive, a Payroll Protection Program loan. They’ve had to lay off a third of the workforce, including front-desk staff, medical assistants, nurses, a physician and two nurse practitioners. David Steele, the managing partner, worries, “We will never return to the world we had.”

Northampton Area Pediatrics is unfortunately one of many practices that are rapidly shrinking. The American Academy of Family Physicians projects that up to 60,000 primary-care practices may close between now and the end of June. A national survey of more than 2,600 primary-care clinicians conducted April 10-13 by the Primary Care Collaborative found that “financial strain on primary care practices is impacting their ability to keep staff employed and doors open.” Only 47 percent of respondents said they had enough cash on hand to stay open for four more weeks, and 42 percent are furloughing or laying off staff. Some practices I spoke with hope to rehire employees once the economy reopens. But others expect that in-office volumes and uncertainty around telehealth reimbursements won’t keep them viable.

As the point of first contact for most Americans when they are ill, primary care is where the testing and treatment of newly sick coronavirus patients will occur. In other words, the reopening of America will depend in part on a working primary-care infrastructure, and that infrastructure is collapsing.

Providing great care to a population is not about individual face-to-face encounters between a doctor and a patient — the way it is financed today — but is instead a team sport that requires expensive IT and groups of providers working together. As the incoming chief executive of the American Academy of Family Physicians put it: “Primary care is comprehensive, continuous, holistic, portable and patient-centered,” while fee-for-service “is focused on units of care, units of time and sites of service.”

What does holistic care look like during this pandemic? Perhaps the safest way to treat frail elders is to visit their homes. Contact tracers and community health workers may become a part of every patient’s care team. Many more patients will need mental health and addiction treatment than we can currently serve. But the fee-for-service system doesn’t allow for the sort of flexibility and adaptation required to meet these needs.

The good news is that the Center for Medicare and Medicaid Innovation had already devised a 2021 project to move some primary-care practices to a “global budget.” It’s a per-patient per-month payment system that allows doctors to care for a population in whatever ways are necessary. If the government wants primary-care practices to survive, it should roll out that project now, at the biggest scale possible. Commercial insurers and Medicaid will follow.

It is also true that health care in America is too expensive. We spend more than $248 billion a year on an entire industry of billers, coders and IT professionals whose purpose is to resolve the friction between insurance companies and physicians in the payment of bills. No other country organizes payment like this, and the waste is astounding. Global budgets will help eliminate this waste. For remaining fee-for-service care, the government could require health systems and insurance companies to adjudicate bills while patients are still in the office. Insurers would transmit the money the same way you pay Starbucks for your coffee — at the time you receive your service. These changes could easily fund the kind of patient care that would support a thriving population in good times or during a pandemic.

Finally, saving primary care won’t matter much if Americans don’t have ready access to health insurance. The ranks of the uninsured are now soaring. The only chance for many unemployed people to have coverage is through an expanded public option.

It has been heartwarming to see our nation recognize health-care workers as the heroes they are. At the same time, those workers are contending with profound insecurity surrounding their work — both the availability of basic gear and the stability of their employers. We are weathering these challenges with bravery and idealism. It would help to know that our faith will be rewarded with a more rational system.

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Imagine Running Public Relations for Lysol Right Now Print
Written by <a href="index.php?option=com_comprofiler&task=userProfile&user=11104"><span class="small">Charles Pierce, Esquire</span></a>   
Sunday, 26 April 2020 13:42

Pierce writes: "One of the mental exercises I do to stay relatively sane in this strange, aquarium-like existence we're all living these days is to put myself in the place of someone else."

Reckitt Benckiser, the British company that makes Lysol and Dettol, warned customers on Friday against using disinfectants as treatments. (photo: Jeffrey Greenberg/Universal Images Group/Getty Images)
Reckitt Benckiser, the British company that makes Lysol and Dettol, warned customers on Friday against using disinfectants as treatments. (photo: Jeffrey Greenberg/Universal Images Group/Getty Images)


Imagine Running Public Relations for Lysol Right Now

By Charles Pierce, Esquire

26 April 20


On Thursday's edition of the Five O'Clock Follies, the president* was one step away from telling Dr. Birx to find a virgin to throw in the volcano.

ne of the mental exercises I do to stay relatively sane in this strange, aquarium-like existence we’re all living these days is to put myself in the place of someone else. For example, on Friday morning, I imagined myself working in the corporate communications office of Reckett Benckiser, the British-based company that manufactures Lysol.

Working from home, you come into your kitchen. You put down your coffee and your morning copy of the Times of London, and switch on your computer to check your email. There’s one there right at the top of the queue marked, “URGENT,” and it’s from the executive board of the company. Concerned, you open the email, read it twice (because you didn’t believe it the first time), and then set yourself to the task of doing what your bosses want you to do. An hour or so later, the company shares the statement you’ve written with the world, and with NBC News.

"As a global leader in health and hygiene products, we must be clear that under no circumstance should our disinfectant products be administered into the human body (through injection, ingestion or any other route). As with all products, our disinfectant and hygiene products should only be used as intended and in line with usage guidelines. Please read the label and safety information.”

Then, you type up your resignation and move to a sheep farm in the Orkney Islands.

This company felt obligated to issue this statement because the President* of the United States said the following at Thursday’s episode of the Five O’Clock Follies.

"The disinfectant, where it knocks it out in a minute, and is there a way we can do something like that by injection inside, or almost a cleaning. It gets in the lungs.”

And this was after the Quack-in-Chief had said this:

“Supposing we hit the body with tremendous, ultra-violet or just very powerful light? Supposing you brought the light inside the body, either through the skin, or some other way?”

This spasm of thought-like activity was occasioned by a report delivered by Bill Bryan, the head of the science and technology division of the Department of Homeland Security. Bryan mentioned that, yes, disinfectants like Lysol are effective in killing the coronavirus on things like playground equipment, handrails, and doorknobs. Bryan also reported that the virus seems to die in bright sunlight and in warmer and more humid weather.

(Fans of the original Star Trek will recognize the latter solution as the same one that wiped out the vampiric rubber splatter aliens on the planet Deneva in “Operation: Annihilate.”)

Then, with every spark gap in his mighty brain sizzling and cracking, the president* launched into the above improv while, over on the sidelines, Dr. Deborah Birx suddenly found herself in a thousand memes, looking as though she’d been hit on the head with a polo mallet. El Caudillo del Mar-a-Lago was really rolling, folks. He was one step away from advising Birx to go out and find a virgin to toss into a volcano.

Dear America,

Lysol should not be taken internally. Also, half-mad, malignant television personalities should not be elected president.

God help us all.

Sincerely,

The Management

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Trump Set to Fall Back on Xenophobia With Re-Election Plan in Tatters Print
Written by <a href="index.php?option=com_comprofiler&task=userProfile&user=51571"><span class="small">David Smith, Guardian UK</span></a>   
Sunday, 26 April 2020 13:42

Smith writes: "Donald Trump had been intending to run a re-election campaign based on a strong economy and a socialist opponent. Both have vanished in the past month. But the US president still has his ultimate weapon: xenophobia."

'This is a president who doesn't use the dog whistle of Republicans in the past,' said one Latino civil rights campaigner. 'This guy talks about it openly.' (photo: Win McNamee/Getty Images)
'This is a president who doesn't use the dog whistle of Republicans in the past,' said one Latino civil rights campaigner. 'This guy talks about it openly.' (photo: Win McNamee/Getty Images)


Trump Set to Fall Back on Xenophobia With Re-Election Plan in Tatters

By David Smith, Guardian UK

26 April 20


The president had been intending to campaign on a strong economy and facing a socialist opponent but scapegoating foreigners has worked for him before

onald Trump had been intending to run a re-election campaign based on a strong economy and a socialist opponent. Both have vanished in the past month. But the US president still has his ultimate weapon: xenophobia.

Trump this week announced in a late-night tweet that he would “temporarily suspend immigration” into America. Two days later, when he signed an executive order, it only applied to people seeking green cards to move to the country permanently, not to temporary workers, and there were plenty of loopholes.

But by then the headlines had been written, the outrage expressed and the objective achieved: Trump was cracking down on immigration again because, he claimed, he was putting America and its workers first. The exercise was arguably less about policy than politics.

A nativist, populist message helped him win the presidency in 2016. He tried it again in the 2018 midterm elections for Congress with mixed results. Now, with his handling of a deadly pandemic under scrutiny and the economy in freefall, critics say he is ready to bet the White House on his ability to stir nationalist and racist sentiment with little subtlety.

“This is a president who doesn’t use the dog whistle of Republicans in the past, and even Democrats in the past who used dog whistle politics to talk about race in code,” said Juan Cartagena, president and general counsel of Latino Justice, a civil rights organisation. “This guy talks about it openly. Under normal circumstances he would have been a one-term president, but his base is pretty loyal and we’re still talking about a country that barely comes out in large turnout numbers.”

Apart from antipathy towards globalised trade, Trump is said to be a man of few core political beliefs and little ideology. But when he descended an escalator at Trump Tower in New York in June 2015 to declare his long-shot candidacy for president, he started as he meant to go on. Mexico, he complained, was not sending its best people across the border. “They’re bringing drugs. They’re bringing crime. They’re rapists.”

Trump also announced his signature issue: “I would build a great wall, and nobody builds walls better than me, believe me, and I’ll build them very inexpensively, I will build a great, great wall on our southern border. And I will have Mexico pay for that wall.”

There followed an incendiary, taboo-busting election campaign in which “Build that wall!” became a familiar chant at Trump rallies, where he railed against the presidency of Barack Obama and threw red meat to his base. He lashed out at a judge of Mexican ancestry and a Muslim whose son died fighting for the US in Iraq. He threatened to ban Muslims from the country. He promised “America first”. And he won.

Two years later, campaigning on behalf of senators and representatives, Trump used rallies to stoke fears that “caravans” of undocumented immigrants from Guatemala, Honduras and El Salvador were set to pour into the US from Mexico. To the frustration of Republicans who wanted him to focus on economic achievements, he used vivid language to demonise criminal gangs and human traffickers and put victims’ families on public display.

This time, the strategy was only partially successful: Republicans expanded their majority in the Senate but lost 40 seats in the House of Representatives, where the new Democratic majority went on to impeach Trump.

Early in 2020, the Trump re-election campaign appeared to be built on firm foundations. There were economic talking points – unemployment at its lowest for half a century, the stock market at record highs – even if it did not always feel that way on the ground. Meanwhile, Senator Bernie Sanders, a democratic socialist, was leading the Democratic presidential primary race, prompting Trump and allies to warn darkly of the radical left.

These scripts have been torn up. The coronavirus pandemic has killed about 50,000 Americans and is likely to surpass US losses in the entire Vietnam war. Since the outbreak also put the economy into a coma: at least 26 million people have requested unemployment benefits, wiping out all the job gains since the great recession of 2008.

Rick Wilson, a political strategist and author of Running Against the Devil, an analysis of how the 2020 election could play out, said: “The predicates of Donald Trump’s campaign were fundamentally: ‘The economy is great and I made the economy great and also, by the way, this is my great economy. Have you noticed my great economy?’ That’s gone. If you claim you have sole control and credit for something, then when it goes wrong, the shoe gets placed on the other foot rather quickly, and it has.”

In the Democratic primary, meanwhile, Sanders quickly fell away against former vice-president Joe Biden, a moderate who served under Obama and will be much harder to caricature as a socialist menace.

Short of ammunition, his record in tatters, Trump can still fall back on the politics of division and made-for-TV partisan outrage. His daily White House coronavirus taskforce briefings have become a substitute for campaign rallies and regularly include progress reports on the border wall. The executive order on immigration, probably bearing the fingerprints of senior adviser Stephen Miller, was billed as a way to ensure that American workers take priority over foreigners in any economic recovery.

It has struck a chord with some of Trump’s supporters. Douglas Collins, 86, a neurologist from Pensacola, Florida, said: “We’ve got to get the economy up and running, and people who live pay cheque to pay cheque and are American have to be the first consideration. Is prejudice a major factor? I don’t think so.”

Doug Peltier, 69, from Forest Lake, Minnesota, said: “It’s a valid position to be concerned about the economy and immigrants coming and taking jobs from Americans. I’m not a bigot, I’m not against immigrants, I have a great deal of respect for Mexicans and blacks. I do believe Americans should come first. I guess you could call me a nationalist.”

Peltier, a retired school administrator who attended a Trump rally in Minneapolis last year, added: “I think Trump has more support than a lot of people believe. We don’t boast; we tend to be more silent. I would never put a Donald Trump sticker on my car because I know it would get keyed.”

But opponents see something else: a president whose world collapsed around him, suddenly flailing in strange surroundings and grabbing on to a familiar lifeline. Wilson, the political strategist, argues that bigotry, hatred and prejudice “aren’t a bug of the Trump program – those are a feature.

“He will pursue what he looks at as something that was highly effective for him in the last campaign and that is a racially and ethnically inflected campaign that tries to tell Republican voters in particular that all of their problems and concerns and issues come from the brown people.”

Already Trump and Republican allies have hardened their line on China, fuelling a theory that the coronavirus might have accidentally escaped a laboratory in Wuhan and condemning the country for not raising the alarm earlier. They hope to couple this with an attack on Biden, dubbing him “Beijing Biden” and claiming he had a cosy relationship with China in the past.

Wilson, who is co-founder of the Lincoln Project, a political action committee aiming to prevent Trump’s re-election, added: “What you will absolutely see this fall is that Donald Trump will come out and he will make up a story and it will be something like, ‘There’s boats full of diseased Chinamen coming our way, bar the door’.”

Democrats are braced for another bitter fight with a president who looks certain to lose the popular vote again but hopes to squeeze by in a few battleground states that decide the electoral college.

Neil Sroka, communications director for the progressive group Democracy for America, added: “What we should expect in 2020 is, because of the economic implosion, because of his massive mishandling of this crisis, he will pursue a xenophobic campaign that makes the 2016 effort look like patty cake.”

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FOCUS: Did John Bolton Outfox Himself on His Own Tell-All Book? Print
Written by <a href="index.php?option=com_comprofiler&task=userProfile&user=51459"><span class="small">Jeffrey Toobin, The New Yorker</span></a>   
Sunday, 26 April 2020 10:45

Toobin writes: "During the impeachment investigation, John Bolton, President Trump's onetime national-security adviser, played a cagey game with Congress."

John Bolton. (photo: Jose Luis Magana/AP)
John Bolton. (photo: Jose Luis Magana/AP)


Did John Bolton Outfox Himself on His Own Tell-All Book?

By Jeffrey Toobin, The New Yorker

26 April 20

 

uring the impeachment investigation, John Bolton, President Trump’s onetime national-security adviser, played a cagey game with Congress. He dropped hints suggesting that he knew a great deal about the President’s dealings with Ukraine—information that would have been highly relevant to the investigation. He also had a big deal with Simon & Schuster for a tell-all about his time in the Trump Administration, and the book had a tantalizing title: “The Room Where It Happened: A White House Memoir.” Bolton dodged testifying before either the House or the Senate, thus preserving his news-making disclosures for the book-buying public.

But Bolton may have outfoxed himself. Like anyone with access to classified information, he signed a prepublication-review agreement. Each government agency that allowed Bolton access to its information—and, in the case of a national-security adviser, that would have been virtually all of them—has the right to review his manuscript and to excise purportedly improper disclosures. Bolton left the government on bad terms with Trump, and it looks like the Administration may be taking revenge through the review process. Charles Cooper, Bolton’s lawyer, has already complained about how the Administration is delaying and revising Bolton’s book, and his publication date has already slipped from March to May. But there’s no guarantee that the review process will even be finished by May, either. (Cooper and a spokeswoman for Simon & Schuster declined to comment.)

House investigators asked Bolton to testify last year, but he said he would do so only if a court ordered him to. The Democrats leading the probe declined to enter into lengthy court battles with witnesses, so the House voted for impeachment without hearing his testimony. At the last moment, Bolton said that he would comply with a subpoena to testify before the Senate trial, but the Republican majority refused to call any witnesses. So Bolton made it through the Ukraine investigation without having to reveal what was in his book. Still, if he had testified, most of his story would already be out in the open, and the Administration would have no grounds to claim that it was still classified since he had already revealed it in testimony to Congress. In other words, by ducking public testimony, Bolton protected the commercial value of his book, but he left himself at the mercy of the prepublication-review process. That may turn out to have been a bad bet.

The key legal precedent involving prepublication-review agreements involves the book “Decent Interval,” by Frank Snepp, who was a strategy analyst for the C.I.A. at the U.S. Embassy in Saigon when that city fell to the North Vietnamese. Snepp had signed a contract allowing the agency to review any of his books for classified information prior to their release, but in 1977 he went ahead and published “Decent Interval,” a devastating critique of the agency’s handling of the end of the war, without doing so. In 1980, the Supreme Court ruled that the government could not withdraw Snepp’s book from circulation, but it could impose a “constructive trust” on his earnings from the book. The Snepp case established the law as it remains today. If you publish a book in violation of a prepublication-review agreement, even if it turns out that the book includes no improper disclosures, the government will take your publisher’s advance and any other revenue you earn from the book. (For example, the government has sought to obtain Edward Snowden’s book revenues, because he, too, failed to comply with a prepublication-review agreement.)

I have firsthand experience with this rule. From 1987 to 1990, I worked as a prosecutor in the Iran-Contra investigation, a complicated scandal involving the secret sale of American weapons to the government of Iran, and the use of the proceeds to help anti-Sandinista rebels in Nicaragua. I signed two prepublication-review agreements: one with the C.I.A. and one with my boss, Lawrence Walsh, the independent counsel. When I wrote a book about my experiences, I submitted it to both the agency and Walsh for review. The C.I.A. promptly approved it, without any changes, but Walsh refused to either approve or disapprove the manuscript. If I had gone ahead and published without his approval, I risked the loss of my advance and future earnings from the book. So Penguin Books, my publisher, and I, who were represented by Robert Baron , Aaron Marcu, and Martin Garbus, sued Walsh in federal court in New York for a declaratory judgment that we had a right to publish. Judge John Keenan ruled in our favor, finding that I made no improper disclosures, and my book, “Opening Arguments: A Young Lawyer’s First Case—United States v. Oliver North,” was published in 1991. (Here is a good primer on prepublication-review agreements. )

Bolton now faces a similar dilemma. He can publish the book with the redactions which have apparently been demanded by the Trump Administration. Some books by former government employees have been published with whole sections blacked out. Alternatively, he can do what I did: go to court and challenge the Trump Administration’s treatment of the book as unreasonable. This is a tough road, because most judges defer to executive-branch officials about what’s classified, and court cases take months, if not years, to be resolved.

Bolton may yet resolve his dispute with the Administration and publish a largely unredacted book next month. And it may also turn out that it would have been better for Bolton’s reputation, and for the public interest, for him to have done his civic duty and testified before Congress in the first place.

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