The fiasco with the initial opening of the exchanges at healthcare.gov has become a well-known IT glitch from the Obama administration, but that might not turn out to be their biggest mistake regarding computers and health care. As it primarily involves physicians and hospitals, as opposed to the general public, far fewer people are aware with the ongoing problems regarding implementation of Meaningful Use Stage 2 requirements for electronic medical records.
The original stimulus package after Barack Obama took office included a program to provide funds to medical practices to be used for conversion to electronic medical records. In order to qualify for the incentive payments, physicians and hospitals have to follow a set of Meaningful Use requirements which have increased requirements for each stage. Initially there would be incentive payments (which turned out to be far less than the costs of conversion to electronic medical records), and subsequently there are penalties for failing to comply. The first stage was successful in terms of getting large numbers of doctors to adopt electronic medical records, but it is more questionable as to whether this is really resulting in the desired cost savings.
Stage 2 was initially required by October 2014. This would have greatly increased the use of electronic medical records, possibly resulting in more medical cost savings, but the requirements were unrealistic. The law originally required that physicians comply with the requirements of Stage 2 for a 90 day period in 2014, which essentially meant that we could wait until October 1 to implement them. When it was apparent that most physicians could not comply with this, the government postponed this until January 2015.
It was quickly apparent that this was no solution, partially as the new requirements required a full twelve months of compliance with the Stage 2 rules. By requiring compliance by this January, this only gave an additional three months. The same problems which prevented compliance with the rules by October 2014 are still present this January.
The biggest obstacle is that the rules require communication between systems which do not exist in the present software. Before making such requirements, the government should have set up a secure system for communication between computer systems rather than hoping that each individual vendor would offer a solution. Another problem is that the requirements include factors which are outside of a medical office’s control. For example, a medical office could set up a patient portal as required in order for patients to assess medical information. However, there are requirements not only to establish this, but for five percent of patients to utilize it. Many physicians, such as those with primarily elderly patients are especially concerned that not enough will even be interested in using such computerized tools. Fortunately this requirement was at least reduced from ten percent in the original regulations to five percent.
Compliance with the rules is further complicated by it being all or nothing. A medical office might follow 90 percent of the rules but will get zero incentive money and pay the full penalties for non-compliance. There are some exclusions and some flexibility in some areas, but this still creates far too great a burden on physician practices.
When the government first changed the rules last fall delaying the requirements for Stage 2 until January, some members of Congress did realize that this was not long enough to have any impact. There was a bipartisan bill introduced to reduce the requirements for a 90 day period in 2015, essentially giving physicians until October instead of January. This was not introduced until shortly before Congress went on recess prior to the election, and died before the end of the last session. Earlier this month Renee Ellmers (R-N.C.) and Ron Kind (D- Wis.) introduced The Flexibility in Health IT Reporting (Flex-IT) Act of 2015 to restore the 90 day requirement. The bill also has the support of organizations including the American Academy of Family Physicians, American Hospital Association, American Medical Association, College of Healthcare Information Management Executives and Medical Group Management Association.
Even this only postpones the problem and we don’t know if the technology will be any better this fall than it is now. A recent survey of physicians found that 55 percent do not plan to attest to Stage 2, despite the financial penalties.
This failure in the implementation of computerized medical records could be a far worse fiasco than the initial roll out of the exchanges under the Affordable Care Act. The manner in which the Obama administration quickly fixed that problem turned out to be a tremendous success, and this problem is also fixable. A real fix will take more than just postponing requirements.
The government must rethink the logic behind the requirements. Most industries have computerized on their own without being forced to by the government. Some government assistance in conversion to electronic medical records would be helpful, such as establishing standards for communication between systems. Physicians must also be given flexibility to determine for ourselves which aspects of computerization are really of value for caring for our patients and which are not, rather than being forced to follow a long set of rules and only receive credit for 100 percent compliance, or being dependent on factors beyond our control.
Conservatives used Ebola as one means of spreading fear, helping them in the 2014 midterm elections. PoltiFact has now made exaggerations about Ebola their 2014 Lie of the Year. This includes both conservative hysteria which greatly exaggerated the threat faced in a developed nation such as the United States and many of the right wing conspiracy theories. I have already discussed many of these false claims, often in the context of debunking right wing attempts to restrict civil liberties while ignoring the science. From PoltiFact:
Thomas Eric Duncan left Monrovia, Liberia, on Sept. 19, for Dallas. Eleven days later, doctors diagnosed Duncan with Ebola.
Eight days after that, he was dead.
Duncan’s case is just one of two Ebola-related fatalities in the United States, and since Duncan traveled to Dallas, more Americans — at least nine, and likely many more — have died from the flu.
Yet fear of the disease stretched to every corner of America this fall, stoked by exaggerated claims from politicians and pundits. They said Ebola was easy to catch, that illegal immigrants may be carrying the virus across the southern border, that it was all part of a government or corporate conspiracy.
The claims — all wrong — distorted the debate about a serious public health issue. Together, they earn our Lie of the Year for 2014…
Fox News analyst George Will claimed Ebola could be spread into the general population through a sneeze or a cough, saying the conventional wisdom that Ebola spreads only through direct contact with bodily fluids was wrong.
“The problem is the original assumption, said with great certitude if not certainty, was that you need to have direct contact, meaning with bodily fluids from someone, because it’s not airborne,” Will said. “There are doctors who are saying that in a sneeze or some cough, some of the airborne particles can be infectious.” False.
U.S. Sen. Rand Paul, R-Ky., described Ebola as “incredibly contagious,” “very transmissible” and “easy to catch.” Mostly False.
Internet conspirators claimed President Obama intended to detain people who had signs of illness. Pants on Fire. Bloggers also said the outbreak was started in a bioweapons lab funded by George Soros and Bill Gates. Pants on Fire.
A Georgia congressman claimed there were reports of people carrying diseases including Ebola across the southern border. Pants on Fire. Sen. John McCain, R-Ariz., said Americans were told the country would be Ebola-free. False.
When combined, the claims edged the nation toward panic. Governors fought Washington over the federal response. The Centers for Disease Control and Prevention stumbled to explain details about transmission of the virus and its own prevention measures. American universities turned away people from Africa, whether they were near the outbreak or not.
The post went on to discuss the actual medical facts.
Not surprisingly the misinformation came from many of the usual subjects such as Fox and Republicans such as John McCain and Rand Paul. Their conspiracies theories also involved the usual subjects of right wing attacks like Barack Obama and George Soros.
At least one good thing did come about from the Ebola hysteria. Republicans, with the help of the NRA, had blocked the appointment of Vivek Murthy for Surgeon General for months. The Ebola outbreak placed increased attention on this vacancy and he was finally confirmed by the Senate today.
The politicization of Ebola has demonstrated the usual divisions between left and right in this country. As on so many other issues, the right wing has rejected scientific findings, distorted scientific information which conflicted with their political goals, and ignored the rights of the individual. This also provides another example of the emptiness of Republican claims of wanting to keep government out of health care decisions.
While the media has concentrated on a small number of people who have returned from West Africa, Médecins Sans Frontières (Doctors Without Borders) has had a staff of over 3300. Of these 3300 MSF staffers, only 23 have contracted Ebola. The staff includes over 700 who came to West Africa from other nations with only one developing symptoms of Ebola after he returned home.The one doctor who did return to New York subsequently followed protocols for continued monitoring and was hospitalized prior to spreading the infection to anyone else.
With these odds, there is no justification in assuming that Hickox, or any other medical worker, is infected with Ebola merely due to having worked in the affected nations. People who are infected have a very low viral load early and do not spread the disease until after they exhibit symptoms, which Hickox has not done. It is becoming increasingly unlikely that she will. While a twenty-one incubation period is commonly cited by the media, and should be used as a precaution, in reality the vast majority of patients exhibit symptoms in six to twelve days. Monitoring for twenty-one days provides an ample additional margin of safety to the public.
While some Republicans have played politics with the issue and, as happens far too often, some Democrats such as Andrew Cuomo initially acquiesced in fear, the guidelines from the CDC and precautions already in effect are sufficient to protect the public and, to err on the side of safety, call for greater restrictions than are necessary based upon the science. There is no need for politicians to go beyond these precautions and unjustly restrict the civil liberties of Americans. The monitoring protocols already in place from Doctors Without Borders can be seen here.
In response to the controversy engendered by those who have been ignoring the science, the American Nurses Association released this statement on October 29:
The American Nurses Association (ANA) opposes the mandatory quarantine of health care professionals who return to the United States from West African nations where Ebola is widespread. ANA supports registered nurse Kaci Hickox, who recently returned to the United States after treating Ebola patients in Sierra Leone, in her challenge of a 21-day quarantine imposed by state officials in Maine, her home state. Hickox arrived at Newark airport on Oct. 24 and was immediately quarantined in a hospital tent by New Jersey state officials, who eventually allowed her to travel to Maine via private transport on Oct. 27. After testing negative twice for Ebola, nurse Hickox, who continues to be symptom free, poses no public threat yet is restricted to her home.
ANA, along with the American Hospital Association and American Medical Association, supports the Centers for Disease Control and Prevention’s (CDC) guidance based on the best available scientific evidence. The CDC guidance would not require a mandatory 21-day quarantine of Hickox given risk levels outlined by the CDC in her particular case. ANA urges authorities to refrain from imposing more restrictive conditions than indicated in the CDC guidelines, which will only raise the level of fear and misinformation that currently exists.
ANA supports a policy of appropriate monitoring for health care workers who have cared for or been in contact with patients with Ebola. Those who are not exhibiting symptoms of illness consistent with Ebola do not require quarantine. Monitoring should follow recommendations outlined by the CDC based on risk levels and the presence or absence of symptoms, including regular monitoring of body temperature and oversight by a public health agency. If symptoms do occur, the appropriate next step is isolation and transport to a medical facility for further evaluation. ANA seeks to balance protection of public health and safety with individual liberties. Policies to protect the public from the transmission of Ebola must be based on evidence and science, not fear.
Mandatory quarantine for individuals who do not have symptoms or risk factors is not backed by science. Such actions undermine efforts to recruit sufficient numbers of volunteer nurses and other health care professionals, who are essential to help contain the spread of the disease in West Africa.
ANA’s position emphasizing evidence and science as the foundation for decision-making extends to proposals to ban travel to the United States from West African nations affected by the Ebola outbreak. There is no evidence to suggest that a travel ban would be effective; public health experts oppose it. In fact, a ban could be counterproductive, encouraging individuals to try to circumvent reporting and other systems. ANA supports the current requirement that those traveling to the U.S. from affected nations in West Africa, including health care professionals who have provided care to Ebola patients, once they have passed initial screening, engage in monitoring according to CDC guidelines and reporting to their respective public health agencies.”
Louisiana health officials say that anyone who’s been in an Ebola-affected country over the last three weeks will be quarantined in their hotel rooms.
The American Society of Tropical Medicine and Hygiene is telling researchers who’ve recently traveled to Ebola-affected parts of West Africa that they can’t come to the society’s annual meeting. That wasn’t the medical group’s idea.
The convention opens this weekend at the New Orleans Sheraton, but the specialists with the most current experience with Ebola in the field aren’t expected to be there.
The Louisiana Department of Health and Hospitals just ruled that anyone who’s been in Sierra Leone, Liberia or Guinea in the past three weeks “should NOT travel to New Orleans to attend the conference.” (That big “NOT” is in the original letter.)
“While the state of Louisiana’s policies are outside of the scientific understanding of Ebola transmission — and acknowledged by the state health officials’ own admission — we recognize that the state has determined its policy in this matter,” the society said in a statement. “ASTMH does not agree with the policy as outlined by the Louisiana DHH…
Dr. Piero Olliaro had big plans for the conference.
“This is the place to be,” says Olliaro, a researcher at Oxford University who specializes in setting up clinical trials to test drugs in the developing world. “It’s once a year. This is where you get to meet all the others.”
Olliaro was going to present several papers on his recent work involving treatments for malaria and river blindness. But two weeks ago he was in Guinea for the World Health Organization scouting a site to test an experimental Ebola medication.
Yesterday Olliaro got a letter from the Louisiana health department saying that anyone who’d been in Sierra Leone, Liberia or Guinea in the past 21 days would be quarantined…
Olliaro, who’s in England, says the decision is unfair, unwarranted and not based on medical science. But he’ll abide by it…
Olliaro says the problem is much larger than just this one convention. The world’s leading tropical disease researchers often fly back and forth from Africa to their labs in the United States.
The new patchwork of Ebola-related travel bans and quarantine policies, he says, make it unclear whether they’ll be able to continue to do that. And that could ultimately undermine research into a vaccine or cure for this terrifying viral disease.
Kaci Hickox is a hero. First for volunteering to help treat Ebola patients, as eradicating Ebola in West Africa is the only way to handle this disease. She became a hero again for standing up to unjust restrictions upon her civil liberties upon returning home and supporting the concept of making political decisions based upon science and reason as opposed to giving in to public hysteria.
It was Hickox’s protests which forced Governors Christie and Cuomo to back away from guidelines policies which were both unnecessary and counterproductive. Some state governments are still going beyond the extremely cautious CDC guidelines with policies such as home quarantine of individuals who show no sign of the disease for twenty-one days. We know that this is unnecessary based both upon our knowledge of how the Ebola virus is transmitted and based upon our experience to date. Ebola is not contagious early in the disease and is not transmitted by casual contact. While highly contagious when people are having symptoms such as projectile vomiting and uncontrolled diarrhea, those who do not have symptoms are not contagious. People with Ebola do not yet pose a danger of spreading the disease when they initially reach the CDC’s threshold of a fever of 101.4 degrees, and they certainly are not contagious before reaching this point.
We have seen one patient in Texas be released in error by an Emergency Room and return to the community. We have seen a nurse later revealed to be infected with Ebola fly with a low grade fever. We have had a doctor traveling around a city as densely populated as New York City just prior to meeting criteria for isolation. Not a single person has contracted Ebola due to contact with these individuals. That is the nature of the disease.
“I will go to court to attain my freedom,” Hickox told “Good Morning America” today via Skype from her hometown of Fort Kent, Maine. “I have been completely asymptomatic since I’ve been here. I feel absolutely great.”
One of her attorney’s explained her legal position:
New York civil rights lawyer Norman Siegel, said she would contest any potential court order requiring her quarantine at home.
“The conditions that the state of Maine is now requiring Kaci to comply with are unconstitutional and illegal and there is no justification for the state of Maine to infringe on her liberty,” he said.
Hickox will abide by daily monitoring, as recommended the by updated guidelines released Monday by the federal Centers for Disease Control and Prevention, Hyman said. She has been in regular contact with state health officials, Siegel said.
U.S. CDC Director Tom Frieden called for isolation of people at the highest risk for Ebola infection but said most medical workers returning from the three African nations at the center of the epidemic — Sierra Leone, Liberia and Guinea — would require daily monitoring without isolation.
The new guidelines recommend considering isolation only for individuals exposed to Ebola who show symptoms. Those with no signs of illness should be monitored for 21 days after the last potential exposure, with symptom-free individuals at the highest risk subject to “restricted movement within the community” and no travel on public transportation, according to the guidelines…
“She understands the nature of the disease, she treated it,” Hyman said. “She understands the nature of the risk.”
The American Civil Liberties Union has posted an article on the over-reaction to Ebola coming from some politicians, in contrast to the more rational guidelines proposed by the Center for Disease Control and the Obama administration:
One over-reaction to the disease that has emerged is a proposal for a blanket travel ban from the affected countries in West Africa. Public health experts say that such bans are not necessary, would not be effective, and would be a poor use of resources. Worse still, experts say they would most likely make matters worse by further isolating the countries where the outbreak is taking place, worsening the situation in those countries and therefore the threat to the United States. Travel bans “hinder relief and response efforts risking further international spread,” as the World Health Organization warned. Experts say such bans would also inevitably drive travelers underground, making it difficult to retrace the path of a disease when a case does appear.
Proposals to close the border to all travelers from affected nations are not a scientifically and medically legitimate exercise of government power and therefore would be arbitrary and discriminatory whether applied to citizens or non-citizens.
Now, of course, we are also seeing the questionable use of quarantine powers in some states. Medical experts have opposed such steps given that Ebola is not transmissible until after a fever begins and is not a highly transmissible disease generally, and given that individuals have strong incentives to carefully monitor themselves. Doctors Without Borders, for example, has condemned these quarantines as a threat to its battle against the disease in Africa. It cites the effect the quarantines will have in deterring doctors and nurses from taking the already remarkably brave step of entering the fight against the disease—and in stigmatizing them when they do. In short such quarantines threaten to weaken the most effective weapon we have in stopping the disease at its source. (It’s also shameful to treat returning health care workers, who have put their own lives at risk to help others, as anything less than heroes.)
Where individuals cooperate with the authorities in allowing close monitoring of their health and other reasonable precautions, the imposition of quarantines on those without symptoms appears to be driven by politics rather than science, and therefore raises serious civil liberties concerns.
While some political leaders have acted out of fear, Obama Administration officials deserve praise for largely sticking to science and not caving in to some of the fear mongering that is swirling around them. The White House has prioritized medicine over politics. It has resisted calls for travel bans, tried to persuade the governors of New Jersey and New York to reconsider their quarantines, and has largely followed the advice of public health experts in the recommendations that they have made. The Administration has also taken helpful steps such as expediting emergency FDA authorization for the use of new machines for rapid detection of the Ebola virus—which could allow detection of the disease before symptoms appear.
In fact, the Obama Administration has a history of good policy on communicable diseases. As we described in a 2009 white paper on that year’s H1N1 flu scare, the Administration acted calmly and appropriately in response to that epidemic, and overall, President Obama has turned away from his predecessor’s military/law enforcement approach to fighting disease, which we criticized in detail in our 2008 report on pandemic preparedness.
While the outbreak of Ebola began in West Africa about ten months ago, we have now had only nine patients with Ebola in this country. Most were brought in for treatment after contracting it elsewhere. One is currently undergoing treatment. One died. All the rest have recovered. There have been zero cases of transmission in the general population but two nurses have become infected while treating the patient who died.
There is a remarkable amount of hysteria in this country for a disease which has had so little actual impact. Some of this is natural fear, seeing how less developed nations have been affected, and some is due to hysteria being generated by Republican politicians for political gain. Unfortunately the proposals made by Republicans would be counterproductive, making it harder to treat Ebola at its source. Eliminating Ebola in West Africa is the only way to eliminate the problem and prevent further spread.
This is also turning out to be a learning experience, at least for those who respect science and are willing to consider the facts. In terms of treatment, hospitals around the country have learned from the mistakes made in Texas, and these are not likley to be repeated.
In terms of the political reaction, there are many sources which are trying to counter the over-reaction with reason. As we have seen on so many issues, some will pay attention to the facts, and others won’t.
The governors of a number of states, including New York and New Jersey, recently imposed 21-day quarantines on health care workers returning to the United States from regions of the world where they may have cared for patients with Ebola virus disease. We understand their motivation for this policy — to protect the citizens of their states from contracting this often-fatal illness. This approach, however, is not scientifically based, is unfair and unwise, and will impede essential efforts to stop these awful outbreaks of Ebola disease at their source, which is the only satisfactory goal. The governors’ action is like driving a carpet tack with a sledgehammer: it gets the job done but overall is more destructive than beneficial.
Health care professionals treating patients with this illness have learned that transmission arises from contact with bodily fluids of a person who is symptomatic — that is, has a fever, vomiting, diarrhea, and malaise. We have very strong reason to believe that transmission occurs when the viral load in bodily fluids is high, on the order of millions of virions per microliter. This recognition has led to the dictum that an asymptomatic person is not contagious; field experience in West Africa has shown that conclusion to be valid. Therefore, an asymptomatic health care worker returning from treating patients with Ebola, even if he or she were infected, would not be contagious. Furthermore, we now know that fever precedes the contagious stage, allowing workers who are unknowingly infected to identify themselves before they become a threat to their community. This understanding is based on more than clinical observation: the sensitive blood polymerase-chain-reaction (PCR) test for Ebola is often negative on the day when fever or other symptoms begin and only becomes reliably positive 2 to 3 days after symptom onset. This point is supported by the fact that of the nurses caring for Thomas Eric Duncan, the man who died from Ebola virus disease in Texas in October, only those who cared for him at the end of his life, when the number of virions he was shedding was likely to be very high, became infected. Notably, Duncan’s family members who were living in the same household for days as he was at the start of his illness did not become infected…
The American College of Physicians is strongly concerned about the approach being taken by some state health departments to impose strict, mandatory quarantines for all physicians, nurses, and other health professionals returning from West Africa, regardless of whether they are showing symptoms of Ebola virus infection. ACP agrees that physicians and other health professionals must take the necessary precautions to ensure the safety of others and prevent the spread of infection. However, the College maintains that mandatory quarantines for asymptomatic physicians, nurses and other clinicians, who have been involved in the treatment of Ebola patients, whether in the United States or abroad, are not supported by accepted evidence on the most effective means to control spread of this infectious disease. Instead, such mandatory quarantines may do more harm than good by creating additional barriers to effective treatment of patients with Ebola and impede global efforts to contain and ultimately prevent further spread of the disease…
Some newspapers, such as The New York Times, have repeated these arguments for a larger audience:
The Dangers of Quarantines
Ebola Policies Made in Panic Cause More Damage
… two ambitious governors — Chris Christie of New Jersey and Andrew Cuomo of New York — fed panic by imposing a new policy of mandatory quarantines for all health care workers returning from the Ebola-stricken countries of West Africa through John F. Kennedy and Newark Liberty international airports. There is absolutely no public health justification for mandatory quarantines…
Lost in this grandstanding was one essential point. The danger to the public in New York in the case of Dr. Craig Spencer, who had worked in Guinea for Doctors Without Borders, was close to nonexistent. Health experts are virtually unanimous in declaring that people infected with the virus do not become contagious until after they develop a fever or other symptoms, such as diarrhea, vomiting, or severe headaches, at which time they need to be hospitalized and taken out of circulation.
Health care workers like Dr. Spencer know that it is in their interest to ensure that — if symptoms do arise — they get care quickly to improve their chances of survival and to reduce the risk of infecting their friends and families. Dr. Spencer reported his temperature promptly when it was a low-grade fever of a 100.3 degrees and was rushed to Bellevue Hospital Center for isolation and treatment while his fiancée and two friends were put into voluntary isolation…
The problem with a mandatory quarantine, even if done at home, is that it can discourage heath care workers from volunteering to fight the virus at its source in West Africa. Doctors Without Borders, the nongovernmental organization that has led the battle there, typically sends its workers on arduous four- to six-week assignments. The risk of being quarantined for another 21 days upon return has already prompted some people to reduce their length of time in the field and may discourage others from volunteering in the first place…
Fortunately the response has been more rational at the federal than state level, including the statement from Barack Obama earlier today, pointing out that “If we don’t have robust international response in West Africa, then we are actually endangering ourselves here back home.”
President Obama pledged support for health care and aid workers in West Africa Tuesday, saying new rules for monitoring them for Ebola once they return to the United States would be “sensible and based on science.”
Obama gave brief remarks on the federal response to the disease after speaking with U.S. aid workers on the front lines of battling Ebola in West Africa.
“They’re doing God’s work over there, and they’re doing that to keep us safe, and I want to make sure that every policy we put in place is supportive of their efforts. Because if they are successful, then we’re not going to have to worry about Ebola here at home.”
Besides being counterproductive, there are civil liberties concerns when the government forcibly quarantines people who do not have the disease or who are not contagious.
While discussing the Republican hypocrisy in their response to an Ebola Czar earlier this month, I pointed out how the Republicans blocked Barack Obama’s nominee for Surgeon General due to his concerns about gun violence, which kills far, far more people than Ebola in this country. Republicans who 1) are rarely willing to take responsibility for their action, and 2) are fond of projecting their faults upon others, have been trying to shift the blame and falsely claim that the Democrats are responsible for blocking the nomination. Juan Williams of Fox News has called them out on this in a column at The Hill (also a Republican-leaning site even as not as overtly Republican as Fox). Williams also debunked the Republican claims that Harry Reid has not been fair due to not allowing them to add their “poison pill” amendments to bills, which would cause even greater gridlock. Williams wrote:
Republicans on the campaign trail tell voters that the Senate gets nothing done because Senate Majority Leader Harry Reid (D- Nev.) blocks votes on GOP legislation.
Away from the Halloween funhouse mirror, the reality is this: Reid is willing to hold votes — but not with an endless open amendment process that merely creates a stage for Republican political theater. “Poison pill” amendments on partial birth abortions and gay marriage would sprout everywhere.
The real problem is that Senate Republicans can’t agree on which amendments to attach to bills because of the Tea Party versus Establishment war raging among them.
Yet I’ve personally seen voters nodding in agreement at Senate debates and campaign events as Republicans put the fright-night mask on Reid as the evil ogre responsible for dysfunction in the Senate.
The GOP is having success by repeating this distorted version of political life on Capitol Hill. Their tactic on that score is consistent with an overall strategy that includes blocking President Obama’s nominees to courts, federal agencies and ambassadorial posts while condemning any mistakes made by the administration.
According to the Senate’s website, there are currently 156 nominations pending on the executive calendar.
With all of the fear-mongering by Republican candidates over the administration’s response to Ebola — part of a broader approach to scare voters by undermining faith in government, the president and all Democrats — there is one screaming nomination still pending that reveals the corruption of the GOP strategy.
The nation has not had a surgeon general since November 2013 because the GOP is blocking the president’s nominee, Dr. Vivek Murthy. At a time of medical emergency, what is the Republicans’ problem with Murthy?
In October 2012, the doctor tweeted: “Tired of politicians playing politics w/guns, putting lives at risk b/c they’re scared of the NRA. Guns are a health care issue.”
Dr. Murthy, a graduate of Harvard and the Yale School of Medicine, has impressive credentials for a 36-year-old. He created a breakthrough new company to lower the cost of drugs and bring new drugs to market more quickly.
But his big sin, for Senate Republicans, is that as a veteran of emergency rooms Dr. Murthy expressed his concern about the nation’s indisputable plague of gun violence.
When Dr. Murthy was nominated, the National Rife Association announced plans to “score” a vote on the doctor’s nomination, meaning any Republican or Democrat running in a conservative state who voted for Murthy would be punished in NRA literature and feel the pain in their fundraising come midterm election season.
When public anxiety over Ebola became a GOP talking point, 29 House Democrats wrote to Reid calling for the Senate to expose the Republicans for their deceitful strategy. They wanted, and still want, Senate Democrats to push for a vote on the surgeon general nominee and force the Republicans to explain their opposition. Their thinking is that swift action is needed to put a surgeon general in place and give the American people a trusted source of guidance on Ebola.
The Tea Party’s favorite senator, Republican Ted Cruz of Texas, last week agreed on the need for a surgeon general in a CNN interview. But in the funhouse mirror-style so loved by the Republican base, Cruz blamed Obama for the vacancy.
“Of course we should have a surgeon general in place,” Cruz told CNN’s Candy Crowley. “And we don’t have one because President Obama, instead of nominating a health professional, he nominated someone who is an anti-gun activist.”
Sen. Roy Blunt (R-Mo.) was also put on the spot recently over the GOP’s refusal to deal with the surgeon general vacancy. As he railed against the president for perceived errors in handling the situation, NBC’s Chuck Todd interrupted to ask: “The NRA said they were going to score the vote and suddenly everybody froze him… Seems a little petty in hindsight, doesn’t it?”
“Well, the president really ought to nominate people that can be confirmed to these jobs, and frankly then we should confirm them, there’s no question about that,” said the senator, trying to find his footing as he backpedaled.
The fact remains that Senate Republicans, in lockstep with the NRA, have left a worthy nominee dangling while this vital post remains vacant.
This kind of game playing is what led Senate Democrats to consider using the so-called “nuclear option.” In its original form, it would have changed the Senate rules to require a simple majority for all confirmations, instead of the current 60-vote supermajority. But the Democrats decided to go with a more modest change that allowed a simple majority vote to confirm only federal judicial nominees, not presidential picks for the Supreme Court, the cabinet or the position of surgeon general.
Reid, speaking on the Senate floor this summer, said that despite the rules change “Republicans are still continuing to try and slow everything down…It is just that they want to do everything they can to slow down [Obama’s] administration, to make him look bad…even though they’re the cause of the obstruction… Everyone will look at us and say, Democrats control the Senate — why aren’t they doing more?”
As a matter of brazen politics, the Republican strategy of obstruction has worked.
What a shame.
I have seen contradictory interpretations regarding the filibuster rules as to whether the Surgeon General can be confirmed with 51 votes or if the post still requires a super-majority. It is academic in this case. Republican Senators have placed a hold on this nomination and if it goes to a vote are likely to vote unanimously against it. The NRA has indicated that they will include a vote on Murthy in their ratings, which makes it difficult for some Democratic Senators in red states who are up for reelection. Between these Democrats and the uniform Republican opposition there are probably not 51 votes for confirmation, although this could change after the election.
Despite the Republican actions to block the Surgeon General nomination, it is questionable as to how much of a difference it would have made. We don’t know how much Murthy would have said on the topic, and if he could have gotten a discussion of the science through, considering all the fear and misinformation being spread about Ebola by Republicans.
Despite all the panic, we have seen how small a threat Ebola actually is in a developed nation such as the United States. Ebola is a problem of developing nations which lack an adequate Public Health infrastructure. While the outbreak began in West Africa last December, we have had a tiny number of people who are infected enter this country, and the potential harm has been easily contained. Even in Texas, which does share some of the problems of a third world nation due to Republican rule, multiple mistakes were made with minimal harm. A patient was sent home despite meeting criteria for hospitalization, and yet he did not spread the infection to anyone else in the community. This is because Ebola is not contagious early in the disease before someone is symptomatic, and even then it does not spread by casual contact.
Maybe if there was a Surgeon General speaking about Ebola, the Emergency Room staff at Texas Presbyterian Hospital would have been better acquainted with the guidelines and hospitalized Thomas Duncan when he first presented. Maybe the hospital would have done a better job at following protocols to protect the staff. While possible, it is far from certain that having a Surgeon General would have made any difference.
Perhaps if there was a Surgeon General discussing the science there would have been less panic when Dr. Craig Spencer was found to have traveled on the subway and visit a bowling alley, where he did not spread Ebola. (Similarly the nurse from Texas Presbyterian who flew with a low grade fever has not spread the disease despite turning out to be infected). This might have prevented the poor, and unscientific decisions made by the governors in states such as New Jersey and New York. While I can see Chris Christie make such a mistake, I would hope for better from Andrew Cuomo, even if he is faced with a Republican using fear tactics against him in his reelection campaign. This might have spared Kaci Hickox from being quarantined in an unheated tent in New Jersey despite showing no signs of being infected. Inhibiting health professionals from volunteering can only harm the cause of eradicating Ebola in West Africa–which is the only way of ending this matter.
It is impossible to know if a Surgeon General could have been effective in reducing the hysteria. Republicans are masters at spreading fear, and never have any qualms about ignoring science. It is very possible they could have still won out. We already have many Infectious Disease experts explaining the facts about Ebola, but that hasn’t been enough to maintain reason. While a Surgeon General might have had a little bigger soap box to speak from, I don’t know if that would have really mattered.
A mood of fear is engulfing the country which might very well affect the midterm elections. Hopefully people will react rationally and reject the Republicans who promote unwarranted fears, play politics, and advocate for counterproductive responses such as travel bans. Unfortunately but this is not the probable response.
As I discussed last week, even citing a report on Fox, we have no need to fear Ebola as long as proper precautions are taken.
There is no need to panic, or initiate measures which would be counterproductive such as a travel ban at this time. There is no meaningful problem with Ebola in this country and the biology of the virus makes it unlikely we will have a problem in the future. The nature of Ebola makes it a serious problem in countries without a Public Health infrastructure, but not in countries like the United States.
To date we have had exactly one patient with Ebola come into the country beyond medical personnel transported back here. Despite some serious mistakes being made, he did not infect a single person in the general population. The spread was limited to two nurses who cared for him at the most infectious stage, but before this stage the viral load is very low and Ebola is not likely to spread. This is also why, despite people who did come into contact with him having traveled, not a single other person has contracted Ebola.
Ebola is a serious problem in countries without sufficient infrastructure to deal with it, and if we are ever to be at serious risk it would be due to more widespread infection outside of the United States first. Our major focus must be on eradicating Ebola in West Africa, and anything which hinders this will make this more difficult and be counterproductive.
We also must closely track those who have been exposed, and a travel ban would also make this far more difficult. One of the major reasons for Ebola spreading in West Africa is an atmosphere which causes people who have been exposed to hide this until they are very sick and courageous. We must avoid an atmosphere such as this in the United States if we are going to prevent spread here.
Nigeria has not closed its borders to travelers from Guinea, Sierra Leone and Liberia, saying the move would be counterproductive. “Closing borders tends to reinforce panic and the notion of helplessness,” Shuaib said. “When you close the legal points of entry, then you potentially drive people to use illegal passages, thus compounding the problem.” Shuaib said that if public health strategies are implemented, outbreaks can be controlled, and that closing borders would only stifle commercial activities in the countries whose economies are already struggling due to Ebola.
Similarly, Republicans are playing on exaggerated fears of terrorism and unfounded claims that the Affordable Care Act will cause increases in premiums when insurance companies are actually reporting plans for lower premium increases than were the norm prior to Obamacare.
Flatline managed to provide an episode of Doctor Who which successfully combined elements of both horror and humor. While not a totally original idea, it was something not seen on Doctor Who before, and realistically few television shows manage to come up with ideas which have not been influenced by other works. Think of it as if the residents of Flatland by Edwin Abbott Abbott were to invade earth, with a touch of The Adams Family thrown in.
Besides the idea of two dimensional beings invading, there was the added component of the TARDIS shrinking when the “structural integrity is compromised.” This did contradict The Name of the Doctor which showed such leaking to cause the TARDIS to swell in size, not shrink. The shrinking of the TARDIS, with the Doctor trapped inside, did enable Clara to take a leading role in this episode. This whole situation was quite difficult for the Doctor: “I mean this is just embarrassing. I’m from the race that built the TARDIS. Dimensions are kind of our thing.”
The Doctor did win out in the end. Ultimately the aliens from the two dimensional world were defeated by their inability to distinguish a two dimensional picture of a door from a real three dimensional door.
With the Doctor separated from the action for most of the episode, Clara took on the role of the Doctor, including taking on a companion, Rigsy, and calling herself the Doctor:
Rigsy: “What are you the doctor of?”
The Doctor: “Of lies.”
Clara: “Well, I’m usually quite vague about that. I think I just picked the title because it makes me sound important.”
The Doctor: “Why, ‘Doctor Oswald,’ you are hilarious.”
Clara did show Rigsy the inside of the shrunken TARDIS leading to the classic comment, “It’s bigger on the inside.” This set up the Doctor’s response: “I don’t think that statement has ever been more true.”
Clara also showed that she can act like the Doctor, from using the Sonic Screwdriver to using his tactics:
Clara: “I just hope I can keep them all alive.”
The Doctor: “Ha. Welcome to my world. So, what’s next, ‘Doctor Clara’?”
Clara: “Lie to them.”
The Doctor: “What?”
Clara: “‘Lie to them.’ Give them hope. Tell them they’re all going to be fine. Isn’t that what you would do?”
The Doctor: “In a manner of speaking. It is true that people with hope tend to run faster, whereas people who think they’re doomed …”
Clara: “Dawdle. End up dead.”
The Doctor: “So, that’s what I sound like?”
Ultimately, when Clara asked if she did a good job, the Doctor did respond, “You were an exceptional Doctor, Clara. Goodness had nothing to do with it.” We still have the question from the start of the season as to whether the Doctor is a good man, and whether they are doing good.
The most amusing gag of all in the episode was seeing the Doctor’s full sized hand emerge from the tiny TARDIS to walk it away from an oncoming train. The episode was very light on Danny Pink, but we did have another amusing scene with Clara talking on the phone with Danny, hiding the fact that she was in danger. The previews do show him taking an active part next week, but it still remains unclear whether we will ultimately see a return to two teachers from Coal Hill School being companions aboard the TARDIS as was teased last summer.
The ending scene with Missy took a different turn from her previous scenes, with Missy saying, “Clara, my Clara. I chose well.” It has already been suggested that it was Missy who gave Clara the Doctor’s phone number back in The Bells of Saint John, but we still have no idea as to what Missy’s overall plan is. Also uncertain is whether this has any connection to Clara’s role in The Name of the Doctor to become fragmented in time and have a role in each of the Doctor’s regenerations.
The writers this season do seem to be writing as if some of the past events have not taken place, almost starting fresh with Clara and the Peter Capaldi Doctor. Even going back to the season premiere in Deep Breath, the Clara who saw each regeneration in The Name of the Doctor should not have been as surprised by seeing the changes in the Doctor after his regeneration. Perhaps the events of The Time of the Doctor, with the Doctor gaining additional regenerations and not dying on Trenzalore, also mean there was never a giant TARDIS tomb for the Doctor and Clara never was fragmented in time. The Missy story line might wind up providing a completely different version of Clara’s life.
The Doctor Who Extra for Flatline is above.
While both the Doctor and now Clara having claimed to be a doctor without formal qualifications, there are some actual doctors who have done considerable harm despite having true medical degrees. One example, Dr. Henry Cotton, has appeared on cable television shows in the past week both on The Knick (at the start of his career and Boardwalk Empire (near the end). He was a real person. Henry Cotton believed that psychiatric problems were based upon infections and his treatment often began with pulling the teeth of psychiatric patients. If this did not provide a cure, then he would proceed to remove other organs which he believed were the cause of the infection. Needless to say, in an age before antibiotics, such unnecessary surgery could have catastrophic results. At one point during his career Cotton even had a nervous breakdown. He responded by pulling his own teeth, then proclaimed himself to be cured and returned to work.
Knowing the factual basis behind Dr. Cotton’s life leaves me concerned about Gillian Darmody’s fate after she told Dr. Cotton that she felt she was cured. We already saw another woman at the asylum undergo surgery, and Cotton would not be likely to accept Gillian’s assessment that she is cured without surgically removing what he believes to be the site of her infection. Being the final season, Boardwalk Empire does have the ability to show tragic endings for its characters. This included the deaths of two long time characters last week. While Boardwalk Empire is ending, The Knick just ended its first season and has done an excellent job of showing what medical care was like back in 1900 and the development of new ideas such as transfusions.
News came in last week that a cable series which debut last summer, Manhattan, was renewed. While I have not seen the series, I feel comfortable in recommending this show about the development of the atomic bomb based upon several favorable reviews. (Although I have not seen Manhattan yet, do I get any points for reading Joseph Kanon’s novel, Los Alamos, several years ago?)
Still no news on whether Continuum will be renewed.
I would also recommend another new cable series which I did see the premiere of last weekend, The Affair. The main story involves an affair from the viewpoint of both parties, each telling their version for half the episode. We have narrators who are unreliable at least due to the faults in human memory. There might be additional reason for intentional deceit as we found that the stories are being told as part of a possible criminal investigation years afterwards, similar to in the first season of True Detective. It also reminds me of William Landay’s novel, Saving Jacob, in which there are glimpses of future questioning but we don’t know who the accused is or the crime until the end of the novel.
The creator of The Affair, Sarah Treem, discussed the dual narratives in an interview at The Hollywood Reporter:
With Noah and Alison remembering different accounts of the same stories, the series explores the notion of objective truth. Do you think there’s such a thing?
I think there is such a thing as objective truth. There are events that actually happen. As individuals our understanding of what happens is often quite limited. Sometimes the only way to get at objective truth is to have multiple people tell their own version of the same event. It is the job then of the interrogator, the therapist, the audience member, whomever, to basically try to find the commonality between the accounts in order to figure out what actually happened. That’s basically what we’re trying to do with this show. We’re not saying there’s no such thing as truth — there absolutely is — but we don’t think that one person is usually the arbiter of the truth. We think that it comes forward in conversation. There’s this quote, I think it’s from Hegel, but it’s the idea that all understanding is dialectic, meaning that nothing gets understood unless it’s as a result of a conversation. That’s how I think of the two sides of this show, that it’s a conversation from which the audience gains an understanding.
Will we see the perspectives of other characters besides Alison and Noah?
Not this season but maybe in subsequent seasons, if we get them.
We see a lot of overlapping stories that vary slightly depending on who’s telling them. What’s it like to have to regularly write two versions of the same event?
It’s a really fun exercise for a writer. It’s just about putting yourself in another character’s perspective, seeing the scene through the other character’s eyes. For the scene at the end of the pilot [where Alison and Cole have sex on their car], I was interested in writing a scene that looked like an attack on one side, and then coming back into it knowing more about what was actually happening to where all of the sudden the scene plays as a very different negotiation. Writers are trained at this because you’re always approaching the story through somebody’s eyes so it’s just a great, enjoyable exercise to go back and think, “Well, I wrote it this way the first time and now let me jump into a different character’s body and a different character’s mind and let me try it again and just see what happens.”
Both Warner (DC) and the various studies which own the rights to Marvel characters have recently released news on their upcoming movie plans. Comics Alliance has more information and has put together the above infographic.
“Batman v Superman: Dawn of Justice,” directed by Zack Snyder (2016)
“Suicide Squad,” directed by David Ayer (2016)
“Wonder Woman,” starring Gal Gadot (2017)
“Justice League Part One,” directed by Zack Snyder, with Ben Affleck, Henry Cavill and Amy Adams reprising their roles (2017)
“The Flash,” starring Ezra Miller (2018)
“Aquaman,” starring Jason Momoa (2018)
“Justice League Part Two,” directed by Zack Snyder (2019)
“Cyborg,” starring Ray Fisher (2020)
“Green Lantern” (2020)
Batman v Superman: Dawn of Justice producer Charles Roven recently gave an interview with more information on the movie, including the origin story for Wonder Woman which is being used.
Unlike Marvel, DC is keeping their movie and television universes separate. While Gotham will probably need to be kept in a separate world of its own, Green Arrow, The Flash, and next Supergirl are forming their own television universe. Many fans are angry that Stephen Amell and Grant Guston won’t be appearing as Green Arrow and The Flash in the Justice League movie. While fans would probably prefer such continuity, it does make it easier to wrote both the television shows and the movies if there is not a need for consistency. We saw how Agents of SHIELD was harmed by a need to postpone mention of HYDRA taking over SHIELD until after Captain America: The Winter Soldier was released.
Marvel fans are getting more excited by what appears to be planned. While Robert Downey, Jr. has not agreed to do another stand alone Iron Man movie, he may be appearing in Captain America 3, which reportedly involves the two being on opposing sides over the Superhero Registration Act. This could also be the end of Chris Evans as Steve Roberts. of There have also been rumors of Marvel making a deal with Sony, which owns the cinematic rights to Spider-Man, to allow him to appear, which sounds plausible as Spider-Man had a role in this storyline in the comics. Several other Marvel characters are also rumored to be appearing.
Meanwhile Emma Stone, when not playing the role of Gwen Stacy in Spider-Man, will be playing Sally Bowles on Broadway in Caberet.
With Twin Peaks coming back we have twenty-five years to catch up on. Mark Frost is writing a book to fill in this gap. I am looking forward to see what they do with the series and which characters return. I do hope that Audrey Horne returns and has a daughter who can tie a knot in a cherry stem with her tongue.
NBC has commissioned Bill Lawrence (Scrubs) to do a remake of the fantastic British sit-com, The IT Crowd. I have mixed feelings about such attempts to remake UK shows here. NBC’s first attempt at a remake, with cast including Joel McHale, was reportedly a total flop and never aired. NBC also failed in adapting Coupling, another excellent British sit-com written by Steven Moffat.
Fox has had their own problems in attempting to remake British shows, both with Gracepoint (a remake of Broadchurch) and Us and Them (a remake of Gavin and Stacey).
On the surface, Republicans have been all over the place regarding the idea of a government official to coordinate handling of Ebola. For example, there’s John McCain. Back in 2009 he attacked Obama over having too many czars:
Obama has more czars than the Romanovs – who ruled Russia for 3 centuries. Romanovs 18, cyberczar makes 20.
“From spending time here in Arizona, my constituents are not comforted,” Senator John McCain (R-AZ) told State of the Union host Candy Crowley Sunday morning. “There has to be more reassurance given to them. I would say that we don’t know exactly who’s in charge. There has to be some kind of czar.”
So Obama appointed an Ebola czar. Ezra Klein explained why Ron Klain is an excellent choice:
Today, the White House will announce that Klain is being named “Ebola czar.” It’s a good choice because it shows a healthy respect for how hard the bureaucratic job of coordinating the Ebola response really is.
The Ebola response involves various arms of the Department of Health and Human Services (particularly, though not solely, the Centers for Disease Control and Prevention), the Pentagon, the State Department, the National Security Council, the World Bank, the World Health Organization, President Obama’s office, private stakeholders, and many, many more.
The “czar” position requires someone who knows how these different agencies and institutions work, who’s got the stature to corral their efforts, who knows who to call when something unusual is needed, who can keep the policy straight…
Actual government experience is badly underrated in Washington. Politicians run for office promising that they know how to run businesses, not Senate offices. “Bureaucrat” is often lobbed as an insult. But in processes like this one, government experience really matters. Nominating Klain suggests the White House is thinking about this correctly: as an effort that requires the coordination of already ample resources, where the danger is that the federal government will be too slow in sharing information across agencies and getting the resources where they need to go.
John McCain’s reaction to the appointment of an Ebola czar was to again attack Obama for doing what he recommended:
“Frankly, I don’t think Mr. Klain fits the bill, as a partisan Democrat, certainly not in any effort to address this issue in a bipartisan fashion,” McCain said Friday evening on Fox News.
“He has no experience or knowledge or background in medicine,” he added.
McCain is hardly the only Republican with irrational attacks. For example, Steven Taylor has looked at even more irrational attacks from Mike Huckabee. The only common thread to Republican response appears to be a knee jerk opposition to whatever Obama does.
The duties of an Ebola czar are exactly the bureaucratic skills which Klain has, not being a medial expert. Of course there is a position in government which should have a background in medicine, and work closely with the Ebola czar. That would be the Surgeon General–a nomination which Republicans have blocked as Obama’s nominee has shown concern for gun violence. Now Democrats are demanding that the Senate vote for approval of the Surgeon General nominee:
More than two dozen House Democrats are calling on the Senate to swiftly approve Vivek Murthy’s nomination to serve as surgeon general to help combat the spread of the deadly Ebola virus in the U.S.
Murthy’s nomination got sidelined after Republicans and vulnerable Senate Democrats voiced reservations about the Harvard Medical School physician’s outspoken views on gun violence and public health. But the House Democrats, in a letter set to be released next week, argue that the Obama administration needs a top official in place to help with the Ebola response.
“The American public would benefit from having a Surgeon General to disseminate information that is desperately needed,” the Democrats wrote. “The Surgeon General can also work to amplify the Center for Disease Control’s actions, reassure the American people, and combat misinformation here at home.”