OASIS D Classes *FREE*

To: Federally Certified Skilled Home Health Facilities Administrators, Directors of Nursing, OASIS Coordinators, Billing and Coding Personnel, Licensed Home Health Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

ETA will offer classes on specific OASIS topics in Craig, Colorado Springs, Pueblo, Montrose and Aurora featuring OASIS D items and guidance. Some Colorado Springs sessions are full, and Pueblo is almost full. You may choose to take sessions all at once or individually as your interest and needs dictate. All registration is first-come, first-served, even for sessions within a hosting facility.

ETA reserves the right to cancel classes with low registration. Early registration is helpful.

OASIS D Basics (One Session): Course ID 1082008
This beginning three-hour class is how to get started with OASIS D.

OASIS D Item-by-Item (2 Sessions): Course ID 1082009
This practical application class reviews item-by-item data set completion. We will follow Mrs. Green’s assessment, which will require two sessions to complete. Attendance at both sessions is required to complete this class.

OASIS Quality Measures (One Session): Course ID 1066910
This course assumes familiarity with the OASIS D Item Set, covering more advanced content and application.

To see additional session details and register for on-site attendance for one of these offerings:
1. Go to http://www.train.org/ 
2. Log in to your existing TRAIN account, or new users click “Create an Account”
3. Once you’ve logged in, or created an account, Search (top right) for the appropriate Course ID. (See above for desired training)
4. Click link for desired course.
5. Click the “Registration” tab.
6. Click the “Register” button for the session you wish to attend.
7. Remember to register separately for each desired course.

A detailed example of the above process (if needed)

Questions?: Please email betty.metz@state.co.us

The Rise of Ideologically or Theologically Based Medicine, Public Health, and Health Policy – Recent Examples


I have long been a proponent of evidence-based medicine (EBM), and evidence-based health care, public health, and health policy.  EBM, for example, is about medical-decision making based on critical review of the best applicable evidence from clinical research informed by knowledge og biology and medicine, of the patient’s biopsychosocial circumstances, the patient’s values, and of ethics and morality.  We have discussed challenges to EBM based on manipulation and suppression of clinical research, often in the financial interests of those hawking particular medical products of services.

A newer challenge to evidence-based medicine, health care, public health and health policy seems not to be commercial, but ideologically or theologically based.  I noticed the following recent cases that illustrate this concern. 

Theologically Based Medicine and Public Health Promoted at the DHHS

In July, 2018, we discussed the case of Dr Diane Foley, who was appointed Deputy Assistant Secretary for Population Affairs in the US Department of Health and Humas Services (DHHS).  At the time we noted that Dr Foley publicly proclaimed that adoption of children is harmful because it is a “double death;” and teaching children about barrier contraception is harmful because it is “sexually harassing.”  Dr Foley also ran an organization called Life Network, which ran so-called “crisis pregnancy centers,” which ran abstinence-only sexual education programs in part based on Dr Foley’s beliefs about the harms of teaching about barrier contraception.  There seems to be no good evidence about the sort of harms Dr Foley attributed to adoption or barrier contraception.

Nonetheless, on April 4, 2019, ReWire reported that the DHHS would give control of  Title X federal family planning and teen pregnancy prevention and the Office for Adolescent Health (OAH), which administers the Teen Pregnancy Prevention Program to the Office of Population Affairs, which is run by Dr Foley.  In response, Senator Patty Murray (D-WA),

the ranking Democrat on the Senate appropriations subcommittee with oversight over HHS, questioned the Trump administration’s motivations behind the plan. ‘It is unclear how the reorganization will result in better policies and services for those served by these offices, including adolescents, women, low-income communities, and individuals with infectious diseases, including HIV/AIDS,’ she wrote. ‘In fact, it is difficult to understand how this reorganization does anything other than consolidate control at HHS headquarters and prioritize ideology over the needs of the women, teenagers, and children the affected programs serve.’

In fact, there is reason to believe that Dr Foley based her beliefs
more on her ideas about theology than on a political ideology.  Life
Network’s website has stated (see our post linked above) 

‘Through our pregnancy centers we have the opportunity to see God use
the miracle of ultrasound to change and save lives,’ Life Network’s
website says. The first element of its mission is ‘presenting the gospel
of Jesus Christ.’

Thus the Trump administration seems to be consolidating power over US government family planning programs in the hands of an individual who is basing her decision making not on medical or public health evidence, but on her version of a particular type of Christian theology.

Ideologically or Theologically Based Public Health Policy about Pornography Promoted in Another State Legislature

NBC Montana reported on April 16 that Montana legislators are the latest to join the quest to label pornography a public health hazard.  

One resolution state house lawmakers are taking up in Helena would label pornography as a public health hazard in Montana.

If passed, Montana would have to address pornography through education, research and state policy.

The state would have to implement measures to prevent pornography exposure and addiction, offer recovery help, and create programs that hold broader influences accountable.

The proposed resolution included assertions that, for example, pornography causes

violence and abuse of women and children by presenting rape and abuse of women and children as harmless

and

psychological and physical distress, deviant sexual arousal, difficulty
in forming or maintaining intimate relationships, and problematic or
harmful sexual behaviors and addiction

and

increases sex trafficking of women, sex trafficking of children, child sexual abuse, and child pornography;

Yet as we noted in March, 2019,
there is no clear evidence supporting any of these assertions.  So
Montana Republican legislators join those in Arizona, and also those in
Kansas, Utah, and Idaho (look here)  in pushing legislation that attacks the “public
health” hazards of pornography based on no clear evidence.

The genesis of the notion that pornography is a dire public health hazard is not clear.  As we noted here, though, in Utah, at least, beliefs about pornography could come from the doctrine of the Church of Latter Day Saints, which includes:

‘depiction, in pictures or writing, that is intended to inappropriately
arouse sexual feelings’ to be ‘a tool of the adversary,’ the descriptor
Mormons often use for Satan.

At any rate, since the proponents of these measures all seem to be Republicans, there also is suspicion that their beliefs about pornography are ideologically-based.

Ideologically Based Beliefs About Vaccination Policy Espoused by President Trump, the Governor of Kentucky, and in Multiple State Legislatures

We recently discussed how a Russian disinformation campaign has led parents in the US and elsewhere to avoid vaccinating their children for various diseases, in turn leading to outbreaks of measles in the US and other countries. Along with this disinformation campaign, various government leaders have also espoused views about the benefits and harms of vaccination, and vaccination policy that are virtually free of evidenciary support.

In March, 2019, the Louisville Courier Journal reported on the example set by the Republican Governor of Kentucky. 

Gov. Matt Bevin said in a radio interview Tuesday that he deliberately exposed all nine of his children to chickenpox so they would catch the disease and become immune.

‘Every single one of my kids had the chickenpox,’ Bevin said in an interview with WKCT, a Bowling Green talk radio station. ‘They got the chickenpox on purpose because we found a neighbor that had it and I went and made sure every one of my kids was exposed to it, and they got it. They had it as children. They were miserable for a few days, and they all turned out fine.’

Governor Bevin seemed to imply that chickenpox is an annoying disease, but one that does not cause severe adverse effects.  However, varicella is not innocous.  According to the CDC clinical summary, it can cause secondary bacterial skin infections in children.  Rarely in children, but more commonly in adolescents, adults, pregnant women, and people with immunocompromise, it can cause severe complications including pneumonia, sepsis, and various other secondary bacterial infections.  Varicella is highly contagious, so unvaccinated children can infect other unvaccinated people who are more susceptible to complications.

Yet Governor Bevin ignored all that.  His rationale for not vaccinating his own children and not mandating varicella vaccine for other children was conveyed in his interview.

Bevin also suggested that the government stay out of mandating vaccines. In Kentucky, varicella (chickenpox) is among vaccines mandated for all children entering kindergarten, though parents may seek religious exemptions or provide medical proof that a child has already had the disease.

‘And I think, why are we forcing kids to get it?’ Bevin said in the radio interview, speaking about the chickenpox vaccine. ‘If you are worried about your child getting chickenpox or whatever else, vaccinate your child. … But for some people, and for some parents, for some reason they choose otherwise. This is America. The federal government should not be forcing this upon people. They just shouldn’t.’

So his ideology that “the federal government should not be forcing this upon people” seemed to trump any risks children run because their parents choose to not vaccinate them, even just “for some reason.”

The Louisville Courier Journal also interviewed “Dr. Robert Jacobson, a pediatrician and expert in vaccines and childhood diseases at the Mayo Clinic in Rochester, Minnesota,

Before vaccination was available, chickenpox killed as many as 100 adults and children a year, he said.

‘I think it is taking a big risk that you don’t need to take,’ Jacobson
said. ‘It’s not just a risk your children are going to have. You’re
putting other people in the community at risk because of your decision.’

 Note that this is not the first time that Governor Bevin expressed beliefs about public health that were not evidence-based.  In this post, we noted that in 2018 he suggested that mass school shootings are due to exposure to television shows about zombies, and in 2019 he suggested that exposing children to severely cold weather is risk free.  So he does seem consistent in the absurdity of his public health beliefs.  Unfortunately, he is in a position to endanger the public’s health according to these beliefs. 

There are other US state level political leaders who seem to rely on idology rather than evidence in making decisions about health care and public health.  On April 16, 2019, Politico reported widespread attempts by Republican state legislators to free people from requirements that they vaccinate their children,

Democrats in six states — Colorado, Arizona, New Jersey, Washington, New York and Maine — have authored or co-sponsored bills to make it harder for parents to avoid vaccinating their school-age children, and mostly faced GOP opposition. Meanwhile in West Virginia and Mississippi, states with some of the nation’s strictest vaccination laws, Republican lawmakers have introduced measures to expand vaccine exemptions, although it’s not yet clear how much traction they have.

In Washington state, which has one of the biggest measles outbreaks, a bill in the state Senate to narrow vaccine exemptions passed through the health committee without the support of a single Republican. The same thing happened in legislative committees in Colorado and Maine over the past week.

Again, the Republicans seemed to base their attempts to decrease vaccination requirements on their ideology of expanding personal choice.

many are loath to diminish the right of parental control over their children’s bodies, and yield that power to the government.

Politico provided an example of a New York state legislative leader who opposed a bill that would limit religiosu exemptions to vaccination mandates.

Andrew Raia, ranking Republican on the New York Assembly’s health committee, said he wouldn’t support the bill. While not totally convinced by constituents who link their children’s autism on vaccines, and unaware of any real religious injunction against vaccination, he said, ‘I’m not a religious leader, and I’m not a scientist either, so it’s my job to weigh both sides.’

I suggest that his arguments are at best evidence free, but also could have been

complicated by the fact that President Donald Trump and two of his Republican primary foes, Sen. Rand Paul (R-KY) an ophthalmologist, and Ben Carson, a neurosurgeon who is now HUD secretary, both voiced support for disproven theories linking vaccine to autism during a 2016 debate.

In fact, as reported by the (UK) Independent in 2018,

On more than 20 occasions, Mr Trump has tweeted about there being a link between vaccines and autism, something experts at the government’s leading public health institute say is not true. He also repeated the claim during a Republican primary debate, a remark that was immediately dismissed as false by the Autistic Self Advocacy Network.

Summary

Outbreaks of infectious diseases previously considered controlled now bedevil the US and other developed countries.  They seem to be caused in part by parents’ resistance to vaccinating their children, despite strong evidence that the vaccines are relatively effective and have harms that exceed their benefits, both for the children vaccinated and the public health.  In turn, the resistance to vaccination seems increasingly inspired by government leaders whose actions are based on ideology, or sometimes theology.

The ideologically based arguments seem to come from some sort of a crude libertarianism that holds that parents should be free to choose not to vaccinate, more or less regardless of the effects of their decision on their children, or other people.  Such arguments should alarm health care professionals who are sworn to put the patients’ and the public’s health ahead of other concerns, including political ideology.

The theologically based arguments are also concerning because they seem to be an attempt to use the govenrment to promote a particular set of religious beliefs ahead of patients’ and the public’s health, and to impose these beliefs on people of other faiths.  This apparently contradicts the US constitutional prohibition against governmental establishment of religion.

True health care reform would require government officials to use evidence, rather than personal ideology and particularly rather than their own religious beliefs when making health care and public health policy. 

CANCELLED – 4/25/19 Assisted Living Advisory Committee meeting

Health Care and Pharyngitis

Your Best Health Care: Health Care and Pharyngitis

Health Care and Pharyngitis

Have you
ever had Pharyngitis? Then you’ve had a sore throat, which
 often entails more than just a “sore” throat.
It may include throat itchiness, scratchiness, difficulty swallowing, or just
general pain in the throat. The reason you experience this discomfort is
because of swelling in the pharynx, which is the back of the throat, and the
larynx, which is your voice box.

Typically, according to Medspring Urgent Care,
a sore throat is caused by one of these culprits:
·         One of many cold
viruses.
·        
Coxsackie virus.
Unless your pharyngitis is caused by a bacterial
infection, like strep throat, pharyngitis is a viral infection and is not
treated with antibiotics.
Seeking medical attention depends on the
severity of your symptoms and risk factors; the more discomfort you are
experiencing, the wiser it is to promptly pay your doctor a visit.
For
more details, visit this website:
https://medspring.com/treatments/pharyngitis-sore-throat
.
According to the American Family Physician, pharyngitis is one
of the most common conditions encountered by the family physician.
 The
optimal approach for differentiating among various causes of pharyngitis
requires a problem-focused history, a physical examination, and appropriate
laboratory testing. Identifying the cause of pharyngitis, especially group A
beta-hemolytic streptococcus (GABHS), is important to prevent potential
life-threatening complications. More detailed information about testing
for pharyngitis is located at this website:
https://www.aafp.org/afp/2004/0315/p1465.html
.
In the majority of cases, pharyngitis
will disappear within a week, though can last longer.
 Treatment will usually focus on managing the symptoms,
according to Ada Health. However, antibiotics may be prescribed to treat the
bacterial form of the condition. Generally, it is a non-serious condition,
though in some instances it can cause severe symptoms or a serious infection.

Antibiotics
are ineffective against viral pharyngitis, though, they may be prescribed for
those with a bacterial infection. Doctors are often reluctant to prescribe
antibiotics for bacterial pharyngitis due to the fact that they are not always
effective and may cause side-effects. To decide if an individual should be
prescribed antibiotics, doctors will sometimes use a test known as the Centor
score. Physicians will look for:
·        
Pus
on the tonsils.
·        
Painful
or tender glands on the neck.
·        
The
absence of a cough.
·        
Fever.
If three or
more of these features are present, a doctor will often prescribe a delayed
prescription, whereby antibiotics will be prescribed for two or three days in
the future, to be used if symptoms have not disappeared or have gotten worse.
You can find much more information about symptoms and treatment at this site: https://ada.com/conditions/acute-pharyngitis/
.
According
to Infectious Disease Advisor, there
is no single vaccine that prevents pharyngitis, since it can be caused by many
different bacteria and viruses. Influenza vaccine may prevent some community
causes of pharyngitis. Prophylactic drug treatment is not recommended.
Additionally,
according to Johns Hopkins Medicine,
pharyngitis and tonsillitis are infections that
cause inflammation. If the tonsils are affected, it is called tonsillitis. If
the throat is affected, it is called pharyngitis. If you have both, it’s called
pharyngotonsillitis. These infections are spread by close contact with others.
Most cases happen during the winter or colder months.
Your healthcare provider will figure out the best treatment based
on:
  • How old you are
  • His or her overall health and
    medical history
  • How sick you are
  • How well you can handle
    specific medicines, procedures, or therapies
  • How long the condition is
    expected to last
  • Your opinion or preference
Most cases of pharyngitis and tonsillitis will run their
course without any complications. But, if the disease is caused by strep, rare
complications, including rheumatic fever, rheumatic heart disease, and kidney
disease can happen. Treatment with antibiotics can prevent these complications.
If a
sore throat is severe and includes trouble swallowing, drooling, or neck
swelling, see a healthcare provider right away.
More details are
available at this site:
https://www.hopkinsmedicine.org/health/conditions-and-diseases/pharyngitis-and-tonsillitis
.
Sore
throats are usually a nuisance, and they make you feel under the weather as
long as you have one. However, in some cases, you should visit a medical practitioner
if the symptoms seem out of the ordinary or last longer than normal. If your
immune system is compromised, or your age or other underlying health factors
are problematic, then go to your doctor to make sure you don’t have other issues
beyond pharyngitis.

The HIV Epidemic, and Now the Measles Outbreak: The Russian Connection

I am old enough to remember having measles as a child, a thoroughly unpleasant experience.  Some children had much unhappier results of measles than I did.  So as a parent, I was happy to see that a reasonably effective measles vaccine had practically eliminated the disease from the US and most developed countries.

However, we currently are in the midst of a measles outbreak in the US.  The current number of reported cases for the first three months of 2019 is greater than all cases reported in 2018.  (See this CDC update.)  Other so-called developed countries are also seeing more cases of measles.  Why has measles returned?  A likely cause is the number of parents with negative opinions about the vaccine is rising, and their clamor to exempt their own children is getting louder (look here for just the latest example.)

The negative opinions seem not to come from reasoned arguments based on logic and facts, but from disinformation campaigns.

Prelude: the 1980s Soviet Disinformation Campaign About HIV

How disinformation can disrupt public health is a story which seemed to have been largely forgotten until 2016.  That year, how the campaign to control HIV in the 1980s was impeded by disinformation  was brought up again after so many years by the Washington Post.  The article opened

On July 17, 1983, a small pro-Soviet Indian newspaper called the Patriot published a front-page article titled ‘AIDS may invade India: Mystery disease caused by US experiments.’ The story cited a letter from an anonymous but ‘well-known American scientist and anthropologist’ that suggested AIDS, then still a mysterious and deadly new disease, had been created by the Pentagon in a bid to develop new biological weapons.

‘Now that these menacing experiments seem to have gone out of control, plans are being hatched to hastily transfer them from the U.S. to other countries, primarily developing nations where governments are pliable to Washington’s pressure and persuasion,’ the article read.

The Patriot’s article was subsequently used as a source for an October 1985 story in the Literaturnaya Gazeta, a Soviet weekly with considerable influence at the time. The next year, it ran on the front page of a British tabloid. After that, it was picked up by an international news wire. By April 1987, it was suggested that the story had appeared in the major newspapers of more than 50 countries.

The problem? The story was patently false. 

It was a product of a deliberate Soviet disinformation campaign.  A New York Times article from 2017 amplified the specifics:

Called Operation Infektion by the East German foreign intelligence service, the 1980s disinformation campaign seeded a conspiracy theory that the virus that causes AIDS was the product of biological weapons experiments conducted by the United States. The disease disproportionately impacts gay men, and the Reagan administration’s slow response had escalated into suspicions in the gay community that the United States government was responsible for its origins.

‘The K.G.B. picked up on that, and added a new twist with a specific location: Fort Detrick, Md.,’ where military scientists conducted biological weapons experiments in the 1950s and 1960s, said Douglas Selvage, the project director at the Office of the Federal Commissioner for Stasi Records in Berlin.

The K.G.B. campaign began with an anonymous letter in Patriot, a small newspaper published in New Delhi that was later revealed to have received Soviet funding. It ran in July 1983, under the headline ‘AIDS May Invade India: Mystery Disease Caused by U.S. Experiments’ and pinned the origin of the disease to Fort Detrick.

The choice of Patriot was deliberate, said Thomas Boghardt, a military and intelligence historian who traced how the campaign unfolded. ‘It had no explicit links to the Soviets and was an English-language newspaper easily accessible to a global audience.’

‘The Soviets intuitively understood how the human psyche works,’ Dr. Boghardt said. He said the playbook was simple but effective: Identify internal strife, point to inconsistencies and ambiguities in the news, fill them with meaning and ‘repeat, repeat, repeat.’

A September 1985 memo to Bulgarian intelligence from the East German secret police served as a conduit. The disinformation campaign aimed, according to the Stasi, ‘to generate, for us, a beneficial view by other countries that this disease is the result of out-of-control secret experiments by U.S. intelligence agencies and the Pentagon involving new types of biological weapons.’

A month later, the Soviet journal Literaturnaya Gazeta published a paper titled ‘Panic in the West or What Is Hiding Behind the Sensation Surrounding AIDS.’ It included accurate information about the disease and Fort Detrick but cited the Patriot letter to connect the dots.

The paper received international attention and its allegations were repeated around the world including in Kuwait, Finland and Peru. CBS News, black newspapers, the gay press, niche publications critical of the C.I.A. and the right-wing presidential candidate Lyndon LaRouche all promoted the conspiracy theory. (Mr. LaRouche flipped the claim on its head, accusing the Soviets of using AIDS as a weapon.)

Background on Soviet Disinformation

An earlier 2017 article in the Guardian expanded the background about Soviet use of disinformation:

Unlike misinformation, disinformation is constructed to be deliberately false, with the intention of sowing discord in enemy ranks. While there are undoubtedly historical examples, the industrialisation of disinformation emerged with the modernisation of media and mass communication. This is reflected in the etymology of the word itself, which by the advent of second world war had arisen independently in both Russian and English to characterise the spread of propaganda across Europe. Russia quickly recognised its enormous potential, and as early as 1923 the GPU (forerunner to the KGB) had established an office dedicated to it.

Disinformation fast became an integral part of Soviet intelligence, and by the birth of the KGB in the 1950s, it had become an essential component in the doctrine of ‘active measures’, the art of political warfare. Active measures included media manipulation, the use of front groups, counterfeiting of documents, and even assassinations when required. It was the very heart of Soviet intelligence, described by KGB Major General Oleg Kalugin as:

‘… not intelligence collection, but subversion: active measures to weaken the west, to drive wedges in the western community alliances of all sorts, particularly Nato, to sow discord among allies, to weaken the United States in the eyes of the people of Europe, Asia, Africa, Latin America, and thus to prepare ground in case the war really occurs.’

Throughout the cold war, the Soviets were virtuosos in creating tensions between allies. In particular, they excelled at the use of ‘black propaganda’: crafting damaging material which purported to be from the other side. These attempts were nebulous and prolonged, and included Operation Neptune, a 1964 attempt to use forged documents with the intention of implying western politicians had supported the Nazis. While this was quickly exposed as a counterfeit, other ruses were more successful. Whilst dezinformatsiya was targeted chiefly at the US, it was largely ignored there until 1980, when a Soviet forgery of a presidential document claimed that the administration was supportive of apartheid. This got some traction in US media, and so appalled president Jimmy Carter that he demanded a CIA inquiry.

In fact, by the 1980s, Soviet disinformation was an old story.

Ladislav Bittman wrote in The KGB and Soviet Disinformation: an Insider’s View, published in 1985 that disinformation is part of what the Soviets called

‘active measures’ directed by the KGB … designed for internal demoralization and erosion of power in targe countries [p 2]

He later wrote [p 48]

Disinformation is a carefully constructed false message leaked into an opponent’s communication system to deceive the decision-making elite or the public.  Disinformation can be of political, economic, miliary or even scientific nature. To succeed, every disinformation message must at least partially correspond to reality or generally accepted views….

Then he noted that each message is crafted so that [p 56]

it dissuades leaders of the target country from critical analysis of the deceptive segments.  The overall purpose is not only to deceive but to cause damage to the target.  The victim of disinformation  must be led to inflict harm upon himself, directly or indirectly – either by acting agains his own interests on the basis of spurious intformation or by remaining passive when action is needed.

These elements of disinformation now may seen as echoed in the Russian campaign to manipulate the 2016 and 2018 US elections to favor now President Donald Trump and his supporters, and in some of the UK campaign for Brexit. 

The 2015 Measles Epidemic

As the years passed, and the USSR fell, the notion of disinformation seemed to fall into the dustbbin of history.  Yet, in early 2015, before anyone thought of Donald Trump as a presidential candidate, there was a small US measles epidemic.  In February, 2015, the New York Times discussed the strange inability of some then Republican candidates for the presidency to discuss the issue clearly.

The politics of medicine, morality and free will have collided in an emotional debate over vaccines and the government’s place in requiring them, posing a challenge for Republicans who find themselves in the familiar but uncomfortable position of reconciling modern science with the skepticism of their core conservative voters.

As the latest measles outbreak raises alarm, and parents who have decided not to vaccinate their children face growing pressure to do so, the national debate is forcing the Republican Party’s 2016 presidential hopefuls to confront questions about whether it is in the public’s interest to allow parents to decide for themselves.

Gov. Chris Christie’s trade mission to London was suddenly overshadowed on Monday after he was quoted as saying that parents ‘need to have some measure of choice’ about vaccinating their children against measles. The New Jersey governor, who is trying to establish his credibility among conservatives as he weighs a run for the Republican nomination in 2016, later tried to temper his response.

Then,

Senator Rand Paul of Kentucky, a physician, was less equivocal, telling the conservative radio host Laura Ingraham on Monday that parents should absolutely have a say in whether to vaccinate their children for measles.

‘While I think it’s a good idea to take the vaccine, I think that’s a personal decision for individuals,’ he said, recalling his irritation at doctors who tried to press him to vaccinate his own children. He eventually did, he said, but spaced out the vaccinations over a period of time.

The Times article speculated that

The vaccination controversy is a twist on an old problem for the Republican Party: how to approach matters that have largely been settled among scientists but are not widely accepted by conservatives.

In fact, Mr Christie had walked into a similar controversy earlier, about Ebola:

As concern spread about an Ebola outbreak in the United States, physicians criticized Republican lawmakers — including Mr. Christie — who called for strict quarantines of people who may have been exposed to the virus. In some cases, Republicans proposed banning people who had been to the hardest-hit West African countries from entering the United States, even though public health officials warned that would only make it more difficult to stop Ebola’s spread.

It all seemed odd.  After all, a lot of conservatives up to that time cultivated an image of hard-headed realism. Why would understanding of the favorable benefit/ harm profile of the measles vaccine, or of public health measures used to combat diseases like Ebola not be accepted by conservatives?

A 2018 Study of an Internet Based Disinformation Campaign About Vaccination

In 2018, a study of the role of twitter bots and Russian trolls in online vaccine discussions appeared (Broniatowski DA et al.Weaponoized health communication: Twitter bots and Russian trolls amplify the vaccine debate. Am J Pub Health 2018; 108: 1378-1384. Link here). It was an observational study designed to compare “‘bots’—accounts that automate content promotion—and ‘trolls’—individuals who misrepresent their identities with the intention of promoting discord.”
 
To summarize its methods:

In our first analysis, we examined whether Twitter bots and trolls tweet about vaccines more frequently than do average Twitter users. In a second analysis, we examined the relative rates with which each type of account tweeted provaccine, antivaccine, and neutral messages. Finally, in a third analysis, we identified a hashtag uniquely used by Russian trolls and used qualitative methods to describe its content.

To summarize its results:

Compared with average users, Russian trolls (χ2(1) = 102.0; P < .001), sophisticated bots (χ2(1) = 28.6; P < .001), and “content polluters” (χ2(1) = 7.0; P < .001) tweeted about vaccination at higher rates. Whereas content polluters posted more antivaccine content (χ2(1) = 11.18; P < .001), Russian trolls amplified both sides. Unidentifiable accounts were more polarized (χ2(1) = 12.1; P < .001) and antivaccine (χ2(1) = 35.9; P < .001). Analysis of the Russian troll hashtag showed that its messages were more political and divisive.

The authors’ discussion of results asserted:

Russian trolls and sophisticated Twitter bots post content about vaccination at significantly higher rates than does the average user. Content from these sources gives equal attention to pro- and antivaccination arguments. This is consistent with a strategy of promoting discord across a range of controversial topics—a known tactic employed by Russian troll accounts. Such strategies may undermine the public health: normalizing these debates may lead the public to question long-standing scientific consensus regarding vaccine efficacy. Indeed, several antivaccine arguments claim to represent both sides of the debate—like the tactics used by the trolls identified in this study—while simultaneously communicating a clear gist (i.e., a bottom-line meaning).

Note that they felt these results were applicable to the 2015 measles outbreak:

We recently found that this strategy was effective for propagating news articles through social media in the context of the 2015 Disneyland measles outbreak.

So here we have at least some evidence suggesting that the Russians were mounting a modern version of a disinformation campaign focused on scientific information meant to sow discord in the US and perhaps other developed countries, and to enable its victims to harm themselves or their children by dissuading them from measles and perhaps other generally beneficial vaccination.  Probably because disinformation had largely not been the subject of polite conversation since the fall of the Soviet Union and the disappearance of the old KGB (or at least, its name), US public health authorities and politicians  had failed to critically analyze what was going on.

The 2018 study got a bit of attention, and several authors suggested some responses.  In StatNews Beier and Sullivan suggested lessons learned:

First, we’ve learned that the Russians operate from a playbook that links seemingly disparate events. In the case of both AIDS and vaccine safety, they exploited pre-existing cynicism among groups or individuals outside the mainstream, planting doubts without apparent Russian links. For vaccines, Russians exploited a controversial report in the Lancet (that was later retracted by the journal) to exacerbate skepticism of vaccine safety so more parents would decline to vaccinate their children. (To be sure, the article had already generated home-grown anti-vaccine sentiment in the U.S.)

Second, we need to pay closer attention to public health measures that generate fear among those they are intended to protect, like vaccinations for children or fluoridated water.

Third, we must pay special attention to areas in which the West is widely seen as ‘winning’ compared to Russia — in this case public health — making them targets for disinformation campaigns.

The authors then suggested what should be done:

The federal government must take the lead on alerting the media and the public to the risks of purposefully misleading disinformation attacks. Public officials, including President Trump, must show a greater dedication to truth and facts. Whenever a prominent public official espouses support for baseless science, it helps those trying to subvert democracy. By relying on a swamp of bogus science, Russia has exploited loving parents with false, misleading, and dangerous information.

The federal government needs to work with the tech community to develop programs and algorithms to detect threats to our vital health information infrastructure from harmful lies about public health. Once such attacks are detected, Americans must work together to erect cyberwalls to thwart them.

That seemed well-intentioned, albeit unrealistic.  In particular, why would you expect the Trump regime, which appeared to gain power with the help of Russian disinformation (look here), suddenly turn into a tough, clear-headed foe of such disinformation?

Junaid Nabi in Project Syndicate made some more global suggestions:

health officials and experts in both developed and developing countries need to understand how this online misinformation is eroding public trust in health programs. They also need to engage actively with global social media giants such as Facebook, Twitter, and Google, as well as major regional players including WeChat and Viber. This means working in tandem to create guidelines and protocols for how information of public interest can be disseminated safely.

In addition, social media companies can work with scientists to identify patterns and behaviors of spam accounts that try to disseminate false information on important public-health issues. Twitter, for example, has already started using machine-learning technology to limit activity from spam accounts, bots, and trolls.More rigorous verification of accounts, from the moment of signing up, will also be a powerful deterrent to the further expansion of automated accounts.

Again, this seems well-intentioned.  But why expect social media companies, which seemed to be making lots of money through the viral spread of both information and disinformation, to be so helpful?

Of course, none of that happened. Now we are in yet another measles outbreak, considerably bigger than the one in 2015, with no end in sight.

Discussion

Life used to be so simple.  We used to write about propaganda and disinformation used to market health care goods and services (stealth marketing campaigns), and advocate for policies favorable to private health care organizations, usually under the auspices of pharmaceutical/ biotechnology/ device companies, health insurance companies, and hospital systems  (stealth health policy advocacy and stealth lobbying).  The organization and complexity of stealth marketing, lobbying and
policy advocacy campaigns have often been sufficient to characterize
them as disinformation
For example, we characterized the campaign by commercial health
insurance companies to derail the Clinton administration’s attempt at
health reform in the 1990s, as described by Wendell Potter in his book, Deadly Spin, as just that (look here). 
The tactics employed in that campaign included: use of front groups and
third parties (useful idiots?); use of spies; distractions to make
important issues anechoic; message discipline; and entrapment
(double-think).

While these efforts were done to improve corporate bottom lines and thus enhance the income of top corporate management, at least these organizations had some interest in providing or facilitating health care.

Although I had heard about Soviet disinformation, and even thought that some of the modern techniques used by big corporations for marketing and advocacy were uncomfortably close to disinformation, I, like many others, was not particularly worried about disinformation again used as a powerful weapon by a hostile foreign power.  How naive I was.  

Now we see propaganda and disinformation in the service of hostile and authoritarian foreign states meant to disrupt more democratic governments, whatever the cost in human health and lives.  And we see at best indifference to this problem on the part of politicians who may benefit from such foreign largesse.  (The hope in the StatNews piece that President Trump would become more dedicated to truth and facts was already naive at the time of publication.)

So we may need much more energetic and muscular solutions to the propaganda and disinformation that is now rotting our already dysfunctional health care system.  We cannot complacently expect a conflicted and corrupt government executive to help us.  Health care professionals, and all people who care about health care and the public health are going to have to stop wringing our hands and actually do something.  Or measles outrbreaks will be the least of our problems. 

HCBS Settings Final Rule – FAQ Part IV

To: Provider Directors

From: HFEMSD

The Department of Health Care Policy and Financing (HCPF) sent an Informational Memo to inform providers of Home and Community-Based Services (HCBS) of the issuance of guidance regarding the HCBS Settings Final Rule. Please review the attached Informational Memo and the frequently asked questions (FAQ) Part IV, addressing employment-related services. 

For further information, please see contact information provided in the Informational Memo. 

HCPF Announcement of FAQs

HCPF Settings FAQs Part IV

HHA IDR Committee Meeting

This blog publishes information typically sent through the Health Facilities Web Portal to health care entities regulated by the Colorado Department of Public Health and Environment. Please note that the Web Portal is the official medium for business communication between the Department and licensed and Medicare/Medicaid certified health care entities. Health care entities should continue to monitor their portal accounts routinely.

Statewide Analysis of Women’s Health-The Impact of the Attack on Reproductive Health

Most Restrictive for Sexual Activity
Least Restrictive for Sexual Activity
Access to Abortion Clinics (Citizen
Access.org, 2019)
States with the fewest
number of abortion clinics for the eligible population of females, each with
only 1 clinic: MS, MO, KT, ND, SD, WV
Other states with a dearth
of facilities: AL, SC, LA, WI, UT, TX
These states may have
adequate abortion facilities, based on population but they are not geographically
dispersed: MN, IA, ID, WY, NE, KS, OK, AR, TN, DE, RI, HI
States considered to have
acceptable access to abortion clinics: CA, OR, WA, CO, MT, GA, AK, NC, VI,
MD, NJ, PA, NY, NH, VT, ME, CT
Availability of Morning After Pill
This is commonly known as
Plan B was approved by the FDA in 2011 (Princeton
University, 2019)
Because this is emergency
contraception it must be administered within 120 hours of sperm exposure.
States which do not mandate
information on emergency contraception even in the event of rape: MS, MO, GA,
NC, LA, ND, SD (NCSL.org,
2019)
States permitting
pharmacists to prescribe emergency contraception to women of any age: AK, WA,
CA, HI, NH, NM, VT, ME, MA
States with reporting
mechanisms for hospitals that do not comply with emergency contraception
notification for rape victims: HI, MN, NJ, NM, IL OR, UT, WA, and WI (Washington
Women’s Law Center, 2019)
Birth control RX is mandated coverage for private
insurance
; although self-insured
plans under ERISA are exempt as are religious entities (Laurie
Sobel, 2019)
No mandate to cover RX
contraceptives on government plans in: TX, TN, VI, OH
All other states mandate RX
contraceptive coverage on private insurance plans
Birth control RX is mandated coverage for state
agencies,
except for religious entities
Abortion covered by insurance
(Guttmacher Institute, 2019)
No mandate to cover RX
contraceptives on government plans in: TX, TN, VI, OH
States with limited
insurance mandates to cover abortion: AZ, ID, IN, KS, KY, MI, MO, NE, ND, OK,
UT
These states will not allow
any exemptions for state or private agencies: CO, GA, IA, MT, NH, NV, VT, WA,
WI (Laurie Sobel, 2019)
Medically necessary
abortions must be covered by insurance: WA, OR, NJ, NM, NY, IL, HI, CT, CA,
AZ, AK
Mandated sex education in public schools (Guttmacher
Institute.org, 2019)
These states have no
mandate for sex education in public schools: AZ, CO, FL ID, MA, VI, TX, LA,
States requiring sex
education to be medically accurate and also provide education on sexually
transmitted diseases: CA, DE, DOC, GA, HI, IA, KT, MN, MD, MS, MT, NV, NJ,
NM, NC, ND, RI, SC, TN, UT, VT, WI
Nonprescription birth control measures (condoms) widely available at retail outlets
Some states like TX, AR,
and DE have laws requiring condoms to be distributed by MD’s or
Pharmacists-These laws are typically not enforced. (McDevitt, 2016)
Metropolitan areas
throughout the US have condoms in grocery, drug, and convenience stores.
Individuals can have condoms delivered to their home from Amazon or the Condom
Super Store.com
Adequate supply of OBGYN and primary care providers (Citizen
Access.org, 2019)
Inadequate supply of primary
care for women in: ND, SD, MO, IO, IND, WI, KT, WV, UT, MS, TX, GA, LA
Adequate supply of primary
care for women: WA, OR, CA, NY, MA, MI, IL, PA, NJ, NC, VI, MD, FL