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Global Risk Report: Davos, Trump and Climate Change

During the recent World Economic Forum in Davos, Switzerland, President Trump once again noted his objection to the Paris climate accord.  In an interview with Piers Morgan, Trump again called it a “horrible deal” because, as has been widely reported, climate change or global warming is, per the president, a “hoax” perpetrated by the Chinese.  “There is cooling and there’s a heating – I mean look,” Trump explained to Morgan, “it use to not be climate change.  It used to be global warming.  That wasn’t working too well because it was getting too cold all over the place.  The ice caps were going to melt.  They were going to be gone by now, but now they’re setting records, okay?” 

Trump was asked about climate change because the topic was on the Forum’s agenda.  Not surprisingly, in the days leading up to the confab, climate scientists once again found the proceeding calendar year one of the warmest on record.  NASA ranked 2017 the second warmest since 1880 (or since reliable record keeping began), or after 2016.  NOAA, using a slightly different methodology, ranked it the third warmest after 2016 and 2015 respectively.  Not only were the last three years the warmest on record, the five warmest years on record have occurred since 2010, 17 of the 18 warmest since 2001 and last year marked the 21st consecutive year the contiguous United States had above average temperatures.  Record 2017 temperatures were somewhat unanticipated however because of the lack of an El Niño (or Pacific trade wind), effect that is associated with increased global temperatures.  Because air temperatures are largely determined by ocean temperatures, also not surprisingly the five warmest ocean temperature years recorder have been 2017, 2015, 2016, 2014 and 2013 respectively.  Ocean temperatures in 2017 were exceptionally warm.  Measured as heat energy in Joules, 2017 ocean temperatures exceeded 2015 by 1.51 x 10^22 Joules, or the amount of electrical energy China produces annually.

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The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President

The resurgent debate about President Trump’s mental health prompts me to update a piece I wrote for THCB last June. That piece drew lively comments and debate.

It’s also the one-year mark of the Trump presidency.

As The New York Times editorial page recently asked, bluntly, on Jan. 11: “Is Mr. Trump Nuts?”

Since last summer, that question has gained more traction and spurred more earnest debate. The results from Trump’s medical and “cognitive” exam on Jan 12 are unlikely to quell concern.   (More about those results below.)

Nearly every major newspaper and magazine has run stories. Print media columnists and TV commentators dwell on it constantly.   It’s catnip for late night comedians. It’s been a trending topic on social media for months.   And, of course, it’s a topic of discussion and banter almost everywhere you go.

Lawmakers have finally joined in, too, after reluctance for the better part of 2017. Some even render an opinion publicly.

Articles have begun to pop up in medical journals, too—most recently Dr. Claire Pouncey’s piece in the New England Journal of Medicine (Dec. 27, 2017).

And then there’s the book, which sparked Dr. Pouncey’s piece as well other articles and reviews since it came out last fall.   I’m not talking about Fire and Fury: Inside the Trump White House by Michael Wolff—although that book is certainly relevant in this context.

Rather, I’m talking about The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, edited by Dr. Bandy X. Lee, a specialist in law and psychiatry at the Yale School of Medicine.

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The Individual Mandate’s Dead. What Happens Next?

The demise of the ACA individual mandate, along with Trump’s and Republicans’ efforts to repeal Obamacare in 2017, will trigger in election year 2018 a new phase of the long-running, bitter battle over the fate of ACA, the insurance marketplaces, and the direction of health reform in general.

Surprisingly, the Democrats appear to have the upper hand for the moment.   Republican efforts to repeal the ACA in 2017 were deeply unpopular—only about 20 percent of the U.S. population supported them. Independents and moderate Republicans, in Congress and among voters, were notably opposed. And in the Senate, moderates killed the various ACA repeal bills (albeit by narrow margins).

The Republican tax bill is also unpopular.

Recent special election results in Virginia and Alabama—put Republicans off-balance and on-notice as well. In particular, the Alabama result bends the vote math in the Senate against any repeat ACA repeal efforts in 2018, and very likely beyond.

But, perhaps most surprising, the resurgence of interest in “coverage for all,” universal coverage, and “health care as a right” that started with Bernie Sander’s campaign in 2016 has continued to gain traction, even among some conservatives.

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I Finally Understand US Health Policy

The following exchange occurred during an interview of President Trump with journalists of the NYT:

HABERMAN: That’s been the thing for four years. When you win an entitlement, you can’t take it back.

TRUMP: But what it does, Maggie, it means it gets tougher and tougher. As they get something, it gets tougher. Because politically, you can’t give it away. So pre-existing conditions are a tough deal. Because you are basically saying from the moment the insurance, you’re 21 years old, you start working and you’re paying $12 a year for insurance, and by the time you’re 70, you get a nice plan. Here’s something where you walk up and say, “I want my insurance.” It’s a very tough deal, but it is something that we’re doing a good job of.

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The Entertainment Presidency: A Primer For Health Care Professionals

Many physicians have expressed dismay at the conduct of US president Donald Trump.  But whether colleagues find his politics objectionable or congenial, his conduct bold or vulgar, and the man himself an imbecile or a genius, it is important for healthcare professionals to understand that the Trump presidency is a predictable consequence of our times.  In particular, it is an entirely natural outgrowth of the forms of media that characterize our age.

The Medium Becomes the Message

In 1964, media theorist Marshall McLuhan famously declared the medium the message.  McLuhan argued that the consciousness of a people is more profoundly shaped by media themselves – for example, Gutenberg’s movable print, radio, or television – than by the content they convey.  To understand the character of a presidency, McLuhan would argue, we need to shift our attention from specific policies to the media by which the president operates.

When candidates Abraham Lincoln and Stephen Douglas engaged in their famous 1858 debates for an Illinois Senate seat, broadcast media had not yet been invented, and the newspaper dominated.  As print media, newspaper articles could examine a candidate’s position on an issue in great depth, and 19th century debate audiences expected candidates to develop real arguments for their policies.  As a result, each of the Lincoln-Douglas debates was formatted to last three hours.

Today’s media prefer sound bites.  In fact, McLuhan argued that the medium of television operates “at the speed of light.”  It permits “no continuity” and “no connection.”  Instead, he said, with television, “It’s all just a surprise.”   In contrast to the time Lincoln took to carefully craft his arguments, a television president might be expected to rely less on argument than on astonishment, not taking the time to trouble himself over non-sequiturs and contradictions.

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Repeal and Replace. Repeal and Replace. Repeal …

Repeal and replace.  Simple enough on the campaign trail.  We heard this promise in 2010, when voters gave the House to Republicans.  We heard it again in 2012, when voters gave them the Senate.  Despite controlling Congress, Obamacare remained the law of the land.  Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.

Republicans now have their largest electoral majority in nearly a century, and repeal and replace is spinning its wheels, like an old Pontiac stuck in the snow.

Some think a grand bill is still possible, particularly Senate majority leader Mitch McConnell.  Others are skeptical.  Senators Rand Paul and Mike Lee favor a two-pronged approach: repeal first then repeal later.  Herein lies the problem.  Republicans can’t agree on anything.

Democrats had no such problem in 2010 when they passed Obamacare.  The Bernie coalition didn’t get a single-payer plan as they wanted.  Some wanted higher Medicaid reimbursement for their states, as in the “Cornhusker Kickback.”  But they came together and passed Obamacare, each Democrat getting most but not all of what he wanted.

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Trump’s Brain: What’s Going On?

In late May the science and health news site STAT ran a provocative article titled: “Trump wasn’t always so linguistically challenged. What could explain the change?

Not surprisingly, the piece went viral.   After all, aren’t most of us wondering whether something is up with the President’s—how shall I say it—state of mind, psychological status, character, personality, and yes, mental health?

For over a year, there’s been speculation about this. Most of the talk is loose and politically inflected. But substantive reflections by mental health professionals and serious commentators are on the rise.

At first, media outlets were very careful. They didn’t want to say the president was “lying” let alone possibly crazy.   Their caution was grounded mostly in journalistic ethics and policies. But that caution was also attributable to a thing called the “Goldwater Rule,” which warrants explaining because it infuses this whole issue.

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Medical Associations Non-Pulsed by Trump’s Withdrawal From the Paris Accord

By DAVID INTROCASO

Climate change, or changes in weather extremes, are having an increasingly harmful effect on human health. Last year, the 20th consecutive year in which the US experienced above average annual temperatures, saw increasing instances of heat related ailments and deaths and increases in related exacerbations of chronic, including cardiovascular, cerebrovascular, respiratory and mental health, conditions as well as the spread of climate change-related food pathogens and vector borne diseases, most recently Zika.

One study estimated that absent any adaptation to climate change or disruption we will see an increase of 2,000 to 10,000 deaths annually in over 200 US cities. Worldwide, the WHO estimates 800,000 die prematurely each year from urban air pollution stemming from burning coal, oil and gasoline. Not surprisingly, those disproportionately paying the climate penalty are children, pregnant women, the elderly, the disabled, minorities and the poor. Half of those killed by Hurricane Katrina (responsible for almost half of hurricane related deaths over the past 50 years) were over 75 and black adult mortality was upwards of four times higher than for whites. Half of Hurricane Sandy deaths were of those over 65.

When President Trump announced the US would withdraw from the 2015 Paris climate accord, signed by 195 nations, the news was met with widespread criticism. The president’s own Secretary of State, and former Exxon CEO, Rex Tillerson, opposed the decision.

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Would Repealing the ACA Violate International Law?

Barely one month after a stinging and stunning legislative defeat, President Donald Trump has committed to revising the AHCA and potentially resubmitting it for Congressional approval.

In addition to Democrats and widespread popular opinion against ACA repeal, the AHCA may face another obstacle – international law.

This week the Washington Post’s Dana Milbank reported that the United Nations Office of the High Commission on Human Rights forwarded a four-page letter to the Acting Secretary of State, Thomas A. Shannon, to express the Commission’s “serious concern” that the US was in danger of violating its obligations under international law if the U.S. ratified legislation repealing the ACA.

The letter authored by Dainius Puras, a Lithuanian with the somewhat remarkable title of UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, argues that repealing core elements of the ACA would negatively impact almost 30 million Americans’ right to the “highest attainable standards of physical and mental health”, particularly those in moderate and low income brackets and those suffering from poverty or social exclusion.

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The Return of the Angry Granny State

Texas should call itself The Granny State. That’s because it’s a nanny state in which the public officials who run the place have the values of a tea-totaling, Bible-thumping biddy who knows how God wants everyone to live and can’t resist telling them. No buying liquor on Sundays when people are supposed to be at church. No gambling ever. No whacky-weed for medicinal uses or recreation, even in the privacy of one’s home. No gay marriage, preferably no gays, and no transgender folk deciding which restrooms to use. And, of course, no sex, sex education, birth control, or abortions. Women should have sex only in marriage and then only to reproduce, and those who get pregnant must carry their babies to term, regardless of the consequences for themselves or anyone else.

These religion-inspired policies have served Texans poorly. The state’s maternal mortality rate nearly doubled in just two years after Texas cut its budget for family planning by two-thirds and eliminated funding for Planned Parenthood clinics. It’s now the worst in the developed world, not just in the US. Texas ranks 8th from the bottom in the frequency of STDs and has the 5th highest teen pregnancy rate too. Its 35 births per 1,000 girls aged 15-19 are nearly double the national average. Meanwhile, Colorado and other states have achieved miraculous reductions in teen pregnancy rates and abortion rates by providing young women with long-acting contraceptives, like implants and IUDs. If Texas is following God’s plan, then God’s plan is a bust.

Now Granny is once again sticking her nose where it doesn’t belong. Currently before the Texas legislature is Senate Bill 25, which would eliminate the wrongful birth cause of action that the Texas Supreme Court recognized four decades ago in Jacobs v. Theimer. The facts were as follows. While traveling, Dortha Jacobs became ill. Upon returning home, she consulted a physician, Dr. Louis Theimer, who discovered that she was newly pregnant. Fearing that the illness was rubella—also known as the German measles—Jacobs asked Dr. Theimer if there was reason for concern. Rubella can injure a gestating fetus severely. Dr. Theimer told her not to worry, but he did so without performing an available diagnostic test. In fact, the disease was rubella and the child “was born with defects of brain, speech, sight, hearing, kidneys, and urinary tract,” among others. The medical expenses were extraordinary.

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