Opening Elementary Schools Might Make Sense In Covid Time

The original post is this note from Dr. Hoeg.  Her reasoning, while sound at the time, might be faulty, in that the New York Times reports that children have been now shown to harbor large loads of the virus in their nasal mucosa - see here


From Tracy Hoeg MD PHD: (UC Davis)

I wanted to give an update on the research regarding COVID in children. 

I should back up briefly and state that I am a physician with a PhD in Epidemiology who became very interested in this topic when a colleague and friend of mine, Jennifer Kasten, MD MSc, wrote a systematic review of COVID epidemiology in children (https://www.facebook.com/jenniferkastenmd/posts/128898328763114) and found kids 12 and under *might be viral "dead ends", meaning they can get COVID but can't transmit to anyone else. This really captured my interest because this would make COVID very different from most respiratory viruses we know. Then in a physician's group dedicated to school opening, a physician researcher published a document for the group in which said she could identify 0 (zero) cases of certain transmission from children under 12 in the scientific literature and since that time Dr. Rutherford, UCSF Epidemiologist, has also been public about elementary-aged children being a "one way street" for infection - they get it but don't appear to transmit it, much, if at all. (UCSF Grand Rounds lectures are now available on YouTube for those interested in hearing him).

Last month, I did my own summary of the data (https://www.facebook.com/tracy.hoeg/posts/10219217323357158) and found evidence of the following:

*Very limited transmission if any from children ages 12 and under to either other children or adults

*Children appeared to be at least 10 times more likely to die of influenza than Covid and are more likely to be struck by lightning (I rechecked the CDC website today 7/13 and they are still reporting 3 deaths in children under 18 due to confirmed COVID; for comparison, there have been 185 deaths due to influenza in this population in the 2019/2020 season. If anyone has an updated death count in the pediatric population due to COVID, please share).

*Countries that reopened elementary schools as a first step in their country's reopening did not see an uptick in cases (these include numerous European and Asian countries, some of which are displayed in Figure 4. Reopenings not causing and uptick in cases is consistent with children not being a major vector for the disease. Figure 3 shows age of the source of the cases of COVID in Holland, with none ages 18 and under in their study, as just an example of these data. 

What have we learned in the last month?

1. We now have a generally accepted mechanism for younger children getting milder disease and transmitting significantly less than adults, which is paucity of ACE2 receptors in the respiratory tract compared with adults (this is the receptor SARS COV2 uses to enter the cells of the body). This could explain why children get COVID less, have milder disease (lower viral load) and are less contagious (if contagious at all). Yet another way COVID is unlike typical influenza! https://jamanetwork.com/journals/jama/fullarticle/2766524

(Figure 2)

2. Consistent with this was the study showing lower viral load (lower amount of the virus) in children up to age 18. (Figure 1). The original non-peer reviewed print of this article from Drosten et al was reanalyzed as per UCSF Grand Rounds and does indeed show significantly lower viral load in children as seen in image 1. 

3. This is great news for teachers and children, because not only are children significantly less likely to transmit COVID, but IF they do, the dose of the "inoculum" will be expected to be lower and there is mounting evidence (though inconclusive at this point) that the lower the dose of the virus you get, the less severe your disease will be if you even get symptoms at all (https://www.reliasmedia.com/blogs/2-hicprevent/post/146456-Public-Masking-Could-Save-Lives). This may be why Denmark and Norway were able to reopen elementary schools without any mask wearing in children (or adults for that matter!). Now if there IS mask wearing in the US by either children, adults or both, that would make both transmission even less likely and possibly the severity of the disease will be less if it does occur (interesting non peer-reviewed study showing inverse correlation between mask-wearing and mortality rate: https://www.medrxiv.org/content/10.1101/2020.06.22.20137745v2)

4. I am sensing many of your are STILL skeptical we can safely open elementary schools in the US. Well, thankfully we have really good data from the YMCA childcare for essential workers in the US, which has been providing childcare throughout the pandemic (our kids go there) and was even open in NYC at the height of the outbreak and they have had 0/>40,000 kids (ages 14 and under) contract COVID. They have also not had any outbreaks, though a few staff at different sites tested positive (presumably contracted from another adult per the above data) and quarantined so no more than 1 positive case a just a limited number of sites. Adults wear masks, kids don't, temperature checks at the door, each kid has a small "cohort" of kids they do everything with. More details can be seen in this article, but it shows that WE CAN DO THIS SAFELY in the US - even in areas hit severely by the virus and with truly minimal resources. https://www.npr.org/2020/06/24/882316641/what-parents-can-learn-from-child-care-centers-that-stayed-open-during-lockdowns 

Edit: The small cohorts in children may actually not be necessary and the data I am using to support this is guidelines for return to school in Holland in quotes below and from their Ministry of Health Website (https://www.rivm.nl/en/novel-coronavirus-covid-19/children-and-covid-19). This model has worked for them:

"Children up to and including 12 years of age do not have to keep 1.5 metres apart from each other and from adults. This also applies to childcare and primary education.

Young people aged 13 until 18 years old (i.e. 17 years old and younger) do not have to stay 1.5 metres apart from each other. In secondary schools, this applies to all pupils, regardless of their age."

--I also want to briefly address the many "clickbaity" articles in the popular press lately about school and day care outbreaks. Specifically I will mention the school outbreaks in Israel where there were some infections in high school aged children but the "outbreaks" in the elementary schools were among adults only. Also, if you carefully look at the reports of day care outbreaks in our country, most appear to be involving staff that infect each other and, if kids are affected they are infected by the adults and are asymptomatic/have mild disease. I challenge you all to look at the articles coming from the popular press with the above data in mind and you will be surprised in the elementary age group that the adults appear to be the ones responsible for the outbreaks (though it is hard to get all of the info from those articles) and the ones who are severely affected by the disease.

--What are the bottom lines?

1. Kids 13-14 and below (likely around puberty) do not appear to be driving the spread of COVID. They rarely (one can never say never) transmit the disease. Tracing the source case with 100% certainty can be very challenging, but the data overall indicate pediatric transmission to be quite rare compared with adults.

2. Kids up to 18 years of age tend to get mild disease if any symptoms and death in this age group is less likely than getting hit by lightning. 

3. In school settings, adults can and will give to adults and kids, so teachers need to be socially distancing while at work. Adults also should be wearing masks and getting tested and staying home if they have symptoms. 

4. Data and guidelines from Holland suggest distancing among children <19 and="" as="" be="" been="" children="" countries="" div="" economy.="" even="" first="" has="" in="" it="" masks.="" may="" necessary.="" not="" of="" opened="" out="" pointed="" reopening="" scandinavia="" schools="" should="" step="" successful="" that="" the="" their="" these="" wearing="" without="">

5. I have previously discussed the many downsides of not having kids in school in person this fall: further entrenching socioeconomic disparities, job loss for parents who can't afford childcare worsening poverty and neglect, abuse of children (which will be underreported), lack of support for children with special needs, anxiety, depression and lack of physical activity and peer relationships in children. The list goes on and on. But I want this post to focus more on the science of the disease so it can inform our public policy decisions.

6. I hope the above data are reassuring. The more we know, the better we can tackle and live with this disease.

Edit: Now that this post has been shared hundreds of times (never imagined this), I want to say first of all, that I in no way am intending to detract from the seriousness of COVID-19. It is imperative our country get this disease under control -by social distancing, closing indoor businesses which are not essential, wearing masks, etc, but the above data at least suggest to me that children are not driving the pandemic; adults are. And I also want to say that a lot of what I shared above was recently discussed in the UCSF combined Medicine and Pediatric Grand Rounds lecture (an inspiration for me to write this to get this scientific info to the public). I encourage anyone interested in the above data to watch this recording of the Grand Rounds : https://www.youtube.com/watch?v=yh9gmca6o_A&feature=youtu.be&fbclid=IwAR2HH3myAdjOBmebb23iI2DWPSkdYrEp2niYa_KRiwWStxrqN5f6JNxXPD4

And this article about the above UCSF physicians' stances on reopening schools and transmission in children: https://missionlocal.org/2020/05/ucsf-medical-grand-rounds-the-doctor-is-ready-to-send-children-back-to-school-with-care/

I welcome any data or questions you have. The science about COVID in pediatrics is evolving and we don't have all the answers (far from it), but I hope people can use the above data to help them make informed decisions about children's activities and school openings. 

Now in my OPINION- elementary school is an essential service of a country. All other first world countries prioritized opening their elementary schools BEFORE their economies. When one considers the number of couples or single parents who are essential workers, or now working again in the US, with kids too young to watch themselves - I ask you- where will they go if not to school? And will the alternative be better?  These children with either be 1. in school, 2. in a day care (IF their parents are privileged enough to afford this) or 3. neglected/potentially left alone at home and not learning and without their usual resources. It is our job together as American people to figure out what is in the best interest of all our children (regardless of socioeconomic status) - they are truly the future of our country and figuring how to open schools safely is infinitely more important than reopening Disney World (WHY is this open??). I hope we can use the above data and strategies of other countries (as well as our own YMCA daycares!) that have successfully managed this pandemic to guide us. Having NO plan for how to most safely open our elementary schools is not an acceptable modus operandi for our country.

*********************************************************

Edit to add new data:

7/16: In Germany, a study of over 2,000 children: "Scientists from Dresden Technical University said they believe children may act as a “brake” on chains of infection." https://news.yahoo.com/german-study-finds-no-evidence-164704005.html

7/16: Study performed by the Swedish and Finish Ministries of Health "closure or not of schools had no measurable direct impact on the number of laboratory confirmed cases in school-aged children in Finland or Sweden. The negative effects of closing schools must be weighed against the positive indirect effects it might have on the mitigation of the covid-19 pandemic." https://www.folkhalsomyndigheten.se/contentassets/c1b78bffbfde4a7899eb0d8ffdb57b09/covid-19-school-aged-children.pdf

Two Things I Was Thinking

Memory is a funny thing.

When we get older, some of us wish we could remember more.

And some of us wish we could remember less.

I guess either.  Or both.

I feel lucky to be alive.

I'll miss it when I'm not.

Budd Shenkin

My Anti-Trump Ad

What was he told and when was he told it?

Starting in December of last year, the intelligence agencies and the CDC started alerting Donald Trump to the impending Corona virus epidemic. They knew what was brewing, no matter what China or the WHO were saying or were not saying. Even though Trump had disbanded the pandemic alert and pandemic response team, even though Trump had, very unwisely and against advice, removed Americans from on the ground surveillance of Chinese viruses, still, our intelligence services knew.

They tried to tell the President. They tried to brief him. They sent him warning messages. They included the warnings in the Presidential daily briefings which the president does not read, but which officials try to read to him, as they try to point him in the right direction.

Instead, the President didn't read the messages, didn't listen to the warnings, and ignored the impending danger..

When cases started to appear, officials tried to warn him again. They tried to get him to act, to get testing materials – but he rejected their advice. He turned down the tests from WHO that other countries accepted and used. He didn't give the hurry up order to CDC to get our own testing in order. CDC under the leadership of his personally chosen commissioner failed miserably to produce tests. When universities and companies wanted to develop and use the tests to detect where the disease was and to take steps to stop it in its tracks, Trump's administration stopped them from doing it.

Without tests, for long months as people were infected and died, we were prevented from stopping the infection because we couldn't test to find out who had it, and where they were. Other countries like South Korea, Taiwan, New Zealand, and Denmark knew just where the infection was and who had it, and they held their countries deaths to very low levels. Under Trump, the United States has been the biggest failure in containing the virus in the entire developed world. He has been the world's biggest loser, which means that our people have had more infections and more deaths per capita than anyone else.

When Trump was urged to get American industry to produce and stockpile ventilators and protective gear to keep healthcare workers and others safe, he refused to do it. Instead he turned to his son-in-law, Jared Kushner, who had convinced him that he could import and distribute everything necessary on his own. He failed, although he was able to let giant contracts to his friends, who couldn't come through, but did manage to go to the bank.

Trump failed at the start, and he continues to fail to meet every challenge that the corona virus presents to us, so the United States' pandemic spread is the worst in the Western world. We have more cases and more deaths per capita than virtually any other advanced country.

It's his fault.

The main job the President has is to keep Americans safe.

Some people hate Donald Trump. Other people love him. But one thing we can all agree on. Donald Trump is really bad at his job.

Post Trump Reforms - David Frum Weighs In

When I heard that David Frum had a new book coming out, Trumpocalypse:Restoring American Democracy, I was excited. I like Frum, he's very smart, regularly has original ideas, has a nice sense of humor, and he's interested in just what I am – Post-Trump Reform. So I preordered and read it right away. And sure enough, he has an acute analysis of Trumpism, an acute analysis of our current troubles, and some ideas that I hadn't thought of. Although I have to say, without being too competitive with a very smart guy who does this for a living and has done so for decades, I've had some ideas that he hasn't thought of. (Especially reforming the presidential power of the pardon.)

I agree with the bulk of Frum's analysis, which is not far from my own. We both agree that post-Trump reforms are likely, comparing the post-Trump environment to that of post-Watergate. He says: “Democracy is tested by its ability to deliver security, prosperity, and justice. Relatively modest reforms to the US system could improve all those outcomes. This is not to negate the value of bigger ideas: changes to the voting system, changes to the campaign-finance system. But those things are hard to do.”

While he has some specific suggestions for changes, in general, he hopes that Americans will come to their senses after Trump, and that the new victorious forces will seek reconciliation rather than revenge, except for the leaders who will deserve opprobrium and often appropriate punishment. For two good summaries of what he says, check the book reviews in the WaPo and the NYT.

Although he doesn't dwell on it, it's interesting to look at the reforms he does offer. Let me recall the six tools and the eight problems I identify in my basic post, keeping in mind that one of the tasks of reform will be to turn some of the former norms into new law.

The six tools:

• Constitutional amendment
• New Legislation
• Presidential executive action
• New interpretation or resuscitation of existing congressional power
• Reassertion of norms or declaration of new norms
• Efforts to affect public opinion

The eight problems:

Problem #1 – Attacks on oversight

Problem #2 – Attacks on fair electoral processes

Problem #3 – Abusive extension of presidential powers

Problem #4 – Department of Justice has come under complete control of President

Problem #5 – Corruption and conflicts of interest are rife

Problem #6 – Extensive inattention and incompetence in directing basic governmental functions

Problem #7 – A coarse, mendacious, thuggish, racist, cynical and dictatorial demeanor and tone

Problem #8 – Population of the United States widely ignorant of governmental processes and concepts

Here are Frum's observations and suggestions as they apply to these problems.

#1 – Attacks on oversight. Frum takes this on on page 37. “The Trump years demonstrated the very great extent to which presidential cooperation with the law is voluntary, especially if he or she retains a sufficient blocking vote in Congress.” But then he says there really isn't much we can do about it, that enforcing subpoenas is very difficult, and “even outright lying to Congress can prove exceptionally difficult to punish.” Then, “...there is no 'Congress' anymore; there are only the two parties in Congress.” And then, “The system that protects all of us has failed because the protectors of that system have failed to protect it for us. Democracy does not fly on autopilot.”

Frum doesn't offer a ready remedy in law, although it's clear he wishes Congress had more backbone and independence. As I detail in my post, I think the Congress could and should be more assertive. You can't leave oversight to norms, you need law and muscle.

#2 – The electoral process. Frum spends a great deal of attention on this. Although he doesn't mention it, the great Yale political scientist Robert Dahl predicted that the Connecticut Compromise (two senators per state and the electoral college, both favoring small states power) and the undemocratic elements of the constitution would lead increasingly to trouble. Frum gives statistics that show a gathering skew of these elements – particularly the increasing frequency of electing a president with a minority of votes - and how the skew plus filibuster rules plus gerrymandering ensure continued minority rule and governmental stasis. His fixes are:

• Nuke the filibuster. The filibuster enables 16% of Americans (small states count as much as large states in the senate) to block action by 84%. Just vote it down with a Democratic majority.
• Adopt a modern voting rights act. He includes issuing tamper-proof voter ID for free to all citizens, aqnd making fair and equal the location of voting installations, voting technology, and waiting times at the booths.
• Deter gerrymandering. Here Frum is quite innovative. He says: assume the Democrats win preponderantly. Then offer Republicans two maps of voting districts, one the way the Republicans would draw one if they were in power, and the other one done fairly. He has no way then of ensuring that the next set done 10 years later would be fair if the Republicans win, and seems to count on the moral virtue of reciprocity. Ingenious, but I'd reject it. First pass a statute for independent boards to draw districts in all states, and then set the districts.
• Statehood for the District of Columbia. Now, that's a surprise! He points out that this can be done easily by a simple majority of the House and Senate and a presidential signature. This would help redress the structural strength of the preponderance of small state Republicans. Pretty good move, I'd say. He said in a radio interview that he wouldn't do the same for Puerto Rico because of a substantial independence movement there, which I understand, but it seems to me a quick referendum in Puerto Rico could change that decision quickly. My hesitation would be more about the nature of a nation; language is important to carry culture, and Puerto Rico's language is Spanish.

#3 Abusive extension of presidential power. I think his hope here is that better people will be elected president. I have several suggestions here, including that the constitution be modified to require the presidential pardon to be cosigned by the Speaker of the House. That one would probably be dismissed by Frum as too long-term, but then again, if Trump really goes wild with it as expected, I would contend that it might not be so long-term at all. It could sweep the country like the wind.

#4 Department of Justice repair. Frum recognizes the importance of this problem and proposes that the assistant attorney general for the Criminal Division be changed from a political to a career job. He is deterred from seeking a fully nonpolitical criminal justice system at the federal level because of the bureaucratic constraint – career bureaucrats are not paid enough to attract the very best, and to change the pay structure of DOJ would wreck havoc with the rest of the bureaucracy.

I see his point. In fact, the point is applicable throughout the government, and the quality of government standards of work reflect it. It might be a good idea to start with DOJ, make it a hybrid of regular bureaucratic structure for regular staff, and make the top professional staff above supergrade (GS18) with the expectation that they would elect to stay for long periods of time, and make them dismissible by combined action of the White House and the congress. Then other governmental units could be looked at for a similar structure. But, this would take time. For the moment, some serious personnel housecleaning and restaffing would be necessary. Or, as I suggest in my post, find a completely new way to insulate the DOJ. This comes under the category of bringing norms into legislation.

#5 – Corruption. Frum suggests as I do that tax return transparency be mandated, with more extensive, explicit, and modern financial statements. He compares the bank mandate to “know your customer,” which seems like a valid comparison. We are on the same page here.

#6 Poor direction of governmental functions. Anne Applebaum calls this “a three-year assault on professionalism, loyalty, competence, and patriotism.” Frum sees this, too, of course, but his solution is find a better president, which is hard to argue with. My suggestions bear on increasing transparency and putting Congress on record as approving or disapproving current operations.

#7 Thuggish demeanor and tone. Frum certainly has an exquisite distaste for this vile aspect of Trump, but once again, he thinks Americans simply have to come to their senses. He's right, they do. My idea is that they need help to do so, which would be helped by extensive education in civics.

#8 Population ignorance of governmental processes and concepts. Frum doesn't deal with this. I think it requires a major effort of public education in the schools with three years of civics required.

I liked the book. Frum is smart and an excellent writer. His ideas on #2, the electoral process, are quite good. I would add those to our list of possible solutions to these important problems. Likewise on his suggestion on #4, how to fix DOJ. I think his ideas about how people should appreciate more what good government is like is right on, although I don't think he's got great ideas about how to get there. His analysis of the current situation is penetrating, better than he is on solutions. Read it to your profit.

Budd Shenkin

Post Trump Reforms -- Executive Summary

Planning For Post-Trump Reforms

Executive Summary

This paper examines what might be done to reestablish and solidify American liberal democracy and our system of checks and balances if Trump is defeated in November.

The tools for reform are:

• Constitutional amendment
• New Legislation
• Presidential executive action
• New interpretation or resuscitation of existing congressional power
• Reassertion of norms or declaration of new norms
• Efforts to affect public opinion

Problem #1 – Attacks on oversight

Possible Solutions – Strengthen laws for disclosure of materials and witness testimony, with specific instances and time limits, expedited review by SCOTUS in executive disputes, Congress declare intention to use Sergeant at Arms and imprisonment for witnesses who do not obey subpoena.

Problem #2 – Attacks on fair electoral processes

Possible solutions – New legislation detailing forbidden foreign interference acts with stronger penalties, rewards for whistle-blowers, penalties up to decertification of election. Federal standardization by constitutional amendment of state laws on gerrymandering, voter role purging, voting methods. Reinstate pre-clearance in Voting Rights Act, reform Federal Elections Commission. Increase sanctions for election violations by officials.

Problem #3 – Abusive extension of presidential powers

Possible solutions – Many measures are suggested, including constitutional amendment requiring Speaker of House co-signature for pardons; requiring IG firings be for cause; time limits for “active” status; legislation to protect judges from intimidation; specific legislation forbidding nepotism; putting teeth into the Hatch Act; and a constitutional amendment prescribing penalties for crimes against humanity and genocide. Invention is also called for to produce presidential sanctions north of censure but south of impeachment. This problem is so important that major efforts in public education and a high-level commission should be considered.

Problem #4 – Department of Justice has come under complete control of President

Possible solutions – DOJ's norm for independence and protection of the constitution should be regularized by law, perhaps constitutional amendment, making it quasi-independent. The 1973 decision that a President cannot be indicted should be reversed. A special commission would probably be warranted.

Problem #5 – Corruption and conflicts of interest are rife

Possible solutions – Very specific new laws are required, compelling submission of tax returns and financial statements, spelling out the details of forbidden emoluments, and ethics offices need to be strengthened and reorganized to represent both legislative and executive branches with much stronger investigative abilities.

Problem #6 – Extensive inattention and incompetence in directing basic governmental functions

Possible solutions – Transparency is the key. Reports need to be full from departments to congress, and response of congress needs to be public as well. Science based agencies might have senior semi-independent science boards to enforce that science not be compromised.

Problem #7 – A coarse, mendacious, thuggish, racist, cynical and dictatorial demeanor and tone

Possible solutions – Make the Trump experience an educational opportunity to highlight the difference of democracy and autocracy, and the characteristics of a demagogue, while continuing to explore publicly the basis for the obvious resentments harbored by Trump supporters.

Problem #8 – Population of the United States widely ignorant of governmental processes and concepts

Possible solutions – Epic educational efforts required, with mandatory civics classes for three years in middle and high school, funded by federal government.

The Realities of Reform

The closest precedent for the Trump administration is probably Watergate. The strength of the Watergate reforms was their thoughtful changes of procedures and laws that have been lasting, and the fact that the perpetrators, except for President Nixon, received penalties of justice that included prison sentences. By contrast, Iran-Contra perpetrators received pardons that short-circuited the course of justice, and those transgressions have receded into memory with few consequences. Pursuing reforms with vigor, and allowing justice to take its course unimpeded, is certainly indicated, and would be more important than the risk associated with a precedent for persecuting the party out of power. We would be lucky if the post-Trump reforms were as significant as the Watergate reforms.

The longer article is here.

Planning For Post-Trump Reforms

It is hard not to think that the Trump administration represents a major inflection point in American history. If he is reelected, will anything ever be the same, either the specific policies (health, environment, immigration, tax, etc,), or the ability of government to act competently (COVID 19 being only the latest and most blatant example), or our very mode of government (liberal democracy vs. populist authoritarianism)? On the other hand, if he should be rejected, what steps will be necessary and possible to take us back from the brink?

Should Trump be defeated for reelection, it's not clear what steps the new administration would take. It would depend on the situation – what's happening with COVID-19 and the economy, for one thing; how the Democratic coalition shakes out, for another; and how big the Democratic victory is, for a third. But no matter what the unknowable future holds, it will be a good idea to be ready for it with plans to achieve reform.

Certainly, many, many substantive policies will need to be reversed, revised, rethought, and reestablished, and many new ones instituted. But as hugely important as that will be, I want to concentrate instead on what might be done to reestablish and solidify American liberal democracy and our system of checks and balances. Trump checks every box to qualify as a would-be populist authoritarian, so it is no exaggeration to say that what he has done is a threat to our system. (see Levitsky and Ziblatt).

We know, of course, that the constitution is really an outline, and that the functioning of our government evolved with laws and norms adopted through the years, as our people and conditions and understanding have changed. So as singular as this time feels, it's one of a series – think Civil War, Depression, Watergate. Maybe this time the adjustment won't be as big as those were, but it will quite possibly be significant.

One more point before we launch into examination of the Trump innovations and possible responses. If reforms are to be effected, it's a good idea to remember what tools are in the toolbox. I think these are the major ones:

• Constitutional amendment
• New Legislation
• Presidential executive action
• New interpretation or resuscitation of existing congressional powers
• Reassertion of norms or declaration of new norms
• Efforts to affect public opinion

Trump Transgressions and Possible Solutions 

 

Problem: Trump's attacks on oversight, by congress, Inspectors General, ethics units, and other bodies, has been devastating. He has ignored requirements to supply documents, has blocked testimony from employees and former employees, has retaliated against those who do testify, has dangled pardons for those who are non-compliant with law enforcement, has sought to publicly identify whistleblowers, has fired officials not compliant with his demand for loyalty to the person of the President, and has claimed immunity not only from indictment, but even from investigation. Congress has been hamstrung in enforcing its rights, partially because of Republican connivance, but more decisively because disputes between congress and the White House have been tied up in lengthy court proceedings, showing graphically that justice delayed is justice denied. Just the most recent incidence of escaping oversight has been his dismissal of legislative oversight on the corona virus rescue package, both by declaring he has no intention of abiding by the law, and then dismissing monitors who might be independent and replacing them with loyalists.

Possible Solutions: There are already laws on the books for disclosure of materials and witness testimony that Trump is flagrantly disregarding and contesting. These laws should be made even stronger, with time limits given along with concrete examples of what materials and witnesses congress is empowered to command, including grand jury testimony. Should there be a dispute, there should be mandatory rapid review of disputes by the Supreme Court. Congress could also declare its intention to use its power to compel directly, specifically including using its Sergeant at Arms to jail subpoena resisters. 

 

Problem: Trump has notoriously attacked the electoral process itself by allowing and soliciting foreign interference. A longer standing problem not directly attributable to Trump has been actions in the states to suppress the Democratic vote, such as purging voter rolls, gerrymandering, and limiting time and place for voting.

Possible Solutions: Legislation should supply clarifying and precise language for the constitutional prohibition on foreign interference, and sanctions other than impeachment should be prescribed for violation, including fines and jail for perpetrators, rewards for whistle-blowers, and possibly even including decertification of the election. Stronger laws and probably a constitutional amendment are needed for the federal government to intercede on state-run elections and set standards. New evidence and arguments need to be brought to the Supreme Court to reinstate pre-clearance established by the Voting Rights Act. The Federal Elections Commission needs to be resuscitated, with steps taken for appointment of commissioners with long terms, high ethics, and a new process of appointment. Sanctions for election law violations by officials or those associated with officials need to be increased, including jail terms. 

 

Problem: Trump's concept of presidential powers is so extreme, even in the era of the Imperial Presidency, as to constitute a qualitative change that many have rightly judged to bring the powers of the office close to those of a king. Typical has been his misuse of the pardon; his use of demotions, transfers or dismissals of Inspectors General and those who testify against his will; transfer of monies illegally from one intended use to another (from defense to the wall); overuse of the “acting” status; tolerance of violations of the Hatch Act; not to mention blatant nepotism. These are just examples. 

 

Possible Solutions: Many individual acts of reform, bolstering the clear intent of the constitution, are possible. For instance, reforming the presidential pardon by requiring a cosignature from the Speaker of the House is an attractive option. Requiring that demotions, transfers, or dismissals for IG and other posts to be “for cause” would be protective, as well as giving fired IG's a private right of action to sue for reinstatement, which would force the President to show cause for the action in court. Putting a time limit on officials serving with “acting status” should be considered. Legislation on Presidential intimidation of judges and suborning defiance of judicial decisions should provide a basis for indictment. Forbidding federal employment of relatives of the President and high officials unless they were in place beforehand could be enacted. The Hatch Act should be strengthened with significant penalties prescribed. Adding prohibition of crimes against humanity (children in cages, defying international law on asylum) and genocide, and making that a basis for both impeachment and indictment in the United States and in the International Court of Justice, would be an admirable constitutional amendment.

More generally, it seems that we need to invent penalties for presidential infractions north of censure but south of impeachment in an era when “name and shame” cannot deter the shameless. An example might be that, should a president be found culpable of a significant deviation from law, but one that did not reach to the level of meriting removal from office, that a monitor be appointed who would have real time access to the actions in question and real time ability to transmit this information to congress, which would then have the ability to suspend the President's authority in that field. This would be an extreme change from the present, and might not work out, but something has to be invented to provide something more forceful than shaming and less extreme than impeachment. We don't know now what that something might be. 

 

This issue of abuse of power, however, is one where extensive individual repairs and bolsters might not be enough. Beyond individual fixes lies the more general issue of the gestalt of the Presidency and the gestalt of the interactions of the branches of government. Maybe a commission is needed to highlight how things should work, to make the norms very clear. A high-level commission with a report to the nation, then endorsement by both houses of congress and the President, might have a lasting effect. Commentaries on basic documents and prescriptions for action based on those documents has precedent in many religions.

Problem: The Department of Justice has become a political arm of the President to excess. Especially since the appointment of William Barr, it has misrepresented the Mueller Report and discredited its findings, it has dismissed long time high career employees for fabricated reasons, and it has opposed and ignored House of Representatives notices and requests in a most political way. It has acted increasingly and startlingly as a personal arm of the President, and indeed both Trump and Barr have expressed sentiments indicating that that is the way it should be.

Possible solutions: Although it is a relatively modern innovation for DOJ to be regarded as non-political, the new post-Watergate norm of DOJ's working for the constitution and the people rather than the President should be institutionalized, maybe even by establishing it as a quasi-independent body. Legislation rejecting the 1973 DOJ finding that the sitting President cannot be indicted would be an essential step. This matter of the norms of DOJ attitudes and actions is so important that it, too, could well be the subject of a special commission, which would then produce a document that would guide actions in the future, although not by specific rules.

Problem: Out and out conflicts of interest and corruption are rife in the Trump administration, many of them abetted by nepotism. Financial documents such as tax returns have not been submitted as is customary, financial statements have been so lax as to have necessitated innumerable filing of additions (with no penalties for the “incompleteness”), relationships with foreign entities with extensive prior and current relationships with the President and his family and other officials have been extensive and secret. Presidential properties have benefited from US government payments, and staying at Trump properties has apparently been de rigueur for those who would do business with the government. Ethics violations have been rife, and ethics officials have been summarily replaced by loyalists. The Department of Justice has been inactive in this sphere. 

 

Possible Solutions: Tax returns and detailed financial statements need to be required on an ongoing basis of all top officials, and then be available publicly. High public officials in all branches should be forbidden from trading in individual stocks. Other activities need to be specifically delineated as prohibited, with illustrative examples, many of which would be available from this administration. Stronger investigative efforts independent of the President need to be institutionalized. Ethics officials are now spread out among agencies, many can be dismissed at the President’s pleasure, and the President is insulated by having a White House ethics operation that, if staffed by loyalists, insulates the President from true investigation. Legislation might instead establish two separate Commissions on Ethics, one in the Department of Justice and the other in Congress, with a strong liaison between them, and with connections to the IG’s and independent means of enforcement. Independence and transparency would be key.

No doubt investigations will find illegal activities in the Trump administration. But just as important are those activities that are legal but shouldn’t be. This would be a perfect time to attack this issue head-on, and to pass very specific laws making illegal specific acts and practices, and prescribing financial and incarceration penalties. It would seem that many younger members of the House might be perfect members of a committee with this mission.

Problem: Beyond disagreeing with prior objectives of governmental officials, the Trump administration has often simply declined to do its duty in operating them (see The Fifth Risk by Michael Lewis). The simple ability and will to operate the functions of government has been deficient as never before.

Possible solutions: Transparency might help with this: all cabinet departments report their activities to Congress each year. Congress might be compelled to issue a responding document where they must go on the record as accepting some and rejecting other contentions, and the documents would be public property. Furthermore, the departments dealing with science might be required to have professional panels of senior respected officials who would sit in scientific judgement on the department and be able to accept information from internal personal on an anonymous basis, with public disclosure of their findings, and powers of inquiry. 

 

Problem: The coarse demeanor, unbridled mendacity, elevation of thuggish behavior, racism and support of white supremacy, and preference for dictators as friends and preferred allies is informal, not illegal, but very destructive. The moral ideals of a nation are important, even when we know that hypocrisy is a frequent companion. Cynicism is the enemy of good government and a progressive future. The problem here is that the Trump base often thrills to this rebellious quality of Trump, and many of them feel that his posturing embodies many of their own resentments of their life’s frustrations.

Possible solution: It would be a mistake to bless the election and move on without examining this phenomenon. It should be taken as a learning and educational opportunity, rather than simply a chance to condemn and boast that “we won.” Finding a way to examine and meet the grievances directly, finding a way to respond to those who represent these issues in a less-threatening and more decorous way, and strengthening laws that prevent intimidating and hateful behaviors and supporting them with fines and arrests, would be an admirable pincer movement. 

Problem: Large parts of the public are either ignorant of the basics of civics education, or are inattentive. Democracy requires that voters have information on which to base their votes, and that they be educated to know how to judge this information. They need to know what a President is required to do and how he or she might be prepared to do that, and they need to know how our liberal democracy works in theory and practice. They need to know how a democracy differs from an autocracy, and the definition of a demagogue. 

 

Possible solution: In a country where perhaps a majority of citizens cannot name the three branches of government, and where civics education has drastically declined, nothing short of a major effort at civics education is necessary. This effort might include a requirement of civics and American history classes for three years in middle school and high school, with the Department of Education leading the efforts to produce the necessary materials and supplying generous funding, national awards for excellence, and special teacher stipends.. There are a myriad of programs that can be imagined. The project needs to be made a high priority and acted upon.

The Realities of Reform

These are just ideas of what might be the elements of a Post-Trump reform. Who knows what will be possible and which items will receive the highest priority when conditions change? Reforms will be dependent on the will of the people as expressed in the November election, and events as yet unforeseen.

It’s always a good idea to visit “the last time this happened.” The most obvious analogy to our present situation might be Watergate. There are obvious similarities in both the flouting of laws and norms, as well as Presidents with deeply flawed and aggressive personalities. In both cases, the Republican party stuck with their chief, until the endgame in Watergate, and we don’t know the endgame yet with Trump. 

 

Trump’s deviations from a “normal” President, however, are more extreme than with Nixon, both in the extent of the official violations and the extremity of the personal qualities. Whereas Nixon was highly capable and experienced, and accepted the game as it was generally played, Trump has no basic abilities beyond that of a showman, and is acquisitive to the extreme, as Nixon was not.

In addition, the times are different. In Nixon's time the United States was much stronger internationally than now, still rising in power and wealth, and the palpable sense of decline of preeminence was not present. In Nixon's time children could still expect to do better than their parents as a matter of course. In Nixon's time the Republican party was more moderate, dark money was not so much of a factor then, and Nixon's world didn't have a rise of authoritarians who celebrate their form of government as superior to the stodgy old liberal democracy of the United States and the West. And in Nixon's time, white people were still a strong majority in virtually all parts of the country.

Despite these differences, Watergate is probably the most useful guide our thinking. The effort to reform after Watergate was profound.

“(The Watergate reforms) sought to restore faith in the U.S. political system by combating the corrupting influence of money in politics; promoting ethics and transparency in government; protecting people against abuses of government power; and limiting certain extraordinary exercises of presidential authority.” Berger

In addition to the strength of these reforms – which included the establishment of the IG system, by the way – the imprisonment of so many of the Nixon officials was shocking and impressive, even though the course of justice for Nixon personally was diverted by President Ford's pardon. Nothing says “wrong” like jail. The image of Watergate still reverberates, the headlines are still striking, the stench is still in the air. And the reforms, by and large, have stuck.

A cautionary object lesson in the opposite might be how Iran-Contra was resolved when George H. W. Bush accepted the suggestion of Attorney General William Barr and preemptively pardoned the conspirators, thus also exculpating himself. The shame and the lesson were lost as an example to the public, and the illegal usurpation was not even mentioned when President Bush died. The difference in how Watergate and Iran-Contra were handled and what their impact was, is striking and informative.

Will there be active reforms that contradict the trends of the Trump era? Will there be a V-bottom, and will liberal democracy rebound even more robustly? Will active investigations and pursuit of miscreants of the Trump era resemble those of Watergate, if not for prison sentences, then at least for claw-backs of ill-gotten gains? While some say we don’t want to be a Banana Republic where political opposition is jailed, immunity for miscreants would be a worse message. Given the extent of the Trump depredations, this is likely to be a full employment program for investigators and lawyers, but it is hard to think of a just alternative to intense discovery, reparative actions, and very active reform.

 

Or, possibly, will a new coalition in power decide that they like the system Trump has instituted, and find the new executive freedom to act congenial? In that case they might concentrate on reversing policies, instituting new ones, and going easy on reverting to checks and balances. It seems unlikely, but it's possible.

They say that history doesn’t repeat itself, but it rhymes. Or, as Marx said about the 18^th Brumaire of Louis Bonaparte in perhaps his most cited quotation: “History repeats itself, the first time as tragedy, the second time as farce.” Farce may be funny and ironic, but it can also be very, very sad.

We shall see.

Budd Shenkin

With the help, corrections, and suggestions of David Levine, who is not responsible for deficiencies, of course.

Do You Need To Pay For Health Care To Value It?

I had an exchange of opinions (respectful, I think) on Twitter with a Georgia-based consultant who says he has run many practices. He's very pro High Deductible Health Plans, and talks about how patients only value what they pay for, along with advancing the old "skin in the game" argument.

It then struck me -- so many of my patients were Medicaid and didn't have "skin in the game."  Yet I think we had an excellent relationship and I have no doubt about their appreciation.

It seems to me that it's the relationship, and the patient's understanding that you care, and that you are trying, and that you have respect for them, that is the crucial element.  The patient's paying is like another way of attacking it, that substitutes for that relationship.  Because if you pay for it, there's a cognitive incentive for you to value something, because you figure if I paid for it I had better value it or it's wasted money.

So looked at that way, the skin in the game argument is taking advantage of the cognitive error of sunk costs (I think that's what it's called) in lieu of establishing a caring relationship.

I don't know, maybe gets at part of the truth some of the time.  Certainly doesn't work for everyone and every relationship.

Budd Shenkin