A matter of definition.

datePosted on 12:43, May 16th, 2020 by Pablo

Recent reports have surfaced that hospital officials in some US localities are inflating the CV-19 death count by classifying anyone who dies in their care who is not the victim of an accident or other obvious non-viral cause as a CV-19 victim. Apparently this is because the US public health scheme, Medicaid, pays hospitals USD$5000 per non CV-19 death versus USD$13,000 for CV-19 related deaths. Most hospitals in the US are private, for profit entities so the hospital administrators (not doctors) who do the paperwork submissions to the federal government for Medicaid death reimbursements have financial incentive to falsify the real causes of death.

There is no independent body above hospital administrations regularly overseeing how cause of death in hospitals is classified unless some gross error comes to the attention of local and state authorities, and there is no way for the federal government to unilaterally challenge the legitimacy of CV-19 death claims. Moreover, since local coroners are swamped by an influx of CV-19 dead and Medicaid is stretched to the breaking point by the upsurge in (legitimate) CV-19 claims, there is little way to hold the dishonest hospital administrators to account unless a whistleblower from within a hospital provides concrete proof of institutional malfeasance.

In contrast, official Russian statistics show that there are over 263,000 cases in the country, with nearly 2.500 deaths and new cases exceeding 10,000 per day. That death count has raised eyebrows outside of Russia, as it is remarkably low when compared to other countries given the number of cases and rate of infection.

Russian officials counter the skeptics by claiming that their definition of a CV-19 death refers only to those that can be directly attributed to the pathogen. They deliberately exclude other causes that are exacerbated by CV-19 contagion, such as heart failures and smoking-related pulmonary embolisms, liver failures etc. Because of this the Russian CV-19 mortality rate is not only very low but also does not disproportionately affect the elderly, whose deaths are most often attributed to the underlying condition rather than to CV-19.

These differences in reporting remind me of an incident that happened to me when conducting research in Brazil in 1987. I had an interest in national health administration because I had worked on that subject when conducting Ph.D. dissertation research in Argentina earlier in the decade, I lived in Rio at the time and had experienced Carnaval in February, when thousands of sex tourists of every persuasion descended on the city in the middle of what was clearly an AIDS epidemic (in a cultural context where men refused to use condoms because that was considered “unmanly” and in which many (usually) straight men used Carnaval as an excuse to enjoy gay sex). Around that time I had to donate blood for my then-wife to use in a blood transfusion after she picked up a water-carried blood infection while cleaning vegetables and because we were told that most of the blood supplies in Rio were infected with both AIDS and syphilis, so I was acutely interested in how health authorities dealt with the convergence of viral calamities.

I managed to arrange an interview with a senior official in the Health Ministry in Brasilia, one who just happened to be involved in infectious disease mitigation. As part of our conversation I asked him how many AIDS cases there were in Brazil. He said “100.” I laughed and said “no, seriously, how many cases are there because I just came from Rio during Carnaval and it was a 24/7 bacchanal of unprotected sex, drug use, drinking, dancing and other assorted debauchery, plus I am told than the blood banks are unreliable because the supplies are infected with AIDS and syphilis.”

He smiled and leaned back in his chair for a moment, and then said “you see, that is where my country and your country are different. In this country a person gets the AIDS virus, loses immune system efficiency, and eventually succumbs to an infectious tropical disease such as malaria or dengue fever. We put the cause of death as the tropical disease, not AIDS. In your country a person gets AIDS and eventually dies of a degenerative disease such as a rare thyroid or other soft tissue cancer. Since they otherwise would not have likely had that cancer, your health authorities list the cause of death as AIDS. For us, the methodology for defining cause of death is not only a means of keeping the official AIDS count low. It also keeps the foreign tourist numbers up because visitors are not fearful of contracting AIDS and have much less fear of malaria or dengue because those are preventable.” I asked him what he thought about those tourists who did contract AIDS while in Brazil on holiday. He replied “that is a problem for their home authorities and how those authorities define their cause of death.”

I recount this story because it seems that we have entered a phase in the CV-19 pandemic where definition of what is and what is not has become a bit of a hair-splitting exercise that has increasing levels of political spin attached to it. It opens a Pandora’s box of questions: Is the lockdown approach overkill? Is the re-opening too soon? Are the overall US CV-19 death figures inflated because of the structural imperatives layered into their health system? Are the Russian figures underestimated because of their politics or because of their accounting methods? Has the PRC lied all along about the extent of the disease before and after it left its borders (in part by assigning different causes of death than CV-19)? At what point do honest medical professionals assign primary cause of death to CV-19 rather than an underlying condition?

There is one thing that I am fairly certain about. In Bolsonaro’s Brazil, I have little doubt that the rationale I heard in 1987 is still the rationale being used today, except that now it is CV-19 rather than AIDS that is the scourge that cannot be named.

8 Responses to “A matter of definition.”

  1. Barbara Matthews on May 16th, 2020 at 21:37

    Is there no end to the venality of sections of the United States? High level officials dumped shares (insider trading), before the lockdown now private hospitals are cashing in on legislation to enrich the private sector. Thank God we live in NZ where corruption stays at a level of a bit of illegal fishing, the occasional drug bust and unethical lawyers try to rip off the system. We are such amateurs at corruption, thankfully.

  2. Pablo on May 16th, 2020 at 22:21

    Barbara:

    Although NZ is comparatively clean when it comes to corruption at an international level, do not be fooled into thinking that in absolute terms NZ is in fact an honest society. The difference is that in NZ corruption is high level, highly political and highly discreet for the most part. NZ First’s relationships with the (esp. Russian-linked) fisheries and racing industries is a case in point, and then there is the issue of PRC influence on the major parties and significant parts of the business sector that overlaps with the political class (i.e. all of the major players). This influences everything from commodity expoet policy and foreign affairs to local law enforcement (say, on things like freedoms of speech and peaceful protest). And then there is the more petty (but large as well as small stake) corruption of DHB boards, financial service providers, food suppliers, university managers and even the cops. Corruption is endemic, but not as vulgar as some simple street level shake down.

    So yes, NZ is better than the US by a far stretch, but by no means is it angelic. Remember Peter Thiel and the two week granting of NZ citizenship to him without his ever having set foot in this country? He promised investment and wound up making money on the deal even after reneging on his promises. The National government of the day looked the other way even though taxpayer money was lost on the deal, and the Labour-led government that followed declined to look into circumstances of the citizenship grant or attendant financial arrangements. One might argue that somewhere along the line the skids were greased on both sides, and that is all there is to know when it comes to NZ corruption.

  3. Görkem on May 17th, 2020 at 09:08

    Make no mistake Barbara, corruption in New Zealand is endemic. Bureaucrats in New Zealand ministries are time serving nobodies interested only in padding their pockets. Don’t believe those who say “It can’t happen here”. It can, and it has, and it has been happening here since the 90s. We have nothing to teach the Americans or the Russians or CHinese in terms of an honest public service.

  4. Barbara Matthews on May 17th, 2020 at 09:52

    Points taken. Peter Thiel is still hovering around. I’ve taken off my rose coloured glasses! Still I’d rather be here than in the US of A.

  5. Görkem on May 17th, 2020 at 10:36

    Can you believe that according to the “Corruption Perception Index” New Zealand is the world’s least corrupt country? Utterly ridiculous. Presumably corrupt businessmen bribed the corruption perception index assessors.

  6. Pablo on May 17th, 2020 at 11:03

    It has always amused me that NZ and Singapore, two countries that I have lived in, are always ranked at the top of the corruption indexes even though it is patently obvious that corruption is an institutional rather than street level characteristic. More to your point about who does the corruption assessments, I was involved in a Transparency International survey of the NZ military and intelligence services. The survey looked at degrees of professionalism, politicisation, integrity, honesty etc. They scale was 1=bad to 5=excellent, plus a number of long form questions. Although I rated the NZDF quite high on a number of issues, on several others I gave it 2s and 3s. For the intelligence services I rated them on average even lower, particularly the SIS, When the TI survey was eventually published a year later, both the military and intelligence services were rated 4.8 or so. I consulted with someone else who participated in the survey and he also had given the NZDF and SIS low marks on several issues, thereby reducing his average overall score to around 4 (as was mine).

    What that suggested to us is that, given the small pool of people surveyed, our low marks were either ignored or dropped in a “high/low” counting system (like figure skating judging). Either way, it gave the impression that NZ has exemplary military and intelligence services. That is simply not true. They may be good when compared to peer organisations in other countries, but not quite as good as the TI report made them out to be. Worse yet, the false high average insulated the services from the type of self-critique and organisational reform required to address the problems that I identified because an ostensibly independent and objective international agency such as TI had given them the all clear.

  7. Di Trower on May 17th, 2020 at 17:25

    What a fascinating story, Pablo. I’ve been wondering for quite a while what the true figures relating to global infections and deaths will look like in a few years time, and when we have more complete information – if that is ever going to be possible. And It’s pretty depressing, really – your story and also your insights into corruption within NZ politics and public service, but no real surprise.

    On a completely different matter, I’ve been greatly enjoying Kurt Elling’s Cocktail Hour, screened live from New York around 10am on Saturdays, NZ time. You may have been watching them, but this week’s was a wonderful interview he had with Sheila Jordan (of whom I did not know) but at 91 years of age had the most wonderful stories (oral history, really) to tell. I think you’d enjoy it if you haven’t already seen it.

  8. Görkem on May 17th, 2020 at 20:28

    @Pablo: I think it is quite likely that corrupt officials bribed the Transparency International organisers to ignore your extremely pointed and valid criticisms of corruption in the NZ military and security services. Sadly not even a surprise given how much corruption is endemic in New Zealand today. We live in a society where graft, bribery and money laundering are part of the everyday fabric.

    What terrifies me is that many financial businesses use these ratings to inform a “risk based approach” which means financial transactions originating in New Zealand are often subject to “reduced due diligence” meaning that the vast sums of dirty money originating from New Zealand are passed globally with nothing but a brief review. Can you imagine? It means that a transaction coming from Finland (another endemically corrupt country that is falsely rated as “clean”) and New Zealand get the easy route, while transactions from China, Russia, Turkey or Brazil are disected. Truly farcical. And yet this clown show is how the infrastructure the global economy works on is administered. It makes me mad just to think about it.

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