April 1, 2020 4:09PM

Employment in Federal Health Agencies

Some pundits are blaming the slow federal response to Covid‐​19 on budget cuts and supposedly shrunken federal bureaucracies. Bloomberg columnist Noah Smith claimed, “Recently, though, the U.S. has allowed its civil service to shrink and its salaries to become less competitive with the private sector, outsourcing many of the bureaucracy’s functions.”

However, budgets for the CDC and NIH have risen substantially, as I charted here. And while the claim about salaries is debatable, it is not correct that overall federal compensation including benefits is uncompetitive.

What about the size of the federal workforce? Smith includes a chart showing that the overall government workforce in the nation is declining as a share of the overall U.S. workforce. But a more relevant issue these days is the size of the federal health workforce.

The chart below shows the total number of employees in the NIH, CDC, and FDA from 1998 to 2019, sourced from OPM.

NIH employment dipped over the past decade but is a bit higher than 20 years ago.

CDC employment increased almost one‐​third over the past 15 years.

FDA employment soared two‐​thirds from 2007 to 2016 but has dipped slightly since then.

Are more employees better? The NIH mainly hands out grants to researchers, an activity in which productivity has probably increased as technology has improved. Thus, more workers would likely not be needed even as the budget increased.

As for the FDA, more employees may be a negative to the nation since one of the agency’s activities is to hinder the introduction of new medicines and devices. In this crisis, the agency’s blockage of private‐​sector virus testing was hugely damaging.


Note: Data are for September of each year except 2019 which is June.

David Kemp assisted with this blog.

April 1, 2020 3:39PM

Governors Send Out S.O.S. for More Doctors—Immigrant Doctors Can Heed the Call

As hospital emergency rooms and intensive care units swell with patients infected with the COVID-19 virus, political leaders coordinating responses in “hot spots” are asking doctors and other medical professionals in parts of the country less impacted by the pandemic to come to the rescue. New York Governor Andrew Cuomo issued such a plea the other day. Governors are issuing executive orders that relax occupational licensing restrictions on the free movement of health care practitioners. Some are also expanding the scope of practice of various licensed health care professionals, permitting them to provide the health care services they are trained to do. Meanwhile, a large pool of doctors trained at excellent institutions outside the borders of the U.S., referred to as International Medical Graduates (IMGs), goes untapped. A cumbersome approval process begun in the 1950s places daunting obstacles in the way of IMGs who want to practice in the U.S. and keeping tight reins on the already short supply of doctors.

The process is overseen by the Educational Commission for Foreign Medical Graduates. The ECFMG is a private non‐​profit organization established in 1956 to “evaluate the readiness” of IMGs to enter graduate medical education programs (residencies and fellowships) in this country. (Graduates of Canadian medical schools are not considered IMGs.) The American Medical Association and the American Hospital Association soon recognized the ECFMG as the standard for evaluating IMGs entering the U.S. health care system and serving patients in its hospitals. The ECFMG obtained responsibility for visa sponsorship of Exchange Visitor physicians (J‑1 visas).

Graduates of medical schools outside of the U.S. and Canada must become certified by the ECFMG before they can enter U.S. graduate medical programs. This means they must receive their diplomas from an ECFMG‐​approved medical school, pass steps 1 and 2 of the 3‑step U.S. Medical Licensing Examination, complete a graduate medical education program, and then pass Step 3 of the USMLE.

State licensing requirements vary with regard to IMGs. Some require more years of graduate medical education training than they require from graduates of U.S. and Canadian medical schools before they issue them a license. Most issue licenses to graduates of U.S. and Canadian medical schools after applicants have passed step 2 of the USMLE and several don’t require these licensees pass to step 3 in order to maintain their license.

Yet IMGs who received their diplomas a while ago and have been practicing medicine outside the U.S., often for several years, must go through the same process as fresh medical school graduates. This means they must get ECFMG certification—including taking and passing all three steps of the USMLE—and go through a residency training program all over again. Then they must apply for state medical licenses. Many experienced foreign‐​trained doctors take positions in ancillary medical fields, such as nursing, lab technician, and radiology technician instead of starting all over again. Some even work as waiters or taxi drivers.

I worked with an Operating Room Technician (the person who passes instruments to the surgeon) from Syria who had impressed me with his knowledge and focus on the operations I perform. He would occasionally offer an excellent suggestion or insight during a technically challenging segment of the operation. I soon learned that he had been a general surgeon who practiced in Syria before coming to the U.S. He decided to divide his time between working as an OR tech and starting up a Middle Eastern restaurant rather than starting all over again.

To be sure, the quality and approach to the practice of medicine varies in different parts of the world. In some parts of the world doctors deal with a different constellation of health problems than exist in the U.S. and some may have less exposure to the technological advances that abound in the U.S. health care system. There may also be cultural differences that affect their understanding and communication with American patients. For this reason, certification organizations like the ECFMG, specialty boards (e.g., American Board of Surgery, American Board of Internal Medicine), as well as rating and evaluation services, play an important role in providing critical information to consumers of health care.

In Canada the provinces have domain over medical licensing. Some provinces grant licenses to experienced immigrant primary care physicians from certain countries to practice without having to repeat the residency program. Some also welcome medical specialists who are trained and experienced in certain other countries without having to start over.

To address the current public health emergency, several states are granting reciprocity to health care practitioners licensed in other states. Three states—Arizona, Pennsylvania, and Montana—reformed their occupational licensing laws to grant reciprocity well before the advent of COVID-19 pandemic. As I have said before, these reforms should apply to all the occupations and should be permanent—not just temporary responses to the public health emergency.

In the same spirit, states should consider granting reciprocity to health care practitioners licensed in certain other countries with reputations for quality medical education. Meanwhile, certifying organizations should include applicants’ active clinical experience in other countries as a factor in certification criteria. Finally, these changes need to be accompanied by liberalizing immigration rules for medical professionals and their families now—waiting for overall immigration reform to happen will not address the problem fast enough.

April 1, 2020 2:51PM

Combating COVID-19 Misinformation with Disassociation

Social Media Logos

Deadly misinformation spread across social media long before COVID-19 emerged, but amid the ongoing pandemic attempts to tackle such content are once again in the limelight. These efforts provide an opportunity for classical liberals to emphasize the importance of freedom of association and to prepare for discussions about how private institutions handle misinformation amid a crisis.

Too often we think of the freedom of speech to be a freedom that protects speakers from government censorship. And while the freedom to speak is a necessary condition for a functioning liberal society it’s not the only freedom implicated in what people refer to as “the freedom of speech.” The freedom of speech also entails a freedom for publishers and platforms to associate with whomever they want. That The Wall Street Journal is free to reject an op‐​ed submission written by the leader of the American Nazi Party is as important a freedom as the freedom of the leader of the American Nazi Party to write the op‐​ed in the first place.

The Internet has prompted a revolution unlike anything seen since the invention of the moveable type printing press. Billions of people are able to not only express themselves but form communities of like‐​minded people across national boundaries. Fortunately, the widespread availability of venues for online speech has not been accompanied by obligations on the part of Internet companies to host speech they find repellent or dangerous. The online site Medium, for example, removed a controversial essay by Aaron Ginn apparently because they did not wish to be associated with it. In the U.S., Internet companies are shielded from liability for actions associated with removing content.

The freedom of private companies to disassociate from speech that they consider harmful is especially important during the current crisis. Social media companies have implemented a variety of policies aimed at dealing with COVID-19 misinformation. Twitter has expanded its definition of “harm” to include content that is contrary to health information provided by global and local authorities. Facebook established its COVID-19 Information Center and committed to removing content that could “contribute to imminent physical harm.” Twitter and Facebook joined Google, Youtube, Reddit, Microsoft, and LinkedIn to issue a statement on COVID-19 misinformation, stating that they are “combating fraud and misinformation about the virus, elevating authoritative content on our platforms, and sharing critical updates in coordination with government healthcare agencies around the world.”

These policies have affected heads of states, publications, and individuals. Facebook and Twitter removed videos of Brazilian President Jair Bolsonaro falsely claiming that the anti‐​malaria drug hydroxychloroquine was an effective remedy. Twitter also removed a tweet posted by Venezuelan President Nicolas Maduro that claimed a homemade brew could be effective against the coronavirus.

In the Northern Hemisphere publications and pundits have seen their content removed. The Federalist published an article calling for intentional infection gatherings akin to “chickenpox parties.” Twitter locked The Federalist’s account in response. President Trump’s personal attorney Rudy Giuliani, like President Bolsonaro, supported the hydroxychloroquine remedy in a tweet quoting a young conservative activist. Twitter removed the tweet. Conservative pundit Laura Ingraham had to remove a similar tweet in order to avoid her Twitter account being suspended.

Social media companies are the only Internet‐​based firms attempting to stop the spread of dangerous information hurting customers. Amazon is attempting to remove scams associated with the ongoing pandemic, removing more than one million products so far.

Social media companies are often relying on other organizations such as government agencies or the World Health Organization as proxies for content moderation and fact‐​checking. While there are certainly advantages to such an approach, it is not without risks, as my colleague Will Duffield has explained.

Popular Internet companies ought to be free to take steps to tackle COVID-19 misinformation. The spread of bogus claims about cures can result in death. But at a time when official organizations have reversed recommendations on the wearing of face masks we should prepare for a breakdown of these organizations’ reputations to affect the perceived legitimacy of Internet companies’ content moderation decisions. Amid misguided calls to breakup so‐​called “Big Tech” and to amend the law that allows for social media companies to moderate content without fear of liability we should be especially wary of such an outcome.

Special thanks to Cato Institute intern Stephanie Reed and Cato Institute Research Associate Rachel Chiu for their research for this post.

April 1, 2020 2:37PM

Outsourcing Fact Checking, and Reputation with It

By Will Duffield

Twitter has expanded its content moderation policies in an effort to halt the spread of misinformation about Covid‐​19, broadening its definition of harm “to address content that goes directly against guidance from authoritative sources of global and local public health information.”

Twitter wants its platform to offer useful information about the virus while excluding harmful misinformation. A noble mission, but because Twitter has either little competence in identifying Coronavirus misinformation or little confidence in its ability to do so, it has chosen to rely on external institutions to guide its content moderation. Twitter both privileges messages from the WHO on the platform “to ensure that when you come to the service for information about Covid‐​19, you are met with credible, authoritative content at the top of your search experience” and pledges to remove the “denial of global or local health authority recommendations,” which is understood as a proxy for misinformation.

If this understanding holds true, the policy makes a great deal of sense. It would be costly and difficult for Twitter to maintain its own standard of Coronavirus misinformation, constantly updating it as our understanding of the disease improves. Provided the health authorities’ recommendations are correct, Twitter’s enforcement efforts benefit from the authorities’ legitimacy while their advice improves the quality of Coronavirus information on Twitter.

However, external experts and institutions are still fallible. Their advice may be sound in most instances, but when they get it wrong, Twitter’s reliance on their authority magnifies the damage done by their inadvertent misinformation. If Twitter, acting on an officially endorsed, though incorrect, understanding of best practices in mitigating the spread of the virus, removes information that later proves correct, Twitter’s moderation will suffer a blow to its legitimacy as will the official authority. These false positives may also cause real harm to people denied the correct advice.

This is not a hypothetical problem. The WHO and many Western authorities and experts have discouraged the use of facemasks by the general population, simultaneously claiming that they do little to prevent the spread of the virus and must be conserved for use by healthcare workers. This inherently contradictory stance, further eroded by the experience of Asian countries where mask‐​wearing is the norm, amounts to official misinformation. Whether this assertion is the product of a noble lie or simple misjudgment, it has already done tremendous harm. Because of its pre‐​commitment to the advice of health authorities, official misinformation of this sort puts Twitter in a bind.

If Twitter wants to counter misinformation on its platform, it should remove tweets by public health authorities discouraging general mask use. However, Twitter has tied its efforts to combat Coronavirus misinformation to the very authorities it must now rebuke. Without an independent justification for its misinformation determinations, Twitter’s moderators are relegated to implementing the determinations of external institutions, right or wrong.

Thankfully, despite its promise to remove denials of health authority recommendations, Twitter does not seem to have suppressed tweets calling for general mask wearing. While this restraint is laudable, Twitter still hosts official misinformation about mask‐​wearing and purports to remove information at odds with official advice. Twitter’s moderation practices are out of step with its stated policies. While this may be a better state of affairs than if Twitter zealously removed correct information that conflicts with official advice, it renders Twitter’s moderation more opaque and less predictable or seemingly legitimate.

Contrast this with the evolution of Twitter’s policy on misinformation by state actors. Governments and government officials have long been treated with kid gloves by content moderators. In mid‐​March, Lijian Zhao, Director‐​General of the Information Department of the CCP’s Foreign Ministry, repeatedly suggested that Covid‐​19 had originated in the United States, tweeting links to conspiracy theories about the source of the virus.

This deliberate disinformation was met with calls for Twitter to remove Zhao’s tweets. Twitter refrained from removing the tweets but posted an update to their misinformation policies, stating: “Official government accounts engaging in conversation about the origins of the virus and global public conversation about potential emergent treatments will be permitted, unless the content contains clear incitement to take a harmful physical action.” While Zhao’s tweet is grossly wrong, it is unlikely to do any immediate harm and, in time, might prove a reputational albatross for Zhao and the CCP.

Whether or not you agree with the decision, Twitter’s implicit appeal to immanency gave this rule an independent legitimacy that reliance on WHO advice lacks. A line drawn between speech likely to cause immediate harm and speech that might cause harm down the road doesn’t rely on an appeal to expert authority. Twitter made a decision on its own with reference to a universally appreciable value and followed up by removing two tweets from Brazilian President Jair Bolsonaro in which he disputed his government’s social distancing guidance. Unlike Lijian Zhao’s tweet, Bolsonaro’s advice risked causing immediate harm, rather than long‐​term international animus and, in actually enforcing the policy against a covered behavior, Twitter demonstrated that its policy update was not merely a way to avoid upsetting the CCP.

The difficulty of the situation notwithstanding, what might Twitter and other social media learn from COVID-19? Like other platforms, Twitter outsourced “truth” and “the facts” to external authorities. Yet when some users advocated wearing masks contrary to those authorities, Twitter did not remove their posts. Someone at Twitter decided, their outsourcing notwithstanding, to tolerate talk favoring wearing masks. Similarly, Twitter tolerated a falsehood from a Chinese government official because it was unlikely to cause immediate harm. Both decisions to tolerate posts that contradicted expert beliefs came from Twitter rather than external authorities.

Our lesson? External expertise is not enough to legitimate content moderation on social media. Twitter needs to recognize and justify the values that inform its use of expert knowledge. Absent such transparency and justification, Twitter’s moderation will lack the last full measure of legitimacy.

April 1, 2020 2:00PM

Posse Comitatus and Interstate Travel Bans

In the space of a few hours on Saturday, President Trump went from threatening an ALL-CAPS federal “QUARANTINE of developing ‘hot spots’, New York, New Jersey, and Connecticut” to… having CDC issue a “strong Travel Advisory” for the tristate area instead.

It’s hardly the first time this president has floated some eye‐​poppingly authoritarian proposal, only to back away from the Rubicon shortly thereafter. By now, the pattern should be familiar:

Trump hits “send tweet” on some crank theory of absolute executive power. Law professors and pundits cancel their weekend plans, scrambling to figure out “Can he do that?”—only to realize, weeks later, that they needn’t have taken him literally or seriously.

But when I wrote that in Reason magazine a year ago, “weekend plans” were still a thing. In the pre‐​COVID‐​19 era, it was usually safe to take the president’s autocratic reveries with a grain of salt. We’re in new territory now. The pressures for bold action in times of crisis have led far cooler‐​headed presidents to make desperate and dangerous moves, and there are far rougher days ahead. Our radically changed circumstances make this particular proposal worth worrying about.

How Would a Tristate Lockdown Be Enforced?

Where would the federal government get the manpower to enforce a Tristate‐​area quarantine?

A number of questions come to mind: first among them, “can he do that?”—is there any plausible legal authority for a domestic Travel Ban encircling three states and some 30 million Americans? Second, if he tried, how could the feds enforce it? And finally, just how nightmarish would that scenario be?

Let’s start with the legal question. The key statute for federal quarantine authority is the Public Health Service Act (PHSA), which has been used, in recent outbreaks, primarily for international travel restrictions. However, the PHSA also provides authority to issue regulations aimed at preventing disease spreading across state lines, and authorizes the apprehension and examination of

[A]ny individual reasonably believed to be infected with a communicable disease in a qualifying stage and (A) To be moving or about to move from a State to another State.…

The PHSA seems to envision individual testing, not interstate blockades. Regulations issued under its authority:

may provide that if upon examination any such individual is found to be infected, he may be detained for such time and in such manner as may be reasonably necessary.

That language does not appear to support a federal power to impose a cordon sanitaire around the Tristate Area unless virtually any person attempting to leave can be “reasonably believed” to already have COVID-19. Still, even more tortured interpretations of federal law have prevailed, at least temporarily, in past crises. I wouldn’t necessarily count on the courts to enjoin this one.

If the administration opted for an “enforceable quarantine,” how would the feds enforce it? “One option,” as George W. Bush put it in the wake of the Katrina debacle, “is the use of a military that’s able to plan and move.”

Indeed, for an operation on the scale Trump suggested, it may be the only option. “Neither the Public Health Services Act nor CDC regulations specifically authorize military enforcement of federal quarantine orders. But neither HHS nor CDC possess sufficient resources to enforce mass quarantines,” observes Jesse T. Greene in a 2015 Harvard National Security Journal article, “Federal Enforcement of Mass Involuntary Quarantines” (here’s hoping your social‐​distancing reading list consists of somewhat more soothing titles).

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April 1, 2020 8:00AM

Let’s Shift Foreign Policy From Great Power Competition to Global Pandemic Cooperation

Most people find competition exciting. We are constantly organizing individual and team competitions, with rankings and winners and prizes. We do it by city, by college, and by country. An upset by an underdog can be particularly thrilling, but nothing beats seeing the top two go head to head: The biggest and the best fighting it out for supremacy. It could be chess, it could be gymnastics, it could be football. Whatever it is, it is great entertainment.

Foreign policy is prone to the same human instincts. Countries around the world are “competing” for supremacy. Which one is the wealthiest? Which one has the strongest military? Which has the most influence? Who is number one?

For decades, the United States and the Soviet Union were battling it out on many fronts. It kept the foreign policy community occupied, and the people of each nation following closely, if a bit tensely. After the Cold War ended, Radical Islamic Terrorism was eventually put forward as the new rival for the United States to take on, but it did not live up to the hype and (many) people eventually decided to move on.

Now there seems to be a true rival out there: China, with its growing economic and military power. At long last, there is Great Power Competition again!

But a dose of reality has just set in, as the COVID-19 pandemic spreads around the world. As it turns out, if we are looking for rivals to fight, there are much more powerful ones out there. We could pick a country to compete with, but do we really need to? Nature itself is giving us plenty of competition.

There were plagues and flus in the past, but they seemed so distant, and the more recent ones never quite landed their punches. Ebola, SARS, MERS, mad cow disease, etc., got us worried, but all sputtered out before causing too much damage in the United States.

Now COVID-19 is showing us the reality of these threats, with upward sloping curves of sickness and death. And let’s be honest with ourselves: it could be a lot worse. An even more deadly virus is sure to come along at some point.

The lesson from all this for the foreign policy community is that there is no need to construct a competition with other countries: There are plenty of life or death competitions already out there. Instead of picking out other nations as rivals that we need to beat, what we should be doing is cooperating in a fight against external (i.e. outside of humanity) threats.

Let’s beat COVID-19 together, and then start preparing for the next virus. What are all the communicable diseases that might attack humanity? Let’s map out all the possibilities and start preparing now.

There are also natural disasters. Earthquakes, hurricanes, and, every now and then, asteroids hitting the earth. Against, let’s spend time working together in preparation for these sorts of problems.

One flaw in this suggestion is that it’s hard to come up with rankings. With a U.S.-China Great Power Competition, we could put together charts showing how many battleships each country has and how much each country’s GDP has grown since 2001. That’s harder with nature. Perhaps we can rank the threats, as the Colbert Report used to do with the ThreatDown?

More seriously, what we should do is push the foreign policy community to focus more on these external threats. In particular, we should shift funding away from Great Power Competition towards threats from nature. To help brand the effort, we could give it a name: Global Pandemic Cooperation, for example, offers a smooth transition. People’s interest follows the money, and if there are jobs in the area of pandemic prevention, more people will pursue that field instead of conflict‐​oriented ones. (Of course, there are real threats from other countries, but thinking of them as a Great Power Competition tends to harm rather than help in addressing them).

We all want the excitement of competition, but we have learned something these past few weeks. As much fun as it can be to build up a rivalry in your head with a sports team in another city or with a far off country, there are more serious threats out there and if we don’t address them properly we will have to stay inside for months and we might even die. That means it’s time to stop worrying about country rankings for a while and work together to stay alive.

March 31, 2020 4:58PM

Do Crises Foster Authoritarianism?

By Jeffrey Miron and Erin Partin

Times of uncertainty and fear often provide the opportunities for authoritarian governments to consolidate their powers. From the New York Times:

“As the coronavirus pandemic brings the world to a juddering halt and anxious citizens demand action, leaders across the globe are invoking executive powers and seizing virtually dictatorial authority with scant resistance.

Governments and rights groups agree that these extraordinary times call for extraordinary measures. States need new powers to shut their borders, enforce quarantines and track infected people. Many of these actions are protected under international rules, constitutional lawyers say.

But critics say some governments are using the public health crisis as cover to seize new powers that have little to do with the outbreak, with few safeguards to ensure that their new authority will not be abused.”

Hungary, whose Prime Minister was granted the authority to rule by decree, Israel, where intrusive cell phone surveillance is being imposed, and Chile, where the military has been granted nearly boundless control and ordered protesters off the streets, are some of the starkest examples. But they are far from the only offenders.

In the U.S., bans on travel and other daily activities are becoming the new normal. Florida, Rhode Island, and Oklahoma are among 15 states that have issued orders restricting interstate travel.

Reasonable people can disagree about whether particular emergency powers are worth the risks they entail. But we should all recognize the risks.