The US doesn’t have enough infectious disease doctors — and the situation is about to get worse.
When I was in training to be an infectious disease doctor, there was a running joke that if a hospital team didn’t want to review the chart, they could just consult infectious diseases and we’d do it for them.
It got laughs largely because it felt so true. A core function of infectious disease doctors — often abbreviated as “ID” in medical circles — is to diagnose and guide treatment (and, sometimes, prevention) of a variety of conditions ranging from pneumonia to bone infections to HIV to malaria. That requires a lot of highly cognitive work, including taking notoriously detailed histories and, yes, conducting notoriously thorough reviews of medical records.
That kind of work takes a lot of time. Most ID doctors have completed not only the three years of internal medicine residency training most hospitalists have done, but also an additional two to three years of specialty ID fellowship training. Fortunately, it also pays less than many other medical professions.
It’s tough but rewarding work. However, there’s a persistent shortage of these critical physicians, and relatively few medical school graduates are pursuing this career.
On November 30, when thousands of US doctors continuing their medical training learned where they had matched for fellowship, one-quarter of US ID training positions went unfilled. That feels like particularly dire news at this moment, with every season seeming to bring its own unprecedented infectious challenges, and our overburdened public health and health care systems sounding increasingly loud alarms about the need for more resources.
For a profession so demonstrably critical to the nation’s health — one whose most senior practitioner in the US — Anthony Fauci — is influential enough to have inspired entire lines of merch — the news came with a distinct sense of whiplash. How could so many prospective trainees shun a field whose physicians and scientists produced the Covid-19 vaccine, guided mpox treatment, and are currently helping overwhelmed hospitals dig out from under the triple-demic?
Even if you never need the services of an ID doctor, it’s worth understanding what’s at the root of this trend and why it matters.
ID doctors fight infections and antibiotic overuse
The key role of most infectious disease doctors is figuring out whether a patient has an infection and how best to treat it.
Sometimes, that means starting an antibiotic, but often, it means choosing to stop or not start antibiotics, changing intravenous antibiotics to ones people take by mouth, or switching from a “big gun” antibiotic to one less likely to lead to a resistant germ. These physicians also often lead infection control efforts in facilities; that is, they help prevent patients and visitors from contracting infections while inside the hospital.
These individual decisions add up to greatly improved outcomes. Studies have shown infectious disease consultation saves lives in patients with fungal or bacterial bloodstream infections, organ transplants, and a variety of other conditions. Deploying these physicians can also save money and prevent antibiotic overuse.
The judicious use of antibiotics is a key countermeasure against the emergence of antibiotic-resistant superbugs, which the WHO has declared a global emergency. As institutional leaders in antibiotic stewardship, ID doctors often play an important role in helping reduce unnecessary or overly broad antibiotic use.
Other types of physicians and health professionals can perform some of the functions infectious disease doctors do. More than 1,700 infectious diseases pharmacists play critical roles in guiding safe and effective antibiotic use, as do many nurse practitioners and physician assistants, and many internists (that is, general adult medicine doctors) became experts in treating HIV well before specialty HIV training existed.
But whatever their professional category, people need pretty extensive training to do the job of an infectious diseases practitioner right, said Wendy Armstrong, an ID doctor who co-directs Emory’s ID fellowship. “Anybody can prescribe antibiotics — maybe not well, but anybody can,” she said.
When ID doctor training programs go unfilled, that means there are fewer people guaranteed to get the training to do this work right.
The ID doctor shortage is especially bad in rural America
Despite there being a shortage of ID doctors, demand for them is rising, said Carlos del Rio, the president of the Infectious Diseases Society of America.
New drugs for treating immune system disorders and cancers and the increasing availability of organ transplantation (and the immunosuppressive drugs it requires) are resulting in rising numbers of immunosuppressed Americans while advances in critical care mean extremely sick people can be kept alive for longer. And while international travel remains slowed due to the pandemic, travelers continue to return from abroad with infections infrequently seen in the US.
All of these trends increase the likelihood that general practitioners will encounter patients with infections they don’t know how to treat but that are squarely in most ID specialists’ wheelhouses.
In 2017, 80 percent of US counties did not have even one ID doctor, and about 208 million citizens lived in counties where inadequate ID expertise was available.
More recent models from the federal Health Resources and Services Administration (HRSA) suggest the US is currently short about 240 ID doctors, and will be short far more — about 7 percent nationwide — by 2035. These models also suggest the shortfall is entirely concentrated in rural areas, with those areas having only 17 percent of the specialists they need.
T. Neil Ku, an ID doctor in Billings, Montana, said that while rural places may have abundant recreation opportunities in the outdoors, “that can only go so far” when it comes to attracting ID providers to practice.
Fewer providers means a heavier workload for the ones that do opt for a rural practice, making those settings even less appealing, he said. Additionally, due in part to longstanding inequities and political polarization, rural America has higher rates of public distrust for ID specialists and public health.
That has led to politically driven rollbacks in public health protections, and in many rural places, a sense of practicing in a hostile environment. That means that as far as ID provider access goes, the future holds only worse health inequities for rural residents than they already face.
The HRSA projections may underestimate the actual shortages, as they do not account for the possibility that pandemic-related provider strain may lead more currently practicing professionals to leave the profession early due to burnout.
Regardless, it’s not looking like supply is going to meet demand: In 2023, only 328 physicians will enter ID training programs — only a few more than in 2017. That’s a significant drop from an uptick in trainees earlier in the pandemic, as you can see in the chart below.
Crime was expected to be a defining issue of the midterms. Here’s what actually happened.
In the weeks leading up to Election Day this year, the media was awash with stories on how the GOP was using attacks on crime to fuel what some believed would be a red wave of Republican victories.
Headlines proclaimed that crime was the “dark horse issue of this election,” that Republican attacks on crime had become “devastating for Democrats,” that Republicans were “rid[ing] crime wave worries,” and that there was “high anxiety on the air” over crime.
It’s difficult to disentangle just how much influence Republicans’ arguments on crime actually had in the midterms, and the effect wasn’t uniform across the US. Democrats in New York appear to have suffered acute repercussions. But in many competitive races from where Republicans flooded the airwaves with their crime messaging, like in Wisconsin and Pennsylvania, it appears that the media was too hasty to believe that crime was a major deciding issue. In other contests, especially some of the country’s hardest-fought attorneys general races, Democrats were able to diffuse the issue — even, at times, turning it to their advantage.
Belief that crime would be a major issue didn’t emerge from a vacuum. Polling suggested that a majority of Americans were worried about crime ahead of Election Day. And it’s true that the national murder rate remains up over pre-pandemic levels, though it’s still well down from its peak in the early 1990s. The state of violent crime overall is less clear due to changes in how that data is reported starting in 2021.
Republicans have long used concerns about crime to their advantage, perhaps most notably when President George H.W. Bush ran his infamous Willie Horton ad during the 1988 campaign. That history, and the decades that the GOP has spent advertising itself as the party of law and order, helped create the perception that Republicans would be able to capitalize on crime. In part to divert attention from the Supreme Court’s decision to overturn Roe v. Wade, Republicans spent more than $50 million on crime-related messaging between Labor Day and Election Day — more than every other issue except the economy, according to a Washington Post analysis.
Many of the ads Republicans ran blamed Democratic policies for rising crime, trying to tie them to calls to “defund the police,” and invoked racist images and language. But while that kind of rhetoric might have resonated with Republican voters, crime didn’t have the same impact with potentially persuadable independents, who played a decisive role in the midterm results. That’s in part because they prioritized other issues more highly, but also because some Democrats were able to neutralize the threat posed by Republican attacks by having a coherent defense on crime.
Even Republicans have admitted that the attacks ultimately fell flat in many places across the US.
“You saw the Democrats, at a national level, pivot dramatically from the ‘defund’ movement to all of a sudden representing themselves as the ones defending the police,” said Jason Cabel Roe, a GOP strategist in Michigan, where Republicans saw some of their most devastating losses. “It’s something we should have had an advantage on and we just never really exploited.”
Republicans’ flawed strategy on crime
During the fall, crime consistently ranked as a high priority across national and state-level polls. For instance, in a series of October Gallup polls, 71 percent said crime was important to their decision as to which congressional candidates they would vote for and 56 percent said they thought crime has risen in their area since the previous year. But that didn’t necessarily mean that they would support Republican candidates as a result.
As the Democratic strategist Simon Rosenberg has previously pointed out, it’s hard to parse issue polling. Voters may say that they care a lot about a whole range of issues, but that doesn’t necessarily mean that any one of them will impact their decision to vote for a particular candidate or party or to vote at all.
Issue polling can also be misleading if you’re just looking at the aggregate numbers across parties. Crime and immigration were among voters’ top issues overall because they are high-priority issues for Republicans. Among independents, those issues weren’t quite as potent, and among Democrats, not at all.
“You’re misattributing the influence here by not considering that party identification is by far the most important factor in votes,” said Charles Franklin, director of the Marquette Law School Poll in Wisconsin.
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Mark Makela/Getty Images
In many of the high-profile races where the Republican sought to make crime a major issue, the Democrat ended up winning by a larger margin than expected. In Pennsylvania, for instance, Republican Senate candidate Mehmet Oz tried to use Democratic Lt. Gov. John Fetterman’s stance on criminal justice reform, including his support for pardons and sentence commutations, against him, as my colleague Li Zhou noted. One attack ad misleadingly claimed that “John Fetterman wants to release convicted murderers from prison.” Fetterman responded by defending his record, noting that he only granted clemency in cases where he thought it was merited and also denied hundreds of applications, while pointing out that Oz had no experience in combating crime. He ended up outperforming Biden and winning by more than 263,000 votes.
Even in Wisconsin, where Republican Sen. Ron Johnson ultimately won the Senate race against Democratic Lt. Gov. Mandela Barnes after attacking his stance on crime, the data suggests that crime wasn’t the galvanizing force in the race. Johnson saw a rebound in the polls after his campaign and GOP groups spent more than $4 million on TV ads focused on crime in September alone, including some that claimed that Barnes supported defunding the police. (Barnes said he did not support doing so.)
But we should be cautious about concluding that those crime ads caused Johnson’s rise in the polls, Franklin said. At that point, partisans had almost universally lined up behind their party’s chosen candidate. The state’s large share of independent voters appeared likely to decide the result and to be breaking Johnson’s way. That’s in spite of the fact that Marquette’s polling throughout the fall suggested that crime wasn’t the issue that was primarily driving their vote.
Wisconsin voters who said they were most concerned about crime were only modestly more likely to vote for Johnson; independents interviewed between September and October who were “very concerned” about crime said they would vote for Johnson 47-30 percent, according to Marquette’s polling.
There were much bigger differences in support based on other persuasion issues. Independents who had an unfavorable view of Black Lives Matter supported Johnson 61 to 23 percent. And among independents who supported the Supreme Court’s decision to overturn Roe v. Wade, Johnson was ahead 78 to 10 percent.
“The crime issue doesn’t look like it was exceptionally powerful,” Franklin said. “But the way it was used to link Mandela Barnes to unpopular positions and to raise implicitly race as a consideration in those ads, then maybe that did have some effect.”
Ultimately, Johnson won by a narrow, one-percent margin — a little more than 26,000 votes. We don’t yet know the party breakdown of his supporters. But what is clear is that crime just wasn’t “changing any votes,” Franklin said. Rather, he added, it was “simply working on the turnout mechanism and keeping your side engaged.”
Nationally, independents consistently ranked the economy and abortion as higher concerns than crime, suggesting that crime wasn’t an effective persuasion issue. And it’s persuasion, not turnout, that seems to have been a major Republican weakness this cycle.
The GOP was very successful in turning out: Registered Republicans voted in greater numbers than registered Democrats across the US. But the party struggled to persuade their voters to reliably cast ballots for party nominees in places including Georgia and Arizona, where Republicans Herschel Walker and Blake Masters ultimately lost in part because Republicans embraced split ticket voting.
New York is the major exception
Crime did seem to play a major role in Democrats’ crushing losses in New York. There were a few unique factors in the state that may have bolstered its resonance, including an explosion in New York City tabloid coverage that may have helped create the perception that crime was worse than it was.
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Lev Radin/Pacific Press/LightRocket via Getty Images
Crime in New York City has risen by about 30 percent since 2020, but is still 80 percent below its level in 1990. According to crime statistics published by the NYPD in October, property crimes were increasing ahead of the election, but the murder rate had significantly fallen over the previous year and remained lower than in many other cities where homicides have also spiked.
With headlines likening the city to Blade Runner and asking, “Will No One Help Us?” amid concerns about public safety, publications like the New York Post were “putting a megaphone” to the spike in crimes and to individual crimes, including violent attacks on the subway system in Manhattan — “things that made people hyper-aware of it more than I think you saw anywhere else,” Cabel Roe said. Crime in New York City became the subject of almost 800 stories monthly after Democratic Mayor Eric Adams’s inauguration, compared to an average of 132 stories monthly under his predecessor Bill de Blasio.
The tabloids also helped advance Republicans’ argument that New York’s 2019 bail reform law, which ended the consideration of cash bail in the majority of cases involving misdemeanors and nonviolent felonies, was to blame for the spike in crime. (An analysis by the Brennan Center found no evidence supporting that theory.) Republican Rep. Lee Zeldin — who made a credible challenge to incumbent Democratic Gov. Kathy Hochul despite the fact that New York has not gone red in decades — made a campaign promise to repeal the law himself if the Democratic-controlled legislature did not act.
Democrats have accused Adams of giving credence to those Republican attacks on crime, with the Working Families Party claiming that he was “fearmongering.” His primary campaign focused heavily on crime and public safety. And he was a leading voice calling for bail reform, arguing that the 2019 law had created an “insane, broken system” in which offenders were repeatedly getting arrested and released.
The combination of mayoral messaging, GOP rhetoric, and the tabloids helped put the rise in crime front and center in 2022. Republicans consequently picked up four congressional seats in New York, including one currently occupied by Rep. Sean Patrick Maloney, who chairs the Democrats’ House campaign arm. Following those losses, Black Democrats in the state scheduled a summit to chart a path forward on the issue.
That said, crime wasn’t the only factor in Democrats’ disappointments in New York. John Balduzzi, a Democratic strategist based in Syracuse, said that Hochul may have overestimated her popularity and that Democrats struggled with candidate quality, especially upstate.
But more than anything, he said, Democrats in New York really failed to fight back against Republican attacks on crime.
“From my perspective, witnessing what a lot of the New York Democrats running for Congress did compared to my clients in other places, [they] did a poor job of responding,” he said. “It seemed like they didn’t even try to talk it through, to defend. It was just, ‘Let it come, and we’re going to talk about social security, health care, or whatever it is. But we’re not going to fight back.’”
How Democratic candidates successfully defended against attacks on crime
The candidates who were successful in fending off Republican attacks were those who had an affirmative argument for why voters should trust Democrats on crime. That’s exactly what the Democratic Congressional Campaign Committee advised their candidates to develop in a memo sent around in March. And it’s an approach that’s been poll-tested by Democratic consultancy groups Change Research and HIT Strategies, which found that voters responded best to messaging on the solutions rather than laying blame at the feet of police.
To that end, Democrats have mostly turned against the phrase “defund the police,” with President Joe Biden blaming the slogan for his party’s lackluster performance down the ballot in 2020. In its stead, many Democrats have opted for a message that not only focuses on their support for public safety but also attempts to turn the tables on Republicans. To help bolster their case, House Democrats passed four bills in September that delivered funding to hire and train law enforcement officers and mental health first responders. Some Democrats have also pointed to the January 6 insurrection at the US Capitol and Republicans’ lack of support for gun control measures as evidence of their hypocrisy when it comes to law enforcement.
Wisconsin’s Democratic Attorney General Josh Kaul said that he was able to address the crime issue head on because it’s one that he’s “taken seriously throughout my time in office.” He’s supported police, but he’s also advocated for gun safety legislation, including universal background checks and a red flag law; was involved in holding companies accountable for their role in the opioid epidemic; and proposed a $115 million public safety plan that focuses on community policing, crime prevention, and mental health and substance abuse aid.
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Morry Gash/AP
“We had a strong record to run on, and I think that’s something voters saw,” he said.
Minnesota’s Democratic Attorney General Keith Ellison, who prosecuted those responsible for George Floyd’s murder, said his race for reelection was “closer than it should have been,” but he still eked out a win after his opponent tried to paint him as soft on crime. He said he was able to do so because he acknowledged “people’s legitimate concerns about safety.”
That doesn’t mean embracing policies that haven’t worked in the past, such as long sentences, he said. Rather, Democrats should be talking about hiring more unarmed crime intervenors and getting guns off the street, for example.
“Find me the most progressive left winger in America — they don’t want to be shot. They don’t want their family hurt. So we should own this issue,” he said. “I think a lot of Democrats are aware of the excesses of the Nixon administration, they’re aware of the problem with the war on drugs. And they’re a little bit reluctant to just lean into the fact that, obviously, we have to be there for people’s safety.”
Will Fox News have to answer for its misleading coverage of the 2020 election?
Fox News’ Sean Hannity may have uncritically elevated baseless conspiracy theories about widespread fraud committed by voting machine suppliers in the 2020 election — even though he didn’t think they were true.
That’s the latest revelation out of Dominion Voting Systems’ $1.6 billion defamation lawsuit against Fox News and its parent company, Fox Corporation, which is slated to go to trial in April in a Delaware court.
Dominion sells election technology, including voting machines, that was employed in over two dozen states in 2020. And it argues that, following former President Donald Trump’s election loss, Fox broadcasted a series of unfounded and defamatory allegations about the company that it knew to be untrue. In the process, Dominion says Fox “destroyed the enterprise value of a business that was worth potentially more than $1 billion.”
According to Dominion’s March 2021 complaint, Fox advanced the lies that Dominion had “committed election fraud by rigging the 2020 Presidential Election,” including by using its software and algorithms to alter vote counts; that Dominion is owned by a company founded in Venezuela that has tried to rig elections in favor of the dictator Hugo Chávez; and that Dominion paid officials to adopt its machines in 2020.
“Fox, one of the most powerful media companies in the United States, gave life to a manufactured storyline about election fraud that cast a then-little-known voting machine company called Dominion as the villain,” the complaint states.
One way the company claims Fox did this is by giving conspiracy theorists unfiltered platforms.
Sidney Powell, a former federal prosecutor, who is also being sued by Dominion for defamation, appeared on Hannity’s primetime show on November 30, 2020 — a week after she was unceremoniously booted from former President Donald Trump’s legal team challenging the results of the 2020 election. She had also been a guest on Hannity’s radio show earlier that day.
“There was a whole plot going on and a lot of people involved in this,” Powell said on the evening show. She baselessly accused voting machine companies, including Dominion, of using their machines to “trash large batches of votes that should have been awarded to President Trump” and to “inject and add massive quantities of votes for Mr. Biden.”
Hannity, a longtime Trump ally, didn’t push back against those claims, even as concerns grew among Republicans that Powell’s rhetoric had grown too extreme. He stopped short of making those same accusations himself, but didn’t dismiss them either. He asked whether the machines had been investigated for the kind of tampering she was alleging (Powell said it would happen soon) and asked why Democrats weren’t looking into any of these “whistleblower” claims before ending the segment.
Two years later, he was asked about Powell’s theory in a seven-hour deposition that was reportedly shared during a court hearing earlier this week as part of the Dominion lawsuit: “I did not believe it for one second,” he said under oath. Powell also walked back her theorizing in 2021, with her lawyers stating “no reasonable person would conclude that the statements [Powell made] were truly statements of fact.”
Dominion claims that this is clear-cut defamation case
Now, Dominion argues Hannity’s apparently credulous stance toward the conspiracy theories, and the fact that he didn’t push back on them, shows Fox deliberately misled its viewers about Trump’s 2020 election loss, including on what was at the time the most-watched show on cable news. Fox News has previously aired a segment across several of its shows designed to defend its own hosts and distance itself from guests’ statements accusing voting machine and software companies of election fraud.
Hannity’s statement doesn’t exactly help his network’s case. But Dominion still faces an uphill battle to win what could become the most significant First Amendment cases in recent years, particularly if the US Supreme Court gets involved at some point. The Supreme Court has previously ruled that lies or inaccuracies do have some protection under the First Amendment, and that has made it difficult for defamation cases against journalists to prevail, but this case will test just how far that protection goes.
In addition to Hannity, Dominion has also deposed other Fox anchors — including Jeanine Pirro and Tucker Carlson, as well as Shepard Smith, who has left the network — and high-profile figures in the Fox News empire. That includes members of the Murdoch family, which owns Fox in addition to News Corp., the New York Post, and the Wall Street Journal.
NPR reported that Dominion attorneys are trying to prove that Lachlan Murdoch, who presides over those media properties, permitted or even encouraged Fox News to broadcast lies about fraud in the 2020 election despite knowing them to be false. They have also deposed his father, Rupert Murdoch.
Judge Eric Davis has rebuffed Fox’s request to throw out the suit on the basis of several protections for journalists in First Amendment law. The network has argued that in its coverage of the 2020 election, it was merely reporting on newsworthy allegations made by prominent actors against public figures as part of a dispute that had not yet been resolved, which would protect it from libel claims. The network also claimed that its hosts were merely stating opinions that could not be proven true or false and that it had the right to report on defamatory statements that were made during official government meetings.
In the immediate weeks after the election, Carlson also tried to sow doubt about the security of voting machines and called the race “rigged” for Joe Biden. And Pirro lamented that “we are all being told to shut up and move on” after claiming that the “irregularities were beyond minimal” in the election.
Because of statements like these, including by hosts, Dominion says those defenses shouldn’t apply in this case.
“If this case does not rise to the level of defamation by a broadcaster, then nothing does,” it stated in its original complaint.