The Lancet. Dangerous words. The Lancet 2017;390:2740. Redirecting
Medicine is underpinned by both art and science. Art that relies upon strong therapeutic relationships with patients and populations. And science that brings statistical rigour to clinical and public health practice. If allegations reported in The Washington Post on Dec 15 are credible, the Trump administration has seriously undermined both foundations by banning the words “vulnerable”, “entitlement”, “diversity”, “transgender”, “fetus”, “evidence-based”, and “science-based” from government documents for the US$7 billion budget discussions about the Centers for Disease Control and Prevention (CDC). Another phrase allegedly forbidden is “health equity”. A spokesperson for Health and Human Services told The Lancet that “science should always drive the narrative” and that “recent media reports appear to be based on confusion that arose when employees misconstrued guidelines”.
If true, the administration’s Orwellian diktat is both absurd and sinister. As the US National Academies of Sciences, Engineering, and Medicine observed: “such a directive would be unprecedented and contrary to the spirit of scientific integrity”. With individuals and science censored, how would the CDC realise its mission to protect people from diseases? Improve maternal and child health without making the fetus central? Control the opioid epidemic without addressing vulnerability? This interference is a crime against intelligence and insults the diversity and freedom of speech that the USA espouses.
The disenfranchisement of people and perversion of science undermines trust in government and places the health of Americans at risk. The administration needs to provide a full account and explanation of the circumstances around the “misconstrued guidelines”. Failure to do so—or confirmation of the ban—would demand a forceful response, not only from within the USA, but also from her friends and from health leaders around the globe, particularly from WHO, whose constitution specifies a government’s responsibility for the health of its people, recognises the importance of research, and calls for all necessary action to attain the objective of the organisation. Only with loud and united condemnation can this foolishness be overcome; with silence, it will spread.
I worked for CDC: the 7 “banned words” are just the beginning…
When I heard the recent news —
that CDC experts have been banned or discouraged by the Trump administration from using key words, including “
evidence-based” and “
science-based,” in formal budget submissions to the White House and Department of Health and Human Services (HHS) —
I was horrified but not surprised.
(Also on the banned list are “vulnerable,” “entitlement,” “diversity,” “transgender,” and “fetus.”)
I’m a medical doctor and public health expert, and I’ve worked for the CDC 11 out of the past 18 years, serving under four different presidents:first as an Epidemic Intelligence Service Officer, later as Director of CDC-Zimbabwe, and most recently as Director of the Division of Global HIV & TB, where I led an expert team of nearly 2,000 people across 45 countries and was responsible for a budget of about $2.4 billion, saving lives and stopping disease.
I was horrified because CDC, as the agency Americans rely on to keep them safe and healthy, usually receives widespread bipartisan support.It’s usually understood that CDC’s world-class scientists and doctors follow the evidence — irrespective of the popularity of its findings — and apply scientific solutions to difficult problems in order to avoid widespread illness and loss of life.
I was not surprised, however, because I’d already seen the beginning of non-transparent, insidious approaches that can purposely set programs up for failure or block them altogether. I witnessed new steps that “slow-rolled” critical decisions, potentially delaying congressionally appropriated funds from going out the door to important programs. For example, routine Funding Opportunity Announcements (FOAs), are now required to be reviewed outside the agency, at HHS level, for unclear reasons and without specific criteria for approval. Questions — often raised verbally down a chain — were raised about topics such as LGBTQ health, and at one point, it was suggested that my team and I put together a tool to accompany the FOAs to help flag terms that could be perceived as sensitive. Not knowing how such a tool would be used, we deferred. We also saw hiring freezes at certain positions. Although medical doctors and epidemiologists received critical exemptions, staff needed to analyze data (informatics specialists and statisticians, for example) were not seen as mission critical.
Now, we learn about the much-discussed “banned words.” Here, the implications are beyond just that of censorship or the budget narrative itself.
Words matter. “Erasing” words can be tantamount to “erasing” people and priorities. And when the restrictions are attached to “budget justifications,” the intended threat is clear: comply, or risk losing the funding for critical programs that protect the public’s health. For dedicated health professionals who truly care about saving lives and eradicating disease, this has an enormous chilling effect. It takes away the ability to address issues that are specific to particular groups, such as “transgender” individuals and those who are “vulnerable” to health threats.
It leaves these professionals caught in a potentially unwinnable situation: either comply so that funding continues to allow you to do as much of the “right thing” as you can, or refuse, and risk losing the ability to help at all.
That’s why I recently left CDC — I left because I fear these insidious practices are only the beginning.
I left because we deserve a government that serves our communities, not narrow political agendas. I left because I can now be free to help shine a light on the intentional dismantling of programs that keep us safe.
I left to help hold this administration accountable for their attacks on science, facts, and America’s leadership in the world.
I call on the Director of the CDC, Dr. Brenda Fitzgerald, to do the right thing. She must stand strong against any suggestions to censor our scientists. Her recent tweets and messages assure us that “there are no banned words at CDC.”
She must now follow through to protect and actively defend her dedicated staff against any pressures that would impede their confidence to make science and evidence-based decisions. And she must lead us toward safer and healthier communities, fulfilling her oath to protect the public’s health.