Did White House Censor Surgeons General?

Yesterday the House Committee on Oversight and Government Reform held a hearing on "The Surgeon General's Vital Mission: Challenges for the Future." According to Committee Chair Henry Waxman (D-CA):

Political interference is compromising the independence of the Office of the Surgeon General. On key public health issues, the Surgeon General has been muzzled. The Surgeon General's greatest resource — his or her ability to speak honestly and credibly to the nation about public health — is in grave jeopardy. . . . as we will hear this morning, political interference with the work of the Surgeon General appears to have reached a new level in this Administration. We will hear how reports were blocked, speeches were censored, and travel restricted.

Among those who appeared at the hearing was former Bush Administration Surgeon General Richard Carmona, who testified:

the nation's doctor has been marginalized and relegated to a position with no independent budget, and with supervisors who are political appointees with partisan agendas. Anything that doesn't fit into the political appointees' ideological, theological, or political agenda is ignored, marginalized, or simply buried. . . .

Historically, the Surgeons General have occupied increasingly embattled positions where each has had to fight to scientifically address the contemporary health issues of the nation and the world within an increasingly partisan, ideologically, and / or theologically driven political agenda that is often devoid of open discussions of scientific evidence or data.

Carmona's written statement does not provide details of alleged political interference during his term as Surgeon General. This Washington Post story, however, does:

In one such case, Carmona . . . said he was told not to speak out during the national debate over whether the federal government should fund embryonic stem cell research, which President Bush opposes.

"Much of the discussion was being driven by theology, ideology, [and] preconceived beliefs that were scientifically incorrect," said Carmona, one of three former surgeons general who testified at yesterday's hearing. "I thought, 'This is a perfect example of the surgeon general being able to step forward, educate the American public.' . . . I was blocked at every turn. I was told the decision had already been made — 'Stand down. Don't talk about it.' That information was removed from my speeches."

The problem with this example is that the debate over whether the federal government should fund embryonic stem cell research is not a scientific debate, but a moral one. Opposition to such research is almost always based upon a belief that the use of embryos for such research is immoral — not that it is ineffective or that it cannot lead to medical advances. Some opponents of stem cell research spin scientific evidence to support their cause, exaggerating the potential of adult stem cells, but proponents of embyonic stem cell research engage in spin and hyperbole of their own. In the end, the decision whether or not to support funding of embryonic stem cell research is a normative policy decision, and it is not "political interference" with science for an administration to expect political appointees to support the administration's policy on this issue — whatever that policy is.

The Post also provides a second example:

Carmona said that when the administration touted funding for abstinence-only education, he was prevented from discussing research on the effectiveness of teaching about condoms as well as abstinence. "There was already a policy in place that did not want to hear the science but wanted to just preach abstinence, which I felt was scientifically incorrect," Carmona said.

This example is harder to evaluate because it is less clear what actually occurred. If, for instance, the federal government was presenting false or misleading information about the effectiveness of abstinence-only education, and preventing Carmona's office from presenting accurate information, then this would be a good example of political manipulation of science. If, on the other hand, Carmona was prevented from expressing a purely policy disagreement with the administration, then it would not be such a good example. From what I know of the Bush Administration's policies and activities in this area, I suspect the former is closer to what occurred, but the news account does not provide enough detail to be sure.

The point here is that it is important to distinguish between scientific conclusions and normative policy judgments, and to recognize that the former may inform, but rarely determine, the latter. In many instances when scientists charge political interference, their real complaint is that those with policy-making authority do not support the scientists' preferred policies, and many claims of "censorship" are nothing more than the efforts of one administration or another to ensure that federal agencies support administration policy. There are plenty of examples of real science politicization in the current and prior administrations, and these are the incidents that merit our attention.

There is no doubt that the Bush Administration has sought to politicize science in some areas. In this it is not alone, however. As the Post further reported:

[Former Surgeon General David] Satcher, Carmona's predecessor, who served from 1998 to 2002, said that under President Bill Clinton he could not release a report on sexuality and public health, in part because of sensitivities triggered by the Monica Lewinsky scandal.

As I have argued before (in this series of posts), science politicization is not the province of either party. There is plenty of blame to go around, and a need for greater attention to the institutional arrangements that place undue political pressure on science in the first place.

UPDATE: The New York Times story on the hearing provides more evidence of increased politicization of the Surgeon General's office during the Bush Administration, such as some of the accusations mentioned in the comments. (He had to mention President Bush three times per page in speeches!?! What were they thinking?!?) Like the Post story quoted above, however, I think this report also reflects some confusion about the role of science in public policy. For instance, the Times reports:

Dr. Carmona wanted to address the controversial topic of sexual education, he said. Scientific studies suggest that the most effective approach includes a discussion of contraceptives.

"However there was already a policy in place that did not want to hear the science but wanted to preach abstinence only, but I felt that was scientifically incorrect," he said.

Now I certainly would want my children to receive sex education that reduces their chances of contracting sexually-transmitted diseases, but I also recognize that this is based upon a value judgment, rather than a scientific determination. Others may prefer abstinence only education even if it is not the most effective way to reduce STDs. For instance, they may believe such instruction achieves other ends, such as delaying sexual activity by school children (if such education actually achieves this), or is simply more moral. I find this perspective to be misguided, but I do not believe it is "scientifically incorrect." In short, a policy decision to "preach abstinence only" might be wrong, but it would not necessarily be "scientifically incorrect." On the other hand, factually inaccurate or misleading claims about abstinence only education would be. Dr. Carmona would be correct to be concerned about the latter, and insofar as the Bush Administration blocked him it is deserving of criticism, but I think Carmona's statement implies a desire to speak to the wisdom of the policy itself.

Richard Carmona's Political Science:

Earlier this month, former Bush Surgeon General Richard Carmona testified about political interference with his performance as Surgeon General. Carmona sought to portray himself as a medical professional interested in scientific fact who was pressured and obstructed by ideologically motivated political appointees. Yet as Radley Balko reports, Carmona has a political science problem of his own.

It may, indeed, be a fair point to accuse the Bush administration of politicizing science. But Richard Carmona isn't the person to make it. Carmona's entire term as surgeon general has been marked by embracing every last hobgoblin promoted by the public health movement, generally above and beyond what the science says. Sometimes in spite of it.

Balko was unmoved by Carmona's testimony, and thinks the Surgeon General's office today is an inherently politicized post.

The Office of Surgeon General always has been overtly political, a captive of the most hysterical public health activists. Its only real powers are tongue-clucking and finger-wagging, usually about the latest moral panic, lecturing the American public to knock off its bad habits, lest somebody get hurt. Richard Carmona's tenure was no different, which is why it's laughable to hear him lecture someone else about science.

Bush Appointees Blocked Health Report Release:

Today's Washington Post reports that political appointees in the Bush Administration blocked the publication of a 2006 Surgeon General's report on global health. As the Post reports, in recent Congressional testimony Carmona cited the report's "suppression as an example of the Bush administration's frequent efforts during his tenure to give scientific documents a political twist." This episode is part of a broader narrative that the Bush Administration systematically distorts and politicizes science for ideological reasons. The problem is that the facts of this episode do not support Carmona's charge nor the larger narrative.

The draft report at issue here was not a purely scientific or medical document — not even close. The report, The Surgeon's General Call to Action on Global Health, is as much a policy document as anything else, complete with specific policy recommendations on a range of issues. Among other things, the report calls for ratification of the Framework Convention on Tobacco Control, and the acceptance of certain international health regulations. Whether or not these are sensible health policy prescriptions or not, they reflect normative value judgments, not scientific judgments.

My point here is not to defend the Bush Administration, nor is it to suggest that the report should have been withheld. Rather it is that many cases of "science politicization" are in fact policy disputes. The Post's subhead reads "Global Health Draft In 2006 Rejected for Not Being Political," yet the report itself was an inherently political document. The dispute between Carmona and Bush officials was about the extent to which a policy report should reflect, endorse, or promote Bush Administration policy. It was not an instance of politics or ideology trumping science. If the Administration is to be criticized for blocking the release of The Surgeon's General Call to Action on Global Health, it should be criticized on policy grounds — for opposing particular public health measures and refusing to support others — rather than for allegedly censoring scientific expertise.

UPDATE: Here is a good example of how this story is (wrongly) placed in the traditional narrative of science politicization. Contrary to Mark Hoofnagle's claim, this episode has little to do with "scientific integrity." Nonetheless, he terms it "despicable."