Internal affairs
Authors: Douglas Kamerow
Journal: BMJ (2007)

In a July hearing of the US Congress the immediate past US surgeon general, Richard Carmona, testified about the problem of political meddling in what he saw as the proper functions and activities of his office.

Carmona spoke generally about repeated interference by the Bush administration (which appointed him) in his attempts to speak out on controversial issues, such as stem cell research, abstinence only sex education, and the emergency contraceptive pill (BMJ 2007;335:114 doi: 10.1136/bmj.39279.393345.BE). His speeches were scrubbed of any mention of these matters, even when his comments were based on science.

The former surgeon general also said that he was told by an unnamed senior official that he didn't “get it” when it came to the political basis for scientific reports that he wanted to release and that the reports had to agree with the administration's political agenda or they would not be approved. Two other former surgeons general—C Everett Koop, from the Reagan years, and David Satcher, from the Clinton presidency—also testified and cited similar examples from their own tenures but said that the censorship seemed to be getting worse.

The testimony brought a swift response from the Bush administration and Washington's punditocracy. The administration dismissed Carmona's charges, saying that it had given him all the support and opportunities he needed and that it was disappointing “if he failed to use his position to the fullest extent.” The pundits either praised him for coming forward with his story or questioned his courage for waiting until he had left office before speaking out.

Carmona's general accusations became specific at the end of July, when the Washington Post said in a front page story that one of the reports Carmona was complaining about was a 2006 global health study. It was never released, because Carmona would not make political changes demanded by a Bush official named William Steiger. A godson of the first President Bush, Steiger had no medical or public health background when he was appointed director of the government's Office of Global Health Affairs. (He still occupies this post while he awaits Senate confirmation as ambassador to Mozambique.) It is common practice in the United States for presidents to appoint well connected but inexperienced allies to key policy posts. Although they can be depended on to follow the president's political agenda, they often have little or no substantive knowledge about the agencies they administer.

Steiger maintained that the global health report should focus mainly on the steps that the Bush administration had taken to improve health worldwide. Carmona wanted to release a version drafted by international health experts that reviewed the links between poverty and ill health and advocated that disease prevention and treatment become a part of the US's foreign policy. When Steiger wouldn't approve this report, which he called “often inaccurate and out of date,” and Carmona refused to release the administration's version, the report was cancelled.

The Bush administration seems more likely than most to suppress scientific information to further political ideology, with recent complaints surfacing from disgruntled employees at the National Institutes of Health, the Food and Drug Administration, and NASA. Such meddling happens in all administrations, though, and it raises two issues that transcend administration and subject matter: what happens when an official disagrees with an announced policy, and what to do when scientific expertise is disregarded and evidence is manipulated or ignored.

In the first of these cases the traditional advice to political appointees has been to advocate for their opinions strongly in private discussions but support whatever policy eventually emerges. A well known example of this was when President Clinton's health and human services secretary, Donna Shalala, strongly disagreed with making a major change in welfare payment policy that would result in many people being thrown off the welfare lists. But when the president endorsed it she went along publicly, despite opposition from her liberal constituency. Most now agree that it was, on balance, an important and successful reform.

The second issue is trickier. Carmona complained that political ideology was trumping science in the Bush administration when, for instance, he was not allowed to advocate any type of sex education for young people except abstinence, even though scientific reviews showed clearly that abstinence only sex education curriculums don't work. It was reminiscent of an episode in the Reagan administration when Surgeon General Koop was ordered to prepare a report on the adverse psychological effects of abortion. After reviewing the literature Koop refused, saying that he had found none. As a conservative surgeon whose appointment was opposed by liberals, he had enough stature and support to weather that storm, as well as controversies related to his subsequent scientific report on the AIDS epidemic.

Clearly an administration should be allowed to attempt to set its agenda, to focus on what it thinks are important issues, and to prioritise. It also, of course, has a right to tout its accomplishments and take credit for even the serendipitous achievements that have taken place during its tenure. But when officials knowingly cite inaccurate or misleading information or bend the rules of science or evidence in pursuit of a political agenda or policy, it is time for honourable officials—whether career status or political appointees—who are unable to convince the administration to desist from such distortions to call attention to them in the only way they can: resignation.

Carmona complained that political ideology was trumping science in the Bush administration. He was not allowed to advocate any sex education for young people except abstinence, when scientific reviews showed this didn't work