A senior official at the Centers for Disease Control and Prevention (CDC) did advise her colleagues not to use seven words in budget documents, according to a source close to the US Department of Health and Human Services (HHS), to which the CDC belongs. However, although this source confirmed earlier published reports in the Washington Post, the New York Times, and other news outlets citing the seven words, he emphasized that no “directive” was issued.
Three of the words, “diversity,” “entitlement,” and “vulnerable,” were mentioned in a document that went out across all HHS agencies, the source said. “Fetus” and “transgender” “came up” in the CDC briefing, he added.
However, the source stressed, “there wasn’t a directive not to use” any of the words. “It was suggested you try to avoid them. But if you feel it’s necessary to use them, you can.”
There were indications in published reports that CDC staffers were urged to avoid these words only because their use in a budget request might increase the chances of cuts in CDC funding by the Trump administration or Congress.
Meanwhile, as outrage over the banning of the seven words continued to grow among healthcare and biomedical research professionals, HHS put out a new official statement on the flap: “HHS and its agencies have not banned, prohibited or forbidden employees from using certain words. Recent media reports appear to be based on confusion that arose when employees misconstrued guidelines provided during routine discussions on the annual budget process. It was clearly stated to those involved in the discussions that the science should always drive the narrative. Any suggestion otherwise is simply not true.”
Brenda Fitzgerald, MD, director of the CDC, said in a statement, “As I have said previously, there are no banned, prohibited or forbidden words at the CDC — period. I want to emphasize to anyone who may believe otherwise that we continue to encourage open dialogue about all of the important public health work we do. CDC has a long-standing history of making public health and budget decisions that are based on the best available science and data that benefits all Americans — and we will continue to do so.
“I understand that confusion arose from a staff-level discussion at a routine meeting about how to present CDC’s budget. It was never intended as overall guidance for how we describe and conduct CDC’s work.”
The guidelines cited by HHS were included in a “stylistic guide” distributed throughout HHS, the source told Medscape Medical News. This document, part of the instructions for preparing budget requests, is 73 pages long, and just one paragraph in it concerns the terms to avoid, he said.
At the CDC briefing, the source said, “suggestions were given” on how to handle the terms “evidence-based” and “science-based.” According to a CDC analyst who spoke to the Washington Post, one workaround suggested for these terms was “CDC bases its recommendations on science in consideration with community standards and values.”
The Washington Post said that Alison Kelly, a senior leader in the agency’s Office of Financial Services, told CDC staff that she didn’t know why the seven words were being banned and that she was “merely relaying the information.”
The source close to HHS said he had heard that, in a conference call Sunday night, senior leaders at HHS had agreed that “the instruction was never given verbally that the words aren’t supposed to be used.”
The New York Times reported that CDC officials received “feedback” from higher-ups to reconsider certain language in draft documents. But the source for that statement said she was not sure whether those included the seven words in question. The source close to HHS said he did not know whether the CDC was provided this kind of feedback on its budget draft, but he reiterated that no instruction was given to ban the seven words.
Blowback From Healthcare
Some medical societies were quick to criticize the Trump administration for what they viewed as its impermissible interference with science.
“Recent public reports indicate that the Administration has shackled the CDC with inexplicable rules banning certain terms from the agency’s budget requests,” said Michael Munger, MD, president of the American Federation of Family Physicians, in a statement. “This action is an obvious attempt to politicize the most fundamental tenets of medicine and research, which will have a chilling effect on the CDC’s ability to rely on science to justify the work it does to protect public health.”
The American College of Obstetricians and Gynecologists (ACOG) also expressed dismay over the reported muzzling of the CDC. “ACOG warns that political interference has no place in the CDC’s work,” said ACOG President Haywood L. Brown, MD, in a statement. “ACOG urges the Trump Administration…to drop its reported policy banning the CDC from using certain words…in its budget documents. We also object to reports that the CDC been instructed to replace ‘evidence-based’ and ‘science-based’ with the phrase: ‘CDC bases its recommendations on science in consideration with community standards and wishes.’ Public health policy must always be based on scientific evidence, not community wishes.”
In another statement, the Infectious Diseases Society of America, HIV Medicine Association, and Pediatric Infectious Diseases Society said, “We are deeply concerned about reports that budget documents submitted to Congress from the [CDC] may be censored for certain terms…. We find this unacceptable and disturbing. We strongly urge elected officials to prohibit any form of censorship that interferes with accurate communications by CDC, other [HHS] agencies and other federal agencies.”
Bioethicists’ Views
Nancy Berlinger, a research scholar at the Hastings Center, a nonprofit, nonpartisan research institution that focuses on bioethics, told Medscape Medical News that she was particularly concerned that the Trump administration’s clampdown on using certain terms would create a “chilling effect” at CDC. “When public health experts are discouraged from using normal useful public health language out of fear that public health programs will not be funded, that’s the definition of a chilling effect,” she said.
“It’s been said that a budget is a moral document,” she continued. “It shows what society is willing or unwilling to commit resources to. If the word ‘transgender’ is avoided in a budget document, how will the health concerns of transgender people be reflected in that document?”
Berlinger likewise noted that diversity is an important concept in public health because America is such a diverse society. What is different about different groups within our country, whether that be income, language, or geographical location, “must be studied and responded to,” she said.
The word “vulnerable,” Berlinger noted, is commonly used as a modifier for “population” in public health research and clinical trials. Not using that word could be problematic, for instance, in discussing the potential harm that certain people could suffer in clinical trials because of their specific characteristics.
And the word “entitlement,” she said, can be part of describing certain aspects of a program’s budget that apply to particular groups of people, such as those on Medicare or Medicaid. “It’s a strange word to take off the table if you want to talk about our health system accurately.”
Based on her conversations with physicians and nurses, as well as recent Facebook posts, she said, “People are really concerned about this. They see a connection between the chilling effect on language translating into a reduction in funding or obscuring of important issues. And how does that translate into patient care, how public resources are being made available to different patient populations?”
In a Medscape commentary on the episode, Arthur Caplan, PhD, a bioethicist at the University of Pennsylvania, scoffed at administration avowals that none of the terms had been banned and that HHS would “continue to use the best scientific evidence available to improve the health of all Americans.”
“Once the government tells a key agency like the CDC not to use utterly legitimate words, does anyone really think that any more needs to be said?” Dr Caplan wrote. “The chilling effect on all scientific agencies of the federal government is cold enough to make polar bears dying in the Arctic due to human-fueled climate change rejoice.”
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