The Corpus Callosum

href="http://scienceblogs.com/corpuscallosum/images/Carmona-CTAGlobalHealthdraft.pdf">This
report (PDF 260KB file) is what set off the controversy over
the former Surgeon General of the United States.  It is a
draft report, entitled The Surgeon General’s Call
to Action on Global Health 2006
.  It was written by
the former Surgeon General, Dr. href="http://www.hhs.gov/about/bios/sg.html">Richard Carmona.

In this post, I will review the history of Dr. Carmona’s service as
Surgeon General, outline the controversy, and end with a discussion of
of some recent criticism of the controversy.

Born
and raised in New York City, Dr. Carmona dropped
out of high school and enlisted in the U.S. Army in 1967. While
enlisted he received his Army General Equivalency Diploma, joined the
Army’s Special Forces, ultimately becoming a combat-decorated Vietnam
veteran, and began his career in medicine.

After leaving active duty, Dr. Carmona attended Bronx Community
College, of the City University of New York, where he earned his
associate of arts degree. He later attended and graduated from the
University of California, San Francisco, with a bachelor of science
degree (1977) and medical degree (1979). At the University of
California Medical School, Dr. Carmona was awarded the prestigious gold
headed cane as the top graduate. He has also earned a masters of public
health from the University of Arizona (1998).


He was appointed to the post of Surgeon General by George W. Bush in
2002, for a four year term.  His term ended in 2006, and he
was not reappointed.  At the time, it was href="http://scienceblogs.com/effectmeasure/2006/09/surgeon_general_fades_away.php">not
clear why.

Dr. Carmona still has not been replaced.  President Bush has
nominated a replacement, Dr. href="http://en.wikipedia.org/wiki/James_Holsinger" rel="tag">James
Holsinger, who is awaiting Senate confirmation.
 (Holsinger has href="http://scienceblogs.com/corpuscallosum/2007/07/post_3.php">generated
some controversy himself; it still is not clear how that will
play out.)

During Congressional
hearings
prior to the consideration of Holsinger’s
confirmation, Dr. Carmona was invited to testify.  He
testified — with ample, credible evidence — that the Bush
administration systematically repressed his efforts to advance the
cause of public health.  That was on July 10, 2007.

In the public testimony, he did not name names, but href="http://www.nytimes.com/2007/07/11/washington/11surgeon.html?ex=1341806400&en=e90da41b777967cf&ei=5090&partner=rssuserland&emc=rss">he
agreed to provide specifics in a closed-door session…


On July 29, 2007, the Washington Post published href="http://www.washingtonpost.com/wp-dyn/content/article/2007/07/28/AR2007072801420.html?hpid=topnews">an
article about one of the specific instances of suppression.
 They linked to the report (The Surgeon
General’s Call to Action on Global Health 2006)
,
and provided some background information and some analysis.

The interviewed three individuals, who stated that the report had been
suppressed by href="http://en.wikipedia.org/wiki/William_R._Steiger">William
R. Steiger.  Steiger has been in the news before,
for similar antics.  For example, see href="http://www.motherjones.com/news/outfront/2004/05/04_400.html">this
article by Chris Mooney.  (More on Steiger href="http://stconsultant.blogspot.com/2005/10/william-r-steiger.html">here
and href="http://scienceblogs.com/effectmeasure/2007/04/cdc_the_times_they_need_a_chan.php">here.)

The Blogospheric response was immediate, with nearly-universal
condemnation of the actions of the Administration.  As of this
moment, WaPo notes 156 blog posts on the subject.  That
includes four here at ScienceBlogs:&nbsp
href="http://scienceblogs.com/denialism/2007/07/now_this_is_why_political_appo.php">Now
this is why political appointees shouldn’t have a say in science
,
href="http://scienceblogs.com/bushwells/2007/07/more_from_carmona.php"
target="_main" _base_target="_blank">More from Carmona
,
href="http://scienceblogs.com/effectmeasure/2007/07/small_minds_thinking_tiny_depa.php">Small
Minds Thinking Tiny Things Depatment, and href="http://scienceblogs.com/commonground/2007/07/bush_aide_blocked_report.php">Bush
Aide Blocked Report.  

I mentioned that the response was almost a
consensus that the
suppression had been inappropriate.  Over the time span from
the
original testimony (July 10) and the WaPo article about Steiger’s role
(July 29), there were a few posts that expressed the opinion that the
Administration had acted within reasonable limits in suppressing the
report.  (1
href="http://holycoast.blogspot.com/2007/07/sour-grapes-from-surgeon-general.html">2
href="http://www.cato-at-liberty.org/2007/07/11/science-values-and-politics/">3
4)
Some viewed the whole thing as irrelevant, and called for
the abolition of the position of the Surgeon General.  Others
insisted that Carmona’s experience was not significantly different from
that of previous Surgeons General ( href="http://reason.com/news/show/121543.html">1 href="http://carolliebau.blogspot.com/2007/07/behind-carmona-controversy.html">2).
 That indicates, to me, that hey did not read the reports
carefully.  Carmona and the prior Surgeons General were very
clear that Carmona was subject to much more political pressure than his
predecessors.  

Those that argued that the
Administration had acted within reasonable limits in suppressing the
report seemed to buy into the concept of the href="http://rawstory.com/news/2005/CanExecutive_Branch_Decide_0923.html">unitary
executive:
that the President has complete control over everything that is done
within the Executive Branch.  The corollary of that is that
there is no role for Congressional oversight, and that the President is
free to interpret law as he sees fit.  

Another point arose in the responses to the controversy.  Some
mentioned the opinion that the controversy has been cited wrongly as an
example of the politicization of science.  

From the Volokh Conspiracy
:

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: href="http://scienceblogs.com/denialism/2007/07/now_this_is_why_political_appo.php">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.”

The Volokh post, while thoughtful, misses an
important point.  To understand this, it is necessary to draw
a distinction between a broad, general kind of politics, and the more
specific category of partisan politics.  

It the broadest sense, politics could be defined as “the set of arts
and sciences directed toward the goal of getting other people to do
what you want them to do.”  

In that definition, most medical interventions could be termed
political.  That is because health professionals must enlist
the cooperation of their patients in order to have a positive impact.
 By the broad definition, a doctor trying to get a patient to
quit smoking is engaging in politics.  However, this obviously
would not be partisan politics.

With that in mind, let’s look at the assertion that Carmona’s report
was a policy document, as opposed to a scientific document.
 In a broad sense, it is true.  That is evident from
the title: …Call to Action…”.  Carmona was trying to
influence behavior.  That is natural; it is what every
physician does, as an integral part of medical practice.  

In this conceptual framework, it is apparent that what Stieger was
trying to do was to take a science-based nonpartisan
policy document, and turn it into a ideology-based partisan
policy document.  So instead of referring to to this as an
instance of the politicization of science, perhaps it would be more
accurate to call it an instance of partisanization of nonpartisan
policy.

This may be a subtle distinction, but it is an important one.
 To see more clearly what the implications are, it is helpful
to look at a alternate draft document that Steiger prepared (or had
someone else prepare).  That can be seen href="http://scienceblogs.com/corpuscallosum/images/Steiger%20draft%20of%20Carmona%20report.pdf">here
(PDF), as copied from a href="http://oversight.house.gov/story.asp?ID=1440">website
put up for .  There is also a comparison of the two
drafts, href="http://scienceblogs.com/corpuscallosum/images/Waxman%20comparison%20of%20Carmona%20draft%20and%20Steiger%20draft.pdf">here
(PDF).  

To illustrate the point, here are comparable selections form Carmona’s
draft, and that of Steiger:

Carmona: Caring about the health
of others is of strategic significance since health diplomacy, or
working with other nations on shared health goals, promotes
international cooperation, is critical to the long-term health and
security of the American people. It is the way to protect, promote, and
advance the health and safety of the nation…

Steiger: Health is a diplomatic
tool to promote good relations and improve ties between the United
States and other countries. When you think about it, promoting health
cooperation with other countries is always a win-win situation.
Strengthening health globally will strengthen security, including our
own health security. But it also improves health in our partner
countries. There’s no downside.

This is subtle.  Carmona emphasizes the “strategic” and
“security” implications of global health initiatives.  This
makes sense.  There obviously is no point at all to spending
five hundred billion dollars to combat a dubious terrorist threat, when
spending just five hundred million on disease prevention could save
more lives and have a greater positive economic benefit.  This
is not the line the Administration wants to promote.

In addition, Dr. Carmona devoted substantial attention to the issues of
global poverty, and poverty in the USA.  Steiger used the word
poverty only twice, once in the context of
international health, with no specific reference to the negative health
impact of poverty in the USA.  Carmona addresses obesity at
length.  But, consistent with Steiger’s prior record of href="http://www.nationalreviewofmedicine.com/issue/2004_02_15/features06.html">caving
in to the influence of the US food industry, Steiger does not
address obesity at all.

This illustrates that there was not only partisan political influence,
but antiscientific corporate influence, as well.  So far I
have not seen that issue addressed by either side in this debate.

Comments

  1. #1 MarkH
    August 1, 2007

    Very thorough. I think it’s a stretch though to say that recommendations based on science are of necessity political though. The SG should be able to say, “X is unhealthy, and Y measures to fix it have shown Z” without being accused of being a political actor. Between that and requiring Carmona to be a cheerleader for the president seemed a bit twisted.

    Also, no one seems to remember Koop got in trouble for suppressing information on the safety of abortion during his tenure and was similarly attacked for politicizing the office. I think there is a precedent for railing against suppression of relevant health information from the SG for political reasons.

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