Congress, Federal Agencies, and Public Health

Liz Borkowski writes: I wrote last week about how federal agencies can solve the problems that create conditions for disease outbreaks - or fail to solve them, as is too often the case. This week, I wanted to focus on the role Congress plays in public health agencies' effectiveness, because that's another angle that crops up repeatedly in Inside the Outbreaks.

Congress's creation of federal agencies is clearly a huge achievement, and they've also periodically given new powers to already existing agencies. For instance, Mark Pendergrast tells the story of the Dalkon Shield, an IUD that turned out to cause infections while failing to prevent pregnancy in many of the women who used it; at least 17 pregnant women died with IUDs in their uteruses. The manufacturer, facing lawsuits, eventually took the product off the market, but the episode demonstrated the need to prevent similar problems in the future. Congress responded by passing the Medical Devices Amendment Act, which mandates that medical devices receive FDA approval before being marketed.

Agencies also rely on Congress for their annual appropriations, and public health isn't often the top Congressional priority when it comes to dividing a limited pool of revenue. There are times when Congress responds to a growing health threat by giving an agency more money to address the problem; for instance, after several outbreaks of food-borne illnesses, Congress gave FDA's FY 2010 budget a large increase to help it hire more food inspectors. It seems like more often, though, Congress makes funding decisions that run counter to the advice of public health professionals.

Of course, those of us in the public health field would like to see much larger amounts of money overall going to preventing death and disease - as Karen Starko pointed out in her post last week, public-health efforts bring enormous benefits, but are miserably underfunded compared to other areas. Then there are the problems with Congressional priorities, which can be shaped more by current news coverage or a small-but-vocal group of constituents than by a broad understanding of our nation's health challenges. Inside the Outbreaks includes a few examples of this, including post-9/11 Congressional decisions to increase appropriations for bioterror while cutting other health-related budget items.

In addition to Congress and CDC having different ideas about the relative importance of different public health priorities, there can also be times when members of Congress flat out oppose a CDC effort to tackle a particular public health problem and eliminate funding for that area altogether. Mark Pendergrast gives this example in Chapter 18:

In November 1994, conservative Republicans had won both houses of the U. S. Congress, which spelled trouble for the CDC National Center for Injury Prevention and Control, where EIS alums Mark Rosenberg and Jim Mercy continued to study the impact of firearms. As their EIS officer for the incoming class of 1995, they recruited Etienne Krug, a 34-year-old Belgian.

"I grew up in Europe," Krug said, "where firearms are not available at all. They are considered very unsafe to have in your home." So he decided to compare the rate of firearms deaths in the United States with other developed countries. The results showed children under the age of 15 were twelve times more likely to be killed with a gun in the United States than in the other countries' combined average rates. Krug's study also pointed out that while the overall annual death rate for children in the United States had declined substantially since 1950, the child homicide rate had tripled.

When the MMWR published his findings in February 1997, Krug was interviewed on international TV and radio, resulting in an anonymous death threat. The Republican Congress had just passed a bill eliminating the $2.6 million Division of Violence Prevention budget for firearms research and ordering the CDC never to advocate gun control. Thus, when pressed by reporters about whether tougher laws should be passed, Krug answered, "That is up to legislators to determine based on the data." The Congressional ban on CDC gun control advocacy remains in place.

This is troubling. If scientists think that Congress will eliminate research efforts that yield results Congress dislikes, they're likely to steer clear of investigations that might draw Congressional ire, even if that research could save many lives. This was also something that my colleagues and I found in our Scientists in Government research, when we interviewed scientists from federal agencies to identify policies and practices that could be improved in order to strengthen federal science. In particular, several scientists from the National Institute for Occupational Safety and Health (which is part of CDC) told us that the 104th Congress's threat to eliminate NIOSH still informs agency decisions about research topics, and that new initiatives have been "noticeably in non-controversial areas."

Congress has a responsibility to exercise oversight over the agencies it has created, but its micro-managing has the potential to impede agencies in their work to carry out their Congressionally mandated missions - which in CDC's case is "Collaborating to create the expertise, information, and tools that people and communities need to protect their health - through health promotion, prevention of disease, injury and disability, and preparedness for new health threats." There will be times when the tools and information communities need to protect their health do not sit well with a group of voters, and Congressional (or presidential) pandering to those voters will impede disease prevention.

Inside the Outbreaks' description of CDC's work on HIV/AIDS illustrates just how much is at stake when lawmakers, executives, and agencies themselves let political considerations interfere with research and prevention efforts. I knew the US had been too slow to respond to AIDS, but reading about multiple instances when EIS officers recommended specific actions but authorities declined to act was depressing. As early as 1982, EIS officer Jim Curran's was recommending that blood donations from high-risk groups be deferred - and his advice wasn't being heeded. Because of how AIDS is spread (sexual contact, injection drug use) and because it initially affected marginalized populations, many people were reluctant to discuss or investigate it, and then resisted the kinds of prevention efforts (condom distribution, needle exchanges, etc) that could best prevent its spread.

Aside from reminding Congress (and the White House) just how many lives are at stake from public health problems it would rather not acknowledge, what are good ways to ensure that Congressional actions towards health-related federal agencies don't hinder agencies in fulfilling their Congressionally mandated missions?