On July 10th, the Oversight Committee held a hearing in which Richard Carmona, who resigned as Surgeon General in 2006, gave alarming testimony about what he viewed as political and partisan pressure. During the hearing, Delegate Eleanor Holmes Norton questioned Richard Carmona on various reports that were censored or quashed, in particular one on Mental Health Preparedness:

This weekend the Washington Post reported on one such report:

Bush Aide Blocked Report
Christopher Lee and Marc Kaufman, Washington Post – July 30, 2007

Global Health Draft In 2006 Rejected for Not Being Political

A surgeon general’s report in 2006 that called on Americans to help tackle global health problems has been kept from the public by a Bush political appointee without any background or expertise in medicine or public health, chiefly because the report did not promote the administration’s policy accomplishments, according to current and former public health officials.

The report described the link between poverty and poor health, urged the U.S. government to help combat widespread diseases as a key aim of its foreign policy, and called on corporations to help improve health conditions in the countries where they operate. A copy of the report was obtained by The Washington Post.

Three people directly involved in its preparation said its publication was blocked by William R. Steiger, a specialist in education and a scholar of Latin American history whose family has long ties to President Bush and Vice President Cheney. Since 2001, Steiger has run the Office of Global Health Affairs in the Department of Health and Human Services.

Richard H. Carmona, who commissioned the “Call to Action on Global Health” while serving as surgeon general from 2002 to 2006, recently cited its suppression as an example of the Bush administration’s frequent efforts during his tenure to give scientific documents a political twist. At a July 10 House committee hearing, Carmona did not cite Steiger by name or detail the report’s contents and its implications for American public health.

Chairman Henry Waxman followed up on the hearing by requesting further documents, amongst them “All documents related to the Surgeon General's report on global health,” and by introducing the “Surgeon General Independence Act.” Today Chairman Waxman follows up again, releasing two versions of the proposed Call to Action, one prepared by Surgeon General Carmona and global health experts, one dramatically altered by political appointee Steiger. The documents were obtained independently, not provided by the Administration.

Surgeon General Carmona’s Draft Report (pdf) >>
William Steiger’s Draft Report (pdf) >>

Letter to HHS Secretary Leavitt (pdf):

July 30, 2007

The Honorable Michael O. Leavitt
Secretary
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201

Dear Secretary Leavitt:

On July 10, 2007, former Surgeon General Richard Carmona testified before the Oversight Committee that political officials at the Department of Health and Human Services blocked the release of a Surgeon General’s Call to Action on Global Health. The following day, I wrote you to ask that you provide the Committee “all documents related to the Surgeon General’s report on global health” by July 25. To date, you have failed to provide this information to the Committee.

I have independently obtained two versions of the proposed Call to Action. One is the draft report prepared by a team of global health experts and former Surgeon General Carmona. This is the version described yesterday in a front-page story in the Washington Post.

The second is an alternative draft, apparently written in 2005 by one or more staff in the Office of Global Health Affairs, which is headed by William Steiger, a senior political appointee. According to the Washington Post, Mr. Steiger is the official who blocked the publication of Dr. Carmona’s draft. He also has longstanding ties to President Bush and Vice President Cheney.

A comparison of the two drafts reveals striking differences. Dr. Carmona’s draft includes extended discussions of the impacts of women’s rights, poverty, climate change, tobacco, and obesity on global health. Mr. Steiger’s draft omits or barely mentions these topics. Dr. Carmona’s draft describes a U.N. declaration that establishes health as a human right. Mr. Steiger’s draft omits this language. Dr. Carmona’s draft contains references to condoms. Mr. Steiger’s draft does not mention condoms.

Mr. Steiger’s draft is considerably shorter than Dr. Carmona’s draft: 11,400 words compared to 17,000. Despite the shorter length of Mr. Steiger’s draft, it contains many more references to President Bush (ten references) than does Dr. Carmona’s draft (two references). Mr. Steiger’s draft also contains extended discussions of U.S. efforts in Iraq and Afghanistan. Dr. Carmona’s draft does not.

In yesterday’s Washington Post, Mr. Steiger asserted that Surgeon General Carmona’s report was blocked because it was “often inaccurate or out-of-date” and contained “sloppy work, poor analysis, and lack of scientific rigor.” A comparison of the drafts does not support these assertions. Dr. Carmona’s draft thoughtfully covers a wide range of global health topics. Mr. Steiger’s draft ignores or glosses over serious global health problems and emphasizes the achievements and policies of the Bush Administration.

The differences between the two drafts are further evidence that Dr. Carmona’s report was blocked for political, not scientific reasons. The Committee’s investigation into these issues cannot proceed, however, without the documents requested by the Committee on July 11. Compliance with this request by the Department is not optional. I therefore ask that you provide the documents requested by the Committee, or an acceptable schedule for producing the documents, by Wednesday, August 1.

The Two Draft Reports

At the Committee’s July 10 hearing, Dr. Carmona testified that his efforts to release a Surgeon General’s Call to Action on Global Health were blocked by political appointees in the Department. He testified that he was admonished by an unnamed senior official, who said: “You don’t get it … this report has to reflect American policy.” Dr. Carmona described how he fought during his last year in office to secure release of the report, but could not get the report past the initial vetting. Dr. Carmona stated: “They were clear, this will be a political document or you won’t release it, and I refused to release it. I would not put the political rhetoric into that document that they wanted. It would tarnish the Office of Surgeon General to take a political stand, so I refused.”

The two draft documents I have obtained reveal telling details about the objections Dr. Carmona encountered. As described below, there are multiple significant differences between the draft global health report that Dr. Carmona prepared and the alternative draft that was prepared by the Office of Global Health Affairs headed by Mr. Steiger, a presidential political appointee.

Women’s Health

Dr. Carmona’s draft contains a section entitled “Women’s Health,” which describes the link between women’s rights and status in society and their health. According to Dr. Carmona’s draft:

Large gaps exist between women and men in access to education, health, nutrition, and political power. These inequalities directly and indirectly lead to significant health problems for women that also have an impact on their families and communities.

Dr. Carmona’s draft explains how multiple health challenges, including HIV, sexual violence, and maternal mortality, are linked to “a basic denial of women’s rights as human beings”:

Inequality between men and women is a major threat to women’s health. In some societies where it is unacceptable for women to leave the house without their husbands’ permission, pregnant women who need medical assistance face a risk of serious complications and death if their husbands are not home to grant them permission to seek medical care. Pregnant and childbearing women die because their basic nutrition is compromised, their reproductive rights are violated, and their access to medical care is denied as a result of gender inequality. … As long as these inequalities persist, health outcomes will remain far from optimal; not only for women, but for the vulnerable populations they traditionally care for, including children and the elderly. Allowing such disparity to persist presents a significant moral challenge to all populations.

Mr. Steiger’s draft does not contain a section on women’s health or a discussion of the impact of women’s rights on health. Instead, a section titled “International Family Issues” focuses on family stability and discusses women’s health almost exclusively as an issue affecting children and families. For example, it states that improving women’s nutrition is crucial “because in many countries, women are income earners, food producers, and family caretakers.” While Mr. Steiger’s describes multiple ways in which women’s health affects the health of their children, the report does not mention issues that primarily affect women, such as reproductive rights, women’s rights, or gender inequality.

Dr. Carmona’s draft also has a section on injuries that discusses the impact of violence and sexual attacks on women:

Women are the overwhelming majority of victims of sexual and intimate partner violence. In various surveys, anywhere between 10 percent and 69 percent of women responding have reported that they were physically assaulted at some point by an intimate partner. Physical violence in these relationships is also often accompanied by psychological abuse. Sexual violence is also often linked to intimate partner violence, with the evidence suggesting that almost one in four women experience sexual violence by an intimate partner. Sexual violence affects both the physical health and psychological well-being of its victims, resulting in such problems as unwanted pregnancies, HIV/AIDS, depression, post-traumatic stress disorder, and suicide.

In contrast, there is no discussion of intimate partner violence, sexual or otherwise, in Mr. Steiger’s draft. Violence against women is only discussed in a section on current U.S. efforts to combat human trafficking, a major Administration priority.

Poverty and Health Disparities

Both drafts acknowledge a link between poverty and public health. However, while Dr. Carmona’s draft explores the nature and impact of this relationship, Mr. Steiger’s lacks any discussion of poverty or health disparities.

Dr. Carmona’s draft states that “[p]overty and health are inextricably intertwined.” According to the draft:

The conditions typically associated with poverty, such as poor nutrition and lack of access to health care, lead to disease, disability and death, as well as social instability. On the other hand, disease and poor health is an impediment to economic progress through decreased labor productivity. It is estimated than more than one-fifth of the world’s population lives in extreme poverty. And the gap between the income of the richest 20 percent and the poorest 20 percent of the world’s population doubled between the 1960s and the 1990s. Nonetheless, according to former WHO Director-General Gro Harlem Brundtland, approximately 90 percent of global health resources are concentrated on 10 percent of the world’s health problems.

Dr. Carmona’s report explains that these health care disparities exist not only between countries, but also within countries. As an example, the report describes specific racial and ethnic disparities in health that exist in the United States, stating: “Minorities and low-income populations have a disproportionate burden of death and disability from a variety of health conditions. These populations are in general less likely to have health insurance and access to good medical care.”

Mr. Steiger’s draft lacks a section on poverty and health disparities. Instead, the report states on the first page: “The complex socioeconomic issues that form the substrate of health including poverty, the need for economic development, the overall level of medical care, and cultural issues are acknowledged, but not addressed in this Call to Action.”

Environmental Health

Dr. Carmona’s draft contains extensive information on the links between the environment and human health, including a discussion of the potential health effects of global warming. Mr. Steiger’s draft contains almost no mention of these associations.

Dr. Carmona’s draft states:

The physical environment exerts an enormous influence on global health. In particular, the air we breathe and the water we drink plays a major role in the state of our health. Water and air are essential to life, but can become sources of disease or factors exacerbating disease if contaminated.

As part of this discussion, Dr. Carmona’s draft explicitly addresses the potential health impacts of climate change. According to the draft:

The climate changes that would result from global warming could have various direct and indirect effects on the health of humans. For example, heat stress and heat stroke, which can be fatal, may become more common, especially among susceptible groups such as older adults, children, and those with heart problems. The distribution of insects and other organisms that serve as hosts to the microorganisms that cause infectious diseases is likely to be affected. This could lead to changes in disease patterns. For example, malaria might appear in areas where it is currently unknown because of the spread of the mosquito that carries the disease. Global warming could also adversely affect health if changes in rainfall diminished the variety or quantity of crops available, which could lead to or aggravate food shortages.

Mr. Steiger’s draft, in contrast, contains no discussion of global warming or of detailed effects of air and water pollution on health. Though it acknowledges the importance of clean drinking water to public health, its only mention of human threats to water or air occurs in a section on infectious disease, which states that “Environmental factors that lead to disease outbreaks, including water and changes in climate are being monitored.”

Tobacco and Obesity

There are significant differences in how Dr. Carmona’s draft and Mr. Steiger’s draft address the global health implications of tobacco use and obesity.

Dr. Carmona’s draft states that “[t]obacco is the second major cause of death and the fourth most common risk factor for disease worldwide.” According to the draft:

It is responsible for approximately five million deaths each year. The economic costs of tobacco are also high, estimated to be $200 billion a year globally, with a third of this loss occurring in developing countries. The WHO reports that if current smoking patterns continue, it will cause some 10 million deaths each year by 2020. Half the people that smoke today – approximately 650 million people – will eventually be killed by tobacco. Tobacco control measures can have a significant impact on reducing tobacco consumption, hence decreasing the burden of disease and death due to tobacco use.

Dr. Carmona’s draft also describes the status of the Framework Convention on Tobacco Control, a global treaty designed to reduce worldwide tobacco use. In the “call to action” section of the report, Dr. Carmona’s draft urges Congress to ratify this important treaty.

Mr. Steiger’s draft makes almost no mention of tobacco as a health problem. It does identify reduced tobacco use as one of several ways to reduce the risk of cancer and of cardiovascular disease, but it contains no assessment of the global toll of death and disease caused by tobacco use. It also contains no discussion of the Framework Convention on Tobacco Control.

There are similar differences in the discussions of obesity. Dr. Carmona’s draft includes extensive detail on the link between food, activity, and obesity. Mr. Steiger’s draft makes no mention of the problem of obesity.

Other Differences

There are multiple other differences between the drafts. Dr. Carmona’s draft highlights the 1948 U.N. declaration that pronounced: “Everyone has the right to a standard of living adequate for health.” Dr. Steiger’s draft has no discussion of health as a human right.

Dr. Carmona’s draft acknowledges the value of condoms in preventing HIV transmission. Dr. Steiger’s draft contains no reference at all to condoms. Dr. Steiger’s draft does, however, contain a misleading statement regarding the availability of alternative methods for women to protect themselves against HIV infection. It states: “Two new antimicrobial salves that a woman can administer to herself to protect against HIV/AIDS are now near final development.” In fact, two years later, no microbicide has been approved for reducing HIV infection, and an international microbicide development organization predicts five to seven years until a product is available.

The drafts also differ in their references to President Bush and Administration policies. Dr. Carmona’s 17,000-word draft contains only two references to President Bush; Mr. Steiger’s 11,400-word draft contains ten references. Many of Mr. Steiger’s references to President Bush portray the President in a favorable light. Under the topic of health diplomacy, Mr. Steiger’s draft states: “The President expressed the United States’ deep and ongoing commitment to the tsunami victims.”

Mr. Steiger’s draft also includes several passages that describe Administration accomplishments in Iraq and Afghanistan. It notes, for example, that during “the liberation of Iraq, the United States readily committed HHS resources helping the Iraqis rebuild their health care system.” Dr. Carmona’s draft has no separate section discussing U.S. efforts in either Iraq or Afghanistan.

Conclusion

This comparison of the two draft reports is further evidence that Dr. Carmona’s global health report was blocked for political considerations, not scientific reasons. Dr. Carmona’s draft is objective and science-based, while Mr. Steiger’s draft drops or minimizes subject matters that would be politically sensitive for the Bush Administration. Mr. Steiger’s draft appears designed to put the policies of President Bush and his administration in the most favorable light possible, while Dr. Carmona’s draft maintains an impartial tone.

In the Washington Post yesterday, Mr. Steiger justified the suppression of Dr. Carmona’s report on the ground that Dr. Carmona’s draft was “often inaccurate and out-of-date” and contained “sloppy work, poor analysis, and lack of scientific rigor.” In fact, just the contrary appears to be the case. It is Mr. Steiger’s draft that appears to have sacrificed scientific rigor for political purposes.

The Committee’s investigation into these issues cannot proceed without the documents the Committee requested on July 11. I ask that you provide these documents to the Committee by Wednesday, August 1. If this is not feasible, you should provide a firm and expeditious schedule for producing these documents that is acceptable to the Committee by this date.

In addition, I request that you make Mr. Steiger and Mark Abdoo of his staff available to the Committee for depositions or transcribed interviews during the month of August.

If you have any questions about this letter, please contact me or ask your staff to contact Andy Schneider of the Committee staff at (202) 225-5051.

Sincerely,

Henry A. Waxman
Chairman

cc: Tom Davis
Ranking Minority Member