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Science Versus Politics

Every public health decision involves political decisions. A price came with CDC's expansion beyond infectious diseases, which generally do not have a group of persons who benefit from the disease and are lobbying to reduce control efforts. With infectious diseases, public health decisions usually can be based on the best science available; this is not always true in the larger public health arena. Tobacco companies make their profit by selling cigarettes and will actively fight efforts to reduce tobacco consumption. The new reality at CDC involved groups disputing its findings, such as gun lobbyists, and political pressures from both congressional and administrative personnel regarding occupational health decisions, lead abatement recommendations, and tobacco statements. One Senate Committee demanded the names of persons investigated in the liquid-protein diet deaths so that it could perform its own investigation. The names were not provided. A congressman demanded the names of persons in CDC files who tested positive for HIV. Again, the demand was refused. But the time and effort required to counter such political intrusions increased and became a fact of life that continues to decrease the efficiency of public health workers. CDC needs to continue to base its decisions on the best available science, but factors beyond science continue to contribute to public policy decisions.

A final example involves Reye syndrome, a problem that had concerned CDC for some years. By 1979, CDC had the results of three case-control studies from Arizona, Michigan, and Ohio, indicating that salicylates (i.e., aspirin) were a risk factor under certain conditions. Michigan performed another study during the 1980--81 influenza season that also determined salicylates were a risk factor for Reye syndrome.

None of the studies had reached statistical significance, in an era when meta-analysis for combining studies for statistical analysis was in its infancy. The National Institutes of Health, Food and Drug Administration (FDA), and CDC all had made statements regarding the possible association of medications with Reye syndrome; however, those statements had fallen short of advising against use of salicylates in children with influenza or chickenpox. Outside consultants all agreed that the various shortcomings of the studies were insufficient to neutralize the consistency of the findings. The aspirin manufacturers were unrelenting in their arguments that CDC's scientific reputation would be ruined if the studies were reported without having achieved statistical significance. But CDC and FDA decided to report on the studies in a joint statement, making their shortcomings very clear, in the belief that pediatricians and parents should have all the information that the Public Health Service had. The night before publication, FDA called to say it had received new information from the aspirin manufacturers and that CDC should delay publication.

However, the next day, CDC decided to proceed with its publication plan. The report in MMWR detailed the shortcomings of the studies and concluded with the following statement: "Until definitive information is available, CDC advises physicians and parents of the possible increased risk of Reye syndrome associated with the use of salicylates for children with chickenpox or influenza-like illnesses (12)."

The very surprised aspirin manufacturers descended on the assistant secretary of health, who supported the statement. They went to the secretary of Health and Human Services, who supported the statement. They then went to the White House, which told CDC to start a new study. But the word was already out. Salicylates were withheld in children with chickenpox and influenza, reports of Reye syndrome declined, lives were saved, and science had trumped politics. The challenge for the future is to continue making the best science available for the benefit of everyone.

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