Recently, the Washington Post reported that the Trump administration was attempting to prohibit the Centers for Disease Control and Prevention’s (CDC’s) use of seven words in official documents being prepared for the next budget cycle, including the terms “vulnerable,” “entitlement,” “diversity,” “transgender,” “fetus,” “evidence-based,” and “science-based.” Each term aligns with hot-button issues in American politics that represent anathema to right-wing populist sentiments. The first four terms appear to target programs and research that focus on disadvantaged groups and social safety nets (vulnerable, entitlement, diversity, and transgender). One term may quickly recall debates about abortion rights (fetus), and the final two terms (evidence- and science-based) are part and parcel of essentially everything the CDC does.
Suffice it to say, there was a public backlash against the “ban,” including speculation about political calculations behind each word. Other public outrage was directed at the appearance of censorship, inspiring social media hashtags, such as #CDC7words and #Censorship. In fairness, a spokesperson for the CDC has described the story as a “complete mischaracterization of discussions regarding the budget formulation process.” However, public, medical, and scientific concerns remain.
Beyond the apparent conflicts between the banning of the seven words and the online statement of mission and roles of the CDC, what are the actual policies that might be affected, or at least targeted by such an alteration of the CDC’s vocabulary? As others have also recently noted, looking closely at how the CDC actually employs the targeted words is revealing. Rather than simply relying on speculation, I conducted a quick content analysis of one document that should be representative of the CDC’s recent budget priorities, the Justification of Estimates for Appropriations Committees of the CDC for Fiscal Year 2017. I ran a word search for each of the purportedly banned terms, to explore how extensively such a document might be affected by the alteration or deletion of these terms, as well as to quickly assess the actual contexts in which these terms are used.
How the Terms are Used
As shown in the the accompanying chart, “entitlement” does not appear in the 2017 budget narrative, but health-related entitlements are named throughout, (eg, Medicaid and Medicare). The concept of entitlements (a right to something, guaranteed by law) also applies to such programs as the Vaccines for Children Program, which is an entitlement provided by section 1928 of the 1994 Social Security Law. “Fetus” also does not appear, but “fetal” does, referring to birth defects, fetal death, or fetal alcohol syndrome.
The term “diversity” is used with some diversity, but with only seven instances throughout the 2017 document. The context alternates between reference to the Office of Minority Health and Health Equity’s Diversity Management Program, as well as (separately) to diversity in microbial strains, in the context of the rise of antimicrobial-resistant strains of pathogens.
The term “transgender” is predictably used only in the context of broader discussions related to the LGBT community. This may be notable because of the political division between broader LGBT issues (eg, the wide acceptance of same-sex marriage rights), as opposed to specific public debates that apply directly to transgender people (eg, bathroom usage or military service).
The term “vulnerable” is used more widely, in ways a public health professional might expect, referring to “vulnerable populations.” However, the specific vulnerabilities highlight potential conflicts with administration policy stances. For example, over half of the uses refer to those vulnerable to infectious diseases, and the term overlaps with both refugee resettlement efforts, as well as to trends in new cases of tuberculosis, which appear at a higher rate as new cases in “foreign born” individuals. Introducing vaccination to vulnerable populations is an additional theme.
The usage of both “evidence-based” as well as the near synonym, “science-based,” is so extensive that it is impossible to provide a summary that is both succinct and sufficiently detailed. However, many issues where an “evidence-based” approach is described have generated controversy, including screening guidelines for breast or prostate cancer. Beyond the conflict between evidence and public desire for cancer screening (whether it saves lives or not), the term “evidence-based,” and particularly the term “science-based,” both appear prominently in a variety of discussions about vaccination.
If there is a policy-oriented intentionality to the word ban, then there are ominous themes that link seemingly unrelated terms. Five of the seven words are often used in the context of vaccination, and several refer in some way to underserved care. Across several terms, there also appears to be a link to refugees or foreign-born individuals. Additionally, the specific call-out of the term “transgender” from the broader LGBT context may signal the use of this term—and this population—as a political wedge.
On the other hand, if political exigency or ideology, as opposed to a logical, rational process was employed in the identification of these terms, then the potential for accidental damage in the banning of words, and the downstream effects on policy, will have unintended consequences. For example, concern over the term “evidence-based” will affect programs across the entire CDC; an ideological irritation with the concept of “diversity” will not only impact the broadening of representation in positions of authority, but also may impact how the development of new antimicrobial compounds are developed.
This quick analysis is based on a review of one budget justification, covering the current fiscal year. A broader analysis of documents across all of CDC may reveal other themes in the logic behind the selection of terms by the administration. Or, one could simply ask why the seven words named above are poised to become a “no-go” zone for the nation’s top public health agency. With limited hopes for that line of questioning, we are left to extrapolate from content, knowledge, and professional familiarity with the terms and with CDC programs.
Regardless, this quick analysis underscores the fact that interference in open conversation about the implementation of public health, whether the result of intentional policy targeting, or simply due to ideological word policing, stand counter to the proper functioning of a national, science-driven agency established to protect the health of the American people.
|Table: Terms Indicated as “Prohibited” in CDC Budget Requests by Trump Administration, as per Washington Post|
|Term||Count of Uses||Note|
|Vulnerable||24||50% of instances refer to infectious diseases or vaccination; overlap with immigrant (TB) refugee or international (Ebola) issues||Targets many populations not favored by the right (poor, HIV infected, environmental exposures), also used in relation to TB control, noting “foreign born” individuals are contributing to a larger percentage of new cases; term also connected with refugee resettlement, a substantial issue in current federal politics in the US.|
|Entitlement||0||Not used as a term in 2017 Congressional Justification||Despite not being used as a term, words referring to health-related entitlements appear throughout, eg “Medicare” appears 36 times often in reference to Centers for Medicare and Medicaid, but 10 usages referring to Medicare itself.|
|Diversity||7||Used in a variety of ways, including both diversity of programs, including “Diversity Management Program,” which provides “leadership for CDC wide policies, strategies, planning, and evaluation to eliminate health disparities.”||This term is used in several ways: diversity of thought and of personnel within the CDC; diversity within society; and unrelated to these concepts, diversity of microbial strains in the context of antimicrobial resistance.|
|Transgender||10||Used exclusively in the context of HIV programs, almost always in conjunction with identifiers of other populations (eg, men who have sex with men [MSM])||The term is often used in a broader context of LGBT-focused discussions. However, other terms that would have once been “hot-button” issues are not targeted (eg, “homosexual,” “MSM,” etc)|
|Fetus||0||Not used as a term in 2017 Congressional Justification||At least based upon the 2017 budget document, the term “fetus” is not used. Other related terms were searched (foetus, fetal), and “fetal” appears 17 times, exclusively related to Fetal Alchol Syndrome, Fetal Death, or Birth Defects.|
|Evidence-based||119||119 usages; wide variety of programs||The term is used across the document applied to a variety of other terms, programs, and concepts.|
|Science-based||4||4 usages; 2 in relation to biosafety inspection, 1 related to communication efforts related to vaccines, and 1 related to injury and violence prevention initiatives.||Half of “science-based” occurrences (2 of 4) relate to politically sensitive terms: vaccinations, and “injury and violence prevention initiatives,” which might reflect a sensitivity to programs or research on gun violence.|