By Christopher Lee and Marc Kaufman
Washington Post Staff Writers
Sunday, July 29, 2007
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.
Carmona told lawmakers that, as he fought to release the document, he was "called in and again admonished . . . via a senior official who said, 'You don't get it.' " He said a senior official told him that "this will be a political document, or it will not be released."
After a long struggle that pitted top scientific and medical experts inside and outside the government against Steiger and his political bosses, Carmona refused to make the requested changes, according to the officials. Carmona engaged in similar fights over other public health reports, including an unpublished report on prison health. A few days before the end of his term as the nation's senior medical officer, he was abruptly told he would not be reappointed.
Steiger did not return a phone call seeking his comment. But he said in a written statement released by an HHS spokesman Friday that the report contained information that was "often inaccurate or out-of-date and it lacked analysis and focus."
Steiger confirmed that he sharply disagreed with Carmona on the issue of how much the report should promote Bush administration policies. "A document meant to educate the American public about health as a global challenge and urge them to action should at least let Americans know what their generosity is already doing in helping to solve those challenges," Steiger said in the statement.
Steiger said that "political considerations" did not delay the report; "sloppy work, poor analysis, and lack of scientific rigor did." Asked about the report's handling, an HHS spokeswoman said Friday that it is still "under development."
The draft report itself, in language linking public health problems with violence and other social ills, says "we cannot overstate . . . that problems in remote parts of the globe can no longer be ignored. Diseases that Americans once read about as affecting people in regions . . . most of us would never visit are now capable of reaching us directly. The hunger, disease, and death resulting from poor food and nutrition create social and political instability . . . and that instability may spread to other nations as people migrate to survive."
In 65 pages, the report charts trends in infectious and chronic disease; reviews efforts to curb AIDS, tuberculosis and malaria; calls for the careful monitoring of public health to safeguard against bioterrorism; and explains the importance of proper nutrition, childhood immunizations and clean air and water, among other topics. Its underlying message is that disease and suffering do not respect political boundaries in an era of globalization and mass population movements.
The report was compiled by government and private public-health experts from various organizations, including the National Institutes of Health, the Catholic Medical Mission Board and several universities. Steiger's global health office provided the funding and staff to lead the effort because the surgeon general's office has no budget and few staff members of its own.
"It covered all of the contemporary issues of public health, from environmental health through infectious disease transmission," said Jerrold M. Michael, a former assistant surgeon general and a former longtime dean of the University of Hawaii School of Public Health, who worked on the report.
A few of the issues it focuses on, such as AIDS treatment and research, have been public health priorities for the Bush administration. But others -- including ratifying the international tobacco treaty and making global health an element of U.S. foreign policy -- are more politically sensitive. The report calls on the administration to consider spending more money on global health improvement, for instance. And it warns that "the environmental conditions that poison our water and contaminate our air are not contained within national boundaries. . . . The use of pesticides is also of concern to health officials, scientists and government leaders around the world."
Three people involved in the preparation of an initial draft in 2005 said it received largely positive reviews from global health experts both inside and outside the government, prompting wide optimism that the report would be publicly released that year. The Commissioned Officers Association, a nonprofit group representing more than 7,000 current and retired officers of the U.S. Public Health Service, organized a global health summit in June 2005 in Philadelphia where Carmona was expected to unveil the report in a keynote address -- but he was not cleared to release it there.
Richard Walling, a former career official in the HHS global health office who oversaw the draft, said Steiger was the official who blocked its release. "Steiger always had his political hat on," he said. "I don't think public health was what his vision was. As far as the international office was concerned, it was a political office of the secretary. . . . What he was looking for, and in general what he was always looking for, was, 'How do we promote the policies and the programs of the administration?' This report didn't focus on that."
On June 30, 2006, a Steiger aide sent an e-mail saying that the report should not be cleared for public distribution: "While we believe the subject matter of the draft is important, we disagree with the style, tone and messaging," wrote the aide, Mark A. Abdoo, according to a copy of the e-mail. "We believe this document should be focused tightly on the Administration's major priorities in global health so the American public can understand better why these issues should be important to them. As such, the draft should be a policy statement, albeit one that is evidence based and draws on the best available science."
Steiger, 37, is a godson of former president George H.W. Bush and the son of a moderate Republican who represented Wisconsin in the House and hired a young Dick Cheney as an intern. The elder Bush appointed Steiger's mother to the Federal Trade Commission in 1989. A biographical sketch of her on the American Bar Association's Web site states that Steiger's parents, now deceased, were "lifelong friends" of many members of the same congressional class, including the Rumsfelds and the Bushes.
According to a résumé Steiger supplied to Congress, he obtained a doctorate in Latin American history from the University of California at Los Angeles before teaching at a university in the Philippines and consulting in Angola for the International Republican Institute -- a nonprofit group that is associated with the party and promotes democracy around the world. He was an education adviser to then-Gov. Tommy G. Thompson (R) of Wisconsin and came to Washington when Thompson became HHS secretary. He is now awaiting a Senate vote on his nomination as Bush's ambassador to Mozambique.
Bill Hall, an HHS spokesman, said Steiger promoted interest in global health at the department while more than doubling the number of expert staff members overseas and participating in international negotiations on issues such as avian influenza. "You have to look at his skills as an executive leader in spite of the fact that he doesn't have a medical degree or a public health degree," Hall said.
Public health advocates have accused Steiger of political meddling before. He briefly attained notoriety in 2004 by demanding changes in the language of an international report on obesity. The report was opposed by some U.S. food manufacturers and the sugar industry.
According to Walling and three other public health officials familiar with the current dispute, Carmona at one point suggested that Steiger release the global health report in tandem with a separate report of the sort Steiger wanted, but Steiger rejected the idea. An appeal by Carmona to Health and Human Services Secretary Mike Leavitt and his staff produced no relief, a former HHS official said.
"I fought for my last year to try to get it out and couldn't get it past the initial vetting," Carmona testified earlier this month. "I refused to release it [with the requested changes] . . . because it would tarnish the office of the surgeon general when our colleagues saw us taking a political stand."
Thomas Novotny, a former assistant surgeon general who ran the global health office before Steiger, said, "It's embarrassing, just ridiculous that the report hasn't come out." Novotny, who served at HHS in the Clinton and in both Bush administrations, said that many nations have made health issues central to their foreign relations and trade policies, but that the United States has been reluctant to embrace that idea.
"It made perfect sense for the surgeon general to take up the issue because the U.S. used to be a leader in this field," Novotny said. "For the nation's top doctor to be unable to release the report shows that leadership is gone."
The global health document was one of several reports initiated by Carmona that top HHS officials suppressed because they disliked the reports' conclusions, according to a former administration official. Another was a "Call to Action on Corrections and Community Health." It says -- according to draft language obtained by The Post -- that the public has a large stake in the health of the 2 million men and women who are behind bars, and in the health care available to them in their communities after their release.
The report recommends enhanced health screenings for those arrested and their victims; better disease surveillance in prisons; and ready access to medical, mental health and substance abuse prevention services for those released.
But the report has been bottled up at HHS, said three public health experts who worked on it. John Miles, a consultant and former Centers for Disease Control and Prevention official who helped draft it, said he suspects that the proposed health screenings and other recommendations are seen as a potentially burdensome cost. "Maybe they just don't feel it's a priority," Miles said.
Hall, the HHS spokesman, responded in a statement Friday that the Bush administration has always believed that public health policy should be rooted in science. "While we appreciate and respect Dr. Carmona's service as surgeon general, we disagree with his statements," Hall said.
Staff researcher Madonna Lebling contributed to this report.