CDC on Obesity: Public Health or Politics?
WASHINGTON -- The CDC has operated generally with bipartisan support for several decades regardless of who was in the White House or which party controlled Congress.
Campaigns targeting the issues the CDC has championed -- such as tobacco cessation and obesity prevention -- were funded and backed with little objection. Its hallmark issues have varied little with the political ideology of whichever party controlled Washington.
But now, projects the CDC funds are gaining increased attention from Republicans in Washington, who are saying the CDC's latest efforts are blurring the line between lobbying and what a federal agency can support.
OIG Report Issued
In March, congressional Republicans asked Health and Human Services (HHS) Secretary Kathleen Sebelius for a report on CDC's advocacy activities.
"We urge you to launch a full investigation and accounting to determine whether CDC grantees ... have misappropriated federal tax dollars for lobbying activity," representatives Ed Whitfield and Brett Guthrie, both Republicans from Kentucky, wrote in a letter.
"We respectfully request that you clarify your various understanding of the various federal anti-lobbying prohibitions involving tax dollars and how these prohibitions apply to CDC grantees engaged in seeking to influence state and local government bodies."
The HHS Office of Inspector General (OIG) investigated the issue. In a June letter on its findings to CDC Director Thomas Frieden, MD, MPH, the OIG agreed with the representatives' concerns, saying it also was concerned about "inappropriate lobbying activities" by some of the agency's grantees.
The grants in question -- namely, the Community Transformation Grants and Communities Putting Prevention to Work grants -- went toward fund preventing obesity through limiting children's access to fatty foods and sugary drinks, a once bipartisan issue that has suddenly become partisan.
"What's happening with food and beverages and obesity, I think, is quite different historically" from other CDC advocacy efforts, Gene Matthews, the CDC's chief legal officer for 25 years before leaving in 2004, told MedPage Today.
The CDC has traditionally used its knowledge of public health problems to educate the public and policymakers on possible solutions, and public health experts hope this new-found interest from Congress in the CDC doesn't change the public health agency's mission of preventing communicable and chronic disease.
"What's wrong is to take federal money, learn something, and not tell anybody," Scott Burris, director of the Center for Health Law at Temple University, said in an interview.
"What's going on here is a systematic effort to keep experts ... as much as possible out of the policy debate," Scott said. "This is about translating research into action."
Past Policy Areas Varied
Issues the CDC has backed have changed slightly over the past few decades as different public health events called for action.
During the Nixon to Carter administrations, the CDC backed state immunization laws for school attendance, said Matthews, who is now at the University of North Carolina. The CDC also has supported fluoridation of public water supplies, stricter seat-belt laws, maternal health programs, and anti-violence campaigns. The issue of bioterrorism preparedness was pushed by the CDC after the Sept. 11 terrorist attacks.
All of those issues enjoyed support from Republicans and Democrats alike, CDC advocates said.
There have been some controversial topics that have fallen on or off the radar depending on who controlled the White House and majority in Congress. For example, the Bush administration used the CDC to push abstinence-only education in public schools, Matthews said.
Reducing HIV transmission through needle-exchange programs was another issue the CDC looked at. In the 1990s, after studying 36 different needle-exchange programs, the CDC found the programs reduced HIV transmission with no evidence of increasing drug use.
"In fact, several of the people who participated got into drug treatment programs," said David Satcher, MD, the CDC director under President Bill Clinton from 1993 to 1998.
dle-exchange programs. However, the president changed his mind about an hour before a press conference to announce the support and decided not to push for that funding, Satcher told MedPage Today.
The issue of gun control was never really tackled by the CDC because of its touchy political nature, Matthews said.
As for advocating on the obesity issue, "I think historically the anti-obesity campaign that evolved with the recognition of the epidemic about 15 years ago ... I think that started as bipartisan," Matthews said. "Just within the last several years, it seems to be partisan."
Current Activities Called into Question
The current controversy comes from grant programs funded through the Affordable Care Act and the American Recovery and Reinvestment Act (the latter is more commonly called the stimulus bill). Each was intended to support changes in nutrition, physical activity, and tobacco use.
But the OIG identified what it considered to be questionable grants, such as $2.2 million to the California Department of Public Health to "advance policy changes to limit the availability" of soda in schools. Another was $12 million that went to King County, Wash., to influence policy, including efforts to "change zoning policies to locate fast food retailers farther from ... schools."
The grants may have violated laws that prevent federal dollars from being used for lobbying. But these were efforts generally allowed and supported in the past.
The House of Representatives has held a series of hearings since 2010 drawing attention to these programs. Republicans questioned HHS Secretary Kathleen Sebelius about the grants at a House Energy and Commerce Health Subcommittee hearing on March 1, and earlier at an April 2010 hearing.
The movement reminds Matthews of tobacco controversies that occurred in the 1980s and 1990s. Some of the tactics that tobacco companies used to dissuade public discourse -- and to discourage public health initiatives such as smoking bans and higher cigarette taxes -- are now being used by the food and beverage industries to discourage the soda and obesity initiatives.
"This feels very similar, although the topic appears to be sugary drinks and fast foods," Matthews said.
The quest to add calorie counts to fast food menus, ban sodas in schools, and define pizza not as a vegetable seems to be creating upheaval in the public because they are lifestyle issues.
"These changes seem to be controversial in communities ... and we're having some political backlash because of it," said Marice Ashe, founder and chief executive of ChangeLab Solutions, a public health advocacy group.
Where Does CDC Go From Here?
Congress has now taken additional steps to limit CDC action. Lawmakers inserted language into an appropriations bill in December that distorts 30 years of public advocacy, Matthews said.
The change says agencies can't use federal dollars for grassroots efforts or to lobby on behalf of specific legislation. The language extends the prohibition, which was previously limited to legislative branch actions, to the executive branch.
"It appears to be a deliberate attempt to blur the lines between illegal lobbying and advocacy," Matthews said. "I think the CDC has done a very good job at trying to demystify that to the extent that it can be demystified."
But it's a change that many CDC supporters don't agree with and are still trying to figure out. "Educating people about what steps need to be taken to prevent disease is not lobbying," Ashe said.
Even if the CDC is more limited in what it can fund, public health advocates can still generate money and interest from state funding and private donations.
"I hope that the public health community at large ... is not going to see a lot of change," Ashe said. "Whether the CDC is going to be as up front in the public policy, I don't know."
So far, lawyers are also saying the new law isn't changing things, Scott, from Rutgers, said.
In its June 29 letter to CDC director Frieden, HHS Inspector General Daniel Levinson proposed that the CDC clarify any misleading statements about lobbying activities from its grantees and provide updated and more detailed guidance describing how to avoid violating anti-lobbying statutes in the future.
"Additionally, OIG plans to review CDC grants to reduce chronic disease and promote healthy lifestyles funded with money subject to the lobbying provisions in the FY 2012 HHS appropriation," Levinson wrote.
Leaders of the House Energy and Commerce Committee wrote HHS Secretary Kathleen Sebelius in August asking for information from the two grant programs in question and a detailed correction action plan in response to the OIG letter.
"We certainly haven't heard the last of this from Congress," Matthews said.
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