Amid Uproar Over CDC's 7 Words, a Question: Why Would "Evidence-Based" Cause a Stir?

The news set off alarms among scientists and policy experts alike: a weekend report in The Washington Post said a CDC budget analyst told colleagues to avoid 7 specific terms in their budget requests. The terms were: evidence-based, science-based, fetus, transgender, diversity, entitlement, and vulnerable.

While both CDC’s director, Brenda Fitzgerald, MD, and a spokesman for HHS strongly denied there are “banned words” at the agency, neither disputed the report that staff have been encouraged to find alternate phrasing to win support for their requests, especially from the current Congress.

The question is, why?

For answers, The American Journal of Managed Care^® (AJMC^®) turned to Rush D. Holt, PhD, a physicist-turned-Congressman who is now CEO of the American Association for the Advancement of Science. While Holt said some terms on the list are “obvious ideological targets” (think fetus, transgender, or diversity), the inclusion of “evidence-based” is harder to explain, until one digs a little deeper.

“Evidence-based thinking is actually the antidote to ideologically restricted decision-making,” Holt said. “If you are really trying to advance an ideological agenda, then you should want everyone to avoid evidence-based thinking.”

Holt said no one knows for sure how the 7 terms were developed, or even that they originated within CDC. But it’s clear that something happened, he said. HHS spokesman Matt Lloyd called the Post story was a “mischaracterization” of the episode, but for Holt, this “smacks of being a euphemism to obscure what was actually said.”

As for Fitzgerald’s claim that there are no “banned words” at CDC, Holt said he’s inclined to give her the “benefit of the doubt,” but there’s been a troubling pattern of language control in the current administration that bothers scientists—from the crackdown on the term “climate change” to the State Department coining the term “sexual risk reduction” to replace sex education.

So far, Holt has not heard that the term “evidence-based” is under fire at agencies like FDA or the National Institutes of Health. He spoke with AJMC^® after meeting earlier in the day with a group of biotech executives, and for now, he said, “They aren’t sure what to make of this.”

“They don’t want to do anything that would undercut well-meaning government scientists,” Holt said.

Evidence-based Matters

The rise of evidence-based medicine, and its embrace by payers, has been seen as a way to improve the quality of care while reducing costs, by eliminating unnecessary tests and expensive or possibly harmful variation, sometimes called “low-value” care. Elsewhere in HHS, Medicare and Medicaid have sought ways to increase, rather than decrease their reliance on evidence-based medicine.

On CDC’s website, there are 481 results when one searches under the term “evidence-based,” which include the agency’s main page for HIV/AIDS, environmental health topics, information about how to improve uptake of the vaccine for the human papillomavirus, how excessive alcohol use increases cancer, and a page on “Evidence-Based Teen Pregnancy Prevention Programs.” (The term “science-based” also comes up on pages about teen pregnancy prevention.) The pages show birth rates among females ages 15 to 19 have been cut nearly in half from 2007 to 2015, to 22.3 per 1000 women, with sharper declines for black and Hispanic teens.

Is “Vulnerable” Also Vulnerable?

Within CDC, the term vulnerable populations describes many groups; it’s been particularly important in the quest to prevent diabetes in certain high-risk populations, including Native Americans and people living in Appalachia. Groups in Ohio, Kentucky, Michigan, Arizona, New Mexico, and California have received funds to promote better nutrition, improve diabetes self-management, and reduce the risk of chronic kidney disease—one of the most expensive long-term conditions for Medicare and Medicaid.

The term “vulnerable populations” is also used in CDC’s emergency response planning to identify those with a disability or other medical need who could have trouble evacuating.

HHS took issue with the Post’s original report that CDC staff were encouraged to use phrases like, “CDC bases its recommendations on science in consideration with community standards and wishes.” Instead, Lloyd’s statement said, “HHS will continue to use the best scientific evidence available to improve the health of all Americans. HHS also strongly encourages the use of outcome and evidence data in program evaluations and budget decisions.”

For his part, Holt sees an opportunity to educate. “It’s never a bad time to insist that every citizen ask government policy makers or regulators—on any issue—what’s the evidence? You can’t get too much of that. It’s never a bad idea to say, ‘We want evidence-based thinking.'"