What does “Public Health without Politics” really mean?

After spending 27 years in public health at FDA, one of the most common complaints about public health was political interference. Specifically, interference in agency decisions.

Most people don’t realize how politics is riddled throughout these agencies. I’m talking about agency decisions—not funding—although the issues are similar.

To start, public health is not about individuals. Individual health is covered by medicine; public health is about populations and their overall health. It is because of population health that we created organizations to discover problems and figure out how to prevent or address them. Medicine, by contrast, is primarily focused on treatments for individuals.

It is mostly public health that gets politics involved. But just as we don’t turn the military loose without civilian oversight (politicians), we generally don’t turn scientists loose to handle public health issues.

Public health institutions like the CDC, FDA, USDA, OSHA, NIH, EPA and others are structured so that their senior officials are appointed by—and report to—politicians, who are also their bosses.

Here's where it gets interesting.

Usually, politicians only weigh in when there is tremendous controversy and leave the management of those institutions to the senior managers. The senior managers will have experience in at least some of the relevant fields they oversee. For example, even though FDA controls human and veterinary medicine, biological products, and medical devices, the Commissioner will generally only know a few of those areas, such as human medicine and medical devices.

If they know medicine, they will typically not know about food issues. This means they must, or should, rely on social science experts within and outside of the agency. They also won’t know much about trade-offs, such as the risks of replacement products for those that are banned or priced out of the market. These alternatives come with risks of their own.

They may also overlook the opportunity costs of spending money on very low risks, which would be better spent on high risks. That’s why they must rely on experts in these fields within the agencies (though they don’t always do that). Other key advisors include lawyers and political specialists.

In turn, their political bosses will not know much about the science that the political appointees and the agency staff bring to the table. But, in the end, it is the politicians, such as the president, who are held accountable for decisions, and they have the final word.

Why then do I insist that we should have public health without politics?

I don’t.

When we hold public health agencies and politicians accountable, it should be to ensure that they use the best, unbiased natural science and social science when they make their decisions— recognizing that politics will inevitably play a role.

There are two reasons this ideal often breaks down. Within the agency, there are bureaucrats who, either to advance their own agenda or to appease a political appointee, will present biased science.

They will, for example, overstate risks (e.g.., chemicals) or understate them (e.g., vaccines) because they want to drive the decision and they don’t trust either their political bosses or consumers with the truth. Bias also emerges when uncertainty is ignored and presented as certainty

But the reverse also happens. Scientists are routinely ignored or their evidence suppressed within agencies by appointed officials. This is one reason for whistleblower laws.

When we criticize an administration’s policies, we should be aware of these dynamics. We can and should hold politicians accountable for poor decisions—but they, in turn, should hold their scientists accountable for supplying unbiased, truthful information on which to base those decisions. Good laws and regulations depend on it.

No one gets it right every time. Even the best political appointees make mistakes. I once admired a political appointee who stood up publicly to the president who was caught in a sex scandal. But when she met with FDA employees she said, “To me, something is dangerous or it’s not.” Well, no, there are degrees of risk, and it depends on exposure. The risk analysts all groaned inwardly when we heard that.

It’s not about keeping politics out of public health—it’s about making sure it’s the right people bringing politics in, and that they’re doing it with input from objective science.