Response to Reynolds: Centers for Disease Control and Prevention: protecting the private good?
Andrew Reynolds objects to the term “revelations,” which The BMJ used to describe my article, since he says no information “came about from a whistle-blower exposing corruption or leaked documents.” He says the CDC Foundation has a website www.cdcfoundation.org “for all to see,” and that, “The Foundation’s audited financial statements are widely available on its website for anyone to research.”
However, what is not stated in the CDC Foundation’s audited statements is who/which entities made the donations listed (nor are non-profit organizations required to list donors). Nor does it clarify that the “donations” are not general fund donations, but directed donations given on condition they are put to a specific purpose. Given the widespread shock and dismay expressed by so many doctors, this certainly was news to many. Investigations don’t have to rely solely on whistleblowers and leaked documents; in-depth investigations can provide information about important but obscure or little-known issues. It took tax documents and multiple email exchanges over a period of months with the CDC and the CDC Foundation to establish what was not at all evident: Who knew that the CDC’s “Take 3” campaign recommending antiviral drugs for flu was funded by the manufacturer of a flu antiviral drug?
Further obscuring industry funding is the CDC disclaimer (which can be found on the hepatitis C guideline mentioned by Reynolds) that “CDC, our planners, and our content experts wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products . . . CDC does not accept commercial support,” Yet the manufacturers of hepatitis C drugs and test kits gave millions of dollars in directed donations to the CDC’s Viral Hepatitis Action Coalition, which promotes expanded testing and treatment. Who knew?
Reynolds says controversy about expanded hepatitis C screening is by “by an author who stands on the outside of the consensus of HCV public health officials.” That is partly true; those (and it is more than one author) who challenge expanded screening are indeed “outside of the consensus”; however, history should teach us to be cautious about guidelines based on surrogate markers and untested assumptions – especially when those recommendations are complicated by commercial interests.
On the matter of financial conflicts of interest; Reynolds says he is “in complete agreement with the statement: ‘The CDC must have the highest of moral ground. For if we are to believe them about public health matters, there can be no conflicts of interest.’” But then he contradicts the statement saying, “Indeed, we need transparency in the funding of research and full disclosure of conflicts of interests. By all accounts, the CDC Foundation has done just that.”
Transparency is not the same thing as saying “there can be no conflicts of interest.” The two are quite different. Transparency has been shown to have paradoxical effects that can actually worsen bias.[2-4]
Here’s a thought experiment: If we want to know which make of car gets the best mileage, and is the safest in traffic accidents, most of us would turn to an independent organization, such as Consumer Reports, and we’d be unlikely to take the word of the Ford or Toyota dealer down the street. Moreover, if we did turn to Consumer Reports and found they’d been taking money from the Ford Foundation and recommending Fords, we might be perturbed. However, Consumer Reports explicitly refuses any industry funding from any source. And they refuse industry funding for a reason; they want to be trustworthy and trusted. Shouldn’t we be able to expect at least as much from the the CDC?
Finally, Reynolds misunderstands the reason for mentioning the cuts in funding to CDC caused by the gun lobby; it was not a tit for tat comparison with drug company donations as he suggests. Instead, the two problems are cited to show the CDC has provided and continues to provide some terrifically important public services by compassionate and dedicated employees who are stymied and undermined by external forces, whether it is Congress cutting public funding and allowing industry funding – or by Congressional cuts in funding in response to gun lobbyists. This means that the CDC itself or alone cannot solve the problem. Instead we need politicians in Congress who are not beholden to industry who are willing to ensure that the CDC is insulated from commercial influences, and that the public interest – and only the public interest – is behind their recommendations.
1. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965. Morbidity and Mortality Weekly Report. 8/17/2012 2012;61(4):1-36. http://www.cdc.gov/mmwr/pdf/rr/rr6104.pdf.
2. Cosgrove L. Opinion: Bias Is Unavoidable: Simply disclosing conflicts of interest is not enough. The Scientist. 08/07/2012 2012. http://www.the-scientist.com/?articles.view/articleNo/32462/title/Opinio....
3. Cain DL, G; Moore, DA. The Dirt on Coming Clean: Perverse Effects of Disclosing Conflicts of Interest. Journal of Legal Studies. 2005;34. http://www.cbdr.cmu.edu/mpapers/CainLoewensteinMoore2005.pdf.
4. Ben-shahar O, Schneider CE. The Failure of Mandated Disclosure. University of Pennsylvania Law Review. 2011;159(3):647-749. http://www.jstor.org/stable/41149884.
Competing interests: author of the article