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PLOSBLOGS Network & Public Health Perspectives are pleased to present this guest post discussing a public health controversy that, because it occurred late in December of 2017, arguably did not receive the attention it deserves within the scientific community. Our thanks to U.K. researchers Ben Kasstan, Meghann Gregg and Jonathan Kasstan for helping us do so by drawing on multiple disciplines, including: anthropology, maternal and reproductive health and linguistics (see their bios and affiliated institutions below). Please note comments on this post will be moderated by PLOSBLOGS. As usual, your civil and constructive responses are welcome; please scroll below the post (and register if you haven’t previously) to offer your view on any of the issues raised. –Victoria Costello, PLOSBLOGS.
Claims that the Center for Disease Control and Prevention (CDC) had considered revising its language to suit socially-conservative tastes is a clear example of ‘verbal hygiene,’ meaning here an attempt to make language more acceptable by ‘cleaning’ it up. The recent CDC language controversy must be considered as part of a broader politicisation of public health services used by women and minority groups in the US, which has international implications given the influential work of the CDC in global health governance.
Politics of public health language
On 15 December 2017 The Washington Post reported that the US Department of Health and Human Services, which includes the CDC, were being prevented from using specific terms in documents by the Trump administration. These documents would apparently be circulated at the federal government level in relation to the Trump administration’s 2018 budget, and the terms in question included:
- Foetus
- Transgender
- Evidence-based
- Science-based
- Vulnerable
- Entitlement
- Diversity
The CDC Director, Brenda Fitzgerald, flatly denied this report in a series of Tweets and stated ‘there are no banned words at CDC.’ While the above terms may not have actually been banned, the CDC may have been advised to ‘reconsider’ the language it uses when engaging with politicians and policy-makers (as reported in The Guardian). Some of these politicians would include socially-conservative Republicans who make economic decisions (because Republicans hold the majority of seats in the Senate and the House of Representatives), so it is obvious why the CDC as a government-funded body would need to appeal to their tastes. It is in the public interest to highlight that some of these individuals maintain oppressive positions on women’s sexual and reproductive health and rights, especially when it comes to restrictive access to abortion care. It is no surprise then that accommodating socially conservative values within public health language has resulted in ‘verbal hygiene.’ While verbal hygiene might be practiced for different reasons, in the context of sexual and reproductive health and rights it reflects conflicting positions on abortion in the US. Our concern is the implications of verbal hygiene for sexual and reproductive health and rights, which are increasingly under threat in the US and internationally.
The suggestion that the CDC should revise (or conceal) its language is serious because it would shape a public health service that is in danger of infringing on human rights. It would also legitimise the damaging actions that have been implemented in the US and internationally by the Trump administration in the context of women’s health and welfare, such as the decision to reinstate and expand the New Mexico Policy (which we go on to discuss).
Public health and language share a commonality in the way they are political and politicised, and the interaction of which can be seen clearly in restrictions enforced over sexual and reproductive health and rights.
Let us take the term ‘foetus’ as one example, and let us imagine that the CDC acted upon cautions to instead use ‘unborn child’ in documents submitted to politicians and policy-makers. Many people who are not active in sexual and reproductive health and rights might not notice the consequences of using a term like ‘unborn child.’ It might even be interpreted to some as a pragmatic step to obtain necessary funding for the CDC’s research into the Zika virus, which is known to cause birth defects (and has primarily affected areas with dangerously restrictive abortion legislations). Yet using the term ‘unborn child’ in CDC outputs would actually tread further down a dangerous path for women’s health and rights.
Using the term ‘unborn child’ in place of ‘foetus’ is not a synonym: it carries a very different linguistic value. Adopting (or suggesting as an alternative) ‘unborn child’ would be part of a systematic, intentional and politictised attempt to restrict access to abortion care and undermine the sexual and reproductive health and rights of women. The term ‘unborn child’ is common in anti-abortion discourse, both in the US and the UK, and its use shifts the emphasis away from the welfare, health and rights of a pregnant women.
Women in certain US states, for instance, are compelled to undergo ultrasound screening in order to access abortion care as part of a disgraceful attempt to dissuade women from making sexual and reproductive health decisions under the pretense of ‘informed consent.’ Texas recently attempted to enforce laws that would see aborted foetal tissues and remains treated as deceased people and legally entitled to a funeral (e.g. burial or cremation), which would bestow the foetus with social personhood and political rights.
None of these interventions are informed by evidence-based and science-based research that might benefit women who need to access abortion care, but only to serve the political interests of the anti-abortion lobby.
Earlier in January 2017 the President of the United States made the regrettable decision to reinstate and widen the Mexico City Policy (also termed ‘global gag rule’), which withholds funding from NGOs in low- and middle-income countries that actively perform or promote abortion care as part of sexual and reproductive health and rights programmes. Restricting access to safe abortion care does not deter women from needing abortions, it only makes women vulnerable by forcing them to seek out unsafe abortions at great risk to their lives and health. Reducing abortion rates is complex, and requires promoting gender equity while protecting reproductive rights by giving women the power to decide the terms of their pregnancies. The World Health Organization, for instance, estimates that up to twenty million women will have to resort to unsafe abortions, and almost fifty thousand of those women will die as a result of complications. So, if CDC documents frame the foetus as an ‘unborn child’, it supports, like the Mexico City Policy, a discourse and a culture that gives rights to a foetus, while taking away women’s reproductive rights.
We can consider any attempt to avoid using the term ‘transgender’ in CDC documents within a deeper history of how people identifying as (or identified as) LGBT were stigmatised through the politicisation of public health language. The emergence of the HIV/AIDS epidemic in the 1980s brought tremors to the CDC at a time when healthcare professionals, policy-makers, and politicians struggled to grasp the enormity of a disease that had never been encountered before. Public health ‘facts’ made HIV/AIDS appear as an exclusively ‘gay disease’ in the early 1980s. Yet these ‘facts’ were not actually built on evidence but on misinformation, and institutionalised homophobia. Recognising the specific and diverse health needs of transgender and LGBT people entails recognising them as people, and this is achieved through language.
Our position on the politicisation of public health language is clear and unequivocal. Public health bodies such as the CDC are mandated to meet the needs of all people, in all their diversity. Access to quality healthcare services is the entitlement of everybody, and public health language is the basic way through which inequalities and inequities are made visible and addressed. The type of socially-conservative language ideology that is being promoted by the Trump administration serves only to intentionally erase realities that stand in opposition to Republican worldviews and political agendas. Everybody can use language to support and shape inclusive cultures, and we can all more actively participate in creating the kind of world we want by remaining mindful of how powerful language is.
Restoring public confidence: Our recommendations
In light of recent events we recommend the following actions to restore international confidence and credibility in the important work of the CDC and its public health outputs, which may have been undermined by the language controversy:
- The CDC should unequivocally and transparently state whether it was advised to review or reconsider the language it uses, and to clarify whether it intends to act accordingly.
- If the CDC confirms it will be reconsidering the language used in documents submitted to politicians and policy-makers then this should be made public knowledge.
- The CDC should conduct a review into the possibly unintended consequences of revising the specific language used in documents that are submitted to politicians and policy-makers.
- If said language is reconsidered, then the CDC should make it clear that public health bodies in low- and middle-income countries should not adopt the revisions in kind, particularly at a time when global sexual and reproductive rights are under attack.
- The CDC should meet with leading NGOs and stakeholder groups to offer reassurance that public health policies and guidelines will continue to be designed in consultation with the intended beneficiaries, especially those groups concerned with gender, equality, and diversity.
- The CDC will continue to ensure that its work is grounded in research- and science-based evidence, including qualitative research, to ensure its policies are informed by a full range of academic interfaces.
The views expressed in this post represent the perspective of its authors, and are not necessarily shared by PLOS.
Ben Kasstan is a Research Fellow in the Department of Anthropology at the University of Sussex (UK). Ben combines research and activism in all areas of sexual and reproductive health and rights, and has specific research interests in family health and family-making dynamics among ethnic and religious minority groups. B.kasstan@sussex.ac.uk
Meghann Gregg is a PhD Researcher at the London School of Hygiene and Tropical Medicine. Her work encompasses community development and health research, with current projects focussing on improving maternal health with complexity theory and participatory research. Meghann.gregg@lshtm.ac.uk
Jonathan Kasstan is a Leverhulme Early Career Fellow in the Department of Linguistics at Queen Mary University of London (UK). He holds a PhD from the University of Kent, and an MPhil from the University of Cambridge. J.kasstan@qmul.ac.uk
This post is a revised version of the authors’ response that originally featured as part of the Somatosphere collection, ‘Language, public health, and #CDC7words.’