attacks on science: the risks to evidence-based policy

⏐ ETHICS AND PUBLIC HEALTH ⏐

American Journal of Public Health | January 2002, Vol 92, No. 114 | Ethics and Public Health | Peer Reviewed | Rosenstock and Lee

AS GOVERNMENT AGENCIES,academic centers, and their re-searchers increasingly providethe science base for policy deci-sions, they are also subject toforces that seek to politicize or si-lence objective scientific re-search. We refer not to the hon-est differences and conflicts thatarise in response to scientific un-certainty, but to the pressure touse science to justify policy (evenwhen the data are inadequate),as well as the vulnerability of sci-ence to attacks driven by vestedinterests—interests that exploitscientific uncertainty to deflectattention from what is knownand from the actions that wouldcredibly follow that knowledge.

Attacks on science are notnew. Galileo, for example, wascharged with “vehement suspi-cion of heresy” and put on trialin 1633 when he was 69. Tosave his life, Galileo publicly re-nounced his belief that the sun,not the earth, was the center ofthe universe. In 1992, after morethan 350 years had passed, theVatican deferred to Galileo’s sci-entific theory and granted him afull pardon.1–3

As attention and respect forscientific research grow, attemptsboth to overdetermine scientificfindings and to undermine thepolicy implications of sound sci-ence are becoming increasinglysophisticated and complex, put-ting evidence-based policymak-ing at risk.

USING SCIENCE FORPOLICY MAKING

The increasingly global econ-omy is influencing investments inresearch, scientific publications,and research alliances.4 UShealth research and developmentfunding has increasingly shiftedfrom public to private sources.Between 1965 and 1995, theproportion of health researchand development funded by fed-eral sources dropped by almosthalf, to 37.4%, while industry’sfinancial support increased morethan 2-fold, to 52% of the total$35.8 billion expended.5 Nearly12% ($1.5 billion) of researchfunds to academic institutionsnow come from the corporatesector.6 Universities are also in-creasingly turning to Congress asa direct source for research fund-ing; universities and their lobby-ists have secured more than $7billion since 1980 through con-gressional earmarks inserted intospending bills.7

Meanwhile, the public isdemonstrating an increasing in-terest in technology and health.Developments in medicine andhealth care outranked moral val-ues, the stock market, nationalpolicies, and television content ina recent survey of the issues thatmost affect peoples’ lives.8 Ap-proximately 1 in 5 people in theUnited States consider themselvesvery well informed about the useof new inventions and technolo-

As government agencies, aca-demic centers, and researchers af-filiated with them provide an in-creasing share of the science basefor policy decisions, they are alsosubject to efforts to politicize or si-lence objective scientific research.Such actions increasingly use so-phisticated and complex strategiesthat put evidence-based policy mak-ing at risk.

To assure the appropriate use ofscientific evidence and the protec-tion of the scientists who provide it,institutions and individuals mustgrow more vigilant against these tac-tics. Maintaining the capacity for ev-idence-based policy requires differ-entiating between honest scientificchallenge and evident vested inter-est and responding accordingly,building and diversifying partner-ships, assuring the transparency offunding sources, agreeing on rulesfor publication, and distinguishingthe point where science ends andpolicy begins.

Attacks on Science: The Risks to Evidence-Based Policy

| Linda Rosenstock, MD, MPH, and Lore Jackson Lee

gies and 40% have a great dealof confidence in the leadership ofthe scientific and medical com-munities, a level that is far higherthan levels reported for the lead-ership of other major institutionsin society.4 This trust may be atrisk, owing to a number of forcesthat are arrayed to influence theuse of scientific evidence.

TACTICS USED TOUNDERMINE SOUNDSCIENCE

A wide array of vested inter-ests—and here we mean thosewho, for whatever reason, arecommitted to a predeterminedoutcome independent of the evi-dence—may drive the undermin-ing of sound science to forestallthe policy implications that wouldnecessarily follow. These inter-ests, which are often financial butmay also be emotional, ideologic,and political, may be acting aloneor in combination. Although eco-nomic interest is a common moti-vation and may drive both corpo-rations and individuals (e.g.,lawyers, physicians), emotional in-terests have played an increasingrole in undermining sound sci-ence to achieve their desiredends (as in the case of victims’groups). The role of corporate in-terests has been best reported, atleast in part because of the signif-icant economic resources corpo-rations can bring to bear to influ-ence policy outcomes.


January 2002, Vol 92, No. 1 | American Journal of Public Health Rosenstock and Lee | Peer Reviewed | Ethics and Public Health | 15

orders of the back, neck, andupper extremities.19

Although the National Acad-emy of Sciences study heartilysupported NIOSH’s conclusions,in fiscal year 1999 Congressagain asked the academy to re-view the same issues.20 Not sur-prisingly, since the large scientificdata base remained the same,the second review corroboratedthe conclusions of the first.21 Thedelay process proved ultimatelysuccessful when one of the firstacts of the incoming Bush admin-istration was to withdraw thelong-delayed but just-finalized er-gonomics standard that had beenpromulgated in the last weeks ofthe Clinton administration.

Hidden IdentitiesIn attacking science, vested in-

terests may also hide their identi-ties by masquerading as grass-roots coalitions or by affiliatingthemselves with neutral organiza-tions. Consider, for example, theNational Coalition on Ergonom-ics, a research group that op-poses a national ergonomics stan-dard; the Food Chain Coalition,which represents the pesticide in-dustry and works to prevent reg-ulations; Doctors for Integrity inResearch and Public Policy, phys-icians who oppose gun controland handgun research; and theCenter for Patient Advocacy, theorthopedic group that lobbiedagainst the Agency for HealthCare Policy and Research’s backtreatment recommenda-tions.14,15,22,23 Most recently, whathad appeared to be a grassrootscoalition striving to raise aware-ness about the hepatitis C viruswas actually shown to be a mar-keting effort run by the pharma-ceutical company Schering-Plough Corp to promote theirproduct, Rebetron, which is theprimary hepatitis C therapy.24

Economic ManipulationFirst and foremost, vested in-

terests may use money to inhibitor stall sound science. The in-creasing role of industry-spon-sored research, despite its manybenefits, also raises concerns. Atthe extreme are instances inwhich an industry sponsors re-search with the direct goal ofcountering existing scientific opin-ion. Economic interests may ad-versely affect scientific integritythrough the delaying or withhold-ing of research results and by di-rectly or indirectly influencing thecontent of results.

In a survey of more than 3000scientists in the 50 universitiesthat received the most NationalInstitutes of Health funding in1993, 20% of respondents re-ported delays of more than 6months in the publication of theirresearch results at least once inthe previous 3 years to allow forfinancial interests, such as patentapplications, or to slow the dis-semination of undesired results.9

Another study of corporate in-vestments in academic researchfound that donors often expectthe right to prepublication reviewof research results, ownership ofpatent rights, and future consult-ing relationships.10

Still other studies have found astrong association between au-thors’ opinions and their financialaffiliations. A review of studieson selected chemicals (alachlor,atrazine, formaldehyde, and per-chloroethylene) found that 60%of studies conducted by nonin-dustry researchers found thesechemicals hazardous, while only14% of industry-sponsored stud-ies did so.11 A review of 70 arti-cles about the use of calcium-channel antagonists found that96% of the authors supportive oftheir use had financial relation-ships with manufacturers of cal-

cium-channel antagonists, com-pared with 60% of neutral au-thors and 37% of critical au-thors.12 A study of review articleson the health effects of passivesmoking found that 74% of thosewho disclaimed the widely heldview of the relationship betweenhealth effects and environmentaltobacco smoke had affiliationswith the tobacco industry.13

Federal research is not im-mune to this type of economic in-fluence, which is usually broughtto bear through congressionalchannels—often in response tovested interests—mostly throughspecific appropriations or barriersto appropriation. A program or,occasionally, an entire agencymay become the victim of suchefforts. The Department ofHealth and Human Service’sAgency for Health Care Researchand Quality, then known as theAgency for Health Care Policyand Research, was slated for zerofunding in fiscal year 1996 afteran organization of orthopedic sur-geons, angered over the agency’sscience-based recommendation ofnonsurgical approaches for man-aging acute back problems, lob-bied Congress.14 Similar effortswere launched by the same Con-gress to eliminate or reduce fund-ing for the Centers for DiseaseControl and Prevention’s NationalCenter for Injury Prevention andControl and the National Institutefor Occupational Safety andHealth.15,16

Vested interests also use hiredscientists, on a full-time or verylucrative part-time basis, for spe-cial tasks that aim to derail theuse of sound science. Ongoing to-bacco lawsuits uncovered a to-bacco industry investment of$156000 to hire more than adozen scientists to write lettersand manuscripts discrediting a1993 federal report that linked

secondhand smoke to lung can-cer. These “for hire” materialsappeared in the likes of the Jour-nal of the American Medical Asso-ciation, the Journal of the NationalCancer Institute, Risk Analysis, theJournal of Regulatory Toxicologyand Pharmacology, and the WallStreet Journal.17 Pharmaceuticalcompanies have employed simi-lar tactics, paying for favorablearticles and editorials.18

DelayWhen economic manipulation

fails to influence research, vestedinterests turn to a complex arse-nal of delaying tactics to forestallthe release or influence of scien-tific evidence. These tactics in-clude initiating litigation, fightingfor access to raw data, fundingparallel studies, inundating re-searchers with administrative pro-cedures, and catalyzing congres-sional reports or inquiries. One ofthe favorite delay tactics is de-manding greater or different peerreview, such as invoking the Fed-eral Advisory Committee Act tofault agency approaches to peerreview.

A prime example is an ongoingeffort to retard work on the de-velopment of a national occupa-tional ergonomics standard. Sincefiscal year 1995, the heavily lob-bied Congress had either pro-posed or passed ergonomics rid-ers to the Occupational Safetyand Health Administration appro-priations, prohibiting or delayingwork on development of the stan-dard. In 1998, Congress alsocommissioned a National Acad-emy of Sciences study to review,among other things, a 1997study released by the National In-stitute for Occupational Safetyand Health (NIOSH) that found apositive relationship between spe-cific work activities and the de-velopment of musculoskeletal dis-



Vested interests have alsofound ways to infiltrate profes-sional organizations under theguise of academic neutrality. Thiscan have serious ramificationsfor national policy, since the cre-dentials and expertise of profes-sional organizations give themhigh credibility. The InternationalCommission on OccupationalHealth, which assists in the de-velopment of scientific and policyrecommendations, recently fellvictim to this strategy when sev-eral members with a vested in-terest in the asbestos industryused their affiliation with thecommission to develop an Inter-national Labor Organization doc-ument that was unusually favor-able to the industry.25,26

HarassmentIn their efforts to squelch un-

wanted scientific findings, vestedinterests have also been knownto harass investigators, federalagencies, and even the scientificand policy-making processesthemselves.27,28 For example, apharmaceutical company, usinga variety of approaches, was suc-cessful in delaying for years thepublication of research resultsnegative to its thyroid treatmentproduct.29 A researcher atToronto’s Hospital for Sick Chil-dren was sued by a pharmaceuti-cal company for publishing hernegative conclusions about oneof the company’s products.30,31 ABrown University academicianand physician became involvedin a similar controversy when hediscovered a cluster of cases ofinterstitial lung disease amongworkers at a local textile flockingindustry plant.32 The latter inci-dent is particularly worrisomebecause the employing institu-tion did not support the right ofa faculty member to publishfindings, citing the murky restric-

tive covenant that he hadsigned.33

It is not only commercial inter-ests that have learned the bene-fits of harassment. To cite justone example, a group of victimsof multiple chemical sensitivityvery publicly attacked the scien-tific integrity of authors whopublished findings that there wasno evidence for an immunologicbasis for multiple chemical sensi-tivity.28

A CASE STUDY OF TACTICS

A case study that illustratesthe majority of the strategies dis-cussed above involves an epide-miologic study of diesel exhaustand lung cancer, jointly con-ducted by NIOSH and the Na-tional Cancer Institute. The studyis important not only to the morethan 1 million US workers whoare regularly exposed to dieselexhaust, but to the millions ofpeople worldwide, particularly inthe developing world, who areexposed both at work and in thenonwork environment to dieselexhaust.

After conducting a joint feasi-bility study, NIOSH and the Na-tional Cancer Institute initiatedpeer review of the study protocolin 1995. It was not until 1998,however, that the study actuallybegan. Despite evidence of dieselexhaust’s potential carcinogenic-ity and a strong study design, theMethane Awareness ResourceGroup, a coalition of mine own-ers and operators and other in-dustry representatives, initiatedlitigation in 1996 asserting thatthe peer review process violatedthe Federal Advisory CommitteeAct.34 When multiple subsequentlegal efforts failed to block thestudy, the group lobbied Con-gress to include language in the

fiscal year 1998 appropriationsbill that required both agenciesto review the issues once more.35

Additionally, there were attemptsto insert more peer review, afight for access to raw data sothat the industry could simulta-neously analyze these data andrun its own parallel study, publicharassment of the study peer re-viewers, copious Freedom of In-formation Act requests, and pro-motion of congressional inquiriesinto the most minute details ofthe study design.

The net result is that an impor-tant study with broad occupa-tional and environmental implica-tions has been delayed by manyyears. In addition, the constantneed to defend the science andthe scientific process resulted indecreased attention paid to otherpublic health efforts.

RESPONSES TO THREATSTO SCIENCE

The threats to science are ex-ceedingly complex and inter-twined. We propose that the sci-entific community increase itsawareness of the existence ofthese threats and that it mountinstitutional responses, ratherthan the issue-by-issue reactionsthat are now the norm. It is ourhope that the responses sug-gested here will generate discus-sion among universities, profes-sional societies, governmentagencies, and individuals aboutthe best ways to ensure the ap-propriate use of scientific evi-dence and the protection of thescientists who provide it.

First, consider the context andthe source of the attack. It is cru-cial that we respond appropri-ately to honest scientific chal-lenges as opposed to challengesissued by vested interests. Wecurrently tend to react too defen-

sively to both, and as a result, theeconomically and politically pow-erful can too easily compromisethe use of good science. Again, itis important to recognize that al-though commercial interests aresometimes the most obvioussources of attack, others withvested interests (e.g., victims’groups and their lawyers) mayadopt the same tactics.

Second, the scientific commu-nity should build and diversify itspartnerships, especially in contro-versial areas. Appropriate in-volvement, early in the process,of potential critics who are hon-estly seeking scientific answershelps forestall later unfair attacks.The field of occupational safetyand health, for example, is nowimplementing the National Occu-pational Research Agenda, an ef-fort launched during a period ofagency vulnerability.36,37 Some ofthe harshest critics of a federalrole in workplace research arenow engaged in guiding and sup-porting this effort.38,39

Third, institutions and individ-uals should strive to ensure thetransparency of funding sourcesand an appropriate balance ofneutral funding between the pub-lic and private sectors. Fundingshould follow well-delineatedguidelines to protect the integrityof the research process—particu-larly important given the widevariability in conflict-of-interestreporting and policies among themajor biomedical research insti-tutions in the United States.40

Institutions should agree onrules for publication of researchresults well in advance to ensurethe timely and uninhibited dis-semination of scientific findings.Financial disclosure and recusalrequirements should be univer-sally implemented for peer-re-viewed journals and publications,whose policies currently vary


January 2002, Vol 92, No. 1 | American Journal of Public Health Rosenstock and Lee | Peer Reviewed | Ethics and Public Health | 17

13. Barnes DE, Bero LA. Why reviewarticles on the health effects of passivesmoking reach different conclusions.JAMA. 1998;279:1566–1570.

14. Deyo RA, Psaty BM, Simon G,Wagner EH, Omenn GS. The messen-ger under attack—intimidation of re-searchers by special interest groups. NEngl J Med. 1997;336:1176–1180.

15. Kassirer JP. Partisan assault on sci-ence: the threat to CDC [editorial]. NEngl J Med. 1995;333:793–794.

16. Rogers D. GOP steps up efforts tocut funding for US agencies opposed byits allies. Wall Street Journal. July 13,1995:A12.

17. Tobacco industry paid scientists tocriticize report. Washington Post. August5, 1998:A2.

18. Brennan TA. Buying editorials. NEngl J Med. 1994;331:673–675.

19. Bernard BP, ed. MusculoskeletalDisorders (MSDs) and Workplace Fac-tors: A Critical Review of EpidemiologicEvidence for Work-Related Musculoskele-tal Disorders of the Neck, Upper Extrem-ity, and Low Back. Cincinnati, Ohio: Na-tional Institute for Occupational Safetyand Health; 1997. Also available (inPDF format) at: http://www.cdc.gov/niosh/ergosci1.html. Accessed Novem-ber 8, 2001.

20. National Research Council. Work-Related Musculoskeletal Disorders: A Re-view of the Evidence. Washington, DC:National Academy Press; 1998.

21. National Research Council and In-stitute of Medicine. Musculoskeletal Dis-orders and the Workplace: Low Back andUpper Extremities. Washington, DC: Na-tional Academy Press; 2001.

22. OSHA struggles to develop rulesgoverning ergonomics hazards. WallStreet Journal. June 16, 1998:A1.

23. Unreasonable Risk: The Politics ofPesticides. Washington, DC: Center forPublic Integrity; 1998:24.

24. O’Harrow R. Grass roots seeded bydrugmaker; Schering-Plough uses “coali-tions” to sell costly treatment. Washing-ton Post. September 12, 2000:A1.

25. LaDou J. ICOH caught in the act[editorial]. Arch Environ Health. 1998;53:247–248.

26. Castleman BI, Lemen RA. The ma-nipulation of international scientific or-ganizations [editorial]. Int J Occup Envi-ron Health. 1998;4:53–55.

27. Russell RH. In the not-so-public-in-terest: is science for hire (and fire)? Con-servation Matters: Journal of the Conserva-tion Law Foundation. 1998;5:27– 30.

28. Daniell W. Science, integrity, andinvestigators’ rights: current challenges.

widely. One recent survey showedthat only 43% of medical journalshad policies requiring disclosureof conflicts of interest.41 Weshould establish additional guide-lines to support investigators’ rightto publish; bar prohibitionsagainst publication; and requirecarefully structured, third-partyreview for industry-funded re-search on industry products.

Professional societies shouldset limits on the extent and cir-cumstances of industry sponsor-ship and should raise awarenessof the scope and magnitude ofthreats to science. Individualsshould increase their vigilanceabout accepting gifts, speakingfees, and travel; should be clearabout implicit or explicit expecta-tions of private sponsors; andshould be careful to ensure thatany signed agreements conformwith basic institutional require-ments for reporting, disclosure,and conflicts of interest.

Fourth, and perhaps most im-portant, we must be on guard todistinguish the point where sci-ence ends and policy-making be-gins. Consider, for example, the1998 White House decision notto fund needle exchange pro-grams and the 1997 National In-stitutes of Health decision regard-ing breast cancer screening. Inthe case of the needle exchangeprograms, although emotionaland ideologic vested interestshad worked successfully to un-dermine the scientific database,the cumulative evidence wasclear in finding that such pro-grams do not increase drug useand do reduce cases of HIV.42

The administration recognizedthe science but nonetheless re-fused to lift a ban on federalfunding of needle exchange pro-grams.43,44 Thus, policy wasdriven by political factors, notscientific ones, and the distinc-

tion was clearly acknowledged—no attempt was made to hide thedecision behind the caveat of sci-entific uncertainty.

Compare this episode with thedevelopment of breast cancerscreening guidelines. A NationalCancer Institute consensus panelconcluded that the science wasinadequate to support routinescreening of women aged 40 to49 years.45 Yet, in response to ex-ternal pressure from a variety ofvested-interest groups with finan-cial and emotional commitmentsto screening, the science was re-visited and repackaged, resultingin the recommendation thatwomen in their 40s be screenedevery 1 to 2 years.46 Both ofthese examples involve a varietyof complex issues, but the bottomline of both is the same: there is aneed to more rigorously defineand clarify the boundary be-tween science and policy.

Taking steps to protect our-selves against threats to sciencerequires effort, and it would benaïve to assume that science canever be truly free of vested inter-ests and influences. But it is clearthat if we fail to act, we lose anopportunity to strengthen thecredibility of scientific evidence inpolicy-making and to protect sci-entific researchers and research.The ability to maintain the capac-ity for evidence-based policy is vi-tally important to our society.

About the AuthorsLinda Rosenstock is with the School ofPublic Health, University of Californiaat Los Angeles. Lore Jackson Lee is withthe School of Public Health and HealthServices, George Washington University,Washington, DC.

Requests for reprints should be sentto Linda Rosenstock, MD, MPH, Schoolof Public Health, University of Califor-nia at Los Angeles, PO Box 951772,Los Angeles, CA 90095-1772 (e-mail:[email protected]).

This commentary was accepted August27, 2001.

ContributorsL. Rosenstock conceptualized the mainpoints and wrote the paper. L. J. Lee pro-vided background research and con-tributed to the writing of the paper.

AcknowledgementThe authors would like to thank Dr JoIvey Boufford for her critical review ofand comments on an earlier version ofthis commentary.

References1. Hellman H. Two views of the uni-verse: Galileo vs. the Pope. WashingtonPost. September 9, 1998:H1.

2. Montalbano WD. Earth moves forVatican in Galileo case. Los AngelesTimes. October 31, 1992:A1.

3. Broad W, Wade N. Betrayers of theTruth. New York, NY: Simon & Schuster;1982:26–27, 226.

4. Science and Engineering Indicators2000. Washington, DC: National Sci-ence Board; 2000. Also available at:http://www.nsf.gov/sbe/srs/seind00/start.htm. Accessed October 15, 2001.

5. Health, United States, 2000. Hy-attsville, Md: National Center for HealthStatistics; 2000:337.

6. Blumenthal D, Causino N, Camp-bell E, Louis KS. Relationships betweenacademic institutions and industry inthe life sciences—an industry survey. NEngl J Med. 1996;334:368–373.

7. Weiner T. Academic learning tolobby for pork; congressional fundingbypasses peer review. New York Times.August 24, 1999:A7.

8. Duff C. Among factors that influ-ence people’s lives, politics ranks towardthe bottom. Wall Street Journal. Septem-ber 18, 1998:A9.

9. Blumenthal D, Campbell EG, An-derson MS, Causino N, Louis KS. With-holding research results in academic lifesciences—evidence from a national sur-vey of faculty. JAMA. 1997;277:1224–1228.

10. Campbell EG, Louis KS, Blumen-thal D. Looking a gift horse in themouth: corporate gifts supporting lifesciences research. JAMA. 1998;279:995–999.

11. Fagin D, Lavelle M, Center forPublic Integrity. Toxic Deception: Howthe Chemical Industry Manipulates Sci-ence, Bends the Law, and Threatens YourHealth. Seacaucus, NJ: Birch Lane Press;1997:57.

12 Stelfox HT, Chua G, O’Rourke K,Detsky AS. Conflict of interest in thedebate over calcium-channel antago-nists. N Engl J Med. 1998;38:101–106.



Regul Toxicol Pharmacol. 1996;24:S152–S162.

29. Rennie D. Thyroid storm [edito-rial]. JAMA. 1997; 277:1238–1243.

30. Olivieri NF, Brittenham GM,McLaren CE, et al. Long-term safety andeffectiveness for iron-chelation therapywith deferiprone for thalassemia major.N Engl J Med. 1998;339:417– 423.

31. Taylor P. A doctor takes on a drugcompany. Toronto Globe and Mail. Au-gust 13, 1998;A1.

32. Shuchman M. Secrecy in science:the flock worker’s lung investigation.Ann Intern Med. 1998;129:341–344.

33. Davidoff F. New disease, old story[editorial]. Ann Intern Med. 1998;129:327–328.

34. Methane Awareness ResourceGroup Diesel Coalition vs United Statesof America, filed October 23, 1996.

35. Departments of Labor, Health andHuman Services, Education, and RelatedAgencies Appropriation Bill, 1997.Washington, DC: Senate Committee onAppropriations; September 12, 1996.Report 104-368.

36. Rosenstock L, Olenec C, WagnerGR. The National Occupational Re-search Agenda: a model for broadstakeholder input into priority setting.Am J Public Health. 1998;88:353–356.

37. Wegman DH. NORA—more than aname [editorial]. Am J Public Health.1998;88:349–351.

38. National Occupational ResearchAgenda Update. Washington, DC: Na-tional Institute for Occupational Safetyand Health; 2001.

39. Smith SL. The rebirth of NIOSH.Occupational Hazards. 1998;60:30–32.

40. Cho MK, Shohara R, Schissel A,Rennie D. Policies on faculty conflicts ofinterest at U.S. universities. JAMA.2000;284:2203–2208.

41. Van McCrary S, Andersen SB,Jakovljevic J, et al. A national survey onpolicies on disclosure of conflicts of in-terest in biomedical research. N Engl JMed. 2000;343:643–645.

42. Interventions to prevent HIV riskbehaviors, February 11–13, 1997.Bethesda, Md: National Institutes ofHealth, Office of Disease Prevention;1997. National Institutes of Health con-sensus statement.

43. Goldstein A. Clinton supportsneedle exchanges but not funding.Washington Post. April 21, 1998:A1.

44. Harris JF, Goldstein A. Puncturingan AIDS initiative; at last minute WhiteHouse political fears killed needle fund-ing. Washington Post. April 23, 1998:A1.

45. Breast cancer screening for womenages 40 to 49, January 21–23, 1997.Bethesda, Md: National Cancer Institute,1997. National Institutes of Health con-sensus statement.

46. Fletcher SW. Whither scientific de-liberation in health policy recommenda-tions: Alice in the wonderland of breast-cancer screening. N Engl J Med. 1997;336:1180–1183.

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