Media reports last month that the Trump administration banned officials at the US Centers for Disease Control and Prevention from using seven words may have been overstated, according to a government document obtained by CNN and interviews with two officials.
According to stories widely reported in the media, CDC leaders told employees that in official documents being prepared for the budget, they were forbidden to use words such as "diversity", "vulnerable" and "transgender."
The response was immediate, intense and viral.
Medical groups decried the political "censorship" and the measures were called "Orwellian" on social media.
Some doctors posted photos of themselves with tape over their mouths along with the hashtag #ScienceNotSilence.
But the document obtained by CNN, along with interviews with two officials from the Department of Health and Human Services, paints a different picture.
They describe not a ban or prohibition on words but rather suggestions on how to improve the chances of getting funding.
"Words to avoid: vulnerable, diversity, entitlement," states the HHS document, "Instructions for Preparing the FY 2019 Congressional Justifications."
The other four words on the list -- "transgender," "fetus," "evidence-based" and "science-based" -- were brought up by employees at the meeting who wanted to know if they could be used, according to the two HHS officials, who were familiar with what transpired at the meeting.
"Nobody ever told them they couldn't use these seven words. It was just said, 'if you think these words would cause someone to jump to a conclusion, then use a substitute. But if there isn't a good substitute, then go ahead and use the word,' " said one of the officials.
"That's not censorship to me -- that's strategy," the official said.
"It was clear that they should avoid those seven words, but it was OK to use them if they felt they needed to," said the other official, who added that CDC leaders give guidance every year on word choice in budget documents and that the guidance changes based on who's in the White House and in Congress.
The officials asked that their names not be used because they don't have permission to speak with the media. They were not present at the meeting but said they had been briefed by someone who was there.
Much of the outrage -- the references to George Orwell's "1984," the photos with the taped mouths -- seemed to assume that CDC officials were not allowed to use these words at any time, such as on the CDC's website.
But the HHS officials who spoke with CNN pointed out that this obviously isn't true, since the seven words are used countless times throughout the CDC's website: there are pages with "diversity," "transgender," and "vulnerable" right in the titles.
Some of the response from scientists was likely colored by recent news that references to climate change have been removed from several pages on the Environmental Protection Agency's website.
Memories of George Carlin's 'seven dirty words'
When David Hemenway at Harvard's T.H. Chan School of Public Health first heard about the Post story, he immediately thought of comedian George Carlin's 1972 routine about the seven dirty words you can never say on television.
Based on the media coverage and the outrage that followed, he thought the CDC's seven words were like Carlin's seven words: absolutely and completely forbidden.
Then CNN shared the HHS budget guidance document with him.
"What you sent me affects how I think about this," said Hemenway, a professor of health policy. "It's very different."
Hemenway said public health experts sometimes switch out words in funding requests based on the sensibilities of the people who are giving out the money.
"For the past 20 years, including under the Obama administration, people at the CDC have been afraid to use the word 'guns' or 'gun control,' " he said. "So if you want to do research on guns and suicide, you say you want to do research on suicide."
Dr. Thomas Farley, Philadelphia's health commissioner, said public health researchers often favor the term "childhood obesity" instead of "obesity" as it's perceived that some funders might have more sympathy for overweight children than adults.
"Everyone knows you get more traction talking about childhood obesity," he said. "If I were doing a budget document, I'd reflexively put in childhood obesity."
Emily Rothman remembers that when she worked for the Massachusetts Department of Public Health in 2001, she and her colleagues were told not to use the term "intimate partner violence" in communications with the George W. Bush administration.
"Word came down that the federal government thought 'intimate' was too -- well, too intimate, too sexy," said Rothman, now an associate professor at the Boston University School of Public Health. "So instead we were told to say 'partner violence,' even though 'intimate partner violence' is much more specific. 'Partner' violence could be any partner -- your business partner, your golf partner."
Such switching out of words is not uncommon, even in previous administrations, the experts said.
"You phrase your request to match the political bent and world view of the people who will make decisions about your budget," Farley said.
"It's a pretty narrow thing. Instead of using 'vulnerable,' you use 'high-risk' to help get money for a good cause," he said. "It would be nice to live in a world where we didn't have to do that, but it's not a horrible thing. There are 10 million things worse than that."
'What kind of culture are we living in?'
Even though public health experts have been careful about word choice through many administrations, both Republican and Democratic, they said the most recent guidance from the Trump administration stands out.
Some of it seemed downright silly. The document obtained by CNN says the "Affordable Care Act" and its acronym "ACA" should be called "Obamacare" in budget documents.
"Obamacare" has been President Trump's preferred term for the legislation.
"Come on -- that's just crazy!" said Hemenway, the Harvard researcher. "Obamacare is not the name of the act. It's the ACA!"
Other parts of the Trump administration guidance were deeply troubling to Hemenway and the other experts -- particularly the advice to avoid using the word "vulnerable."
"Everyone of every political stripe should care and be concerned about vulnerable populations," said Farley, the Philadelphia health commissioner.
"What kind of world are we living in -- what kind of culture are we living in -- when words like 'diversity' and 'vulnerable' produce such a negative reaction?" added Stuart Shapiro, a former policy analyst at the Office of Management and Budget and now a professor of public policy at Rutgers University.
"The fact that they were instructed to avoid those words says something -- and I would say something not very good -- about where we are now as a society," he said.
Boston University's Rothman added that the advice to avoid "vulnerable" and "transgender" and "diversity" shows who the administration does and doesn't care about.
"It doesn't matter if you ban these words or subtly suggest that you don't use them. People will connect the dots and see who they're hoping to leave by the wayside," she said.
A document obtained by CNN does not show words banned at the CDC
Instead, it suggests wording to improve chances of getting funding
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