The U.S. Department of Health and Human Services (HHS) has undergone a major shakeup under Health Secretary Robert F. Kennedy Jr., who has fired scientific experts in what he calls an effort to eliminate industry influence in federal health decisions.
But how widespread are conflicts of interest at federal health agencies? And can Kennedy’s new policies actually improve public trust?
To answer these questions, we caught up with Genevieve Kanter, Associate Professor at the USC Price School of Public Policy and Senior Scholar at the Schaeffer Institute for Public Policy & Government Service. She recently published an article in the New England Journal of Medicine about her research on conflicts of interest at federal health advisory committees.
Her answers were lightly edited for length and clarity.
Why should the public care about conflicts of interest?
Government jobs are very different from most jobs in the world. In the private sector, if you, say, work for an investment bank, your job would be to make a lot of money for the bank, and if you did well for yourself too, that would be great. You wouldn’t be criticized for it.
But the people that we expect to work in government – whether they’re elected officials or appointed officials or civil servants – are supposed to act in the public interest. For that reason, government staff are very valuable, but it also means that they need to be held to a different standard.
A conflict of interest is a situation where government officials are faced with incentives to act in their own interest, which conflicts with the public interest, and that is a serious concern for all of us.
How widespread is this problem?
One way we can get a sense of how widespread the problem is, is by studying something called the “revolving door.” In these studies, we look at civil servants and appointees, and the degree to which they previously worked in industry jobs and could be influenced by industry, or the degree to which they leave their government jobs for private industry, and therefore might make decisions as they’re leaving that would be favorable to industry.
In the revolving door research I’ve done, I found that about a third of government appointees from HHS take jobs in private industry within two years after leaving their government roles. I found something like 15% of government staff worked in industry immediately before their appointment. That is not necessarily a bad thing, but it is something that we might want to look at more carefully, in terms of conflicts of interest and how that affects government decision-making.
Another potential concern is advisory committees. These advisory committees consist of outside experts. The government doesn’t always have expertise in the many areas that it regulates, so with advisory committees, they’re able to obtain expert advice. But the issue is that many of these people have financial interests that might conflict with the public interest.
What I found is that there’s been a big change between 2000 and today. If you looked in the early 2000s, many of these committees had a lot of financial conflicts of interest. For example, in Food and Drug Administration (FDA) drug advisory committees, about 80% of meetings had at least one person with a financial conflict of interest. On the vaccines committees, we can calculate that it was something like 40% – almost half – so pretty high in the early 2000s.
That’s been decreasing continually over the past 25 years. More recently, we’ve actually seen pretty low levels of financial conflicts of interest with vaccine committees before Secretary Kennedy’s firings. With FDA committees reviewing prescription drugs, though, there has been a resurgence in conflicts of interest.
RFK Jr. said he wants to remove all conflicts of interest from HHS advisory committees. Would that improve public trust?
I’m a little skeptical that these efforts would improve public trust. A big reason is there’s this huge gap between what the public says that it wants – that is no industry influence in government decision-making – and how the government approaches conflicts of interest.
Government ethics laws and regulations take what’s known as a “particular matters” approach to conflicts of interest, and that’s very specific to the issue being discussed. With the FDA, a conflict of interest would be defined as: Do you have a current relationship with the manufacturer of the drug that’s being discussed, and is your relationship related to that specific product?
Suppose the FDA is reviewing a drug to treat colon cancer made by a specific firm. Here are some financial ties that would not be considered a conflict:
- If you had a financial tie to the same company, but your work was related to breast cancer and not colon cancer;
- If you had a tie to a competing company, but again, your work was not related to colon cancer;
- In addition, if you had a previous relationship with the same company, even on colon cancer, but it was more than a year ago, that would also not be a conflict of interest.
Given this “particular matters” approach, there are various ties that most people would consider to be a little worrying but would not actually be a conflict of interest.
What would be a more dramatic policy approach?
A more dramatic policy shift would be to eliminate even these broader conflicts of interest. That’s much harder, and it’s also much more likely to affect a broader range of experts. We may be concerned about some possible downsides if we take that approach.
Even though that seems to be what the public would like to do – eliminate industry influence – there are some trade-offs here. For example, there has been at least one study showing that external experts do seem to have more expertise – if you measure by research citations – than individuals who don’t work on these committees.
I would also be concerned about particular health areas where we don’t have a lot of researchers, such as rare diseases. So if we take a more stringent approach, we may be excluding a majority of people who work in that area.
What should policymakers do?
I think the key is that conflict of interest policies can’t be considered in isolation, so any policy related to conflicts of interest has to be part of a broader strategy of building public trust by being more trustworthy as an agency.
That includes providing comprehensive scientific justification for decisions, being transparent about how decisions are made, being transparent about meetings with industry and enforcing existing rules, as well as making collection on data on conflicts of interest and their impact a routine and transparent part of advisory committee meetings. That way we can have evidence- based policies, not only in relation to science, but also in relation to conflicts of interest.
