Four times during the past nine months, Governor Mitt Romney and his aides have reversed decisions by his public health commissioner or heavily influenced the adoption of policies consistent with the governor's conservative social views.
Those decisions involved issues such as abstinence education, stem cell research, and the sale of drug needles to prevent AIDS. In interviews, more than a dozen current and former Department of Public Health officials and other health specialists said the Romney administration has also exerted increasingly stringent control over the agency behind the scenes.
Public appearances by agency officials, and even the contents of some of their slide shows, are routinely reviewed by Romney appointees, and the public health commissioner regularly consults with the governor on matters he thinks could prove controversial.
The intense oversight is occurring as Romney, a Republican from a state known for its liberal politics, considers a run for president in 2008, a campaign that would wind through early primary states such as South Carolina that favor more conservative social agendas.
Massachusetts has the nation's oldest state public health department, and many of its staff members and outside health specialists contend that science and statistics alone should govern its actions. But the issues on the agency's expansive agenda -- sexuality, addiction, and communicable disease, for examples -- can turn into political tinderboxes for a governor who might seek higher office.
Romney's chief spokesman, Eric Fehrnstrom , acknowledged that the governor has no hesitation about becoming involved in the actions of the agency, which is part of the state government's executive branch. For example, Fehrnstrom said, Romney made the decision this summer to conduct aerial spraying in Southeastern Massachusetts to combat disease-spreading mosquitoes, after weighing the public health benefits and the environmental risks.
``Most of the issues handled by the Department of Public Health are nonpolitical and don't require the governor's involvement," Fehrnstrom said. ``But there are some matters where a political decision has to be made, and it's going to be the governor's political view that carries the day."
State Representative Peter J. Koutoujian , chairman of the House Committee on Public Health , said he is so concerned about the intrusion of politics into the department under Romney that he intends to introduce legislation changing the way the agency's commissioner is selected.
Instead of leaving that choice to the governor, the Waltham Democrat said, he will call for an independent panel to select the public health chief.
``Public health is something that should never be politicized, because, truly, people's lives are at stake," Koutoujian said.
Public health veterans said political pressures have intensified in the past two years -- the same period when Romney was casting himself as a healthcare visionary after proposing a law designed to provide medical coverage for all adults and children in the state.
``I'm very concerned that politics is trumping science," said Geoffrey Wilkinson , executive director of the Massachusetts Public Health Association, an interest group whose members include officials from local and state public health agencies. ``We've seen a variety of issues where he seems to have either changed positions or crafted positions that will appeal to a conservative national audience."
Governors of other states have also become increasingly involved with public health agencies, said Dr. Georges C. Benjamin , executive director of the American Public Health Association .
``When governors didn't care about health and they didn't think it was a political issue, they kind of stayed away from us," said Benjamin, a former top health officer in Maryland and the District of Columbia. ``But now that covering the uninsured is a big issue, now that healthy lifestyles is a big issue, we're increasingly seeing that they're paying much more attention to us."
An internal memo obtained by The Boston Globe shows how the Romney administration has insisted on controlling the message conveyed by representatives of the Department of Public Health. The Feb. 11, 2005, e-mail from Nancy Ridley, now an associate commissioner, ordered emergency preparedness officials to submit for prior approval any materials being presented at public forums.
According to the memo, a department official named Lewis Howe then the agency's legislative director, would send the materials to the Executive Office of Health and Human Services.
``If any of you are scheduled to speak at a meeting or conference of ANY type about ANYTHING that media MAY be present at you must send a copy of your comments or an outline of your presentation or your slides IN ADVANCE " to Howe, the memo reads. ``To make this more complicated, even if you are NOT a listed speaker, but are going to attend a meeting that MAY have media present and MAY either be called upon or offer a comment or ask a question, you must notify Lewis in advance."
On Friday, Ridley confirmed the e-mail's authenticity and said similar memos were sent by other division heads.
A state public health official, who requested anonymity because of concerns over job security , said Romney aides in the governor's office or at the Executive Office of Health and Human Services must review any policy changes or educational materials perceived as having political consequences. It is a level of oversight, not seen in the past several administrations, the official said.
A former executive at a leading private social service agency said her experience winning department approval for a 2004 health poster showed how heightened political sensitivities had slowed important campaigns.
Lee Swislow , who was a vice president at Justice Resource Institute , recalled that it took nearly a year for public health officials to give their blessing to the Department of Public Health -funded poster aimed at reducing discrimination against transgender patients at medical offices. That was longer than previous administrations took to approve similar materials, she said.
``I would not have expected this much time to pass before a decision was made," Swislow said. Ed Kiely , chief of staff at the DPH , said last week that it was not at all unusual for approval of a poster campaign to take that long.
Jean Flatley McGuire directed the department's HIV/AIDS Bureau for six years, but she left in 2003 in large part, she said, because of the Romney administration's interference with the DPH.
``That was ultimately why I left: because my authority and autonomy and ability to address the programs and the policies . . . under my responsibility were being actively constrained," said McGuire, now a visiting professor at Northeastern University .
Romney's first public health chief , Christine Ferguson, said she spoke regularly with the governor and had occasional policy differences with him, though she declined to go into detail.
Her successor, Paul J. Cote Jr. , estimated that in the past 12 months, he has consulted directly with Romney regarding department affairs two dozen times. Cote, appointed in 2005 by Romney, said he consults the governor when ``my gut tells me that my boss would want to know."
But it was several occasions when Cote did not consult Romney before making decisions that propelled both him and the governor into the headlines -- and, department critics said, demonstrated the depths of the administration's involvement in setting public health policy. Cote had to backtrack on two decisions after hearing from Romney aides.
In May 2005, the Department of Public Health provided testimony to the Legislature supporting over-the-counter sales of hypodermic needles to drug addicts as a way to prevent the spread of infectious diseases.
Opponents of making clean needles available to addicts fear that the policy encourages drug use, but repeated, independent scientific studies have found no evidence of that. But Romney adamantly opposed over-the-counter sales, and a year after voicing support for the measure, the DPH reversed course.
The Legislature eventually approved the sale of needles, overriding a Romney veto.
Cote said he had erred by failing to notify the administration before he submitted the testimony in favor of needle sales . Similarly, the commissioner said that before the agency adopted regulations prohibiting the distribution of infant formula gift bags to new mothers, he should have sought the blessing of the governor's office.
``This was one where I got out in front of the issue and didn't get appropriate feedback on it, and thus to my chagrin, had egg on my face and asked that the regulation be recalled," Cote said. ``I changed my mind, or let's say we modified the regulation, based on the feedback from the governor's office as well as the Office of Health and Human Services."
In the spring, Romney removed two members of the state's Public Health Council who expressed their dismay in public over the reversal of the gift bag ban.
Fehrnstrom said that while Romney does not dispute the benefits of breast-feeding, he believes mothers should be able to choose whether they receive formula samples.
``You had two political agendas," Fehrnstrom said. ``The liberal agenda of a narrow special interest group that wants to punish women who want to bottle feed, or the agenda of a governor who thinks women shouldn't be punished for bottle-feeding.
``In that case, it's the governor's view that carried the day."
Alice Dembner of the Globe staff contributed to this report. Stephen Smith can be reached at firstname.lastname@example.org.