COVID-19 war requires nationwide strategies and sacrifices: Q&A with former CDC chief

With 32 states adding COVID-19 cases faster than in the worst spring week, USA TODAY’s Editorial Board spoke Wednesday with Dr. David Satcher, former Surgeon General and director of the Centers for Disease Control and Prevention. Satcher, 79, is now director of the Satcher Health Leadership Institute and a professor at the Morehouse School of Medicine in Atlanta. His new book, "My Quest for Health Equity: Notes on Learning While Leading," is due out later this summer. Questions and answers have been edited for length and clarity:

Q. We are in the midst of the worst public health crisis in a century. As a professor, what grade would you give to the nation's response so far to COVID-19?

A. It’s not good, let me put it like that. I think we can do much better. If I had to give a grade, it would probably be about a C at this point. 

Q. What can we do to improve on that?

A. First, I think we need a plan that's nationwide in terms of when we close down, when we open up. It is very difficult to have one state open and another state completely shut down. We have to have some rules, some pattern that people can look to and predict what we're going to do and when we're going to do it.

Q. What about local decision-making?

A. Obviously, we value our freedom. We value the fact that we give people the opportunity to make decisions on a local level. But when you deal with something like a pandemic, I think you have to set up some special rules for that situation. And I don't think we've done that. We're going to have to make some sacrifices and have some rules in place that people would abide by. A pandemic is like war. In some ways, it's worse than war, so you have to put in place rules and strategies that are appropriate for the situation.

Q. Should schools reopen in the fall?

A. Schools need to reopen when they can reopen safely. I think most of us want them to reopen. I have grandkids in school, and I've had kids in school, so the idea of being in school appeals to me. But the key word is "safely." That includes not just children themselves, but their parents and grandparents and all the people who will be exposed when they go home. We should do everything we can to prevent that.

Q. You've spent so much time in your career talking about racial disparities in health care, which is certainly showing up in this epidemic, too. And you've said that we need leaders who care enough, know enough and do enough to combat the racial disparities in health care. Do we have the right leadership focusing on this issue right now?

A. I think we have a problem with leadership. I don't think we have the kind of consistency of leadership that's really important in a situation like this. So, I would say that we still seem to have problems deciding who's going to lead and how they're going to lead. And in all frankness, we have leaders who I don't think are taking their role and their responsibilities as seriously as we need them to take them. More than 130,000 people have already died in this country from this pandemic. This is serious. The leadership has to be serious and predictable. It's really tough when you can't predict what leadership is going to do today or tomorrow.

Q. What else?

A. We've got to allow the science to function as science. We've got to allow the scientists to take leadership in dealing with the scientific issues. We've got to allow research to continue to dictate our actions. We've got to separate the science from the politics, which is not always easy.

Q. Where do you put the greatest responsibility? Is that the governors, is it the mayors, is it the president? Who should be taking the leadership role? 

A. I think the president, in this case, has to provide a special kind of leadership that incentivizes other leaders at different levels, whether it's the governors of the states or the mayors of cities. If the top leader is not clear about where we're going as a nation, why we're doing what we're doing, then it's going to be a problem up and down the line. I don't want to just join the cause and criticize President Trump, but if you don't have that clarity of leadership at the top, it's going to be very difficult to expect that you're going to get it at other levels.

Q. What do you think about the conflicting or mixed messages around science coming from political leadership? Does that undermine public willingness to rally around the best recommendations?

A. You have to hold leadership responsible for making clear who does what and who has what responsibility. It doesn't mean that the scientist is always going to be right. Nobody is. But it means the scientists are responsible for making sure we find the right answers. We don't always have them. Look at Dr. Fauci's articulations, and you may well find some things that he said earlier that we now know better. We've never seen this virus before. We are learning new things about this virus every day, and that includes Tony Fauci, whom I deeply respect. I've known Tony for a long time. He's a class act, but he's not gonna always be right. He's not going to, because we don't have all of the answers yet.

Q. How do we get the answers?

A. That's why we do research. That's why the CDC does research. Let's face it, anybody who thinks that the CDC is supposed to always be right is going to be sadly disappointed. We rely upon the CDC to articulate the latest science. The CDC has some outstanding public health scientists. The scientists there are doing research every day. I mean, they've been looking for the latest answers. I think you have to respect scientists, not because they're always right, but because they're always on the path of finding the right answer, using the scientific approach.

Q. What do you think about the White House decision to bypass the CDC on the collection of certain data on hospitalized COVID patients?

A. It's very scary. You can't expect the CDC to do valid guidelines and develop valid programs of immunization if we don't respect their role that's been very clearly defined. There is conflict right now between the CDC and the White House, and maybe HHS (Health and Human Services) and the White House, but somehow we've got to get past the conflict in the interest of saving lives. If we're going to make decisions that are best for saving lives and preventing illness, then we've got to get past some of the conflicts that seem to be really overwhelming the system right now.

Q. Does it make sense to sideline the CDC and withdraw from the World Health Organization if they make mistakes?

A. You can punish the CDC today or you can punish the WHO tomorrow, but somebody needs to stop and say, "What has this relationship been like in the past? What have we gotten out of the World Health Organization? What are we getting from the CDC that we could not have gotten all over the world?" I've had this experience. All over the world, people seem to respect the CDC and the World Health Organization. The World Health Organization respects the CDC. When WHO gets a major challenge like Ebola, when we were dealing with it back in the '90s, they almost invariably turned to the CDC for help. I know that was true when I was director of the CDC, and the two organizations worked very well together. CDC has technology that even the World Health Organization does not have. I think when the WHO calls upon us for help, we should be proud to respond.

Q. What was it like when you became director of the CDC in 1993?

A. I had been president of Meharry Medical College for almost 12 years when I was selected to be director of the CDC. Everybody was trying to figure out, "Why did you select somebody from outside the CDC, outside of public health?" The bottom line is that their goal was to reduce health disparities. The CDC had been unsuccessful in many ways in immunizing people in the Black community, especially. They had set a goal of getting immunization rates up to 80%. But the problem was, that was not working in the Black community, because so many people didn't have access to health care and so many people didn't have a relationship with the CDC. I didn't fully realize until I got there the magnitude of the concern and the expectation.

Q. How was your introduction?

A. It was interesting in a lot of ways. There was a press conference to sort of announce my appointment as director. And the first question, of course, was, “Well, Dr. Satcher, how does it feel to be the first Black director of the CDC?” I hadn't actually thought about it. I explained to them that my goal was not to be the first Black director. I had already achieved that. I was hoping to be the best director that the CDC has ever had. That was the last time they asked me that question.

Q. How do your life experiences inform your public health role?

A. I almost died of whooping cough when I was a child. At that time, which was in the early 1940s, the hospital in Anniston (Alabama) did not admit Blacks. I'm not saying that's why I almost died, but I'm sure that didn't help. There was only one Black physician in Anniston. For some reason, he responded to my dad's pleas and he came out to the farm and spent the whole day. He didn't think I was going to survive. He made that very clear when he left. I wanted to meet Dr. Jackson (again), but he died when I was 5 years old. By then, I was telling everybody I was going to be a doctor, just like Dr. Jackson. The issue of disparities in health is very personal for me. I lived that; I've lived through them.

Q. Why do these disparities persist?

A. We don't have a system in place that says that if the nation selects these goals, then the nation is going to support them until the goals are achieved. We don't have that kind of system in place.

Q. Last week, the mayor of Atlanta disclosed that it took her eight days to get her COVID test results. The same is true in some other hot-spot cities right now. What can be done, you think, to improve this?

A. Testing is very important. In terms of getting a handle on a pandemic, we need to know as much as we can, including its distribution in the population. We don't have that information because we haven't had that kind of testing. We've picked up the testing a lot in the last month or two. CDC has run into some challenges. There are some people who don't trust testing programs.

Q. How come?

A. I remember getting a call from a mayor whom I happen to know. She was concerned that it was so hard to get people to agree to take tests. I said, "Why is that?" She said, "Well, because they keep bringing up Tuskegee." (The Tuskegee study) occurred from 1932 to 1972, and the Black community was deceived. Black men who were diagnosed as having syphilis were given the impression that they were being treated, but they were not. When I became director of the CDC, the CDC had responsibility for looking after the families of men who had died in this study thinking they were being treated. On May 16, 1997, in the East Room of the White House, President Clinton made an official apology on behalf of the nation for this study that was carried out using these Black men. I never will forget that experience.

Q. How do we instill trust?

A. At the CDC, we realized that we were never going to increase immunization rates to 80% unless we got the Black community more involved and we got more vaccines. We decided to see if we could develop a partnership with the National Council of Black Churches. We spent time with them explaining why we were trying to get the immunizations rates up. And our goal was to get kids immunized by the age of 2 for things like measles, mumps, rubella. We needed their help, and they had a lot of questions. But as a result of that interaction, we were able to virtually eliminate disparities in immunization rates. It was the relationship that we developed with the church, someone people in the community trusted. They didn't necessarily trust us, but they certainly trusted the church.

Q. How do you sustain progress?

A. The principle, in my view, is you've got to find the leadership in the community that people trust in order to get people to feel comfortable with any major intervention like an immunization program. Now, you can't do that just one time. That's the thing I want to make clear. These interventions are not a one-shot thing. I’m a long-distance runner, and eliminating disparities is a long-distance run. You've got to be committed to distance, and the same thing is true with immunization. The immunization levels almost got up to 85% overall. Well, you don't do it just once. You’ve got to keep it going.

Q. What else needs to be done?

A. A lot of people don't have a relationship with a physician. Physicians are important in this equation. If a patient has a good relationship with the doctor, they are much more likely to follow all of these rules and recommendations that we make. The relationship between doctor and patient is really important, and I'm not sure there's any substitute for it.

Q. You’re the same age as Dr. Fauci. How are you leading your own life during COVID-19? What advice do you give to friends and associates?

A. I'm trying to follow the CDC guidelines. … Wearing a mask has probably been the most successful intervention. Every time we get new information about the impact of wearing a mask, the better it gets. There's no question anymore about the fact that if I wear a mask, it reduces my risk of passing on to you the virus if I have it. If you wear a mask, it reduces the likelihood that you would pass the virus onto me. The data looks good that wearing a mask makes a difference.

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