Scott Gottlieb on Covid, a better CDC, and how he does it all

Former FDA commissioner Scott Gottlieb can now add published author to his long list of titles, which also includes board member of Pfizer and Illumina, senior fellow at the American Enterprise Institute and CNBC contributor. His book about the pandemic, “Uncontrolled Spread: Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic,” was released Tuesday. He spoke with STAT to discuss his book, his thoughts on the pandemic, and much more.

This interview has been lightly edited for clarity.

One of the themes in your book is how we thought we were prepared for something like this. You point out that all those plans turned out to be what you call a ‘technocratic illusion,’ which is just such an evocative phrase. Our stockpile was drastically insufficient at the core of the issue. You write that we prepared for the wrong pathogen. So why was the U.S. so convinced that the next pandemic would be a flu? And why were we so unable to pivot when it turned out to be something different?

If you’re looking at pandemic preparedness through the lens of a potential pathogen like influenza, the types of things you worry about and focus on are different. First of all, the preparations that we had made for flu were inadequate. And the stockpile is just one metaphor for that inadequacy — where we had things in the stockpile that simply didn’t work, respirators that we had stockpiled didn’t work. The masks were out of date. So even if influenza had struck us, we still weren’t prepared because the kinds of preparations we made were inadequate. But if you’re looking at things through the lens of influenza, certain contingencies that become very important in preparing for a coronavirus aren’t as important when it comes to flu. For example, diagnostic testing isn’t going to be an essential component to actually responding to a pandemic with flu. And if you look back at the pandemic tabletop exercises like Crimson Contagion, diagnostic testing wasn’t a big part of those exercises. There was no difficulty getting access to screening because with an influenza, the incubation period is very short and people are typically contagious after they manifest symptoms. So getting people diagnosed while they’re asymptomatic as a way to control the spread of the pathogen isn’t as critical.

In the book, you’re very critical of the Centers for Disease Control and Prevention. You point out that in the early days of the pandemic, the agency botched the development of the first SARS-CoV-2 test. They failed to come up with a plan for widespread testing and actually impeded the development of tests by outside commercial labs. You also criticized the CDC for some of its public health guidelines, like establishing the six-foot social distancing requirement without evidence that would help. So I guess the question is, can the CDC be fixed and should it be fixed? Meaning should we be relying on the CDC in future pandemics or should the responsibilities for surveillance and response go somewhere else? 

I think it can be fixed and I think it has to be fixed. I don’t think that when we engage in pandemic planning going forward, and we come together and have a commission and try to reach a bipartisan consensus on what the new framework is going to look like, that we should be creating a new agency. I think we need to vet these kinds of capabilities within CDC, but it’s a reimagined CDC. It’s a CDC that has an operational focus, has a national security mindset that isn’t so retrospective, that’s comfortable surfacing real time information to inform active policy decision making.

An even more fundamental challenge that we’re going to face, in my view at least, is that there is now a large portion of the population that has lost confidence in public health decision making in the setting of a crisis – that has lost confidence in the guidance that was issued, that felt that the recommendations were arbitrary, that they were inconsistent, that they weren’t articulated in a way that people could find practical value from the issues of should I wear a mask? Shouldn’t I wear a mask? When should I wear a mask? What kind of mask should I wear? And the agency wasn’t transparent about how speculative some of the recommendations were at the time that they were being made. And so this breaks down along ideological lines for sure. I mean, there is a right-left divide on this, but it is much broader than that. I think it transcends just pure politics. And so we’re going to need to earn back the public’s trust and convince them that public health agencies should be empowered in the setting of a public health crisis. Before we even have the discussion about how then to empower public health agencies going forward in the setting of a public health crisis. There were failures of public health authorities, not just in how we executed, but also in how we expressed uncertainty with the public. I think that there were many moments where we expressed too much certainty and showing more humility actually would have earned more public trust.

On that point – your book does focus mostly on the agency level and you deliberately avoid framing too many of the failures in political terms, but so many of the decisions in question, whether federal, state or local, are made by elected officials. And so considering that voting is pretty much the only thing most readers of your book can do to influence the nation’s future pandemic preparedness, what should we be saying to our leaders and our political candidates? Like what would a pandemic-smart platform look like?

I think that voters should care about public health and voters should care about candidates being willing to invest in strong public health measures, strong public health infrastructure, and that transcends just pandemic preparedness. This pandemic showed how excessively vulnerable our society is because of systemic challenges that we face with getting adequate health care to communities in society that were made excessively vulnerable to Covid precisely because they lacked access to care. They face bias in how care was delivered. They worked in jobs where they didn’t have the social capital at work to demand conditions that would keep them safe. Something as simple as a mask on the job, a high-quality mask if you were working in a confined space that was conducive to spread.

So I think voters should care about politicians being willing to take strong positions on trying to reinvigorate the nation’s public health. That’s why I say, you know, we have to have this discussion about how to properly empower resources. The CDC had to change its orientation, how to give it more of a national security mindset. But all of that is predicated on a belief that you think public health institutions should be strong. And there’s a lot of people who are very skeptical of that notion. And it’s a lot of my fellow conservatives. But it’s broader than that. And that really worries me. Building back that consensus, I think is going to be difficult.

What do you see as your role in helping accomplish that? You have this unique position now – you were in government, you’re no longer in government. You sit on many different seats of power and access. Do you ever think about going back in? Would you be a sort of pandemic preparedness czar, are you the person to coordinate this on the government level, or are you more effective from this sort of more private sector role you’ve now taken on?

I haven’t really thought about how I could be effective or where I could be most effective from in this debate. I look at this in the lens of where I am right now, and I think I could be effective in trying to just articulate why it’s important that we have strong public health institutions that are able to execute this kind of a mission. It’s not just about building a better CDC, but it’s about looking at why certain communities were made excessively vulnerable and how do we rectify that.

What’s your access like today with the Biden administration? In the book, you talked about having a lot of access, being at the White House under the Trump administration. What is it like under a Democratic president today? Are there people listening to you?

I have dialogue with members of the Biden administration. I have preexisting relationships with a number of people who are in roles right now where they have involvement in the response to Covid. I feel that if I have a strong opinion on something that people in the administration, who are in positions of authority and able to execute on aspects of this response, are willing to take my call. And I’m very grateful for that.

One thing that stood out in your book is just the quantity of hats that you wear. You were in the room for a lot of key deliberations about pandemic response even after you were a federal employee, but at the same time, you’re on TV most days. You’re stitching together Twitter threads that I assume get hundreds of thousands of impressions. And then, of course, you’re on the board at Pfizer. How do you navigate between your public-facing persona and the behind the scenes work?

I navigate it by being very upfront about what my different relationships are when I am engaged in the public aspects of the work I do, and being very studious about not divulging conversations and private relationships in the private aspects of what I do. If I’m having conversations with public officials, where there is a level of trust that that’s going to be a private conversation, I make sure it remains a private conversation. And that’s how I navigate it. I’m very transparent.

You dedicate the book to your three daughters. As you mentioned before, you were on CNBC most days, sometimes starting at 6 a.m. throughout the whole pandemic. You’re on several boards. You have, I think, at least two day jobs at AEI and NEA. And then you wrote a book. So I guess this is sort of like a talk show question, but how did you do it all? 

All my free time was spent writing this book, and that’s why I dedicated the book to my family because I really was absent over the last year. I mean, I spent every moment that I had, that I wasn’t engaged in something where I had to work on behalf of NEA or something related to AEI or Pfizer or some of the other business engagements that I have, writing this book. So it consumed all my free time.