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Heading up the American dream of health
INTERVIEW
Interview
Heading up the American dream of health
David H Frankel, Julie Rovner After a punishing 5-month confirmation process during which conservatives opposed to President Bill Clinton launched a series of accusations about the administration’s health policies, David A Satcher was sworn in on Feb 13 as the 16th US Surgeon General—a post vacant since Joycelyn Elders was abruptly fired in 1994. Satcher is also serving as Assistant Secretary for Health, the first time one person has filled both positions since the administration of President Jimmy Carter. Satcher, an African-American who grew up poor in the racially segregated south, trained as a family practitioner. He developed and later headed the King/Drew University Department of Family Medicine (Los Angeles, CA), and then became head of the Department of Community Medicine and Family Practice at Morehouse School of Medicine (Atlanta, GA) before moving to Nashville to serve for a decade as president of Tennessee’s Meharry Medical College. In 1993, Clinton appointed him director of the Centers for Disease Control and Prevention (CDC). During his confirmation battle for Surgeon General, conservative Christian groups criticised Satcher for CDC’s role in a controversial study of short-term zidovudine (AZT) therapy to prevent perinatal transmission of HIV-1 in Africa, as well as for his support of Clinton’s stand against a ban on a late-term abortion technique. Satcher, however, gained the enthusiastic support of the nation’s medical community, including not only the American Medical Association, but also conservative Republican physicians in Congress.
Your confirmation process was rough. What did you learn about some of the possibilities and limitations of what you can do as Surgeon General? We learned some negative and some positive lessons, let me just put it like that. I guess what I was most disappointed about has to do with charges that are made without confirmation and seemingly the unwillingness to really sit down and talk to people and understand where they stand on issues. What most surprised me about Washington and about politics is the fact that people will attack without knowing you. I don’t think that works in the best interest of the country but I think it is sometimes part of the political process here in Washington. The positive thing was that people do listen to information. I think that’s what prevailed. I’ll never forget the interview that they did with Sid Wolfe [Public Citizen]. Sid and I go way back to when we were medical students at Case Western University. Sid and I disagreed on the AZT trials in Africa, as you know. When they interviewed Sid, he said “yeah, we disagree on this one issue but I would never question the ethical standards of David Satcher”. To be honest, when I look back, on balance I feel good about what happened in the confirmation process. I think truth prevailed. So, that’s what I remember. Even though people often come up to me and say how bad it was, I remember the positive things about it.
for 4 years. By now, people know me and I am going to rise or fall based on that. The other thing was the way people responded. Even sometimes without my expecting it. I mean, the Lancet editorial; I had no reason to expect it. And yet it happened [Lancet 1997; 350: 1489]. On balance, I came into this position with a lot of confidence that we can make a difference.
Did you think at some point that you would not be confirmed? I never really doubted it. I was dean at Drew, I was a department chairman at Morehouse, I was president at Meharry for almost 12 years, and I was director of CDC Lancet 1998; 352: 978–81 The Lancet, New York, NY 10010, USA (D H Frankel MD); and 10525 Englishman Drive, Rockville, MD 20852, USA (J Rovner AB)
978
THE LANCET • Vol 352 • September 19, 1998
INTERVIEW
There’s a tremendous opportunity here. The American people still take very seriously the best available science. It may not always be politically popular. But I think that you must keep basing your statements on two things—the best available science and a sensitivity to the concerns of the American people. That’s my goal. The needle-exchange programme, for example. The science is there—I don’t think there is any question about it. That’s why the American Medical Association, the National Institutes of Health Consensus Conference, the Institute of Medicine, former Surgeon General Koop, former Secretary of Health and Human Services Louis Sullivan, and different administrations have come out and said that these programmes work. However, I have never made a speech about needle exchange when I didn’t say that I understand the concerns of people about what message we are sending to our young people. We are not saying it’s okay to do drugs. We never would say that. We are saying that we want to stop this deadly HIV virus.
The USA is enjoying prosperity right now. But the gap between rich and poor is growing. Economic and political issues always influence public health, especially in poor communities. You are “only” a public-health official. What can the Surgeon General do? I think it’s a problem that we have to come at from many different angles, and my angle is public health. And when we say that we are committed to eliminating this disparity in health among racial and ethnic groups, we point to problems like immunisation, infant mortality, diabetes, cardiovascular disease, HIV/AIDS. We know that, in order to achieve this, it’s going to take more than the health-care system. It’s going to take change in the environment, change in the way people behave, and so we are going to need some partnerships. You put all those partnerships together and the impact that they have on communities is one that deals with socioeconomic status too. At CDC, when I was director, one of the things we did as a part of the empowerment zone was to develop a programme to train people who have been on welfare to be community health workers—to go into homes and identify allergens for asthma, to educate parents about how to get rid of those risk factors for their children, to go into schools and talk with teachers. I think we created a model of what could be done. There is a strong tradition of Surgeons General speaking out on some issues that sometimes the President cannot. Elders was fired for speaking out on a public-health matter. Do you think that her being fired will inhibit Surgeons General for years to come? I don’t think so. Different people have different styles, and Elders had her style. I am somebody who has had to work with the constituency of students, faculty, boards of trustees, alumni, community—balancing a lot of interests and working with a lot of different groups. So my style is different, if you will, in how I approach things. Needle exchange is an obvious example. My goal is just to say look, this is what the science says about this issue and this is why we think it’s important. And yet at the same time, I take the time to say we are sensitive to others’ concerns. It’s just my style.
THE LANCET • Vol 352 • September 19, 1998
Do you think there are issues over which you feel you would need to resign, or do you see yourself as being more of a consensus builder? I think consensus building is one of my strengths. I have had to build consensus to be successful, and get things done. Getting the city hospital in Nashville to come together with Meharry Medical College after 100 years required a lot of consensus building, a lot of getting to business—people wouldn’t have supported that before. So obviously I view that as one of the strategies for moving forward. I am willing to be fired, if I have to be fired. In order to tell the American people the truth based on the best available science, I am willing to be fired. We’ve been talking around the needle-exchange issue. What exactly was your role and how disappointed were you in the President’s decision? Well as you all know, I have been involved with this issue since I went to CDC in 1993 when the report was just coming in from the University of California at San Francisco [Lurie P, Reingold A, Bowser B, et al. The public health impact of needle exchange programs in the US and abroad. San Francisco (CA): University of California, 1993]. In fact, President Bush, with the leadership of Sullivan, who commissioned that study, wanted to find out what impact the needle-exchange programmes were having. But the politics changed. So by the time the report came in, I don’t think anybody was ready to deal with it. My job was to transmit the report to the Department of Health and Human Services and this is what we did—and we recommended that it actually did show that needle-exchange programmes reduce the 979
INTERVIEW
spread of HIV. But here things also have to be dealt with politically. Over the years, I have continued to pursue the science by asking the question: do needle-exchange programmes increase drug use in communities? As the science came in, it seemed to state clearly that although these programmes could reduce the spread of HIV, they do not increase drug use. And not only that, but many of the needle-exchange programmes were very successful in getting people into treatment. It also serves to dramatise the fact that one of the major problems we have in this country is that we don’t provide enough treatment opportunities. So, those are the three messages that I think came out of that review and that’s what we brought forward. And you have to admit that the administration did allow us to bring that forward. I mean, we very clearly said what the science showed. Then the administration made a decision that it had a right to make. We are not ready yet to use federal funds to support this programme. Well, that’s not my job. My job is not to decide how federal funds are used. My job is to advise them, in terms of the science, what can be done. And, I try to make it very clear that people who had devoted resources to needleexchange programmes were making a very positive difference. I said I was disappointed in the decision because obviously I wanted to see more of these programmes going forward and I knew that federal funds could expedite that. But I also understood that the Congress was not necessarily ready for that message. And as you know, within 2 weeks the House of Representatives passed legislation permanently banning the use of federal funds for needle-exchange programmes [Lancet 1998; 351: 1415].
You mentioned the controversy over the perinatal HIV transmission study in Africa. What role should US public-health agencies have in global health? There are two roles that are very important. First is the humanitarian role. Surgeon General Shealy in 1951, when he was president of the World Health Assembly, said that the world cannot exist half sick and half well. I agree. That’s the humanitarian perspective. We want a world in which everybody has the opportunity for good health. Second, you can no longer separate the health of the American people from the health of other people in the world. Public health is global, not only because infectious diseases can move across borders—last year, 40% of the new tuberculosis cases in the USA came from outside of the country. If there is an Ebola outbreak in Zaire, as there was when I was the director of CDC, we must send a team there because we want to stop that epidemic because it could become a pandemic. If we had stopped HIV when it started, if we had known it when it started, we could have prevented perhaps one of the worst pandemics that we have ever seen. So the earlier we identify and stop any infectious-disease outbreaks, the better it is for the people in this country and all over the world. We are a global community. Even things like the environment, tobacco, and violence have global implications. So it’s not entirely altruistic Right, not entirely altruistic. Good way to put it. 980
How do you balance the need to devote resources to fighting emerging infectious diseases against the need to address some of the behavioural problems that cause disease? Which is more important? Clearly, behavioural problems are becoming more important. Even with infectious diseases, I think the major risk factors today may well be behavioural: the way we travel, whether or not we wash our hands before handling food, sexual behaviour, invading the rainforest, crowding in homeless shelters. Our biggest problem today is human behaviour, not microbial behaviour. Even with microbial resistance, in some ways, the major factors are human behaviour— somebody is given penicillin for 2 weeks for strep throat and stops when he feels better, or when parents demand an antibiotic to treat their child’s virus. You can no longer separate microbial behaviour from human behaviour. They go together. Does the perception that we have a highly advanced, “almighty” medical ability sometimes influence behaviour and hinder prevention? For example, AIDS researchers worry that kids now think AIDS is curable and they don’t need to use condoms. We put absolutely too much emphasis on treatment and too little on prevention. And you look at our budget—a trillion dollars a year we spend in our health system and 1% of that is for population-based prevention. We depend upon biotechnology. We believe that we can solve anything with it. And it’s just not true and it becomes less true everyday that we live. Do you think it becomes even more difficult to redistribute funds to prevention when the biotech industry not only holds out not only a promise of health but also a great financial and economic promise? The industry does have a lot of clout in Washington. There is a lot of big business in health these days and it’s growing and it employs a lot of people. There is a lot to be said for that. So, prevention is not as rewarding as treatment and that’s one of the real problems. Maybe there is some way to change that, maybe there is some way to make prevention more rewarding. We’ve got to figure out something that would shift the emphasis away from treatment because everybody is concerned about cost. We’ve tried managed care and several other things and we still haven’t been able to get this under control. The cost of health care is still going up at twice the rate of inflation. By 2007, we will be spending US$2 trillion a year. But the problem that is difficult to control, as you imply, is the fact there are a lot of people benefiting from this increase in cost. Do you favour reporting names and contact tracing for HIV infection? I believe that we have to move to a system of reporting HIV that would allow us to identify people as early as possible after they are infected. You see, we have come to the point in our technology, if you will, whereby it’s as important to report HIV as it is to report AIDS, because the sooner we identify people and treat them, the better the prognosis. That’s one thing. But also, the more likely it is that we can reduce the spread of the virus. So for many reasons, I think it is time for us to move forward. I agree with people who are concerned about
THE LANCET • Vol 352 • September 19, 1998
INTERVIEW
AP
Because of recent events in Hong Kong, there were great fears of a flu pandemic this year. Do you think we are prepared? I would be wrong to sit here and say that we are prepared. There is so much of the unexpected and the unknown in any flu outbreak in the nature of that virus. I think we are getting prepared. We have acknowledged that we are not as prepared as we would like to be and as we should be. So, we are moving forward to becoming optimally prepared, not totally prepared.
confidentiality and about whether in fact people who are identified as being HIV positive will suffer some consequences. And therefore I think the government has to make the commitment to protect those people. We haven’t done that yet, but I think that’s what we have to do. We have to be willing to stand behind the programme, similar to what we have done with vaccine safety. The government set up a trust fund to protect people against vaccine injuries, and I think it’s going to be just as important to protect people who have HIV.
But Congress almost let the vaccine trust fund expire. The vaccine trust fund has almost a billion dollars! We do need some commitment at this level, or maybe even higher than this level, because we’re talking about Congress. But we do need HIV reporting. People can argue on name versus other forms of identifiers. Obviously, name reporting gives us more opportunities to intervene. I think that’s where we are with this epidemic. We need to be able to intervene, to help people, and to take whatever steps are necessary to minimise the risk of spread, and to get people in treatment as early as possible. So you are in favour of setting up a trust fund to help protect the process of HIV names reporting? We ought to be willing to make that investment.
THE LANCET • Vol 352 • September 19, 1998
Are we totally prepared for bioterrorism? No. That’s another example of an unknown. But I think you can be much better prepared than we have been in the past. I think you can be optimally prepared. And that’s what we are moving toward.
As you know, the recent Morbidity and Mortality Weekly Report editorial that accompanied a report on rising suicide rates in American youths did not even discuss gun control as a public-health intervention [MMWR Morb Mortal Wkly Rep 1998; 47: 193–96]. In 1995, The Lancet [346: 563] first reported that the gun lobby was trying to eliminate funding for CDC's Center for Injury Prevention because of what they viewed as anti-gun research. Has this kind of influence weakened the CDC's ability to speak out, not only on gun control, but on other controversial issues? Well, let me just say that whenever efforts are made to suppress science, we weaken the public-health infrastructure. We in public health are not politicians, so it’s not about gun control. It’s about being able to share information based on science. Do you think it would be impossible for the US Surgeon General to come out strongly in favour of gun control in America? No, not impossible, not impossible. But, again, my role in that would be to bring the best science to bear and my role would not be to deal with legislation. I think it is dangerous when we adopt political agendas at this level to the extent that people question whether it clouds our science. I don’t want that to happen. You have to be careful not to participate in anybody’s political agenda.
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Interview
Heading up the American dream of health
David H Frankel, Julie Rovner After a punishing 5-month confirmation process during which conservatives opposed to President Bill Clinton launched a series of accusations about the administration’s health policies, David A Satcher was sworn in on Feb 13 as the 16th US Surgeon General—a post vacant since Joycelyn Elders was abruptly fired in 1994. Satcher is also serving as Assistant Secretary for Health, the first time one person has filled both positions since the administration of President Jimmy Carter. Satcher, an African-American who grew up poor in the racially segregated south, trained as a family practitioner. He developed and later headed the King/Drew University Department of Family Medicine (Los Angeles, CA), and then became head of the Department of Community Medicine and Family Practice at Morehouse School of Medicine (Atlanta, GA) before moving to Nashville to serve for a decade as president of Tennessee’s Meharry Medical College. In 1993, Clinton appointed him director of the Centers for Disease Control and Prevention (CDC). During his confirmation battle for Surgeon General, conservative Christian groups criticised Satcher for CDC’s role in a controversial study of short-term zidovudine (AZT) therapy to prevent perinatal transmission of HIV-1 in Africa, as well as for his support of Clinton’s stand against a ban on a late-term abortion technique. Satcher, however, gained the enthusiastic support of the nation’s medical community, including not only the American Medical Association, but also conservative Republican physicians in Congress.
Your confirmation process was rough. What did you learn about some of the possibilities and limitations of what you can do as Surgeon General? We learned some negative and some positive lessons, let me just put it like that. I guess what I was most disappointed about has to do with charges that are made without confirmation and seemingly the unwillingness to really sit down and talk to people and understand where they stand on issues. What most surprised me about Washington and about politics is the fact that people will attack without knowing you. I don’t think that works in the best interest of the country but I think it is sometimes part of the political process here in Washington. The positive thing was that people do listen to information. I think that’s what prevailed. I’ll never forget the interview that they did with Sid Wolfe [Public Citizen]. Sid and I go way back to when we were medical students at Case Western University. Sid and I disagreed on the AZT trials in Africa, as you know. When they interviewed Sid, he said “yeah, we disagree on this one issue but I would never question the ethical standards of David Satcher”. To be honest, when I look back, on balance I feel good about what happened in the confirmation process. I think truth prevailed. So, that’s what I remember. Even though people often come up to me and say how bad it was, I remember the positive things about it.
for 4 years. By now, people know me and I am going to rise or fall based on that. The other thing was the way people responded. Even sometimes without my expecting it. I mean, the Lancet editorial; I had no reason to expect it. And yet it happened [Lancet 1997; 350: 1489]. On balance, I came into this position with a lot of confidence that we can make a difference.
Did you think at some point that you would not be confirmed? I never really doubted it. I was dean at Drew, I was a department chairman at Morehouse, I was president at Meharry for almost 12 years, and I was director of CDC Lancet 1998; 352: 978–81 The Lancet, New York, NY 10010, USA (D H Frankel MD); and 10525 Englishman Drive, Rockville, MD 20852, USA (J Rovner AB)
978
THE LANCET • Vol 352 • September 19, 1998
INTERVIEW
There’s a tremendous opportunity here. The American people still take very seriously the best available science. It may not always be politically popular. But I think that you must keep basing your statements on two things—the best available science and a sensitivity to the concerns of the American people. That’s my goal. The needle-exchange programme, for example. The science is there—I don’t think there is any question about it. That’s why the American Medical Association, the National Institutes of Health Consensus Conference, the Institute of Medicine, former Surgeon General Koop, former Secretary of Health and Human Services Louis Sullivan, and different administrations have come out and said that these programmes work. However, I have never made a speech about needle exchange when I didn’t say that I understand the concerns of people about what message we are sending to our young people. We are not saying it’s okay to do drugs. We never would say that. We are saying that we want to stop this deadly HIV virus.
The USA is enjoying prosperity right now. But the gap between rich and poor is growing. Economic and political issues always influence public health, especially in poor communities. You are “only” a public-health official. What can the Surgeon General do? I think it’s a problem that we have to come at from many different angles, and my angle is public health. And when we say that we are committed to eliminating this disparity in health among racial and ethnic groups, we point to problems like immunisation, infant mortality, diabetes, cardiovascular disease, HIV/AIDS. We know that, in order to achieve this, it’s going to take more than the health-care system. It’s going to take change in the environment, change in the way people behave, and so we are going to need some partnerships. You put all those partnerships together and the impact that they have on communities is one that deals with socioeconomic status too. At CDC, when I was director, one of the things we did as a part of the empowerment zone was to develop a programme to train people who have been on welfare to be community health workers—to go into homes and identify allergens for asthma, to educate parents about how to get rid of those risk factors for their children, to go into schools and talk with teachers. I think we created a model of what could be done. There is a strong tradition of Surgeons General speaking out on some issues that sometimes the President cannot. Elders was fired for speaking out on a public-health matter. Do you think that her being fired will inhibit Surgeons General for years to come? I don’t think so. Different people have different styles, and Elders had her style. I am somebody who has had to work with the constituency of students, faculty, boards of trustees, alumni, community—balancing a lot of interests and working with a lot of different groups. So my style is different, if you will, in how I approach things. Needle exchange is an obvious example. My goal is just to say look, this is what the science says about this issue and this is why we think it’s important. And yet at the same time, I take the time to say we are sensitive to others’ concerns. It’s just my style.
THE LANCET • Vol 352 • September 19, 1998
Do you think there are issues over which you feel you would need to resign, or do you see yourself as being more of a consensus builder? I think consensus building is one of my strengths. I have had to build consensus to be successful, and get things done. Getting the city hospital in Nashville to come together with Meharry Medical College after 100 years required a lot of consensus building, a lot of getting to business—people wouldn’t have supported that before. So obviously I view that as one of the strategies for moving forward. I am willing to be fired, if I have to be fired. In order to tell the American people the truth based on the best available science, I am willing to be fired. We’ve been talking around the needle-exchange issue. What exactly was your role and how disappointed were you in the President’s decision? Well as you all know, I have been involved with this issue since I went to CDC in 1993 when the report was just coming in from the University of California at San Francisco [Lurie P, Reingold A, Bowser B, et al. The public health impact of needle exchange programs in the US and abroad. San Francisco (CA): University of California, 1993]. In fact, President Bush, with the leadership of Sullivan, who commissioned that study, wanted to find out what impact the needle-exchange programmes were having. But the politics changed. So by the time the report came in, I don’t think anybody was ready to deal with it. My job was to transmit the report to the Department of Health and Human Services and this is what we did—and we recommended that it actually did show that needle-exchange programmes reduce the 979
INTERVIEW
spread of HIV. But here things also have to be dealt with politically. Over the years, I have continued to pursue the science by asking the question: do needle-exchange programmes increase drug use in communities? As the science came in, it seemed to state clearly that although these programmes could reduce the spread of HIV, they do not increase drug use. And not only that, but many of the needle-exchange programmes were very successful in getting people into treatment. It also serves to dramatise the fact that one of the major problems we have in this country is that we don’t provide enough treatment opportunities. So, those are the three messages that I think came out of that review and that’s what we brought forward. And you have to admit that the administration did allow us to bring that forward. I mean, we very clearly said what the science showed. Then the administration made a decision that it had a right to make. We are not ready yet to use federal funds to support this programme. Well, that’s not my job. My job is not to decide how federal funds are used. My job is to advise them, in terms of the science, what can be done. And, I try to make it very clear that people who had devoted resources to needleexchange programmes were making a very positive difference. I said I was disappointed in the decision because obviously I wanted to see more of these programmes going forward and I knew that federal funds could expedite that. But I also understood that the Congress was not necessarily ready for that message. And as you know, within 2 weeks the House of Representatives passed legislation permanently banning the use of federal funds for needle-exchange programmes [Lancet 1998; 351: 1415].
You mentioned the controversy over the perinatal HIV transmission study in Africa. What role should US public-health agencies have in global health? There are two roles that are very important. First is the humanitarian role. Surgeon General Shealy in 1951, when he was president of the World Health Assembly, said that the world cannot exist half sick and half well. I agree. That’s the humanitarian perspective. We want a world in which everybody has the opportunity for good health. Second, you can no longer separate the health of the American people from the health of other people in the world. Public health is global, not only because infectious diseases can move across borders—last year, 40% of the new tuberculosis cases in the USA came from outside of the country. If there is an Ebola outbreak in Zaire, as there was when I was the director of CDC, we must send a team there because we want to stop that epidemic because it could become a pandemic. If we had stopped HIV when it started, if we had known it when it started, we could have prevented perhaps one of the worst pandemics that we have ever seen. So the earlier we identify and stop any infectious-disease outbreaks, the better it is for the people in this country and all over the world. We are a global community. Even things like the environment, tobacco, and violence have global implications. So it’s not entirely altruistic Right, not entirely altruistic. Good way to put it. 980
How do you balance the need to devote resources to fighting emerging infectious diseases against the need to address some of the behavioural problems that cause disease? Which is more important? Clearly, behavioural problems are becoming more important. Even with infectious diseases, I think the major risk factors today may well be behavioural: the way we travel, whether or not we wash our hands before handling food, sexual behaviour, invading the rainforest, crowding in homeless shelters. Our biggest problem today is human behaviour, not microbial behaviour. Even with microbial resistance, in some ways, the major factors are human behaviour— somebody is given penicillin for 2 weeks for strep throat and stops when he feels better, or when parents demand an antibiotic to treat their child’s virus. You can no longer separate microbial behaviour from human behaviour. They go together. Does the perception that we have a highly advanced, “almighty” medical ability sometimes influence behaviour and hinder prevention? For example, AIDS researchers worry that kids now think AIDS is curable and they don’t need to use condoms. We put absolutely too much emphasis on treatment and too little on prevention. And you look at our budget—a trillion dollars a year we spend in our health system and 1% of that is for population-based prevention. We depend upon biotechnology. We believe that we can solve anything with it. And it’s just not true and it becomes less true everyday that we live. Do you think it becomes even more difficult to redistribute funds to prevention when the biotech industry not only holds out not only a promise of health but also a great financial and economic promise? The industry does have a lot of clout in Washington. There is a lot of big business in health these days and it’s growing and it employs a lot of people. There is a lot to be said for that. So, prevention is not as rewarding as treatment and that’s one of the real problems. Maybe there is some way to change that, maybe there is some way to make prevention more rewarding. We’ve got to figure out something that would shift the emphasis away from treatment because everybody is concerned about cost. We’ve tried managed care and several other things and we still haven’t been able to get this under control. The cost of health care is still going up at twice the rate of inflation. By 2007, we will be spending US$2 trillion a year. But the problem that is difficult to control, as you imply, is the fact there are a lot of people benefiting from this increase in cost. Do you favour reporting names and contact tracing for HIV infection? I believe that we have to move to a system of reporting HIV that would allow us to identify people as early as possible after they are infected. You see, we have come to the point in our technology, if you will, whereby it’s as important to report HIV as it is to report AIDS, because the sooner we identify people and treat them, the better the prognosis. That’s one thing. But also, the more likely it is that we can reduce the spread of the virus. So for many reasons, I think it is time for us to move forward. I agree with people who are concerned about
THE LANCET • Vol 352 • September 19, 1998
INTERVIEW
AP
Because of recent events in Hong Kong, there were great fears of a flu pandemic this year. Do you think we are prepared? I would be wrong to sit here and say that we are prepared. There is so much of the unexpected and the unknown in any flu outbreak in the nature of that virus. I think we are getting prepared. We have acknowledged that we are not as prepared as we would like to be and as we should be. So, we are moving forward to becoming optimally prepared, not totally prepared.
confidentiality and about whether in fact people who are identified as being HIV positive will suffer some consequences. And therefore I think the government has to make the commitment to protect those people. We haven’t done that yet, but I think that’s what we have to do. We have to be willing to stand behind the programme, similar to what we have done with vaccine safety. The government set up a trust fund to protect people against vaccine injuries, and I think it’s going to be just as important to protect people who have HIV.
But Congress almost let the vaccine trust fund expire. The vaccine trust fund has almost a billion dollars! We do need some commitment at this level, or maybe even higher than this level, because we’re talking about Congress. But we do need HIV reporting. People can argue on name versus other forms of identifiers. Obviously, name reporting gives us more opportunities to intervene. I think that’s where we are with this epidemic. We need to be able to intervene, to help people, and to take whatever steps are necessary to minimise the risk of spread, and to get people in treatment as early as possible. So you are in favour of setting up a trust fund to help protect the process of HIV names reporting? We ought to be willing to make that investment.
THE LANCET • Vol 352 • September 19, 1998
Are we totally prepared for bioterrorism? No. That’s another example of an unknown. But I think you can be much better prepared than we have been in the past. I think you can be optimally prepared. And that’s what we are moving toward.
As you know, the recent Morbidity and Mortality Weekly Report editorial that accompanied a report on rising suicide rates in American youths did not even discuss gun control as a public-health intervention [MMWR Morb Mortal Wkly Rep 1998; 47: 193–96]. In 1995, The Lancet [346: 563] first reported that the gun lobby was trying to eliminate funding for CDC's Center for Injury Prevention because of what they viewed as anti-gun research. Has this kind of influence weakened the CDC's ability to speak out, not only on gun control, but on other controversial issues? Well, let me just say that whenever efforts are made to suppress science, we weaken the public-health infrastructure. We in public health are not politicians, so it’s not about gun control. It’s about being able to share information based on science. Do you think it would be impossible for the US Surgeon General to come out strongly in favour of gun control in America? No, not impossible, not impossible. But, again, my role in that would be to bring the best science to bear and my role would not be to deal with legislation. I think it is dangerous when we adopt political agendas at this level to the extent that people question whether it clouds our science. I don’t want that to happen. You have to be careful not to participate in anybody’s political agenda.
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