A Conversatonwith. . David Satcher

Neil A. Campbell

David Satcher began his about genetic factors in such conditions as heart career as a medical geneti- disease and cancer and even mental illness? cist. In 1972, he helped de- Satcher: I think the future of medicine is greatly tied .? velop the King-Drew Sick- up with medical genetics. Every day we find new f le-Cell Research Center in genes that cause various problems, which means that U Los Angeles and served as in time we will have genetic solutions for those Downloaded from http://online.ucpress.edu/abt/article-pdf/58/6/353/47690/4450176.pdf by guest on 25 September 2021 _ its directorfor six years. In problems. For example, recently we've had reports out _ addition to his abilities as a of San Francisco about the ability to genetically make researcher and physician, cells that could resist the AIDS virus. The implications _. Dr. Satcher began to dis- of that are tremendous. And new genetic information tinguish himself as a gifted and developing technology will also have an impact leader and administrator on sickle-cell disease, diabetes, and other conditions. in a succession of posi- tions, leading in 1982 to Campbell: Speaking of sickle-cell disease, much of the Presidency of in Nashville. In your early work was in that area. What did you do, 1993, when Dr. Satcher was appointed director of the and what accomplishments were especially satisfy- Centers for Disease Control and Prevention (CDC), he ing? becameone of the most visible and important health scien- Satcher: I directed one of the 10 national sickle-cell tists in the world. In this interview, Dr. Satcher talks about research centers starting back in 1972. The center I the responsibilities of the CDC and explains how a child- directed, the King-Drew Sickle-Cell Research Center, hood experience inspired his interest in medicine and his at the King-Drew Medical Center in Los Angeles, continuing commitment to community service. emphasized community education, early diagnosis, screening, and counseling programs as well as treat- ment. I think we made major contributions in all those Campbell: Dr. Satcher, you started your career in the areas. field of genetics, specifically cytogenetics. Could you explain what cytogenetics is and what its medical significance is? Campbell: What exactly happens in sickle-cell dis- Satcher: I was actually in the M.D.-Ph.D. Program at ease, and what's the genetic basis? Case Western Reserve School of Medicine and my Satcher: The genetic basis is interesting: The single Ph.D. was in cytogenetics. Cytogenetics is the study of amino acid valine replacing glutamic acid in the chromosomes located in cells. I studied the effects that hemoglobin molecule is enough to create the sickling. X-radiation and radioactive iodine, 1-131, had on chro- This makes the hemoglobin molecule more rigid, so mosomes and was able to show a linear relationship the blood cells tend to clump up in the small blood between radiation dosage-and, to a certain extent, vessels, leading to severe pain. The immune system is 1-131 dosage-and chromosome damage. That was also affected, so that sickle-cell patients are not as some of the earlier work looking directly at the impact capable of fighting off infectious diseases. For a long of radiation on chromosomes. time, many sickle-cell patients died early in life from pneumonia and other infections. We've made a lot of progress in the development of the pneumococcal Campbell: More broadly, how do you see the future vaccines and the early recognition and treatment of of medical genetics, especially as we learn more infections. There are a lot of sickle-cell patients who now not only live to adulthood but live to be 50, 60 and 70 years of age. That was not true 20 or 30 years Neil A. Campbell is a VisitingScholar in the Department of ago. And in the area of medical genetics, I think we're Plant Sciences at the Universityof California, Riverside, CA 92521. moving toward a significant impact on sickle-cell disease, probably even a cure.

A CONVERSATION WITH ... 353 Campbell: You mentioned screening and counseling. Campbell: So when you started as an undergrad at What is the objective of screening? How is it done? Morehouse, you already wanted to become a physi- And what role do counselors play? cian. How did you decide that? Satcher:That's a very importantissue. In the absence Satcher: That's an interesting story. I grew up in of community education, screening for sickle-cell dis- Anniston, Alabama. Neither of my parents had fin- ease can be a problem.The sickle-cellgene is recessive, ished elementary school. When I was 2 years old, I which means that a person can be a carrier-have came down with a severe case of pertussis or whoop- "sickle-cell trait"-but not be affected with the dis- ing cough and it led to pneumonia. I was severely ill. ease. Because communities didn't understand that in The situation was such that we couldn't go to the the early days of screening programs,there were laws hospital, but my parents were able to get Dr. Jackson, saying that people with sickle-cell trait couldn't go to the only black physician in Anniston at the time, to public schools because it was thought to be conta- come out to the farm where we lived and check on me. gious. This is one of the best examples of what's He came on one of his days off and spent almost the necessary if you're going to develop a mass screening whole day there working with me and my parents. program.We don't recommendmass screening,but if When he got ready to leave, he didn't want to get my you are going to do it, you have to make sure you have parents' hopes up yet, so he told them I probably the education first so that you are prepared to deal wouldn't live out the week. But he did take the time to Downloaded from http://online.ucpress.edu/abt/article-pdf/58/6/353/47690/4450176.pdf by guest on 25 September 2021 with the results. Although the cause is not genetic, we show my mother how to keep my chest clear and my have a similar problem right now with HIV/AlDS. temperaturedown. My mother worked very hard and You might ask why only 15% of the people in this I pulled through. And my mother told me that story country have been tested for HIV/AIDS. Part of the from the time I was old enough to understandwords. answer is that people are afraid to find out the results. By the time I was 8 years old, I was already telling Similarly, if you don't have the appropriatesupport people that I was going to be a doctor,like Dr. Jackson. mechanisms in place, genetic screening programs can All through elementaryschool and middle school and do more harm than good. You also have to have high school, I had this drive: I'm going to be a trained people other than geneticists, for example physician. At that time, I was going to come back to physician's assistants and nurse practitioners,to do Anniston and be a family doctor. As time went on, my genetic counseling. That is happening now, all over vision grew and I realized there were a lot of Annis- the country. ton, Alabamasin the world, and that I could probably contributeto a lot of them. That's how it started. And Campbell: You mentioned that at Case Western that motivation still drives me. Reserve you earned dual medical and Ph.D. degrees. Why did select such a tough course of study, and how does one actually go about an M.D.-Ph.D.? Campbell: As your vision grew, you made the tran- Satcher: Let me first answer the question, "Why?" sition to health science administration at some point. When I came to here in in What motivated that? 1959, my goal was to do premedicine and then go to Satcher:It really started back when I went out to Los medical school to be a physician. At Morehouse, I Angeles to King-Drew in 1972. That was a fairly new became interested in research.Some of my professors institution, one that King Hospital had just opened supported me, and in addition to working and being a three months earlier, and they were developing the preceptorin the laboratory,I actually got involved in school. I pulled people together from throughout the doing research. By the time I graduated from More- institution-basic scientists as well as clinicians-to house, I thought maybe I could make a contributionin get our first major grant for the sickle-cell research the area of researchsince I really enjoyed it. So I went center. Within a few months, I was asked to become to Case Western,where you get both the M.D. and the directorof the center, which meant that I had a major Ph.D. It took seven years, but it was enjoyable. I administrative responsibility, not just a scientific or attributea lot of my success to the fact that I have been medical one. I had to make the team go. I guess I did able to relate to the basic scientist as well as the a good job because people kept asking me to do more physician. things administratively.At one point, I decided that I needed some more trainingin that area so I spent two years at UCLA as a JohnsonClinical Scholar, studying Campbell: It sounds like a good case for getting planning and evaluation. Then I came back and de- undergraduates into the laboratory and involved in veloped the Department of Family and Community research. Medicine at King-Drew and even served as acting Satcher:There's something about research that pro- dean from 1977 through 1979. Then I left California vides a certain amount of discipline and a certain and came back here to Atlanta to the School of amount of vision; it allows you to create. Medicine at Morehouse College. When I was asked to

354 THEAMERICAN BIOLOGY TEACHER, VOLUME 58, NO. 6, SEPTEMBER1996 be the president of MeharryMedical College, I didn't Campbell: Is it becoming increasingly important for want to be a college president. But after I visited the CDC to have a global perspective? Meharry and learned that this institution had sent Satcher:It is, yes. We view health as a global issue. A more of its graduates to serve in inner-city communi- lot of things have helped us realize it, but nothing ties than any other medical school in the country, I more than emerging infections. During the last 15 thought I could make a difference. So I finally said, years or so, we've had several new infections, like "Yes."I ended up spending 12 years there. HIV/AIDS, Lyme disease, Legionnaire'sdisease, and Ebola fever. In addition, we've had reemerging or resurgent infections like tuberculosis, which we Campbell: Then you resigned to become director of thought we had essentially gotten rid of. About 30%of the CDC. Was that a hard decision? the new cases of TB in this country since 1985 have Satcher:It was. I was really not ready to leave Me- come from people traveling, immigration.HIV/AIDS harry. I struggled with it and decided to do it. probably started on another continent. Ebola fever was actually transmitted to this country through an Campbell: Tell us a little bit about the CDC. experimental monkey in Africa. During the recent Satcher: It's interesting how it came to be. During plague in India, we were only one plane flight away World War II, malariawas a majorcause of death for from that plague. Public Health is definitely a global Downloaded from http://online.ucpress.edu/abt/article-pdf/58/6/353/47690/4450176.pdf by guest on 25 September 2021 American troops, so the public health service decided issue. to put together a program to teach our troops to combat malaria-how to rid the swamps of the mos- Campbell: You mentioned that HIV is one of the quitoes that were causing the malaria. They put this biggest problems at the CDC now. What role did the programin the south, of course, where there are more CDC play in recognizing AIDS and the viral cause of swamps. When the war ended, the decision was made the disease? to continue a Communicable Disease Control Center Satcher:When the five original cases in this country in Atlanta. So in 1946, we became the CDC and have were discovered in San Franciscoand Los Angeles, the been here in Atlanta ever since. We are the nation's CDC was called right away. We sent public health prevention agency. Highlights of the CDC's 40-year advisors to the scene. We got blood samples. We were include things like eradicatingsmallpox in the history able to determine after a period of time that the cause with Legionnaire'sdisease, and work- world, working was a virus that was being transmitted through the to eradicate polio. We haven't had a case of ing blood, through sexual relations, or other body fluid wild-virus polio in this country since 1979, and there transmission.The CDC has been involved for the last hasn't been a case in the whole Western Hemisphere, 13 years, and it accounts for over 25% of our budget including Latin America, since 1991. We believe that now. We have over 1,000 employees who work just we can eradicate polio in the world by the year 2000. with HIV/AIDS. Just to show you how serious this Those are just some examples. problem is, there was a 60%increase in the number of In recent years, we've gotten much more involved new AIDS cases in the world last year. In this country, in the of chronic diseases, such as heart prevention we believe we're beginning to make some progress;in and cancer.Our newest centerdeals with injury disease the last two years, it's been increasing only about 3% like automobile accidents-and we've control-things annually. We are very cautious about saying this, there. HIV/AIDS and violence made a lot of progress however, because we want to keep the intensity up two now. are probably our toughest problems right until we really have this disease under control. It We about About 4,000 of have 6,800 employees. doesn't look as if we are going to have a cure or even here in the rest scatteredthroughout them are Atlanta, a vaccine soon, which means that we really must do and the world. Our budget is the country throughout everything we can to prevent the spread of this virus billion a And we have seven different about $2.5 year. by helping people modify their behavior. And that's We have a Center for Prevention, a centers. Injury our majorrole right now. We're working with people for Chronic Disease Prevention, and a Center Center at every level to try to do that. for Health Statistics. The largest and probably the oldest center is the National Center for Infectious Diseases. We have a Center for EnvironmentalHealth, Campbell: You've written that in designing this a Center on Occupational Safety & Health, and a educational strategy for AIDS, it is important for the Center for Prevention Services. We also do a lot with CDC to follow the science. What do you mean by the environmentnow that we didn't do in the past. So that? it's quite an institution.The CDC is known all over the Satcher:There's a lot of politics that surrounds this world. People often look to us before they look to the problem-differing religious attitudes and cultural World Health Organization to help with epidemics, beliefs. I believe it was Arthur Ashe, speaking before such as the recent plague in India. the United Nations in 1992, who asked what we are

A CONVERSATIONWITH .. 355 going to tell our children when they ask us why we responsibility to try to control tobacco usage. Many didn't give our best efforts to solving this problem; people don't realize this, but 85%to 90% of the new why we allowed political, religious, and cultural dif- smokers in this country are teenagers. We have inter- ferences to prevent us from doing that. At the CDC, viewed some of them recently,and a lot of them, at the it's important for us to be the nation's science agency age of 16, are talking about how they wished they had when it comes to preventing this problem.When I say not started. They wished they could quit because science, I don't mean just laboratory science. I also regardless of what some people say, smoking is ad- mean behavioralscience. If we know that something is dictive. So we feel that smoking is clearly a public effective in preventing the spread of this virus, then it health problem. is our responsibility to develop programs to imple- The same thing applies to violence. It is a little more ment that effectiveness.We have school-based educa- difficultto make that argument to some people. There tion programs for teenagers in all 50 states with the are people who argue that violence is a criminaljustice main goal being to make sure they understand how problem: You just put the criminals in jail, and you the virus is spread, how deadly this virus is, and the won't have a problem.There are people who argue on importanceof abstinence.But the science tells us that the other side that violence is a social problem,that it's by the time students graduate from high school, 70% due to unemployment, poverty and racism. And we

of them are already sexually active. We can't ignore don't disagree with any of that. We believe that Downloaded from http://online.ucpress.edu/abt/article-pdf/58/6/353/47690/4450176.pdf by guest on 25 September 2021 that science. So we also have to tell young people who violence is a criminal justice problem and we believe are sexually active how to prevent the spread of this that criminals have to be dealt with. We believe that disease. It is our responsibilityto talk about the correct violence is a social problem, that we must continue to and consistent use of condoms for people who are improve the social environmentwhere people live and sexually active. We've been following both ap- work and grow. When we say it is a public health proaches. We have also worked very hard to try to problem, we're saying that we believe that we can make sure that the blood supply in this countryis safe. identify the risk factors for violence, that we can And I think we've gotten there for the most part. All of develop intervention strategies and decrease the rate these things are based on solid science all the way of violence. We are busy evaluating differentinterven- from epidemiology to laboratory science, to surveil- tion strategies in differentcommunities that we think lance. But also behavioral science. can have a significant impact upon this public health problem. Right now, the majorproblem of violence is with young people, 15 to 19 years of age and maybe 20 Campbell: Why do you think it's been such a chal- to 24. In the rest of the population, the incidence of lenge to develop a vaccine for HIV? violence is going down. But it's going up among 15- to Satcher:I think it's because this is a very smart virus. 19-year-olds,the same group of people who are start- It has the ability to adapt and change very rapidly. We ing to smoke, the same group of people who are at risk know a lot about this virus, probably more than we from their sexual behavior. So it's very clear that we have ever known about any virus. But we can't stop it need to target teenagers more in this society. yet with a vaccine and cure. We will-but not yet.

Campbell: For that age group, is violence one of the Campbell: The public probably thinks of CDC leading causes of death? mainly in connection with epidemiology and com- Satcher:No question about it. In the African-American municable diseases, but you've been advocating population, homicide is the leading cause of death in greater emphasis on some of its broader charges in men and women between the ages of 15 and 34. But terms of the health of the country. I'd like to get your for the society as a whole, homicide is a leading cause reactions to a few of these broader views of public of years of productive life lost. What that means is that health-the health impact of smoking, for example. we look not only at how many deaths we have but at What role does the CDC have there? what age people die. If we use 65 years of productive Satcher:Our mission is to promote health and quality life as a standard,when somebody dies at 65, you can of life and to disease. So when we find that prevent say they didn't lose any productiveyears. If they die at something is impacting the health of the American 55, they lose 10 years. If they die at 10 years of age, and the of we to find out people quality life, try they lose 55. When we ask, "How do we lose years of there are to it. We have about 2 whether ways prevent potential life?" homicide is in the top three. million deaths in this country every year. About 20% of them are related to smoking: 420,000deaths a year. That's a lot of deaths. And they represent the most Campbell: What role is the CDC playing in women's preventable causes of death that we deal with, health issues? whether they're from cancer or respiratorydisease or Satcher: Throughout the Department of Health & heart disease. So the CDC has taken very seriously its Human Services-which includes the CDC, the NIH,

356 THEAMERICAN BIOLOGY TEACHER, VOLUME 58, NO. 6, SEPTEMBER1996 and other agencies, we've acknowledged that wom- Campbell: The CDC also has an interest in environ- en's health has been neglected in many ways. A lot of mental quality? clinical trials have not included women. A lot of the Satcher: Yes. There are actually two agencies here, research has targeted men. There are a lot of areas for CDC and the Agency for Toxic Substance & Disease prevention that have just not targeted women. For Registry. I am the director of CDC; I am the adminis- example, every year we have about 46,000 women trator of ATSDR. ATSDR was set up by the EPA dying from breast cancer and about 6,000 dying from Superfund Act in the early 1980s specifically to exam- cervical cancer. All 6,000 of those cervical cancer ine environmental hazards in communities that have deaths and about 30% to 40% of the breast cancer Superfund cleanup projects. So that agency does deaths are preventable. So we are really intensifying health assessments in various communities and makes our efforts to do just that. Another good example is the recommendations to the EPA for ways to get rid of the fact that every year about 150,000 women in this hazards. We also have the National Center for Envi- country become infertile because they have undiag- ronmental Health, which deals with things like lead nosed and untreated sexually transmitted diseases toxicity and other environmental hazards. And of like chlamydia. In states where we've had demonstra- course, we also have access to the National Institute of tion projects, the CDC has reduced that problem by Occupational Safety & Health, which looks at work- Downloaded from http://online.ucpress.edu/abt/article-pdf/58/6/353/47690/4450176.pdf by guest on 25 September 2021 50% in the last two years. We would like to expand place hazards. So I would say that CDC is heavily that program nationwide. Another example is domes- involved in environmental issues. tic and workplace violence. Last year the National Institute of Occupational Safety & Health reported that homicide is the leading cause of death for women Campbell: Your whole career is marked by public in the workplace. Some people find that very difficult service, and much of that has been community- to believe, but it's number 1. And we haven't even based. How did that commitment to community begun to deal with domestic violence. These are just develop, and how do we encourage young physi- some examples of areas where we believe the CDC cians and others to dedicate time to better the com- needs to focus more attention. We are developing our munity? office of women's health to really begin focusing on Satcher: Well, as I mentioned, my motivation for going those kinds of problems. into medicine in the first place was to make a differ-

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A CONVERSATION WITH ... 357 ence at the community level. I had some good expe- was a symposium going on. Does the CDC train riences early, even when I was in medical school. We students and health scientists? were required to visit patients in their homes during Satcher:Sure. We have our own students, of course. our first year of medical school, to really get to know The CDC has trained more epidemiologists than any the situation in the communities. It was dangerous in other program in the world. And they are trained in some cases, but the feeling was, if you're going to be a the field. They spend about three or four months in the physician, you need to know what is happening to classroom, and then they're sent out to fight epidem- your patients and why. I appreciatethe fact that I went ics, to really learn how to do it on the front line. Then to a medical school that had that commitment. Then they come back and present cases. This morning, it when I was an intern and resident at Strong Memorial was a Legionnaire'sdisease outbreak that took place Hospital in Rochester,New York, I had an opportu- in a hospital. It had infected the cooling tower. They nity to work at migranthealth clinics one night a week had to really researchthat in order to figure out what and in neighborhood health centers. When I left there was going on and to figure out ways to prevent it. I went to Watts and worked for Al Haynes, one of the We bring best epidemiologists in this country, who had a scien- differentstudents here from time to time. In the tific approach to community. His attitude was that summer, high school students, college students, and you bring the best science to bear on problems in graduate students come as interns. One of our goals is Downloaded from http://online.ucpress.edu/abt/article-pdf/58/6/353/47690/4450176.pdf by guest on 25 September 2021 communities. So I was able to bring together strong to get more young people interested in public health, science and strong commitment to community. And so we reach out and bring them in. that's what drives me. I think the way we get young people interested is that we find more mentors, more faculty members, who are willing to go with young Campbell: When I was walking around, I also ex- people and to show them that they can make a plored the photographic archives. difference in communities. One of the real problems Satcher:Let me say something here about the archives. with a lot of young people is that they don't have a lot One of our majorprojects for 1996- our 50th anniver- of hope that they can be successful, for whatever sary-is to develop a CDC museum, something we've reason. We've got to find some way to change these never had. The purpose of the museum will be to tell attitudes the young people have about their futures. the history of the CDC but also to teach public health. We grew up thinking that we could change things, we If you come to the CDC now, unless you are a could make things better. A lot of our young people scientist, there is not a lot to see. We want a museum today don't have that attitude. As adults, we've got to where elementary, junior high, and high school stu- give young people meaningful, successful experiences dents can come and spend hours and learn and get very early so that they can feel the same way. excited about public health as a global problem-what that means and what the history has been, what it Campbell: What other advice can you offer to under- meant to eradicate smallpox, and some of the major graduates who are considering careers in the health events in the CDC's history. sciences? Satcher: In the first place, I think it's important to really examine your motivation for going into health Campbell: How much teaching have you done in sciences. If you care about people and you're comfort- your career, Dr. Satcher? able with science, I don't think there is any better way Satcher:Quite a bit. I started two residency programs to go than health sciences. I do think it requires a real in family practice,and I taught residents and medical commitment to service to people. When you say students at King-Drew.Then at Morehouse,of course, medicine is a profession, you're not just saying it's I taught medical students for three years. I didn't do good science, you're saying it's good humanity. We much teachingat Meharrybecause I was so busy as an have to stress that it is a way to really make a administrator,so I've actually been away from it. But difference in the lives of people, a very positive I do a lot of speaking to general audiences, which is difference.We want to get young people excited about the same thing. My first year here as director of the doing that. CDC I did almost 100 major speeches. That's really teaching, you know, when you try to explain public Campbell: While I was walking around before our health to people, and what we can do together to interview, I noticed all the classrooms and that there prevent diseases.

358 THEAMERICAN BIOLOGY TEACHER, VOLUME 58, NO. 6, SEPTEMBER1996