Interview: David Satcher

David Satcher began his career as a medical geneticist. In 1972, he helped develop the King-Drew Sickle-Cell Research Center in Los Angeles and served as its director for 6 years. In addition to his abilities as a researcher and physician, Dr. Satcher began to distinguish himself as a gifted leader and administrator in a succession of positions, leading in 1982 to the Presidency of Meharry Medical College in Nashville. In 1993, when Dr. Satcher was appointed director of the Centers for Disease Control and Prevention (CDC), he became one of the most visible and important health scientists in the world. In this interview, Dr. Satcher talks about the responsibilities of the CDC and explains how a childhood experience inspired his interest in medicine and his continuing commitment to community service.

Dr. Satcher, you started your career in the field of genetics, specifically cytogenetics. Could you explain what cytogenetics is and what its medical significance is?

I was actually in the M.D.-Ph.D. Program at Case Western Reserve School of Medicine and my Ph.D. was in cytogenetics. Cytogenetics is the study of chromosomes located in cells. I studied the effects that X-radiation and radioactive iodine, I-131, had on chromosomes and was able to show a linear relationship between radiation dosage-and, to a certain extent, I-131 dosage-and chromosome damage. That was some of the earlier work looking directly at the impact of radiation on chromosomes.

Much of your early work focused on sickle-cell disease. What did you do, and what accomplishments were especially satisfying?

I directed one of the ten national sickle-cell research centers starting back in 1972. The center I directed, the King-Drew Sickle-Cell Research Center, at the King-Drew Medical Center in Los Angeles, emphasized community education, early diagnosis, screening, and counseling programs as well as treatment. I think we made major contributions in all those areas.

What is the objective of screening? How is it done? And what role do counselors play?

That's a very important issue. In the absence of community education, screening for sickle-cell disease can be a problem. The sickle-cell gene is recessive, which means that a person can be a carrier—have "sickle-cell trait"—but not be affected with the disease. Because communities didn't understand that in the early days of screening programs, there were laws saying that people with sickle-cell trait couldn't go to public schools because it was thought to be contagious. This is one of the best examples of what's necessary if you're going to develop a mass screening program. We don't recommend mass screening, but if you are going to do it, you have to make sure you have the education first so that you are prepared to deal with the results. Although the cause is not genetic, we have a similar problem right now with HIV and AIDS. You might ask why only 15% of the people in this country have been tested for HIV. Part of the answer is that people are afraid to find out the results. Similarly, if you don't have the appropriate support mechanisms in place, genetic screening programs can do more harm than good. You also have to have trained people other than geneticists, for example physician's assistants and nurse practitioners, to do genetic counseling. That is happening now, all over the country.

You mentioned that at Case Western Reserve you earned dual medical and Ph.D. degrees. Why did you select such a tough course of study, and how does one actually go about an M.D.-Ph.D.?

Let me first answer the question, "Why?" When I came to Morehouse College here in Atlanta in 1959, my goal was to do premedicine and then go to medical school to be a physician. When I was at Morehouse, I became interested in research. Some of my professors supported me, and in addition to working and being a preceptor in the laboratory, I actually got involved in doing research. By the time I graduated from Morehouse, I thought maybe I could make a contribution in the area of research since I really enjoyed it. So I went to Case Western as part of the program where you get both the M.D. and the Ph.D. It took 7 years, but it was enjoyable. I attribute a lot of my success to the fact that I have been able to relate to the basic scientist as well as to the physician.

It sounds like a good case for getting undergraduates into the laboratory and involved in research.

There's something about research that provides a certain amount of discipline and a certain amount of vision; it allows you to create.

So when you started as an undergrad at Morehouse, you already wanted to become a physician. How did you decide that?

That's an interesting story. I grew up in Anniston, Alabama. Neither of my parents had finished elementary school. When I was 2 years old, I came down with a severe case of pertussis, or whooping cough, and it led to pneumonia. I was severely ill. The situation was such that we couldn't go to the hospital, but my parents were able to get Dr. Jackson, the only black physician in Anniston at the time, to come out to the farm where we lived and check on me. He came on one of his off days and spent almost the whole day there working with me and my parents. When he got ready to leave, he did not want to get my parents' hopes up yet, so he told them I probably wouldn't live out the week. But he did take the time to show my mother how to keep my chest clear and my temperature down. My mother worked very hard, and I pulled through. And my mother told me that story from the time I was old enough to understand words. By the time I was 8 years old, I was already telling people that I was going to be a doctor, like Dr. Jackson. All through elementary school and middle school and high school, I had this drive: I'm going to be a physician. At that time, I was going to come back to Anniston and be a family doctor. As time went on, my vision grew and I realized there were a lot of Anniston, Alabamas, in the world, and that I could probably contribute to a lot of them. That's how it started. And that motivation still drives me.

As your vision grew, you made the transition to health science administration at some point. What motivated that?

It really started back when I went out to Los Angeles to King-Drew in 1972. That was a fairly new institution, one that King Hospital had just opened three months earlier, and they were developing the school. I pulled people together from throughout the institution—basic scientists as well as clinicians—to get our first major grant for the Sickle-Cell Research Center. Within a few months, I was asked to become director of the center, which meant that I had a major administrative responsibility, not just a scientific or medical one. I had to make the team go. I guess I did a good job because people kept asking me to do more things administratively. When I was asked to be the president of Meharry Medical College, I didn't want to be a college president. But after I visited Meharry and learned that this institution had sent more of its graduates to serve in inner-city communities than any other medical school in the country, I thought I could make a difference. So I finally said, "Yes." I ended up spending 12 years there.

Then you resigned to become director of the CDC. Was that a hard decision?

It was. I was really not ready to leave Meharry. I struggled with it and decided to do it.

Tell us a little bit about the CDC.

It's interesting how it came to be. During World War II malaria was a major cause of death for American troops, so the public health service decided to put together a program to teach our troops to combat malaria, how to rid the swamps of the mosquitoes that were causing the malaria. They put this program in the south, of course, where there are more swamps. When the war ended, the decision was made to continue a Communicable Disease Control Center in Atlanta. So in 1946, we became the CDC and have been here in Atlanta ever since. We are the nation's prevention agency. Highlights of the CDC's 40-year history include things like eradicating smallpox in the world, working with Legionnaire's disease, working to eradicate polio. We haven't had a case of wild-virus polio in this country since 1979, and we haven't had a case in the whole Western Hemisphere, including Latin America, since 1991. We believe that we can eradicate polio in the world by the year 2000. Those are just some examples.

In recent years, we've gotten much more involved in the prevention of chronic diseases, such as heart disease and cancer. Our newest center deals with injury control, things like automobile accidents, and we've made a lot of progress there. HIV/AIDS and violence are probably our toughest two problems right now.

We have about 6800 employees. About 4000 of them are here in Atlanta, the rest scattered throughout the country and throughout the world. Our budget is about $2.5 billion a year. And we have seven different centers. The CDC is known all over the world. People often look to us before they look to the World Health Organization to help with epidemics, such as the recent plague in India.

Is it becoming increasingly important for the CDC to have a global perspective?

It is, yes. We view health as a global issue. A lot of things have helped us realize it but nothing more than emerging infections. During the last 15 years or so, we've had several new infections, like HIV/AIDS, Lyme disease, Legionnaire's disease, and Ebola fever. In addition, we've had reemerging or resurgent infections like tuberculosis, which we thought we had essentially gotten rid of. About 30% of the new cases of TB in this country since 1985 have come from people traveling, and immigrating. HIV/AIDS probably started on another continent. Ebola fever was actually transmitted to this country through an experimental monkey in Africa. During the recent plague in India, we were only one plane flight away from that plague. Public health is definitely a global issue.

You mentioned that HIV is one of the biggest problems at the CDC now. What role did the CDC play in recognizing AIDS and the viral cause of the disease?

When the five original cases in this country were discovered in San Francisco and Los Angeles, the CDC was called right away. We sent public health advisors to the scene. We got blood samples. We were able to determine after a period of time that the cause was a virus that was being transmitted through the blood, through sexual relations, or other body fluid transmission. The CDC has been involved for the last 13 years, and it accounts for over 25% of our budget now. We have over 1000 employees who work just with HIV/AIDS. Just to show you how serious this problem is, there was a 60% increase in the number of new AIDS cases in the world last year. In this country, we believe we're beginning to make some progress; in the last 2 years, it's been increasing only about 3% annually. We are very cautious about saying this, however, because we want to keep the intensity up until we really have this disease under control. It doesn't look as if we are going to have a cure or even a vaccine soon, which means that we really must do everything we can to prevent the spread of this virus by helping people modify their behavior. And that's our major role right now. We're working with people at every level to try to do that.

The public probably thinks of the CDC mainly in connection with epidemiology and communicable diseases, but you've been advocating greater emphasis on some of its broader charges in terms of the health of the country. I'd like to get your reactions to a few of these broader views of public health—the health impact of smoking, for example. What role does the CDC have there?

Our mission is to promote health and quality of life and to prevent disease. So when we find that something is impacting the health of the American people and the quality of life, we try to find out whether there are ways to prevent it. We have about 2 million deaths in this country every year. About 20% of them are related to smoking, 420,000 deaths a year. That's a lot of deaths. And they represent the most preventable causes of death that we deal with, whether they're from cancer or respiratory disease or heart disease. So the CDC has taken very seriously its responsibility to try to control tobacco usage. Many people don't realize this, but 85% to 90% of the new smokers in this country are teenagers. We have interviewed some of them recently, and a lot of them, at the age of 16, are talking about how they wished they had not started. They wished they could quit because regardless of what some people say, smoking is addictive. So we feel that smoking is clearly a public health problem.

The same thing applies to violence. It is a little more difficult to make that argument to some people. There are people who argue that violence is a criminal justice problem: You just put the criminals in jail, and you won't have a problem. There are people who argue on the other side that violence is a social problem, that it's due to unemployment, poverty, and racism. And we don't disagree with any of that. We believe that violence is a criminal justice problem, and we believe that criminals have to be dealt with. We believe that violence is a social problem, that we must continue to improve the social environment where people live and work and grow. When we say it is a public health problem, we're saying that we believe that we can identify the risk factors for violence, that we can develop intervention strategies and decrease the rate of violence. In the African-American population, homicide is the leading cause of death in men and women between the ages of 15 and 34. So right now, the major problem of violence is with young people, the same group of people who are starting to smoke, the same group of people who are at risk from their sexual behavior. So it's very clear that we need to target teenagers more in this society.

What role is the CDC playing in women's health issues?

Throughout the Department of Health & Human Services—which includes the CDC, the NIH, and other agencies—we've acknowledged that women's health has been neglected in many ways. A lot of clinical trials have not included women. A lot of the research has targeted men. There are a lot of areas for prevention that have just not targeted women. For example, every year we have about 46,000 women dying from breast cancer and about 6000 dying from cervical cancer. All 6000 of those cervical cancer deaths and about 30% to 40% of the breast cancer deaths are preventable. So we are really intensifying our efforts to do just that. Another good example is the fact that every year about 150,000 women in this country become infertile because they have undiagnosed and untreated sexually transmitted diseases like chlamydia. In states where we've had demonstration projects, the CDC has reduced that problem by 50% in the last 2 years. We would like to expand that program nationwide. We are developing our office of women's health to really begin focusing on those kinds of problems.

Your whole career is marked by public service, and much of that has been community-based. How did that commitment to community develop, and how do we encourage young physicians and others to dedicate time to better the community?

Well, as I mentioned, my motivation for going into medicine in the first place was to make a difference at the community level. I had some good experiences early, even when I was in medical school. We were required to visit patients in their homes during our first year of medical school, to really get to know the situation in the communities. Then when I was an intern and resident at Strong Memorial Hospital in Rochester, New York, I had an opportunity to work at migrant health clinics one night a week and in neighborhood health centers. When I left there I went to Watts and worked for Al Haynes, one of the best epidemiologists in this country, who had a scientific approach to community. His attitude was that you bring the best science to bear on problems in communities. So I was able to bring together strong science and strong commitment to community. And 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 people and to show them that they can make a difference in communities. We grew up thinking that we could change things, we could make things better. A lot of our young people today don't have that attitude. As adults, we've got to give young people meaningful, successful experiences very early so that they can feel the same way.

What other advice can you offer to undergraduates who are considering careers in the health sciences?

In the first place, I think it's important to really examine your motivation for going into health sciences. If you care about people and you're comfortable with science, I don't think there is any better way to go than health sciences. I do think it requires a real commitment to service to people. When you say medicine is a profession, you're not just saying it's good science, you're saying it's good humanity. We have to stress that it is a way to really make a difference in the lives of people, a very positive difference. We want to get young people excited about doing that.

©2005 Pearson Education, Inc., publishing as Benjamin Cummings