Extended transcript: Dr. Scott Gottlieb on "Face the Nation," September 19, 2021

The following is an extended transcript of an interview with Dr. Scott Gottlieb that aired on Sunday, September 19, 2021, on "Face the Nation."

MARGARET BRENNAN: So why did you write this book? Who do you want to read it?

DR. SCOTT GOTTLIEB: A lot of the commentary around what happened, what went wrong, I think was very political. It was focused on a lot of the political mistakes that were made. I don't think anyone started to delve into the more systemic problems, more systemic shortcomings, the structural features of government that I think made us excessively vulnerable to the pandemic. And I wanted to start to tell that story. I think if we're going to make sure we're better prepared if this happens again, and this will happen again, we start- we have to start examining, what are the features of government that failed? Why were we made so excessively vulnerable? And there certainly were political shortcomings, but there were a lot of things about the way the agencies were structured, the way the agencies responded, the kind of planning we had done in the past that we thought would better prepare us for this pandemic that weren't up to the task.

MARGARET BRENNAN: So this is something you want public health leaders, lawmakers to learn some lessons from.

DR. GOTTLIEB: Yeah, I think at some point we're going to start to reflect on what went wrong. We're going to put together commissions, put together authoritative groups to try to, you know, come to some consensus about what we need to do differently to better prepare for the future. And I want this book to be part of that dialogue. This was my attempt to, you know, lay out what I think some of the things that left us vulnerable were and how we can start to repair them, how we can start to build better resiliency against these kinds of threats going forward. So I would hope that this book is going to be part of that dialogue.

MARGARET BRENNAN: You have some personal anecdotes in there. In fact, you start the book talking about the attacks on 9/11 and you were a young resident up in New York City. Why did you start there?

DR. GOTTLIEB: Yeah. So I was on elective that month. I remember the day. And so I was sort of swing labor. I was an extra hand. I wasn't assigned to a floor. And I was post-call, so I had come off-call the night before. We saw the first plane hit the World Trade Center and then when the second plane hit, I got called into the hospital. And I spent the day working the floors, mostly trying to discharge patients because we thought that there would be a flood of patients coming into the hospital, so we were trying to clear up beds. And then at night I was assigned to a triage center in- in Chelsea Piers, downtown, near the- near the former World Trade Centers. And when I got there, I walked into a field house and it was a cavernous field house and they had set up, at some point over the course of the day, basically the equivalent of hundreds of hospital beds, but not just staffed hospital beds, but these were surgical beds. They had advanced medical equipment in hundreds of stations. And it was- it was like nothing I've ever seen before or since. So somewhere, you know, around New York City, someone had made a decision that New York needed to be prepared for a mass casualty event, and they had mothballed all the equipment that would be needed to do it, to handle it. And they had mothballed the logistics to set it up within hours. And the reason I told that story was because nothing equivalent really existed here. You know, in New York City, we had the first attack on the World Trade Center. There was a decision made by someone at some point that New York needed to make- prepare certain capacities. What I saw was part of that very clearly. And when COVID came, you know, we had this sort of illusion that we had prepared for a pandemic and that we had certain capacities that had been mothballed and preparations that had been made. But they were ill-suited to the- to the crisis we faced. And even the ones that were sort of appropriately measured to what we were facing weren't ready. A metaphor for it was the masks and the ventilators. We had stockpiled, not enough, obviously, masks and ventilators, and they didn't work. The ones we had didn't work. The masks were expired, the ventilators hadn't been serviced. And that's just sort of a metaphor for the lack of preparation. But, you know, I think we didn't- we didn't really have the foresight to understand that a virus could threaten us in this way.  We had planned for a pandemic flu. I had been part of some of that planning back in 2003 and 2005 when I was at FDA, during my first- my first stint, but we didn't really understand how the planning that we had engaged in for influenza wouldn't be applicable to a coronavirus.

MARGARET BRENNAN: So we prepared for the wrong threat.

DR. GOTTLIEB: We prepared for the wrong threat. But even- even if we had prepared for the right threat, the preparations still weren't adequate. We still didn't have the kinds of capacities we needed to, you know, flip- forward deploy the medical resources that would be required. I think we didn't envision that in a setting of a global crisis, there would be a global run on the supply chains that were needed to properly supply the medical equipment. Just the swabs used to conduct diagnostic tests, we ran out of them. One of the bottlenecks to conducting more diagnostic testing wasn't that we didn't have the PCR machines, the sophisticated machines. It wasn't that we didn't have the labs, we didn't have the swabs to actually collect the samples. So we didn't understand that if you had a global crisis of this magnitude, suddenly the supply chains that we relied on would be pulled on by every country at the same time, and we couldn't rely on them anymore. So what we needed was just a whole different mindset. We needed to build domestic capacity to do the production domestically. We needed to keep the- the apparatus that we thought we would need hot, not just warm. We couldn't just build it and mothball it. We needed to keep it operating. We needed to keep it functional. We needed to have a logistical capability to deploy these tools. We didn't- we didn't have the ability to scale diagnostic testing because we couldn't deploy enough testing centers. We didn't have the ability to mass vaccinate the population because we didn't have any mothballed capacity to set up vaccination sites. And that's what I saw on 9/11. I mean, obviously small microcosm. It was a city. It wasn't across the whole country. I mean, the country wouldn't  have been able to deal with a crisis of that magnitude, but someone had thought about how to build the apparatus and the means to deploy it very quickly for a certain contingency. We didn't do that against a viral contingency, even though we had anticipated and expected that at some point we'd be challenged with a pandemic.

MARGARET BRENNAN: So it's been 18 months now since we were hit with this pandemic. In the book, you write, the next one very well could be a new variant of a bird flu. Are we as vulnerable to that kind of new threat as we were to COVID 19?

DR. GOTTLIEB: I think we're still vulnerable. There's nothing that's really been changed with respect- respect to our posture. I think where we might have less vulnerability is that, you know, fool me once, we're more aware of the threats that could emerge from around the world, we might- we're going to respond more quickly. You know, next time we see an emerging infection, we're not going to wait six weeks or two months to start manufacturing the diagnostic tests. So we're going to make certain decisions up front that could have been made earlier in the setting of COVID, weren't because we didn't properly anticipate the threat that it posed. I think next time, you know, we're going to be more apt to do too much and not too little when something emerges. But in terms of the capacities that we need to respond, I don't know that we're any better in terms of our ability to actually mobilize the sort of manufacturing and the distribution capacity that we're going to need. We don't have the infrastructure to do that. Where we're better probably is that we validated some of the technology that we would use against a new threat. So the idea of fully synthetic vaccines being able to pivot very quickly to a vaccine. A lot of the technologies that were sort of available that allowed us to pivot very quickly to the development of countermeasures in this instance now have been validated. We were at a sort of a technological inflection point in the setting of this pandemic with the technologies we used to develop our vaccines and some of our therapeutics. And now--

MARGARET BRENNAN: That was just luck, is what you're saying.

DR. GOTTLIEB: We were at the cusp of- we were sort of bridging two scientific states. If this had happened four years ago, we would have developed our vaccines the way we traditionally develop vaccines. We would try to grow the virus in cell cultures, the same way the Chinese developed their vaccine. You grow the virus in large quantities in cell cultures, you inactivate it, you cleave off the proteins and you basically put the virus's proteins in a syringe and that serves as the vaccine stock. That's how we make flu vaccine. What we did in this case was we were able to derive vaccine constructs fully synthetically just off the sequence data alone. So if you look at Moderna's vaccine, Pfizer's vaccine, where I serve on the board of directors, even J&J's vaccine and AstraZeneca's vaccine, the constructs were derived from the sequence. They didn't need the live virus, they didn't need to grow the virus. So we were right at that inflection point where that technology was becoming available, and that allowed us to pivot to vaccines very quickly. If this had happened five years from now, that technology probably would have been mainstreamed. And what happened in the setting of the pandemic is we sort of accelerated our way through that technology curve because we developed the vaccines and we deployed them. 380 million Americans have received a vaccine.

MARGARET BRENNAN: So after the 9/11 attacks, we had this wholesale, you know, rejiggering of the U.S. government and you had a 9/11 commission. Do you think in this setting now that that kind of commission is even possible?

DR. GOTTLIEB: I think it's- I think it's necessary. I think we're going to have to do it. I'm--

MARGARET BRENNAN: Politically, is it possible?

DR. GOTTLIEB: It's difficult, you know, and I think it's difficult for a variety of reasons. You know, it's probably, I've asked myself, why haven't we done it yet? I mean, there's been some groups that have come together, you know, The National Academy of Medicine, other groups. The Biden administration put out sort of the blueprint for what a pandemic strategy would look like. My- my assumption is it's too early. You know, we're still- we're still grappling with this pandemic. So I keep telling myself, maybe it's too early and that's why Congress hasn't convened a commission. That's why we don't see a bipartisan group emerging to try to do this work. You've seen some legislation proposed, but nothing that's sort of a grand effort to really come up with a comprehensive approach to how we're going to prepare better for the future. I think the other thing we're going to have to grapple with, it's not just a question of the politics of the moment and the inability to get a consensus around big issues. And that is- that is a problem right now. I think that the public health establishment as a whole has taken a hit in the setting of this pandemic. And this isn't just a sort of Republican, Democrat, conservative, liberal thing. I think that there's a lot of people around the country who feel that the advice they got from public health officials wasn't precise, changed, wasn't- wasn't formulated in a way where it was sort of immutable, wasn't carefully explained, wasn't propagated in a way that it could be assimilated into people's lives. You know, how do I wear a mask? What mask should I wear? When should I wear a mask? When not? And things changed. And so people were confused by it and lost confidence in it. And I think that there's going to be- part of the dialogue we have around how do we prepare better for the next pandemic, I think, unfortunately, is going to also be a discussion of what role should public health agencies and public health officials play and how much should policymakers really be overseeing what they're doing in the setting of a crisis? Should they really be in control? That's going to be a hard discussion because if we're not going to sort of support the primacy of public health and public health officials in the setting of a- of a public health crisis, it's hard- it's hard to start, it's hard to get started. And I think that's going to be the first bridge we need to cross as we step into this.

MARGARET BRENNAN: Well, the elephant in the room with all that politically is also who was president at the time of the pandemic. And I want to come back to that because personality obviously was a factor here. But your broader point is that this is not a book about Donald Trump's leadership. This is a point about the overall health care system in the United States. You say the CDC, which is supposed to be the gold standard public health agency, "doesn't have an operational capability to manage a crisis of this scale." So if the CDC doesn't, who does?

DR. GOTTLIEB: Nobody does. I mean, there was a perception early on in this crisis that the CDC has this, that they would have the capacity to develop a diagnostic test and deploy it and gather the data that we would need and do the analytics to try to gauge, you know, sort of scope out what the contours of the response would be, and they would be able to deploy the diagnostic test and deploy the vaccine and stand up this infrastructure. They're not a logistical organization. CDC has a very retrospective mindset. It's a high-science organization that does deep analytical analysis of data that's oftentimes out of sync to when the decisions need to get made. They're not- they're not the JSOC, they're not the Joint Special Operations Command. They don't surface real time information to- to inform current policy making. 

MARGARET BRENNAN: They're not a quick reaction force.

DR. GOTTLIEB: Right, they'd rather take the data, analyze it for four months and publish it in the Morbidity and Mortality Weekly Report. And the idea that they were going to be able to mass manufacture a diagnostic test and forward deploy it, they clearly- they contaminated their own test. So they- they- they botched the manufacture of their test. But even if they had succeeded, even if they had gotten that test out on time perfectly, what they were going to do- the blueprint was that they would develop tests for the public health labs. Well, the public health labs in this country, there's 100 of them. They can each do about 100 tests a day. So even at full tilt, if everything had gone perfectly, we'd be doing 10,000 tests a day. We needed hundreds of thousands of tests a day. So what had to happen early on was we needed to turn to the commercial manufacturers, like South Korea did, and start mass producing tests. That's--

MARGARET BRENNAN: We needed to turn to private industry earlier in the pandemic.

DR. GOTTLIEB: We needed an all-of-the-above approach. We needed to get the public health labs stood up. We needed to simultaneously get the clinical labs stood up, labs inside hospitals. And we needed to get private manufacturers developing test kits that can go in every commercial lab around the country. That needed to happen in January. Certainly by the end of January, we had enough awareness that this could be a global pandemic, that someone could have hit the red button and said, we need it- an all-of-the-above approach here. But CDC had the ball. CDC was following their standard blueprint. Their blueprint is- could keep up with a slow moving outbreak. It was quasi sufficient in the setting of Zika, which was a slower moving infection. But in a fast moving epidemic like this, it was unmatched. And, you know, in fairness to CDC, there were a lot of policymakers who assumed that they would be able to complete this mission and wrongly assumed what their capabilities were. Now, CDC should have raised their hand and said, we really don't have this. I think--

MARGARET BRENNAN: Why didn't they? Is that a failure of Robert Redfield, the head of the CDC, at the time?

DR. GOTTLIEB: I think it's very difficult for an agency to have this self-awareness that they don't have the capacity to respond the way they're being asked. And I think it's very difficult for an agency to self-organize differently in the setting of a crisis. And- and so that's asking a lot of them. Ultimately, there was a recognition that you needed to marry the sort of scientific capability of government agencies with the logistical capability of something like a FEMA or a DOD. When we created Operation Warp Speed to try to accelerate the development of a vaccine, because that was a marriage between NIH, the scientists, FDA, the regulators, and the Department of Defense. The Department of Defense brought the capability to know how to scale up manufacturing and scale up distribution. We needed to do that at day one. We needed to get FEMA and the DOD engaged with the CDC in trying to organize a national level response, and that- that was a failure of political leadership. I mean, and it was a failure of vision. But, you know, there were a lot of people who were good political leaders who wrongly assumed the CDC had this mission.

MARGARET BRENNAN: So in terms of the American public hearing all these criticisms you're laying out, they're wondering, well has this been fixed yet? When you talk about the CDC, you say they botched the development of a test, they stood in the way of private labs, they applied a flu model, the wrong model, they couldn't imagine looking for asymptomatic spread, they had a lack of data to back up public health decisions. That's a huge indictment. Have any of those things been fixed?

DR. GOTTLIEB: Some of them have been fixed. I mean, I think- I think it's better because there's a recognition of those shortcomings. So those- those statements, I don't think are terribly controversial anymore. I think people, either quietly or overtly, recognize the shortcomings of the agency--

MARGARET BRENNAN: We've heard Dr. Deborah Birx say that on FACE THE NATION, we've heard Matt Pottinger, the former deputy national security adviser, say that on FACE THE NATION. I haven't heard a lot of officials talk about the level of detail you are right now and say, we are still with a real big problem at the CDC.

DR. GOTTLIEB: Well we haven't done anything to create a new capacity. What you're going to need going forward is an organization, if you want to have true pandemic preparedness, if you want to have better infrastructure for dealing with a public health crisis of this magnitude, you're going to need to have an organization that is in the business of serving- surfacing actionable intelligence, has a different mindset around information, doesn't need to be the final definitive answer, but knows how to surface information to policymakers who are making active decisions.

MARGARET BRENNAN: Is this a new agency?

DR. GOTTLIEB: I don't- it could be a new agency, but I think that that would be a mistake. I think the right way to do it probably is to build a capacity inside CDC because if you try to sort of create a new agency, you're going to ignite all kinds of turf wars across Washington. If you try to consolidate agencies, like we did with the Department of Homeland Security, you know, you're stealing other- other agencies' authorities, and that's always difficult. I think this could reside inside CDC, but it needs to be a much different organization. You know, CDC over the years evolved much more towards a disease prevention mission, reducing heart disease, smoking cessation, and away from its core disease control, overseas operations. You know, the- the service that they have, the epidemiological service which goes into hot zones and and, you know, gets samples of viruses and brings them back and studies them and develops countermeasures, that sort of the the heroic part of the agency that's often talked about, movies get made about it. Over time, I think that that has been subordinated to the more policy aspects of the CDC's mission. So I don't know that you sort of fundamentally reform CDC. I think what you try to do is grow up a new capacity inside the organization that has a different culture, different mindset, different resources, different capability. The component that they recently created, where they created this new modeling center inside CDC, a disease- a pandemic modeling center, that could be--

MARGARET BRENNAN: The Biden administration has done this.

DR. GOTTLIEB: --right, by the Biden administration. That could be the kernel that becomes the, you know, the new flower inside CDC. I think that the- the mindset of that organization, the people who are staffing it right now, who come out of a national security world, could bring a new esprit de corps into that organization. And you can grow out this capacity from there, but someone needs to build it.

MARGARET BRENNAN: Well, the Biden administration has asked for $65 billion to strengthen pandemic preparedness. Congress hasn't funded it yet. But--

DR. GOTTLIEB: I don't think this is going to be a money problem. I think people are going to appropriate the funds. I think that it's going to be a strategy problem, and that's really what I try to do here is- is sort of lay out some of the foundation of what went wrong and how we can think of a different strategy. You know, the Biden administration plan that they put forward, it's a high level plan, it has all the right elements, but it's not a plan yet, it's more like a strategic framework for a plan. We still need to decide what that plan is, and there's going to be an intense debate because, you know, people- people's missions are going to be disrupted. You know, CDC, for example, with the diagnostic tests. You know, if we wanted to have the commercial manufacturers early on engaged in developing a diagnostic test, someone had to share the samples, the virus samples, with them. CDC held on to them, wouldn't give them to the commercial manufacturers. Someone needed to create some kind of funding mechanism so the commercial manufacturers had some understanding that they weren't going to just get stuck with the bill. They would have stepped forward. But at some point you needed to fund that. There's no mechanism for that. I mean, BARDA could have done it, but it's not really within BARDA's mandate. They fund very early research. So there was no agency capable of funding the handoff to a commercial manufacturer of a diagnostic test. And I keep coming back to this because a lot of our early problems really flowed from our inability to scale testing. It wasn't just that we couldn't diagnose the infections and tell where the virus was. We couldn't tell where it wasn't. So when we did the '15 Days to Slow the Spread' and the subsequent 30 days to slow the spread, it was basically a national shutdown for 45 days, an extraordinary measure. I mean, a historic decision to shut down most commercial activity in the country. Very clearly, we needed to do that in New York. I mean, New York, the health care system was breached in New York. New York was on the brink of collapse. New Orleans was on the brink of collapse. Boston was on the brink of collapse. Los Angeles had pervasive spread, San Francisco and Seattle. Austin, Texas, didn't have a lot of spread, Jacksonville didn't, Wyoming didn't, but we didn't know. So we shut down the whole country and then when the virus eventually traveled to the Deep South, people down there said, you know what? We're not shutting down now. You told us to do it in the spring and we did, we didn't have to. We're done with shutdowns. And--

MARGARET BRENNAN: And that could have been avoided.

DR. GOTTLIEB: That could have been avoided because if we had a diagnostic test and we knew where the virus was and where it wasn't, we could have targeted the population-wide mitigation just to places where the virus was pervasive and in the places where it wasn't yet pervasive, we could have used testing, tracing, quarantines to try to control the spread. It would have eventually become a confluent epidemic across the whole country, but we could have delayed that. We could have substantially delayed that and we could have preserved the political capital in places where the virus wasn't so that when it got there, they would have still been willing to take the tough decisions to close bars, close restaurants, do all the things that we knew were going to control spread and buy us time until we got to a vaccine. But we basically spent that card right up front. We shut down the whole country and we didn't have to. So not having that diagnostic test, what- set in motion a lot of the challenges that we faced going forward.

MARGARET BRENNAN: You say, "the point isn't that federal health officials were wrong, the point is they were working with faulty tools, faulty data sets." 

DR. GOTTLIEB: Yeah, so--

MARGARET BRENNAN: They didn't know what they didn't know.

DR. GOTTLIEB: They didn't understand that this wasn't spreading like flu. So they didn't have a diagnostic so they said, well we're going to rely on the Influenza-like Illness Surveillance System. This is a surveillance system that was grown up, in part to deal with a pandemic flu, that basically monitors for people presenting to hospitals with flu-like symptoms who are testing negative for flu. But in any given week, 50,000 people present to hospitals with flu-like symptoms and test negative for flu. So you can have tens of thousands of cases hiding in plain sight with the Influenza-like Illness Surveillance System. Plus, this wasn't always presenting like flu, so people were getting symptoms that didn't comport with flu. So if you're just looking for flu symptoms, you might not see coronavirus spreading. So they were very confident early on that there was no community spread. Meanwhile, there was widespread community transmission. And it wasn't until the beginning of March that Redfield saw a signal in the New York data, picked up the phone, I talk about it, and called Howard Zuckerman, the New York State Health Commissioner, and said, you guys have a problem. It was the first time they saw an outlier. But if you look at the data all through February and you look at the percentages of people presenting with flu-like symptoms who were testing negative for flu, it wasn't- it wasn't red, but it wasn't green. It was at the high end of a normal range. So if you looked at a 10 year average, it was at the high end of that 10 year average, certainly against the backdrop of what was happening around the world. We shouldn't have derived any comfort from that. And so we just didn't have the tools, we didn't have sensitive enough tools to know that there wasn't community spread. And in the absence of not having those tools in place, which would have been a diagnostic test, and actually screening people, we shouldn't have been so confident that this wasn't spreading. We should have been doing things differently in anticipation that this probably was spreading, we just weren't picking it up, which in fact was the case.

MARGARET BRENNAN: You also say this should have been viewed as a national security threat, and that's how we need to think of pandemics. President Biden went out in July to the Office of the Director of National Intelligence and said generally he agrees with that. What does that actually mean, though? Have you seen the Intelligence Community, to date, react and protect us going forward? Do they have the tools needed?

DR. GOTTLIEB: Well, look, I think the Intelligence Community has different tools that should be focused on this mission. You know, there's two pieces to that- that idea, that we have to look at public health preparedness through the lens of national security. One is the domestic piece, how we prepare, thinking about this as something that could be a low-probability but high-impact event. And how do we prepare about other events like that? The risk of a radiological attack, the risk of a meteor strike. I mean, we make certain preparations for things that are unlikely to happen. But if they happen, they're so catastrophic that we have to prepare. This crowded- this- this subordinated all our other national priorities. We cannot allow something like this to hit us this bad again. So we have to prepare differently domestically. But internationally, what that means is, we've historically relied on international conventions and capacity-building in other nations, basically going into nations that could be- would be hotspots and trying to build capacities in those nations as a way to create an early tripwire to warn us of an emerging disease. We rely on other nations to tell us when they have an outbreak. That has repeatedly failed. It failed in this case, China didn't surface the early information, they still haven't shared the source strains. But we can go through a litany of country after country that was host to novel outbreaks of SARS-like viruses, novel outbreaks of- of influenzas, novel outbreaks of Ebola, that didn't surface the information in a timely fashion. And so the question becomes, can we still rely on the international health regulations and the W.H.O and the World Health Assembly? Are we going to all hold hands again and promise that we really mean it this time and we're going to share information? Or do we need to get our clandestine services more engaged in this mission? And I think we're going to need to get our clandestine services more engaged in this mission. It's one of things I talk about, because that's a very big departure from where we've been in the past. In the past, there was always an assumption that this- that the public health mission was the CDC's mission. The CDC and the public health officials didn't want the spy agencies anywhere near that because they felt it would corrode their authority to act outside the U.S., that everyone would be perceived as a spy. And traditionally, the National Security Agency said, the CDC has this, this really isn't our mission. It was seen as a sort of a softer aspect of the overall national security mission. I think that needs to change. I think given what we've seen, not just how this impacted us, the death and disease, how this changed the course of history, the geopolitical impact. Would China have moved on Hong Kong if the world wasn't distracted by COVID? So we can't allow something like this to happen again, and that's- we're going to have to get our spy agencies involved. There was data very clearly available in China, in Wuhan, that if we were looking for it, we could have detected this much sooner. We could have answered some key questions. We could have seen the asymptomatic spread, we could have seen the human-to-human transmission. There was sequence data that was being- flying around by mid-December inside China, and probably earlier than that, being sent to commercial labs. That signals intelligence that could be intercepted if you know what you're looking for. So there was a lot of information that could have been had. And in the hands of good political leadership, you could have mounted- you could have had some key questions answered early that could have allowed us to mount a more robust response. And a two or four week head start on something like this can make a very big difference.

MARGARET BRENNAN: On the intelligence front, you said it was- you talk about a lot of this sort of towards the end of your book, and this is a more current conversation about the origins of COVID. The president ordered this 90-day review of intelligence and it came to basically no conclusion. What did you learn in the course of your research about the origins of COVID?

DR. GOTTLIEB: I learned that we're not going to answer this question absent one or two things happening. Either we find the intermediate host, the animal that was the- that spread COVID, or there's a whistleblower inside China. Or someone close to this, who knows that this came out of a lab, comes forward, defects, goes overseas, or we intercept some communication that we shouldn't have had access to. Absent something like that, we're not going to be able to answer this question. This is going to be a battle of competing narratives. I think over time, the side of the ledger that- that says that this might have come out of a lab has grown more robust and the side of the ledger that says this came out of a natural species has not really moved. And if anything, you can argue that side of the ledger has been diminished by a couple of facts. Number one, we've looked for the intermediate host and we haven't found it. And number two, the idea that the- the market, this initial market, was the source of the initial spread has been firmly debunked. Even the Chinese acknowledged that. And that was a big part of the thesis around the zoonotic origin, the animal origin, because the idea was that the animal was in that market. We now know that market wasn't the source of the spread, it was a path along the spread.

MARGARET BRENNAN: Beijing has even acknowledged that to a certain extent--

DR. GOTTLIEB: --Beijing has acknowledged it, right--

MARGARET BRENNAN: When you say intermediate host, you mean what happened between the bat and the human. 

DR. GOTTLIEB: Right--

MARGARET BRENNAN: Who came in between.

DR. GOTTLIEB: There's an animal, maybe a pangolin, there's some other animal in between and it could have been- it wasn't necessarily a bat, and it could've been a bat to a human, but we haven't found the virus in nature. And there's been a pretty exhaustive search. The Chinese have mounted an exhaustive search. And I don't think that the fact that they've been looking for it proves that they know it didn't come out of a lab. I think that they would be looking for it, even if they knew it came out of a lab. And the reality is if it came out of a lab, the number of people who actually are aware of that could be a very small subset of people. 

MARGARET BRENNAN: When you say, came out of a lab, you are saying through a lab accident, not a construct?

DR. GOTTLIEB: Yeah. No, I don't think anyone, and the administration has said this in the intelligence report they put out that they don't believe- they- they've sort of firmly debunked the idea that this was something that could have deliberately come out of a lab or was deliberately engineered. But the possibility is that you've had labs doing research on novel coronaviruses. You had novel coronaviruses being brought to those labs, particularly the Wuhan Institute of Virology. We know that they were doing that research in what's called BSL-2 labs, lower security labs where tight precautions aren't taken. We now know that they were infecting transgenic animals with coronaviruses, with novel coronaviruses--

MARGARET BRENNAN: Transgenic meaning?

DR. GOTTLIEB: --as part of the research. Animals with human--

MARGARET BRENNAN: Partially humanized?

DR. GOTTLIEB: Right, animals with human immune systems. So that- that again makes- is- is another step that makes it more likely that it could have spread to humans because now you're infecting animals with human immune systems, so they're humanized viruses. You're adapting the viruses to animals to try to infect the human immune system. All those set up the conditions for risk. And we also know that the Wuhan Institute of Virology was a sloppy lab. At the time that it opened there was an article in the journal Science raising questions about the integrity of that lab, where scientists at the time that it opened in 2017 said, we're worried about the procedures in this lab. We're worried about the training, we're worried about the way it was built. We know that the lab was conducting high-end research with the Chinese military. The French were in that lab and were eventually kicked out. And the time- at the time that they were kicked out, they were aware that the Chinese military had moved into that lab. So there were circumstances created around that facility and there were operating procedures around that facility that created a lot of risk. That doesn't mean it came out of a lab, but it certainly makes that a suspect location. And there was another lab. The CDC, the Chinese CDC, maintained a lab literally blocks from the wet market that was first implicated in this virus that was also conducting coronavirus research in BSL-2 labs.

MARGARET BRENNAN: So other than the whodunnit factor, why does it matter? Why do we need to know who Patient Zero is and how will that affect the Biden administration's response?

DR. GOTTLIEB: Yeah, it matters a lot because if we determine that- first of all, if we determine if this came out of a lab or we even assess that there's a high probability that this came out of a lab, I think it changes how we try to govern research internationally. We're going to need something like the International Atomic Energy Agency for BSL-4 labs. We're going to have to look much more carefully about who's creating BSL-4 labs, the kind of research going on in those labs--

MARGARET BRENNAN: That's the U.N.?

DR. GOTTLIEB: Should-- it's going to probably be a global organization, come out of the World Health Organization, some kind of international consensus around providing oversight on these labs because there's a lot of them cropping up right now. A lot of countries are building BSL-4 labs and starting to engage in this high-end research. And the- the most speculative, most dangerous research often goes to the countries willing to conduct it. And the countries willing to conduct it are oftentimes the countries that have the poorest controls. The other thing we're going to need to look at is, do we continue to do things like publish the sequences of novel viruses? So when- when labs create novel compilations, when they create a novel virus for purposes of trying to assess, you know what its- what activity it could have in humans, once you publish that sequence as part of normal scientific discourse and part of the scientific process, you basically provide a recipe to anyone who's a rogue actor on how to manufacture that virus. And I think we're going to have to look at, you know, the- whether or not that's a good idea going forward and maybe not publish information like that, have a consensus that we're not going to publish that kind of information because the other thing that comes out of this is that this hurt us a lot more than it hurt other countries. It hurt the West a lot more than it hurt other countries. 

MARGARET BRENNAN: Why?

DR. GOTTLIEB: We proved uniquely incapable of implementing respiratory precautions, getting consensus around things like mask wearing, the mitigation that was required. A lot of countries did better than us. A lot of countries in the Pacific Rim did better than us. And the old doctrine was that no country that's trying to develop a pathogen for a deliberate purpose for- as a bioweapon, and this wasn't a bioweapon. This very clearly was not a weaponized virus. But going forward, a country, a rogue actor that's looking to develop a biological weapon, the presumption was they wouldn't use a respiratory pathogen because it would blow back on them. But now looking at how this disrupted the West relative to other parts of the world, I think that calculus needs to be reassessed. And so it raises the stakes around the risk of doing this research, allowing this research to go on, publishing things that could facilitate this research if we know that there's rogue actors that might be on the margin more likely to look at a novel influenza as something that could potentially be weaponized. And even if you could just develop a respiratory pathogen that could disable, you know, a group of people or, you know, make people sick for three or four days, that might be a weapon you use on troop movements. So, you know, we need to think differently about these risks now, having seen how this disproportionately impacted certain countries relative to others. This was an asymmetric risk to the West and to the United States in particular, relative to other nations

MARGARET BRENNAN: Who handled this the best on the global scale? Which countries?

DR. GOTTLIEB: Well, it's a tough question because there were certain countries that kept the virus out or, you know, were able to preserve life, but--

MARGARET BRENNAN: Australia?

DR. GOTTLIEB: Yeah, but the question becomes, what price did they pay for that, in terms of what they imposed on their population, the economic impact? You know, I think if you look at some of the countries in the Pacific Rim like Singapore, Taiwan, South Korea, they handled it very well insofar as they didn't adopt all the same draconian measures that countries like China did where they locked down the entire country, but they were still able to maintain control over it. And, you know, in South Korea's case, they did it through very aggressive testing and tracing. They employed certain aspects of their, you know, state apparatus to basically collect information on people that wouldn't have been feasible in a Western democracy. We would never have tolerated it. But I don't think- people always point to that and say, you know, we couldn't do what South Korea did because they- they used their police state to basically monitor people. That was a small aspect of what they did. I think the core of what they did was really deploying testing on a massive scale, encouraging people to get tested. They literally had testing devices for sale in vending machines, in subway stations, and using that as a way to get people diagnosed and encouraging people to get into quarantine if they have the infection. That was the core of what they did and they did it successfully. 

MARGARET BRENNAN: Who didn't handle it well? I mean, do you put the United States on the list of worst responders?

DR. GOTTLIEB: Well, I think it's hard to say who handled it the worst. I think that we're at- we're at the top of the list of countries that were the hardest hit by the pandemic for sure, and had a very difficult time putting in place the measures that were going to help control the spread.

MARGARET BRENNAN: Is that simply just because we track what's happening? I mean, is that an unfair criticism to say, the United States?

DR. GOTTLIEB: No, there's I think there is good enough global tracking among a lot of our counterparts that we can make an assessment that we were disproportionately impacted by this. I mean, there were certainly countries that had a higher death rate on a per capita basis. There were countries as hard, if not harder hit, but of the industrialized countries, of countries that- where there was an expectation that we'd be able to do better, where we had tremendous capacities, where we had a very good health care system, where we had access to the technology, we had the ability to develop therapeutics and vaccines and get early access to them. Relative to what our assets set was, we did pretty badly with this virus.

MARGARET BRENNAN: In terms of are we better now, you wrote that the virus "rode in on the breath of hundreds of thousands of travelers." Both Presidents Biden and Trump put in travel restrictions. Would you tell the Biden administration now to lift them? Because you're arguing they're largely ineffective.

DR. GOTTLIEB: Well, they're largely ineffective now. I mean, I think that if we're going to put in place a travel restriction, you know, you could defend, a- a travel restriction that requires people to be vaccinated to come into the country. If we're trying to create, you know, a bubble around activity in this country and putting in place our own mandates around vaccination, it makes sense to require people to be vaccinated if they come in. That's something I think that's defensible. But the idea of broad travel restrictions based on region, when there's just as much virus here as there are in parts of the world where we're restricting access, I don't think that makes sense anymore. You know, the travel restrictions had limited value early on. I think we over-relied on the travel restrictions and we thought we could actually erect walls and keep this virus out or keep it out for longer than we could. We couldn't. They weren't nearly as effective, I think, as people assumed or even people now sort of surmised. But- but there was some logic in putting in place some travel restrictions early when we knew that there were specific countries, Italy in particular was heavily seeding New York. Obviously, people traveling from Wuhan where there was a raging epidemic, those kinds of restrictions made sense at the time. At this point, there's so much virus around the world, I'm not sure what we're keeping out. We're more likely to have restrictions imposed on us than be in a position of imposing restrictions on other nations.

MARGARET BRENNAN: Well you also make the argument that that can backfire because you say then countries are- are basically not incentivized to come clean. 

DR. GOTTLIEB: Well this--

MARGARET BRENNAN: They're- they're incentivized to cover up what's happening.

DR. GOTTLIEB: Right, this gets back to the question of, will we need to rely on our clandestine services more to gather information? So if we go into this, and we've already started down this path, and we go back to the World Health Assembly, the W.H.O. convenes a meeting, everyone comes together and says, we really mean it this time. Now we're going to- if something like this emerges again, we're all going to agree that we're going to share the data, we're going to share the source strains. Well, what did COVID teach the world? COVID taught the world that if you're host to an emerging infection that looks threatening, the first thing other countries are going to do is erect trade and travel restrictions on you and try to isolate you. Like before COVID, that was controversial. The idea of actually isolating an- a nation was highly controversial because there was a presumption that if you isolate a nation that's host to an outbreak, you'll destabilize that nation and make it harder for them to combat the outbreak. But what's the first thing that happened when the British said, we have this- this concerning new strain of COVID called B.1.1.7 that seems more contagious. The French closed the Chunnel, right? So now we've taught nations that if you come forward and raise your hand that you're host to an outbreak, you're going to face some kind of sanction for that. So if that's the case, how can we rely on countries being forthcoming? We're going to have to rely much more on our ability to actively gather the information we need of an emerging outbreak and not just hope that people tell the truth and tell it in a timely fashion.

MARGARET BRENNAN: So away from airports to other borders, here at home. You've advised a number of governors, Democrats and Republicans, on how to respond to this pandemic. Which cities, which states actually handled this well?

DR. GOTTLIEB: I think my home state of Connecticut did a good job. And if you look at what the governor did there, he deployed testing very aggressively early. They rolled out the vaccine on the- on the basis of age. They kept it simple. They got the population vaccinated very quickly by keeping the- the framework by which they were distributing vaccines just simple, you know, older people first and they walked down the age continuum. They put in place community-based sites to try to go into hard-to-reach community and make vaccine accessible. The state has 85 percent of its adult population vaccinated now, one of the highest in the nation. There were a lot of things done early with the testing, the focus on the nursing homes in that state, that I think put it in a better position. Now, Connecticut suffered badly in the first throes of this epidemic, as did the entire tri-state region. That was a time when we were- we didn't know what we were dealing with. I mean, we were literally treating COVID with hydroxychloroquine and Pepcid. So, you know, there was excessive death and disease during that first wave, and Connecticut was not spared that first wave. But I think they learned and put in place a lot of measures that helped them weather this better than other states. Massachusetts, too, I- I worked with Governor Baker up there and had a very heavy focus on testing. In most days, Massachusetts was top of the list of 50 states in terms of the amount of testing they were doing. They pioneered wastewater testing as a way to get an early tripwire. So you shed coronavirus into your feces and so you can actually look at sewage to see when coronavirus levels are rising as a barometer of how much virus is in the population. They pioneered the use of that to be able to detect when the virus was starting to circulate in communities so they could target the public health measures into communities where the virus was starting to spread. So a lot of use of testing very early, I think, put them also in a better position. Now again, the Northeast suffered badly from this virus. You have a lot- you have dense cities, you had early introduction of the virus. But I think relative to where we- they could have been, they made some good decisions.

MARGARET BRENNAN: You named a Democrat and a Republican. 

DR. GOTTLIEB: I did. 

MARGARET BRENNAN: All of this has become politicized. Do you think that with the rollout of boosters, for example, which is again going to test some of the public messaging and trust, what is the lesson for the Biden administration as they roll out boosters? Do they need to change the playbook from what the Trump administration did?

DR. GOTTLIEB: Yeah, I think the logistical lesson on the rollout of the boosters is that they need to have in place the infrastructure to actually distribute those vaccines in hard-to-reach communities and hard-to-reach settings. And so that- the challenge during the Trump administration, with the early days of rolling out the vaccine, the vaccine was authorized by FDA mid-December. We didn't start vaccinating inside the nursing home until weeks after that, and this was a point in time when the nursing homes were really the setting with the most death and disease. We were losing at the peak about 7,000 people a week across nursing homes in the U.S.. And it was a point, I had talked to some health officials at the time, and I said, we've done everything we can. You know, they restricted access to visitors, they were testing the staff, and they couldn't keep the virus out of nursing homes and couldn't keep the patients safe. And so the only thing, people said to me, the only way we're going to prevent this epidemic from spreading in these settings is by vaccinating the population. So there was an awareness of how important a vaccine was in that setting. But it took a full, probably three weeks, until we really started that because the logistical planning hadn't been put in place in advance of the authorization. So the vaccine was authorized, then they started the process of getting the consents, the informed consent in place to actually go into the nursing homes and start distributing the vaccine. I think what the Biden administration has done here is by backing into an approximate date, and I know they were beaten up a little bit for putting out a date ,but by putting out an approximate date, they're now able to start that planning process in advance and so that the boosters are made available by FDA, if FDA does authorize it and the advisory committee, the CDC ultimately judges it to be appropriate for a certain population, they're going to be ready to start making it available to nursing homes right away. So there's not going to be a delay. So I think they're in a better position. I don't know that the vaccine boosters are going to be controversial from the standpoint of sort of right versus left politics. I think where the fault lines are going to be is on some of the mandates that the administration is putting in place. And I think there the question you need to ask is whether or not the benefits of the mandates in terms of what you're going to achieve is going to be offset by the cost in terms of the acrimony and the political division and the hardening of positions of people who see this as something that's being forced on them where their decision making is being taken away. The more we can allow people to feel empowered around this decision, even people who are skeptical of getting vaccinated, the more likely they are to make the decision to get vaccinated.

MARGARET BRENNAN: So you just emphasized some of the fault lines there. You worked for two Republican administrations, for the Bush administration and for the Trump administration. How does it sit with you when you hear members of your party, the Republican Party, describe all this along civil liberties lines? Not making the medical argument, but simply around civil liberties.

DR. GOTTLIEB: Look, I think it's a misjudgment, because I think that there is- there is this argument that this is an individual choice. Your choice to get vaccinated is an individual choice, and it's not an individual choice. This is a- this is a decision that affects your community. This is a collective choice. If you go- and just like with childhood vaccinations, if you go into a school setting and you're not vaccinated for measles and you introduce measles into that setting, you're affecting your community. So these are collective decisions. But I think to the extent that they're decisions that impact the community, impact your workplace, if you're- if you choose to be unvaccinated, you introduce the virus into your workplace and a worker takes it home and then infects their young child. You introduce it into a school, you didn't vaccinate your child, your child introduces it to the school. I think if we're going to impose requirements on vaccination, to the extent possible, we should be making those decisions at the local community level within the context of the community that's going to be affected by that choice, rather than pull this away and make this a federal decision. So I don't think governors should tell schools and businesses, you can't mandate a vaccine. If a business makes a decision that the only way that I could protect my employees or- or my customers is by having a fully vaccinated workforce, they should have the ability to make that decision. 

MARGARET BRENNAN: But it's not just shots, we're talking about masks. I mean, it has become a partisan issue and still is. In the state of Florida, for example, a ban on mask mandates. That is at the local level. 

DR. GOTTLIEB: Yeah, and the- and the mask debate is inexplicable to me. I can't- I can't decouple it. I can't explain it. I can't defend it because, you know, at least with the vaccine, there's people- people generally, I worked at FDA and I had- I've treated patients and I've talked, counseled a lot of patients through difficult medical decisions. People generally have an apprehension about taking a medical product, especially when they're healthy, especially for a preventative purpose. I understand just sort of people's general questions and concerns about a novel medical product, but a mask is such a simple intervention. It's not going to cause you any harm. It's just an act of, you know, community responsibility, it's an act of respect. You know, even after I was vaccinated and prevalence levels were very low in my state, I continued to wear a mask in pharmacies and grocery stores. Not because I felt vulnerable. You know, in- in July and August, I felt pretty safe in Connecticut. Prevalence levels were low, I was vaccinated. But other people were wearing masks and I didn't want them to feel uncomfortable. So I think there's sort of an act of civic virtue and so to- to oppose mask wearing, to me, I don't understand that. I can't, you know, even explain the political rationale that this is somehow an exercise of someone's personal freedom, not to wear a mask in a setting where you're trying to protect the people around you. People's hesitancy around vaccines isn't new. People want to understand a medical product before they put it into them, particularly around children. So that is an understandable discussion. You can counsel patients through that. I think- I think there's a lot of people who right now haven't been vaccinated who are persuadable. They just have a long consideration period, and we should respect that. And my concern around, you know, the mandates. And I think, you know, the federal government is well within its right to mandate vaccination for federal workers, for health care workers. I think even mandating vaccination within the Medicare program could be something that's defensible, that providers and health plans need to get a certain percentage- certain high percentage of their Medicare recipients vaccinated. But when you impose the mandate down to the level of small businesses, now you're setting up the political fault lines and you're taking something that was sort of subjectively political, and it's going to be objectively political. Now- now you're going to see the debate play out and you're going to see the governors oppose it, you're going to see the litigation. And so my concern is that, you know, we might have picked up another, we were- we were going to get to 80 percent of adults vaccinated in this country. We're at 75 percent right now. Actually, 76 percent. The Biden administration has done a good job. We were going to get to 80 on our current trajectory. We might have gotten to 82 by the end of the fall, winter. With a mandate, where are we going to get — 86, 87, so we'll pick up three percent, probably most of them have already had COVID. So are you going to get enough benefit from a public health standpoint for the price you pay in terms of hardening those lines? I think that was worth a very vigorous debate. I- I hope the White House had it.

MARGARET BRENNAN: Which governors handled this the worst?

DR. GOTTLIEB: Well, which governors had the worst outcomes? I think in terms--

MARGARET BRENNAN: And by outcomes, you mean deaths?

DR. GOTTLIEB: Deaths. Certainly looking at South Dakota, you know where this was just allowed to travel largely unfettered with public health interventions, where you saw one of the highest death rates per capita. You have to look back and say that was a bad experience. You know, people always look at the deaths per capita and you know, New Jersey is right up there and New York is going to be high. I think we really need to look at the post initial wave period. What happened after that initial wave in New York? Because New York was devastated by this at a time when we didn't know how to treat COVID. You know, we were using Pepcid. We were using therapeutics that clearly had no value. Once we learned how to treat this, once we were able to reduce the case fatality rate by half, by the summertime, and we got there, we got there pretty quickly. States that were still excessively engulfed by this and had a lot of death and disease, those were in part policy decisions. Those were in part, the result of policy choices that those states made. New York and Connecticut and New Jersey didn't have the benefit of making a lot of policy decisions. I mean, by the time that they were- they started to get an awareness of this, they were already so heavily seeded that they were just trying to keep their health care systems operating.

MARGARET BRENNAN: So for Americans who, I mean, if you accept that this has already become politicized and you look ahead to future elections, one of the governors you just mentioned is projected to be a presidential contender. Right? You have others. So for an American at home, how do they judge response to COVID and say this one worked, this one doesn't. Is it on deaths?

DR. GOTTLIEB: I think it's looking at what happened within the states. There was- there are going to absolutely be disparities in the state-by-state experience. And you know, it's- it's not easy to decouple in every case, the policy from the experience, because, you know, this wasn't an epidemic that was experienced the same way nationally, this was highly regionalized. Some states were made excessively vulnerable through features of the states that had nothing to do with policy, New York because New York City was so dense. But what you were starting to see after that first wave was a much more regionalized experience based on differences in policy approaches. And, you know, certainly Florida made certain decisions. I mean, the governor kept schools open, and a lot of people believe he made a good decision. He- they ignored the advice on six feet of distancing. Probably the single costliest recommendation that CDC made that you had to maintain six feet of distance that wasn't based on good judgment and good science was ultimately changed. And so he said we're only going to maintain three feet, which is where the CDC is now, and was able to keep schools open. But at the same time, you know, they let the virus spread largely unchecked in terms of personal mitigation. People weren't wearing masks. They weren't encouraged to wear masks. Vaccination was encouraged for the elderly population, but not widely. So they didn't aggressively try to vaccinate anyone except their elderly population. So they made policy choices. And the consequence was an infection that largely engulfed most parts of the- of the state. I mean, Florida probably has one of the highest positivity rates of any state in the nation right now. When the seroprevalence data comes out, when the data on- on how many people have had COVID comes out, Florida is going to be up there.

MARGARET BRENNAN: But Governor DeSantis would say, look at the economy.

DR. GOTTLIEB: Yeah, I mean, I'm not in a position to judge his economy relative to other- other states. You know, the decision to try to keep kids in school was the right decision. The decision to let the virus spread the way it has and not even employ mitigation in the school as they're doing now, I disagree with that decision. I think that- that there are things we could have done that were, you know, relatively easy interventions like requiring people to wear masks, trying to get people high quality masks that could have slowed the spread, could have kept certain settings like schools safer. Right now, the epidemic in Florida is largely inside the school. The case- the cases are declining across every age category, except young children because the epidemic has moved into those schools, and Florida has made a decision that they're not going to deploy mitigation in that setting. They're not doing testing in most of the schools, they're not requiring kids to wear masks, so they have spread. Now, it's not clear that those measures are going to be effective against Delta. We're going to find out because in the Northeast, we're adopting those measures and we're going to see whether or not they're able to- we're able to prevent epidemics of Delta in a school setting. But you don't go into a situation like that and tie one hand behind your back because you know what the outcome is going to be. The outcome is going to be that kids are going to get infected with COVID. And there was a study that just came out in Israel showing about 10 percent of kids who get COVID have long- term symptoms. There was a study in England showing about 2 percent have persistent symptoms. That's not trivial. You know, if you end up infecting millions of children and 2 percent have residual symptoms, neurological symptoms, that's a lot of morbidity that a lot of children are going to have to carry for at least some period of time that's going to affect their lives. So I- I wouldn't be cavalier about the risk in kids, even though they clearly do better with the infection than older individuals. And I wouldn't go into these situations, the school situation, without adopting measures that we know can- can potentially prevent the spread. So, you know, that was a decision that is going to- is having a predictable outcome.

MARGARET BRENNAN: I want to talk a little bit about President Trump. So, if I go back in time and I think about the first few days where this strange virus that was just surfacing started to make headlines here at home. February, January, you were starting to see things that weren't yet really being raised as red flags. You were tweeting, you were speaking privately in messages to White House officials. How are you on the outside seeing things that they weren't seeing on the inside?

DR. GOTTLIEB: Well, I think there was- there was a group of us seeing the same things. So there was a group of public health officials that were very alarmed about what was going on. There were people inside the White House who were concerned. Matt Pottinger, who you've spoken to, Joe Grogan, who's one of the people that I conferred with a lot. I remember very- the first conversation I had with him was in- was in January.

MARGARET BRENNAN: You write about that, January 18th. 

DR. GOTTLIEB: Right, Martin Luther King Day weekend, told him he should ask for a briefing from the department on this, was very concerned about the spread. So there were people who were concerned about it. I think that there wasn't a lot of organization around the response early on. There was a presumption again that the CDC has this, the department has this, the Secretary of Health and Human Services is in control. So, you know, they let- they let that health care apparatus run with the ball. And then you had White House people who were alarmed, asking for information, but not actively managing it. It really wasn't until probably more like the end of February, the March timeframe. I went back and I met with the President in early March and the vice president, that you saw the White House really starting to get engaged and pull this away from the Secretary of Health Human Services and the health care institutions and start to at least try to more actively manage it. And that was the- the genesis of the Coronavirus Task Force. But the task force wasn't set up in a way to be operational. It was more a policy forum. So it didn't really- it wasn't really discharging orders and actually setting in motion action.

MARGARET BRENNAN: It's been reported that you were actually considered to come and run that task force. That the president was interested in having you come in and run it.

DR. GOTTLIEB: Yeah, that was written in one of the books.

MARGARET BRENNAN: Is that true?

DR. GOTTLIEB: You know, I don't know for sure. I-I know that there were various points in time that the White House had reached out to me about, would I come in and help them manage certain aspects of this. And every time I said yes. The point at which it felt like it was moving along and it felt real was after the task force. So there was a debate about who should run the task force. The decision was made to put the vice president in charge. It's been reported that I was considered. Yasmeen wrote about it in her book for The Washington Post. Subsequent to that, the president asked me to come in. I met with him, I met with the vice president, and asked me to take a position as, sort of as an adviser or helping oversee the task force after the vice president had been put in charge. That felt like it was moving along and more real. Ultimately, it didn't come together. 

MARGARET BRENNAN: Why?

DR. GOTTLIEB: I don't know for sure. I think--

MARGARET BRENNAN: It wasn't your choice, in other words.

DR. GOTTLIEB: It wasn't my choice. I think like anything else, there were probably people in the White House who wanted to see me in that position and probably people in the White House who didn't. And you know, the people who didn't want to see me in that position were able to stall the process out long enough. You know, one thing you learn in government and you've been around Washington, so you know this, if you delay something, you can effectively kill it. And so, you know, if you delay an action, you delay someone coming into a position long enough, eventually either someone loses interest or it just dies on its own accord. And that's effectively what happened. My coming into that kind of a role got delayed in perpetuity. 

MARGARET BRENNAN: Mhm. It was reported that that was Alex Azar. Is that the person you're smiling about?

DR. GOTTLIEB: Well, the report on Alex Azar in- in the book I referenced was that, the way I- the report that was in that book was that, the White House- Mick Mulvaney, who was chief of staff at the time, said that if the president put me in charge of the task force, Alex would resign, in the meeting with the president. That's the dialogue that she related. I don't- I don't know how she got that. I trust her sourcing. I know her as a reporter. She has impeccable sourcing. The- the subsequent episode when I was- there was thinking about bringing me in in some kind of role on the task force, I think those were different people. I think that the issues were probably being raised more at the White House level about me coming in.

MARGARET BRENNAN: Do you regret though, not being on the inside? You had been with the Trump administration till 2019-- 

DR. GOTTLIEB: Yeah, so I regret not being at the FDA. I don't- I don't know that there is much that I could have done dramatically differently inside the White House, and eventually I would have worn out my welcome because it would have been people inside the White House who wouldn't have liked what I was preaching. And by the- by the election, the White House had gone in a much different direction in terms of the seriousness and what they were doing to approach this. If I had been at FDA with my staff, working with the career staff in the device center, I'm pretty confident that we would have made a very hard pivot to try to instigate the private industry to start getting engaged in developing diagnostic tests early in January. There had been times before when we made that call. After Hurricane Maria devastated Puerto Rico, we were very worried that we were going to have a blood shortage in the country because about 50 percent of all the bags used to collect blood in this country, the plastic bags used to collect blood, are manufactured in Puerto Rico, and we couldn't get that facility online. One of the ingredients that goes into making bags is oxygen. We couldn't import oxygen. The only facility capable of manufacturing oxygen on the island we couldn't get started, because we needed- we didn't have enough power to actually start it. So I called around to other manufacturers of plastic bags used for other medical purposes and asked them if they could pivot their production lines into making bags for blood collection. One company agreed to do it. You know, I told the CEO, I said, if you go down this path, we'll work with you, we'll promise you an efficient process. And I said, I'll make it up to you on the back end. When you do this, you know, I'll either- I'll come to your factory, I'll tour your factory. And when they managed to successfully do it, I actually put up a bunch of photos of the production line on Twitter, you know, and basically gave the company some props.

MARGARET BRENNAN: And so you wish somebody at the FDA was doing that?

DR. GOTTLIEB: I think that could have happened- it would have had to happen at the commissioner level, it couldn't happen below that level. It had to be a political appointee, someone who could call a CEO and, you know, make certain guarantees about what- what you were going to afford them in terms of efficiency, predictability to make this pivot because you're asking a company to shut down a production line that clearly they're making, you know, millions of dollars off of and pivot into something where they might not get reimbursed. I couldn't guarantee that Congress was going to come in and pay for those tests. If I would have called any big manufacturer, though, they would have done it. I- I have no doubt about that. That could have been the secretary, that didn't need to be that- just the commissioner, there were other people in the chain of command who could have made that call. But, you know, having been there and having made those calls and having known that CEOs responded positively in moments of public health crisis, that's the one thing I wish I was there to do. And you know, I wrote articles about doing that at the time. I was writing articles in January, this is what we should do. But, you know, writing op-eds and putting things on Twitter isn't like being there in action and being able to pick up the phone and effectuate the action. I wish I was there. I think that that's- the- the FDA and the optives, the operational divisions of HHS, is where the action happens. That's where you can really affect the outcome. Affecting the outcome from the White House, much harder.

MARGARET BRENNAN: But you- it seems like you were trying to affect the outcome from the outside with the op-eds, your television appearances. Given that that's how President Trump received information quite often, do you think you did shape the COVID response?

DR. GOTTLIEB: Well, there were times when the- when the president engaged me, you know, based on my tweets. I talk about one story where I put out a series of tweets right before I went and did a hit on another network, and as soon as I got off, my phone was lighting up. And sure enough, the president had retweeted me and called me later that day and asked me to come down to the White House to discuss the substance of what I had put out. So I think the messages were getting through, but they were getting through at a point when, early on, when the White House was looking for a strategy, was engaged and was sober about the seriousness of this. I mean, after all, the president did make the decision to do the '15 Days to Slow the Spread' and then the subsequent 30 days, a dramatic action. Later on, I think when the White House pivoted and was wrongly advised that really nothing was going to effectuate the spread, there was no way to really stop this, that we were going to be subject to uncontrolled spread, and we just had this sort of power through this. I don't think that the advice I was given was really consistent with where they were going and what they- what they wanted to be hearing and advice that they were going to take. So at that point, I'm not sure my message was breaking through as effectively as it did at the outset. But- because the orientation changed in terms of how the White House was approaching this.

MARGARET BRENNAN: You write in March, when you went in to speak with the president that he was serious, he knew the grave risks. "When it came to the question of mitigation, he was most sold on the ideas before I had arrived." You're describing him as well briefed.

DR. GOTTLIEB: So I was invited in that day by some senior White House staff with the premise, at least as I interpreted it, to help sell the president on the idea of mitigation. And you know, they sent me into the Oval Office and said, you know, you try to walk him through this, explain to him, you know, your position on it. And by the time I got there, you know, I had the discussion with him, but he was- it was very clear to me that he was already sold on the idea, like he already understood what- what the plan was and it felt to me, and I had briefed him before, I mean, I didn't know him well, but I had been to the Oval Office 10 times, eight times to brief him on various things. It felt to me at that point that he was very receptive to what I was saying and wanted to move on to other topics. We were talking about other things in that meeting. So, you know, yeah, early on, I think that the president was- there was a point in time when he was gravely concerned about this and that came out in the Bob Woodward book as well, because over this very time period, when I was meeting with him, he was also meeting with Bob Woodward and expressing his deep concern about- about COVID. So, you know, he was understandably heavily criticized for saying to Woodward, allegedly, that, you know, he was trying to send a more reassuring message to the public because he didn't want to panic people, but privately he was very worried about this. I think that the- the challenge with the White House approach is it wasn't consistent. They didn't follow it through. You know, there was a point in time when they were very concerned about this, willing to take dramatic actions. But later on, their attitudes really changed to the point where when the president was contagious with COVID, he ceremoniously took his mask off. And so what message does that send to the country? So the- the approach in attitude shifted, and I think my view is- and I wasn't close to it at this point, so I don't know exactly what they were being told. They brought in a different set of advisers. But my view is that they were sold on the idea that you weren't going to be able to really affect the spread and that anything you did was just going to have so many repercussions in terms of impact on children who might not be in school, impact on the economy, that the costs were worse than the disease. The president always said that, the cure can't be worse than the disease. You know, and the schools as a perfect example, because- and a perfect example of the lack of effective policy making. So the single reason why most schools remained shut was because the CDC was telling them they had to keep kids six feet apart. If- if CDC had said you can only- you have to keep kids three feet apart, then a lot of schools would have been able to open. And in fact, when the Biden administration wanted to open schools in the spring, this past spring, they got the CDC to change that guidance from six feet to three feet.

MARGARET BRENNAN: And you write, the six feet was arbitrary?

DR. GOTTLIEB: The six feet was arbitrary in and of itself. But if the administration had focused in on that, they might have been able to effect a policy that would have actually achieved their outcome. But that policy making process didn't exist, and the six feet is a perfect example of sort of the lack of rigor around how CDC made recommendations. Nobody knows where it came from. Most people assume that the six feet of distance, the recommendation for keeping six feet apart, comes out of some old studies related to flu, where droplets don't travel more than six feet. We now know COVID spreads through aerosols. We've known that for a while, so how operative is that? The initial recommendation that the CDC brought to the White House, and I talk about this, was 10 feet. And a political appointee in the White House said, we can't recommend 10 feet. Nobody can measure 10 feet. It's inoperable. Society will shut down. So the compromise was around six feet. Now imagine if that detail had leaked out. Everyone would have said, this is the White House politically interfering with the CDC's judgment. The CDC said 10 feet, it should be 10 feet, but 10 feet was no more right than six feet and ultimately became three feet. But when it became three feet, the basis for the CDC's decision to ultimately revise it from six to three feet was a study that they conducted the prior fall. So they changed it in the spring. They had done a study in the fall where they showed that if you have two masked individuals, two people wearing masks, the risk of transmission is reduced 70 percent with masks if you're three feet apart. So they said on the basis of that, we can now make a judgment at three feet is an appropriate distance. Which begs the question, if they had that study result in the fall, why didn't they change the advice in the fall? Why did they wait until the spring? So the whole--

MARGARET BRENNAN: And that's--

DR. GOTTLIEB: --This is how the whole thing feels arbitrary and not science based. So we talk about a very careful, science based process and then these anecdotes get exposed, and that's where Americans start to lose confidence in how the decisions got made.

MARGARET BRENNAN: You do put blame on President Trump for a few things, masking, you- you mentioned there. You said he politicized masks. You say you heard it's because he thought people looked funny in them. You said, you know, he listened to people on the outside too much. But do you think fundamentally, looking at everything you've analyzed, that the outcome of this pandemic would have been different if President Trump wasn't in office?

DR. GOTTLIEB: Well, look, it would have been different if we had different political decisions and the White House was exercising different leadership. There's no question about that. There's no question that the White House made mistakes, and the lack of consistency was a big mistake, and also the lack of using the White House as an effective bully pulpit to really galvanize a collective action that can make a difference on the margins. I mean, when you're dealing with something of this magnitude, little things practiced on a large scale make a big difference. If everyone just washes their hands a little bit more, we talk about these things as public health officials, and sometimes it sounds silly. But we know when you aggregate small interventions on a mass scale, if people just go to the grocery store one less time a week, they wash their hands, they wear a mask. All those little things added up over a large population actually can affect the contours of an epidemic. And so getting people to do that requires galvanizing the public, inspiring the public to engage in certain behavior. And that's where the- the lack of consistency, lack of messaging, allowing this to sort of get divided along political fault lines in the setting of an election when things were already, the temperature was already very high, I think really hurt us. And then there were the discrete policy mistakes, decisions not to do this or decisions to do that. But stepping back from that, I think that there were fundamental weaknesses with our response that regardless of who is in power, we had an ill-prepared bureaucracy. We didn't have the right infrastructure, we didn't have the right agencies. The agencies weren't properly empowered, properly resourced. So even if you had competent leadership, very effective leadership up and down the chain, you still would have had some of the same problems. And that's what I try to get at here is some of those really deep rooted systemic problems with the structure of our response and also the assumptions we made about how we would respond.

MARGARET BRENNAN: So you resigned from the FDA in 2019. Seeing everything you've seen, do you see a role for yourself in government again?

DR. GOTTLIEB: It's impossible to say. I was--

MARGARET BRENNAN: This isn't a playbook for the future secretary? 

DR. GOTTLIEB: You know, what I would- getting these jobs in government, so many things have to happen right for these opportunities to be open to you, that anyone who wants to be in a position inside government can't plan for it. So- would I- are there things I'd like to do? Is there unfinished business? Are there roles I'd like to play? Sure. Do I think I'm going to have that opportunity? I hope so, but you can't plan for it. And sometimes writing a book isn't the best way to propel a political career, as you know, because sometimes the best way to get a political job is, write less, not more. So, this certainly isn't, you know, a blueprint for that.

MARGARET BRENNAN: But you do hope that this is a blueprint for some kind of change?

DR. GOTTLIEB: I hope this is the part of the conversation that needs to happen about how we plan differently going forward. And we need to bring together a bipartisan commission. We need to bring together thought leaders to try to develop a plan for the future. The blueprint that the Biden administration put out is basically just a structure of that conversation. That conversation needs to happen. I hope this is part of that conversation. I hope that this book becomes something that people who engage in that discussion read--

MARGARET BRENNAN: A 9/11 type commission?

DR. GOTTLIEB: It will be- it will be something of that ilk. It's going to be something- it has to be. In order- in order for it to be effective, it's going to have to be something that's broadly bipartisan, widely respected, because it's not just a matter of getting the right infrastructure in place, you know, getting the right chess pieces on the board and restructuring the agencies. I think we have to have a more fundamental question, a discussion about what is the role of public health officials in the setting of a public health crisis and come to agreement about that because that's-that's where you're going to get, on the political right, that's where you're going to get a lot of consternation. There's a perception now that public health officials exercise too much power, sometimes on the basis of faulty information, propagated guidance that had a dramatic impact on people's lives, oftentimes that wasn't based on good science. And so the reaction to that is going to be, maybe they shouldn't be so empowered. And I think we're going to have to pierce that discussion, get over that, come to a consensus around that, sort of re-elevate the role of public health in a way that people find acceptable in order to get the right infrastructure in place. I don't- I don't know that the public health community senses that yet, but I- I worry that- that- that discussion is coming and that discussion needs to precede any broader discussion about what will the role of the CDC be? Well, the role of the CDC is going to depend on what you think the role of a public health agency in a crisis should be. Should CDC's guidance be more subject to notice and comment like a regulation or subject to an advisory committee process where there is some public scrutiny? Should they have to re-educate their guidance once they issue it to make sure it continues to be science based? You might bring more structure and transparency around how decisions get made, maybe that's the solution, but that discussion needs to happen.

MARGARET BRENNAN: On the global response, you wrote, "COVID crushed the global order of public health cooperation." Are you saying W.H.O is just not up to the task?

DR. GOTTLIEB: Well, it's not just the W.H.O.. I mean, past epidemics crush the global order of cooperation, we just didn't learn the lesson. When H1N1, the swine flu in 2009 struck the world, Australia and Canada nationalized the facilities that were producing vaccine destined for the US. They basically held on to our vaccine that was being manufactured in facilities in those countries until they could satisfy their local demand, and then they allowed the vaccine to be shipped here. And we did the same thing. We had a facility in North Carolina that was manufacturing vaccine for the United Kingdom, being operated by GlaxoSmithKline at the time. And we held on to that vaccine and it actually took a call from the British prime minister to President Bush at the time to get us to allow that vaccine to flow to the UK. So we have seen in moments of global- global public health crisis, there's a little bit of every nation for yourself. And so if we want to work on this assumption that everyone's just going to share and you know, lines are going to flow, vaccines are going to flow across borders, it hasn't worked in the past. It hasn't- it didn't work in a setting of COVID. So I think we're going to have to think differently about how we build capacities here domestically to make sure we have what we need to respond to a public health crisis of this magnitude, and not be dependent upon things coming from other nations where those nations are going to want those- those same materials as well.

MARGARET BRENNAN: Was there quashing of information by the W.H.O.?

DR. GOTTLIEB: I think the W.H.O. for too long--

MARGARET BRENNAN: Did they cover up for China is the allegation.

DR. GOTTLIEB: They- they weren't willing to confront China, right? They were- they put out statements extolling China's behavior and how forthcoming China was. I mean, it's part of the record now. Tedros- it's- it's in his Twitter feed. It's in the Twitter feed of the head of the W.H.O., giving props to China for how forthcoming they were. Now, was some of that an attempt to try to give them public praise because privately you were- you were, you know, giving them a harder sell? I think some of that was going on in the U.S. with some of the tweets and the statements that we were putting out. I don't know that that was happening at the W.H.O. level because I was talking to some W.H.O. officials at the time, and I've talked to a number since. And I think the W.H.O. really did believe China was behaving in sort of an appropriate way and was providing cover for them as they were getting criticized by other parts of the world. Clearly, they weren't, and I think that that was knowable at the time. China didn't share the source strains. Tedros didn't- the head of the W.H.O. didn't want to push China on sharing the source strains publicly because he said, well, they have no commitment to do it, and he's right. Under the International Health Regulations, there was no requirement that you had to share the samples, but the required- there were requirements that you had to share samples of novel emerging resp- respiratory pathogens in other settings. So clearly, the spirit of the International Health Regulations was that this should be shared, but because it wasn't the letter of the law, the W.H.O. didn't want to push China publicly to do it, even though that would have been very helpful for other nations.

MARGARET BRENNAN: You're talking about actual viral samples, not the sequencing.

DR. GOTTLIEB: Right, actual samples of the virus because the sequence alone isn't good enough if you want to develop a vaccine or a diagnostic. You actually at some point need the live virus. Now we eventually got the live virus because we had spread here in the United States. But, you know, at least publicly, we didn't have the virus until there was a case in Seattle. It's possible we got the virus earlier from one of China's neighbors, where there were some earlier spread.

MARGARET BRENNAN: Is that part of the equation being dealt with now?

DR. GOTTLIEB: No, I don't think the W.H.O. has taken any steps to reform how it operates in a global crisis like this, whether or not they're able to- whether or not the organization has a self-awareness to do that and is able to self-organize to actually implement meaningful reform. I'm not sure. I think the Biden administration lost an opportunity to compel different behavior out of the W.H.O. by- by simply rejoining the W.H.O. I was critical at the time that the- President Trump made the decision to pull out the W.H.O. I had actually spoken with him directly, urging him not to do it, suggested that there were other ways he could send a strong message to China. Short of pulling out of the W.H.O. But once we pulled out of the W.H.O. and we were going to re-enter, we should have used the reentry to extract some kind of agreement about the W.H.O. engaging in some reform process and as best I know, as best we all know based on what's public, that wasn't done.

MARGARET BRENNAN: Leverage was given up?

DR. GOTTLIEB: The leverage was given up. Yeah.