USA TODAY

As the stock market was plunging Monday amid coronavirus fears, Dr. Scott Gottlieb, who served as commissioner of the Food and Drug Administration from 2017 to 2019, met with USA TODAY’s Editorial Board to discuss the COVID-19 outbreak. Gottlieb, 47, did a residency in internal medicine at New York’s Mount Sinai Medical Center and is currently a resident fellow at the American Enterprise Institute. Questions and answers have been edited for length and clarity:

Q. Looking at the big picture, where are we, and where are we headed?

A. I think the next two weeks are going to be very difficult. I think that this is going to play out over the next two months, but you're really going to see a change, I think, in the country's perception and mood and approach over the next two weeks. We're entering a period probably of rapid acceleration in the virus in United States.

Q. Why do you say that?

A. Broad diagnostic screening is getting in place, and we’ll start to catch up to the rate of infections. It's probably the case that we have multiple large outbreaks in major metropolitan areas that we're unaware of. Seattle's clearly one. Santa Clara (California) is one. New York is appearing to be one. It could be that it's spreading in other cities, and it just hasn't gotten into an institution where it has become readily apparent.

Q. Can an epidemic still be avoided?

A. We certainly are past containment. We have to think about aggressive steps at mitigation. It's impossible to avoid an epidemic here in the U.S. We do have the potential to limit the scope of the epidemic, but we need to be taking more aggressive steps. My concern now is we're not taking aggressive enough steps at mitigation to prevent a broader epidemic. And so the risk is that we have the potential for tens of thousands of cases and not just thousands of cases.

Q. What can mitigation accomplish?

A. If you implement mitigation steps, what you do is, you slow the rate at which people get the virus. You end up extending the epidemic, it lasts longer, but it doesn't peak as high. You want to slow the rate of infection here so that you can manage it with the health care system. That's got to be a primary concern right now.

Q. What does aggressive mitigation look like?

A. Shutting down businesses where you have a large number of people congregating indoors, where you have rapid spread. Think of movie theaters. Requiring businesses to have nonessential people telework. Slowing transportation.

Q. How about locking down cities like they did in China and are doing in Italy?

A. You don't need to lock down a city or quarantine a city. I think that's the wrong approach. I don't think you can do that in this country. But if you substantially slow economic activity in a region of an outbreak, you're going to have less mobility. People aren't going to be traveling in and out as much. And so you can achieve almost the same goal that you would from forced quarantines.

Q. Is it still feasible to try to trace everyone an infected person has come into contact with?

A. Contact tracing right now is no longer feasible in terms of being a tool to contain. We're past the point of containment, and continuing to focus on containment is diverting a finite pool of public health resources on the wrong mission. We should shift the mission. Now, there is still virtue in trying to do some contact tracing, so you can identify clusters and focus testing, especially since you have limited testing. But you're not doing it with the purpose of trying to contain the outbreak. We're past the point of believing that we can prevent epidemic spread. Now the goal is to have a limited epidemic and reduce the scope and severity of it, and that's still possible.

Q. Could the unseasonably warm weather put a lid on the coronavirus outbreak, like it does with seasonal flu?

A. There is evidence that coronaviruses don't circulate in the summer. It's mostly because the hot, humid air doesn't allow the respiratory droplets to transfer as easily, and also, the viral particles don't survive well in that kind of an environment. So July and August should be a backstop. I think we're still not at a point where it's warm enough that that's really going to have a dramatic impact, although it will have some impact. But I don't think we should assume that transmission is just going to break off as it gets warm. This is such a novel virus that this could continue to transfer in warm months.

Q. What steps are making a difference?

A. All of this is helping — What the businesses are doing, the fact that consumers are nervous and are taking precautions on their own. The fact that mobility and travel have slowed down. The fact that it is getting warmer. All of this will have an impact in slowing the spread of this. But will it prevent us from having an epidemic at this point? No. Could it prevent us from having a very large epidemic? It will help. It will absolutely help. But it needs to be coupled with policy steps that engage the kinds of mitigation tools that we talked about, especially in places where you currently have large outbreaks.

Q. What else can we do, short of shutting down whole cities?

A. All these little things really matter. The temperature checks of food handlers, requiring the taxi cabs are cleaned and the plastic partitions. All those little things. The scope of this social distancing that (the Chinese) engaged in was phenomenal and helpful, beneficial. That stuff we can do. It costs money, but you're not taking away people's liberty by telling them you have to clean the Ubers three times a day. You're going to see a drop off in shared riding pretty soon, because people aren't going to want to get in cars when they don't know who is in the car before. So the businesses should be doing that. It makes good economic sense; it makes good public health sense.

Q. How long is this going to last?

A. We're looking at changing American life for a couple of months. … I think that March and April are really going to be the months that are going to be very difficult. And, hopefully, if we've done the right things, we'll be coming down the epidemic curve toward the end of April. The summer should look different. I think there's still going to be outbreaks, and we're still going to need to be very vigilant about stepped-up hygiene and about taking reactive measures when there is a case identified, so this isn't going to go away.

Q. As we see the numbers spike over the next couple of weeks, how can we determine how much of that is new infections versus testing of existing infections?

A. It's going to be impossible. The numbers are going to grow for a while. I think you're going to know you've turned a corner when a lot of the new infections that you're diagnosing are diagnosed in known clusters.

Q. Should schools be shutting down?

A. Seattle has a large outbreak underway. They might consider just preemptive school closures across the whole district. But otherwise, I think that you want to think about reactive school closures because closing schools has its own impact on social lives and an impact on public health that could be adverse and could potentially even worsen the epidemic. … So broad preemptive school closures, I personally wouldn't advocate that.

Q. And large gatherings?

A. I think right now, we should be limiting large gatherings, especially in areas where we know that there's spread.

Q. Would you cancel March Madness?

A. I think we're going to be at a point very soon where we think of canceling sporting events (or holding) them in empty stadiums like they're doing in South Korea. You don't want to bring together a lot of people in closed spaces, especially indoors, where you can have easy transfer. Look at what happened with the CPAC (Conservative Political Action Conference) and AIPAC (American Israel Public Affairs Committee) conferences. Do you want to continue to hold conferences and have to run the risk that your entire attendee list is put into a quarantine because there was someone there who is infected?

Q. Should the government shut down the cruise industry?

A. I don't think anybody should be taking a cruise right now. Whether or not the government has the tools to step in and do that, I imagine they do. These cruise ships are foreign-flagged cruise ships. They need permission to dock here and disembark here.

Q. Why are cruise ships so problematic?

A. This is a very sticky pathogen that once it gets inside a closed space in an institution, it has wide propagation. It's an awful risk to pack a lot of people on a cruise ship. And look, cruises left Sunday night out of Seattle in Washington state. I think that was a big risk, letting passengers get onto cruise ships out of Seattle, given what we know about the environment in Seattle. And given what we know about the risks associated with cruise ships. There's going to be other cruise ships that are going to end up having outbreaks on them.

Q. How about airplanes?

A. I'm still flying when I have to. I was on a plane this week, and I'm going to be on a plane (Tuesday). I'm taking extra precautions on the planes. I think there's things you can absolutely do to improve your safety on a plane for something like this. And I'm trying to do everything I can to do that. One thing that's been disappointing me, I was on a plane Saturday, and I got on a plane, there was no Purell (hand sanitizer) when I got on the plane. They didn't hand me anything when I got on the plane. The (flight attendant) was passing things around without gloves on, wasn't changing gloves.

Q. What more could the airlines be doing?

A. There's things that the airlines could be doing to implement better infection control on the plane and inspire more confidence that they're just not doing. But they're running around Washington talking about the impact that this has had on their volumes and the economic impact, and probably laying the groundwork for another bailout … and I don't see them doing anything proactive to actually control the circumstances. They could be building in more time between turns of planes to do deeper cleanings.

Q. Which airline did you fly?

A. I flew American.

Q. Should the presidential candidates end their big rallies?

A. We absolutely should think about protecting the candidates in the same way we protect them from other risks. We should be protecting them from the risk of transfer of this. They fly around the country. They see different audiences. They're in regions where there could be outbreaks we haven't detected yet. I would absolutely curtail retail politicking and a lot of touching and handshaking. I think that it would be smart for the campaigns and for the political leaders to lead by example and start to curtail large gatherings. I think for the campaigns to lead by example and do that would be very important. It would send a powerful message. So I would be looking at trying to do things with small town halls and then stream it.

Q. Who is at the greatest risk?

A. The case fatality rates really start to increase dramatically above 60. So you look at some of the literature, 60 to 70 case fatality rate is probably about 4%; 70 to 80, it's probably 10%; above 80, it looks like it's 14 or 15%. It really goes up dramatically. But this isn't a benign illness, even for someone who's 45, or 47 like me. (Potentially) 1 in 250 to 1 in 550 45-year-olds who get this will die. That's enormous.

Q. What about kids?

A. The only group that seems to be spared, thankfully, are young children. And nobody can convince me that they're not vectors. Maybe that's because I have three of them, and I think that they carry everything. But they just don't seem to be becoming symptomatic.

Q. How do you protect nursing home patients?

A. Maybe you limit visitors. Maybe you check every visitor who comes in, put them through a questionnaire, check their temperature, you know, be more vigilant with your staff, require staff to wear masks. I mean, there's things you can do to really reduce risk in those kinds of settings.

Q. What can the president do in a situation like this?

A. The most powerful aspects of the presidency, in a setting like this, is the bully pulpit and the ability to reassure the nation and speak candidly and honestly, talk about the risks in a proper context and also talk about what life's going to look like after we get through this. I think there's also the ability to try to put pressure on local and state governments to take more aggressive actions.

Q. Such as?

A. What we're going to need to do right now is ask local governments and state governments to act in the national interest. Seattle has to shut down its economy not just because of Seattle, but to help save New York and to help save Dallas. And that's a hard thing to ask a local government to do.

Q. What is the appropriate messaging?

A. It needs to acknowledge people's concerns and their anxiety, because people have very legitimate concerns and fears around this virus, and they should. The first thing I think of when someone says don't panic is, maybe I should panic. And so I think you need to acknowledge the fears, explain what the scope of the risk is and talk very plainly about what you're doing to mitigate it and what the other side of this looks like. Because there is another side of this. We're going to look back. This is going to be an historic moment, in my view. But we're going to look back and say that was really bad, but we were able to get through it.

Q. What went wrong with the testing?

A. In a public health emergency like this, when you have a new pathogen, it was always contemplated that CDC (the Centers for Disease Control and Prevention) would go first. And there's good reasons for that one. Number one, CDC has access to the samples. If it's an emerging pathogen, nobody else is going to have access. You want to have special handling of the pathogens. They become pathogens of special interest. You want to make sure any diagnostic you're developing is going to be reliable.

Q. What should have happened?

A. I think what should have happened, and what we were calling for, was simultaneous to having CDC go through the steps that they would go through, we should have been working aggressively with the manufacturers and the academic labs to also stand them up, because that takes time. And also working to develop a point-of-care diagnostic like the flu swab that you can use in a doctor's office, because all that takes time. It could take weeks to do that and sometimes a couple of months. And I think that the mistake we made was we took a very linear approach, rather than sort of an all-of-the-above approach. We ended up doing all those things, but we ended up doing them late, and now we're still behind the curve.

Q. Who decided to not do the all-in approach? Do you see any political influence on that decision?

A. I don't see any political influence on this decision. These are decisions that are made at the high leadership level in HHS (Health and Human Services). It's something that an FDA commissioner can't just easily do on our own. I mean, I might have, but I was perceived as someone who went rogue all the time.

Q. Are more tests getting out there?

A. Any doctor who thinks a patient should be tested should be getting tested. That's not happening right now. I think over the next two weeks, the testing capacity is going to ramp very quickly. If you look at the testing in the United States, we've probably tested about 3,000 patients, based on my analysis. Capacity is more than that right now. Of those 3,000, we've found about 400 positives.

Q. What does that tell you?

A. The people who are getting tested are sort of what we call in medicine "warehoused patients." They were patients we know are positive, and we've just been waiting to test them. And so we're going to be working through that backlog for quite some time. We're probably at the capacity to test 10,000 samples a day right now distributed across the country. Each patient has two samples. So that's 5,000 patients a day. The other challenge is, it's not evenly distributed. New York needs much more testing capacity than it has. So does Washington, D.C.

Q. Is this a pandemic?

A. Containment was never going to succeed. This was going to become a global pandemic. It spread like the flu. It is a pandemic now, notwithstanding the WHO (World Health Organization) not wanting to label it yet out of some odd sense of political correctness I can't fully appreciate.