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State of the Union

CDC Update on Ebola in U.S.; CDC to Look at Proposals for Entry Screening at Airports; Four Past Presidential Chiefs of Staff Advise Obama

Aired October 05, 2014 - 12:00   ET

THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.

CANDY CROWLEY, CNN ANCHOR: We begin with breaking news on Ebola in the U.S. We are moments away from news a conference of the Centers for Disease Control and Prevention in Atlanta.

At last report the Ebola patient in Dallas was in condition. While we wait for the start of CDC news conference, I want to bring in Dr. William Frohna. He is the chairman of the emergency of emergency department at MedStar Washington Hospital Center. And joining us from Nashville is Dr. William Schaffner. He is chairman of the Department of Preventive Medicine at Vanderbilt University.

Doctors, thank you so much for being with us. And so while we await this news conference, let me start with you, Dr. Schaffner and ask you, if there is anything missing in this public discussion of Ebola coming to the U.S.?

DR. WILLIAM SCHAFFNER, CHAIRMAN DEPARTMENT OF PREVENTIVE MEDICINE VANDERBILT UNIVERSITY: Well, perhaps not missing, but perhaps we haven't emphasized enough that the key public health response, finding the close contacts and keeping them under surveillance that was all done by the book. It is not very telegenic (ph), but it is the essential response.

A whole lot of attention has been directed to the fact that it took a couple of days to decontaminate that apartment. That's actually important but of lesser importance than getting the contacts. You know, this virus, Ebola, once it gets out of the body, it is as we say a wimp. It starts to dying right away. So there was not really a major hazard or even a minor hazard to all of that contaminated material in the apartment if nobody touched it.

CROWLEY: So, even for - so what you're saying as we were talking about those people who had to be in the apartment where the Ebola patient had been for four days and quite ill while there, that even they, if they weren't touching things that he touched were not in that much danger?

SCHAFFNER: That is exactly right. What is really important is finding all those contacts, and that is something the CDC and the local health department did exactly by the book excellently.

CROWLEY: Dr. Schaffner, let me interrupt you and ask Dr. Frohna to standby because we're not going to go to the CDC and Dr. Tom Frieden.

(CROSSTALK)

(BEGIN VIDEO CLIP)

DR. THOMAS FRIEDEN, CDC DIRECTOR: Diagnosed on Tuesday within two the hours we announced that - that evening we had staff on the ground helping the terrific staff in Dallas, in Texas to respond to this case, and we have no doubt that we will stop it in its tracks in Texas. It is worth stepping back and saying, how Ebola spreads.

Ebola only spreads by direct contact with someone who is sick or with their body fluids. So the core of control is identifying everyone who might have had contact with them, and making sure they are monitored for 21 days, and if they developed symptoms immediately isolating them to break the chain of transmission. There is no doubt that we can stop Ebola in this country.

Today, I'd like to spend a minute talking about what is happening in Dallas, and then turn to my colleagues there. And then about what is happening in the U.S. more broadly, and finally where we are with the epidemic in West Africa.

In terms of Dallas, the work there by the staff of the local and state health departments with the CDC assistance has been terrific. They have been able to assess all 114 individuals who might possibly have had contact. Of those, they were able to rule out that 66 did not have contact. They identified 10 who appear to have had contact with the individual when he might possibly have been infectious. Of those 10, seven are health care workers and three are family or community contacts.

In addition, there are about 38 other people in whom we could not rule out that they had contact. And so all of those 48 people will be tracked for 21 days to determine whether they have fever. And if any developed fever, they will be immediately isolated, tested and if they have Ebola, given appropriate care and determine whether there were any additional contacts to their case. That is how we have stopped every outbreak of Ebola in the world until this one in West Africa and that is how we stopped it in Lagos, Nigeria, and that is how we will stop it in Texas.

Going on to the U.S. situation, we have seen a lot of understandable concern. Because of the deadly nature of Ebola, and we are really hoping for the recovery of the patient in Dallas, we understand that his situation has taken a turn for the worse. We know that Ebola is a very serious disease and we are hoping for his recovery. But because it is such a deadly disease people are scared. And it is normal to be scared.

In fact, for the health care workers who are caring for people with Ebola we want them to be scared. We want them to have a healthy respect of the risk of any lapse in infection control procedure. We want them to channel that fear into being incredibly meticulous about infection control. Many people have pointed out that initially the individual was not diagnosed. And we have done a lot at CDC and we will be doing a lot more in the coming days and weeks to inform, and empower not just doctors, but nurses, health care professionals of all kinds to think about Ebola and anyone who has been in Guinea, Liberia or Sierra Leone in the past 21 days and has a fever or symptoms suggestive of Ebola. And to make sure that the index of suspicion is such that if that happens we rapidly isolate them, assess them, and if indicated test for Ebola.

CDC has already done -- reached hundreds of thousands of health care professionals with alerts, information, materials, tools, webinars at least once a week, and we will continue to ramp that up working closely with medical associations, with groups of doctors and nurses and others, and this basic issue of making sure that at this time Ebola remains top of mind in people who have had a travel history is something that we will continue to focus on.

At CDC, we have seen the level of interest increase. In fact, we were getting 50 calls or emails per day before the initial patient was diagnosed here. It is up to about 800 calls or emails per day. And we understand the level of concern.

We also understand that people would like to do everything possible to keep Ebola out of the U.S., and we agree with that 100 percent. Our top priority at CDC is to protect Americans from threats. We work 24/7 to do that. In this case, we are doing it by many different ways.

One of them is working to stop the outbreak at its source in Africa, because as long as cases continue there, there is a possibility that someone will travel, infect someone else, come into this country or another country, and possible have another case of Ebola. As long as the outbreak is continuing in Africa, there is a risk in other places. We have long said it and it is worth repeating that an outbreak anywhere is potentially a threat everywhere. But that doesn't mean we can't do anything.

One of the things that we can do is to make sure that everyone leaving the countries is intensively screened with their temperature being taken, questions being asked and being observed if they appear to be ill. That screening has in recent months removed 77 people who would have boarded planes to leave those three countries and didn't because of the screening of that CDC staff helped those countries implement. And I can assure you that the leadership of each of those three countries wants to ensure that the screening is as good as it can be, because they need then the airlines to keep flying, otherwise, they won't be able to keep their societies moving and we won't be able to stop the outbreak there.

In addition, of course, we work with the health care workers around the country, and so there is rapid identification of the cases. And of course, we are now at the issue of entry screening. And we're looking at all possibilities. There have been suggestions from people in congress, from the public, from the media. We will look at those and see what works to the protect Americans and to make sure that whatever we do does not intentionally actually (ph) increase our risk.

If we make it harder to fight the outbreak in West Africa, we actually increase our own risk. So those are the criteria that we are using, and working across the U.S. government. There are many agencies focused on this, and will be committed to doing whatever we can to further increase the safety of Americans.

Getting finally to the issue of what is happening in West Africa today. The situation remains very fluid. It is striking when I speak with the CDC leaders who are there, and we have sent now 135 of our top disease detectives, and they are working not only at the national level, but down to the county and district level in each of the three countries. One of the things that is quite striking is the diversity of the experience. This is not West Africa, this is three individual countries. Each of the individual countries has its own patterns of disease spread.

In some of them, there are districts that have not had a case of Ebola. In some, there are just a handful of cases in some of those districts. So we are moving to looking at each of the 62 districts across these three countries to see what more can be done to hone down this forest fire, to prevent it from spreading to areas it has not spread, to put out the sparks where it has spread to some places and where - places where it has got a huge problem to isolate as many people as rapidly as possible.

We have seen real progress in the response over the past one to two weeks.

The Department of Defense being on the ground has made a big difference. They are moving out and helping with the operations. We have also seen USAid very effectively increase support for families that want to respectfully and safely bury people who have died. And that is very important, because it reduces the spread of Ebola.

So, while we are still not ahead of it, we are certainly getting further along than we were before. I'm looking forward to briefing President Obama on the situation in West Africa tomorrow, and to further ensuring that the president's direction that we move rapidly to do as much as we can to stop this is what we are doing not only at the CDC, not only across the U.S. government, but globally, because we're seeing a tremendous global coalition committed to doing this.

So that is a bit about where we are in Dallas and the U.S. and globally. And before I turn it over to my colleagues in Texas, just to highlight that one thing that happened, and didn't get much notice in the past week, because it happened to be on Tuesday the day that we announced the diagnosis is that we published a report on what happened in Nigeria when they had a single case and they didn't do any infection control, they ended up with 19 secondary cases, additional cases. But because of a rapid public health response, effectively tracking nearly 900 contacts, it appears that they have been able to stop the outbreak in Nigeria. Though we can't give the all-clear yet, it does look like the outbreak is over there, because of good public health action. I am confident that anywhere we apply the fundamental principles of infection control and public health follow-up, we can stop Ebola.

UNIDENTIFIED FEMALE: Thank you, Dr. Frieden. The next speaker is Dr. David Lakey who is the commissioner of the Texas Department of State Health Services.

Dr. Lakey.

DR. DAVID LAKEY, COMMISSIONER OF THE TEXAS DEPARTMENT OF STATE HEALTH SERVICES: Well, good afternoon, this is David Lakey and the commissioner of health in the state of Texas. And again, I want to thank Dr. Frieden for the support of the CDC as we're working on this effort right now. It is one effort and is one team.

As I start off, again, I want to say that my thoughts and prayers and our thoughts and prayers are with the patient right now. Obviously, he is critically ill, but also with the family as they are going through this event, and the contacts that have been identified that are obviously have concern about what is going on with them right now. And with the hospital workers that are caring for this ill patient right now.

As I said earlier, we are doing our work in partnership with the CDC and our local health department here in the state of Texas. A lot of very important hard work is taking place right here in Texas, in Dallas to ensure that the people of Dallas are safe. And the good news is that we have had no more cases, and no one has reported any symptoms, and we are happy about that, and we're reassured that we are very still very cautious to the make sure we continue to care for individuals, monitor the situation the way it needs to be done.

Our focus here is to closely monitor every contact, and the possible contacts, and to identify all of the contact -- and we have identified all of the contacts. And our priority in public health is to continue tracking those individuals. We want to make sure that we are closely monitoring them. And that is why we are focused on.

Also, as we are monitoring individuals, as we identify needs that they may have, we are working through our incident command center to mach sure those issues are addressed. Making sure that food issues are identified or if electricity was turned off during the storm, that those issues are resolved. We have also, you know, the neighbors, also, they have had obviously concern, and we have tried to provide health educators in the community to help address those issues.

Our focus is to make sure that you are informed of what is going on and understand how the public health system works and what the risks may be. That the public health system works to prevent and contain these risks, and I know it has been noted several times, but obviously, a lot of people are listening right now, and I want to the re-emphasize that Ebola is not spread by the air. People are not contagious unless they have symptoms. This can't be stated enough. I think that it needs to be reassuring to the individuals that are listening today.

There are hospitals across the state of Texas and across the nation they are on the lookout for any additional cases and that is what we want. We want the hospitals to be on high a alert and to identify individuals that have a travel history to the areas that are affected and to come in with any symptoms that could be consistent with Ebola so these individuals can be identified quickly, and that health care workers can be protected. We're going to -- they are going to call on us, and that is exactly the way we want the system to work so that the once they are identified as a concern that they can get the testing that needs to be done. So we are all on high alert right now, and that is where we believe it should be.

We continue to plan for contingencies, and a lot of work is taking place to make sure that whatever happens, that we are as prepared as we need to be to address those issues. So again, Dr. Frieden, I want to thank you for the partnership between the CDC and the state of Texas and Dallas City and county as we work together to ensure the safety of the people in Dallas. Thank you.

UNIDENTIFIED FEMALE: Thank you, Dr. Lakey.

Our final speaker is Dallas county judge Clay Lewis Jenkins.

Judge Jenkins.

CLAY LEWIS JENKINS, DALLAS COUNTY JUDGE: Good morning and happy Sunday to everyone on the call.

I want to start off by thanking all of the people who are currently being monitored and their families. I realize that when you are being monitored even with a low risk for Ebola, it is a very unsettling and frankly terrifying process to the worry about. And I am praying for all of you and many others are as well.

This morning, I had the opportunity to participate in half of a mass. It was a mass by the bishop of the archdiocese of Dallas for the Catholic Church where 1.2 million Catholics have been --

CROWLEY: We have been listening to part of a briefing for the Centers of Disease Control now being taken over by folks in Texas, giving us the update, I think we - the bullet points out of here, Dr. David Lakey, who is head of the Texas Department of Health said, no new cases. No one is showing signs of having contracted Ebola from the one patient that is now obviously, and the only one in the U.S. We also learned from Dr. Tom Frieden, the director of the Centers for Disease Control that he will brief the president tomorrow.

We also learned that they are considering other measures, or (ph) there (ph) are some other way to ensure public safety in the U.S., including something he called entry screening which I have to believe while people are screened as they leave these three affected countries, that is kind of it for them. And so the question is, when people come in from the affected countries should there be entry screening. We have also learned that there is a huge uptick in the number of calls to the Centers for Disease Control which Dr. Frieden called a good thing.

I am joined by Dr. William Schaffner, he is chairman of the Department of Preventive Medicine at Vanderbilt, also by Dr. William Frohna, he is chairman of the emergency department at MedStar Washington Hospital Center. Let me pick up with the concern that Dr. Frieden talked about and ask you if you have seen that among - he said particularly among nurses and medical personnel, they have seen increased concern, because, of course, by the time they get them, folks are sick, and that is when it is the most transmittable.

Do you hear that in your emergency room?

DR. WILLIAM FROHNA, EMERGENCY MEDICINE DEPARTMENT CHAIR, MEDSTAR WASHINGTON HOSPITAL CENTER: I have necessarily heard that specifically, and I think that is in part, because we have wonderfully trained and wonderfully experienced professional nurses who have understood gone preparedness training years and years being a major hospital here in the district. That education is what alleviates the fear. And we have education programs ongoing for this disease specifically since July. And we're really obviously, uptick in the last couple of weeks. But I hearken (ph) back to the educational processes that went back with SARS 10 plus years ago. And H1N1 in 2009 and even MERS earlier this year. And all of those educational and those foundational building blocks of infection control are in place today and effective in this disease.

CROWLEY: So by and large, you are also not seeing a huge increase in public concerns in your emergency room?

FROHNA: Not yet. No. But remember, it is still even at the front doors in multiple different languages, the cautionary signs that advertise basically if a patient comes in, and has had international travel to alert their health care provider in the emergency department as soon as possible.

CROWLEY: Dr. Frohna and Dr. Schaffner, I want to ask you to stick with me. We're going to take a quick break and afterwards I want to come to you, Dr. Schaffner, and also talk about some of the news from Dr. Frieden about what is happening overseas at the point at where Ebola has exploded in West Africa.

(COMMERCIAL BREAK)

CROWLEY: Welcome back.

(BEGIN VIDEO CLIP)

CROWLEY (voice-over): The news conference in Atlanta at the Centers for Disease Control and prevention, and that is Dr. Tom Frieden. He is now taking questions. We're going to listen in for a little bit.

FRIEDEN: None of the five patients were initially diagnosed. None of them were cared for with any special precautions beyond what we generally do, and there were no secondary infections in any of those cases. And in fact for the woman who had Marburg, she underwent surgery before anyone knew that she had the Marburg infection.

So the standard precautions work, but they have to be very rigorously applied. And if hospitals want to be - want to have additional safeguards, that is entirely up to them, but we have for many years, in fact decades, cared for the patients in Africa with these conditions and not had infections as long as the infection control procedures are strictly followed. It is not a question of being highly infectious, it is a question of making sure that the precautions that are taken are strictly and meticulously adhered to.

UNIDENTIFIED FEMALE: I just had a second question with regard to the, you mentioned seven health care workers are among those being monitored, when the patient first appeared at the hospital, routine blood work was taken. Did your net include the people in the laboratory who are handling those blood specimens?

FRIEDEN: Yes. We have looked at all potential exposures within the hospital context. We will go to the phone for the first question.

UNIDENTIFIED FEMALE: Our first question is from Elizabeth Cohen with CNN. Go ahead your line is open.

ELIZABETH COHEN, CNN SENIOR MEDICAL CORRESPONDENT: Hi, Dr. Frieden, and everybody else. Thank you so much for having this press conference.

Dr. Frieden, can you tell us if the Dallas patient is receiving TKM Ebola or any other medicine besides the supportive care?

FRIEDEN: I actually did not hear the specifics of your question. Is he receiving -- what did you ask?

COHEN: TKM Ebola or any other medicines besides supportive care?

FRIEDEN: As far as long as understand experimental medicine is not being used. As I mentioned earlier the medication you mentioned can be quite difficult for the patients to take and may transiently worsen their condition. So it is really up to his treating physicians, himself, his family of what treatment to take. Supportive care, managing fluids, supporting the patient's vital functions, these are all critical issues to be addressed.

Next question on the phone?

UNIDENTIFIED FEMALE: Our next question is from Donna (ph) Young (ph) with Scrip (ph) News (ph). Go ahead your line is open.

DONNA (ph) YOUNG (ph), SCRIP (ph) NEWS (ph): Hello. Thank you for taking my call. I had a question about the difference between why you have got the physician that was exposed in Sierra Leone being monitored or treated at the NIH as opposed to the Duncan family and friends why they were kept under guard in an apartment complex and now moved to the private home. Why are they not being monitored in a medical facility when you have got another person being monitored at the National Institutes of Health Clinical Center? And the also, when will the CDC make public the status of the doctor at the NIH and has he actually been tested for Ebola?

Thank you.

FRIEDEN: So, for any questions on individuals, you have to consult the treating facility, and they would consult the family, and that is who would make available any information. The situation in NIH, it is a clinical research center, where clinical research is done, and you have to refer any questions to them. In terms of the contacts in Texas, I will make a brief comment and then turn it over to Dr. Lakey or Judge Jenkins to add.

The concern for anyone who has had contact is not that they may infect other people. Judge Jenkins said it exactly right, they are not a risk to others. The only thing we need to ensure is that their temperature is monitored, and if they develop a fever, that they are immediately assessed, isolated and if found to be positive, then appropriately cared for. The -

(END VIDEO CLIP)

CROWLEY: OK. Again, this is Dr. Tom Frieden, and he is the director of the Centers for Disease and Control and prevention out of Atlanta obviously talking about Ebola as much of the country has been. We're going to continue to monitor that, but right now we want to take a quick break, because when we come back we want to talk to a couple of doctors on the front lines of health care here in the U.S. from the emergency room and from the preventative side how we should be looking at Ebola. We will be right back.

(COMMERCIAL BREAK)

CROWLEY: We are back with Dr. William Frohnan, chairman of the Emergency Department at Medstar Washington Hospital Center and from Nashville, Dr. William Schaffner, chairman of the Department of Preventative Medicine at Vanderbilt.

Dr. Schaffner, I want to take advantage of your 30 years in infectious diseases. You are one of the country's leading expert. So walk me through it when Dr. Frieden at CDC says we are looking at other things that could be done to further protect the U.S. public like entry screening.

Explain to me what that would involve and if there is anything else you see that might, looking at down the pike, be something that the U.S. could do?

DR. WILLIAM SCHAFFNER, CHAIRMAN, DEPT. OF PREVENTIVE MEDICINE, VANDERBILT UNIVERSITY: Well, beyond the general education of the public which is very, very important, the entry screening would entail trying to identify people who have recently been in West Africa.

And they did not necessarily fly directly to the United States from West Africa so you would have to screen a lot of people by questionnaire, and you would ask them if they have been feeling ill, and you could very rapidly take their temperature using new kind of electronic devices.

So I'm sure that is the sort of thing that they are thinking about, but if you have ever been on any plane that has come into the United States, they are huge planes, disgorging a whole lot of passengers, if you think about that for a half moment, you will see how difficult that is.

And even if we could do it quickly and efficiently, it is imperfect also. None of the devices are perfect and the question is, would the juice be worth the squeeze?

CROWLEY: And tell me why we are hearing so many physicians and also from the CDC and the White House saying, you know, stopping planes or passengers who have come from West Africa will not help and might hurt.

SCHAFFNER: Well, one of the ways it might hurt is here we have lots of volunteers and people from the military and the United States public health service going abroad. How are we going to get them there and bring them back efficiently? Will that create further barriers to volunteers for example?

Also, you will impair the economies of these countries. These are already very poor countries. They have fragile economies and somewhat fragile governments. The last thing we need is more unrest in those countries.

CROWLEY: Got you.

SCHAFFNER: Their economies have already been seriously damaged.

CROWLEY: Thank you. Dr. Frohna, taking advantage of your perspective from the emergency room. When I walk into the emergency room, your emergency room today, and say, you know, I feel nauseous and I have a fever, am I immediately going to be getting attention in that emergency room? Are you on that kind of alert?

DR. WILLIAM FROHNA, CHAIRMAN, EMERGENCY DEPT., MEDSTAR WASHINGTON HOSPITAL CENTER: We are on alert that if you would add the epilink of travel to it and travel being from and to one of the three or four countries discussed, that is the trigger.

And you are encouraged from the very time that you step foot into the emergency department in several languages to notify the nurse, the service associate, et cetera, that you have been traveling and to bring that to the attention to those individuals immediately.

CROWLEY: So there are signs up on the walls in your emergency waiting room that say, if you have been to these places, you need to put your hand up.

FROHNA: It's in the anta room before you step foot in. It's in the waiting area. It's at the front desk registration. Redundancy, you can't do enough in the situation.

CROWLEY: And these are new since the Ebola scare?

FROHNA: They are actually modified. So you go back to 2009 with the H1N1 and you go back to MERS. We've had signage up for now it seems like months and with the flu season coming, we will continue to have these signs up for masking cough and protecting others and yourself. CROWLEY: And it is often when you go into an emergency room, if say, I feel like I'm having a heart attack that is an immediate ticket to a room to get hooked up.

If you come in now, is it also an immediate ticket to an examination room if you have those three things, I have just traveled to Sierra Leone or Liberia or Guinea and I'm feeling nauseous?

FROHNA: Yes, that is a free ticket into the room, and it may not be the room that you see yourself being in, but it is the room where you are the safest, where our staff have you in the right place, and they remain safe, and our job is to prepare to detect these cases, prepare to protect the health care workers, and prepare to treat and respond.

CROWLEY: And finally, just in the -- how confident, and it sounds like you are ready.

FROHNA: Yes.

CROWLEY: How confident are you that that is nationwide?

FROHNA: I am confident. I'm actually very confident. Emergency medicine and emergency departments are relatively a small group, but you can count on the 4,000-plus emergency departments in the country to be ready. We are ready 24/7 everyday, but in particular in this situation, doubly ready.

CROWLEY: Dr. Bill Frohna, thank you so much out of the Medstar Washington Hospital Center here in Washington. Dr. William Schaffner out of Vanderbilt for us, chairman of Department of Preventive Medicine, thank you both so much.

Next up, advice for the president from the people who have been there. I will ask four former White House chiefs of staff from both Republican and the Democratic administrations how the president gets out of this mess.

(COMMERCIAL BREAK)

CROWLEY: With me around the table, four former White House chiefs of staff, William Daley worked in the Obama White House, Mack Mclarty was former President Bill Clinton's right hand man, Andrew Card served former President George W. Bush, and Ken Duberstein was with former President Ronald Reagan.

Lots of history sitting at this table so, let me take advantage of all this brain power and say here is a president who is in trouble regardless of whether he should be or was at fault. This is a guy whose ratings are low. He is in his twilight years, last two years.

People are leaving. People are writing books saying not such great things. How does he shake loose from that and have a productive two years or can he?

MACK MCLARTY, FORMER CLINTON WHITE HOUSE CHIEF OF STAFF: Well, I think that he can, Candy. I think Mark Twain moments in the second- term presidency seem to be a fact. We've seen it also with Reagon, with Bush 43 and certainly with Bill Clinton.

But we've also seen all three of those presidents renew the last two years and get some things done and accomplished and certainly there's a hunger for that by the American people.

CROWLEY: Bill, you know this president and have worked with him. What do you say to him now as people are saying, he looks disinterested. He looks weak. He looks sort of like turning the pages.

WILLIAM DALEY, FORMER OBAMA WHITE HOUSE CHIEF OF STAFF: I do know him and I know there's one guy who's not on that mindset and that's the president. He knows that there are enormous challenges, things that he can control, things he can't, Ebola, ISIL. You've got to address them. It's not as though you can take off.

He knows this better than anyone -- and we all know it -- the last two years. We have a big election in five weeks and see what happens because that will really determine, will their leadership change in the Senate. If it does, what does that mean?

Does it mean there is an attempt to get things done or whether or not we stay in this sort of -- as we've done the last two years with this political battle only in transgenes, or a dysfunction in Congress and the executive branch, and it's a terrible thing?

I think there's great opportunity in the last two years no matter who's controlling the Senate. The American people are really fed up with this game.

CROWLEY: They are that. This will be an interesting election. But how do you -- pick a subject, any subject, Secret Service, Ebola, ISIS, what is going happen with Iran, pick any of those and is there something that the president ought to be doing that would help kind of erase this idea that he's kind of attached and not paying attention?

ANDREW CARD, FORMER G.W. BUSH WHITE HOUSE CHIEF OF STAFF: I think he's got to be an aggressive and active leader in all of those categories and demonstrate some emotion and demonstrate some commitment that is real and I think he's also got to reach beyond the partisanship.

Yes, he's involved in a re-election campaign for the United States Senate and for congressional candidates, but he's going to be almost above it and do what is right for the country all the time.

Keep the oath and focus on that, motivate America to understand his responsibilities to lead, but also the world is crying out for leadership. And I think if he were to provide more leadership there, it would help him in his partisan political interests of creating more momentum at home.

KENNETH DUBERSTEIN, FORMER REAGAN WHITE HOUSE CHIEF OF STAFF: Candy, Ronald Reagan was faced with a very similar problem. He was at 37 percent in the polls, Iran/contra had just happened. We had just lost to the Democrats for the first time in his presidency. Ronald Reagan rather than being a lame duck, a virtual dead duck for the last two years decided to clean house, get fresh voices. Every two-term president needs fresh ideas, fresh voices and strong people. He got Howard Baker. He got Frank Carlucci. He got me and he got Colin Powell.

We helped him rebuild those last two years. So in some ways the last two years were the most important two years. Strategic arms talks and a treaty with the Soviet Union.

CROWLEY: Is there opportunity for the president to, A, clean house just personnel wise and also we've seen this week changing the subject. We are seeing him say let's talk about the economy and energy policy. Does that work?

DALEY: Well, obviously enormous scandals like Iran/contra causes an enormous shift in the personnel in the White House because that was a scandal that went to the heart of his administration. You don't have that right now, obviously.

You have enormous problems that are being put on this administration, some that they can control and some that they are addressing quite well. You're talking about the Secret Service. You know, I look at that as -- they are a tremendous organization. It is challenged right now.

No doubt about it. There's been mistakes made, but they are out there and they have to be right 100 percent of the time 24/7 and they do that. So I will separate that from an Ebola or ISIL or other things. That is being handled.

Obviously there was a change in leadership and that's what you had to do and it was done and I think we move forward on that. I think we ought to get off of that trying to beat up these men and women who spend so much time defending the president and doing a great job.

MCLARTY: And I think, Candy, perhaps the president is already on a pathway. I don't think he has much room on domestic policy until after the midterms. I do think there is room after that. Hope springs eternal. We see how hard that is.

But having said that, I think he's already built an international coalition or is in the process of that concerning ISIL. He's brought along Europe in terms of Russia. So I think he's already beginning to build the right pathway and demonstrate some of that leadership that the American people have such a strong desire for.

DUBERSTEIN: Yes, but, look, he can get more done with a Republican senate whether it's trade, whether it's corporate tax --

CROWLEY: I'm going to let you argue that in just a second, as a matter of fact. I want everyone to stay here because we are going to talk more politics coming up. Will President Obama get anything done in his final two years if it all turns Republican?

(COMMERCIAL BREAK) CROWLEY: We are back with our former White House chiefs of staff. We'll start out with an article today. Dan wrote two years after winning re-election, Obama is a muted force on the campaign trail to the extent he's even on the campaign trail.

He's limited in where he can travel, constrained in how he speaks about what has been one of the biggest issues of his presidency, the economy, and struggling to ignite the passions of a Democratic base in a year when turnout is so critical.

So, you have a president and all of those things are true. His poll ratings are quite low. What do you do with him and/or, and this is a dealer's choice question, and what if he gets all-Republican Congress then what?

MCLARTY: You use him in the way that each of the presidents we represented. And you use him with the base, a lot of fund-raising. If he was on a campaign trail full-time he'd be justifiably criticized rather strongly because of all of the difficulties that are going on in the world and in this country with the Ebola scare.

So I think right now you'll see him at the end going to the base as all the president's we've represented or worked for have done, and I think that will be very, very helpful in those races where the base of the Democratic Party in a very low turnout election will make a difference.

CROWLEY: Excuse me, go ahead, Andy.

CARD: He kind of stepped on it this past week by basically saying this election is really a referendum on him. This is a referendum -- and not the economy --

CROWLEY: Kind of stating the obvious a little.

CARD: But when you're at 5.6 unemployment, that's a pretty good thing to talk about. Well, that message is not resonating with the American people.

DUBERSTEIN: A lot of key races are in the red states. All the red states there is not one Democratic candidate who wants President Obama to be there, and every Republican in a red state wants Obama to come into that state.

CROWLEY: And you have been there with George W. You have been there certainly with Bill Clinton.

CARD: Even though he was popular, we got disinvited. So the strength is raising money, being an international leader, a strong international leader, and I'm going to say be where you are welcome and don't be where you're not.

CROWLEY: Which is good advice for almost anybody. Wrap this up for us and tell me what you think could possibly get done in this day and age with an all-Republican Congress should that happen and a Democratic White House? MCLARTY: I think there's a real opportunity, as we've seen in each of these presidencies the last two years for a lame duck indeed to fly. And there is such a demand and a hunger by the American people for leadership to get something done.

The country is anxious, concerned, frustrated. I think you've got trade is going to be front and center. The president is going to Beijing in November to meet with President Xi and other APEC leaders.

You have tax reform. Both of those are Republican issues. I think you have a window. Will it be easy? No. It's the right policy, right politics and the right thing to do for the country.

CROWLEY: We have a minute left. Can we agree that Republicans should they take over Congress have a vested interest in doing something?

DUBERSTEIN: We have to demonstrate an ability to govern the way President Obama has to reach out and start building relationships, even at this late time, relationships not just with Democrats but with Republicans.

CARD: There are two chapters to the next experience, one is the lame duck session and then the new Congress and both of those are opportunities for President Obama.

CROWLEY: We have 15 seconds.

MCLARTY: The new Congress, if it does change, has got to show a willingness to compromise. Not just say we're going to pass what we can pass because we have a majority, but work with the White House, work with the president before they put that bill on the floor.

DUBERSTEIN: The Republicans are not going to have 60 votes in the Senate.

CROWLEY: No, they will not. I know that.

DUBERSTEIN: That's why you have to compromise.

CROWLEY: We should stay here. Thank you all so much for coming. We'll be right back.

(COMMERCIAL BREAK)

CROWLEY: Thank you for watching STATE OF THE UNION. I'm Candy Crowley. "FAREED ZAKARIA GPS" starts right now.