We’d gotten through a horrible April, but even as the cases we could see through our limited testing continued to significantly decline, I was still uneasy. In smaller meetings, when it was just Bob, Tony, Steve, and I, I’d express my gut-level concern.
“What are we missing?” I’d ask.
As we looked at one another, one answer became obvious: sleep. We all looked drawn and pale. The three of them had been at this for weeks before I came on board, and with no weekends to recharge, the toll of twelve- to fourteen-hour (or more) days, seven days a week, had become evident. My husband, whom I’d married only a few months before, had taken on all the household responsibilities. I’d given up walking to work, and he was my chauffeur. I’d also given up on cooking, something I loved, but I couldn’t stop gardening. Every day, in the few moments I had between rising at three thirty in the morning to review data and getting out the door by seven to start my workday, I planted and pruned, weeded and watered, all in the dark. With so many in the neighborhood having walking the streets as their only outings I wanted our gardens to be welcoming and something to make them smile. Some things were still possible. Rain. Sunshine. Flowers.
This was also my thinking time, and during it, the question What are we missing? became part of my breathing—regular, insistent. Those thoughts competed with another set of thoughts: We were making some headway in critical areas. During the first weeks in May, the level of the outbreaks in the major metropolitan areas, like New Orleans, Chicago, and New York, was subsiding. The darkest days of March seemed to be behind us. It certainly wasn’t time to declare anything like an overall victory, but like the flowers in the garden, they served as a reminder that there was hope. But given my natural and professional inclination toward worrying, I kept hearing that other voice asking, What are we missing?
At that point, as I weeded, and planted, I knew how important it was to stay vigilant. Along with those big picture improvements in the metropolitan areas, I was pleased that some of the CDC issues we’d been dealing with had improved. Irum’s-led data team was scouring every source possible to learn of any increase in the rise of cases. Tracking and tracing down to the county and zip code level had proved effective in picking up the first signals of a possible larger outbreak. For example, in early May, isolated hot spots were emerging in Iowa, Nebraska, Kansas, South Dakota, Colorado, and the Navajo Nation. They weren’t statewide; they seemed to be isolated to certain counties. When we picked up that flash of rapidly rising case incidence, we worked closely with the CDC, sending them the counties we were concerned about. The CDC took that data, and its investigators called local public health agencies where those sparks and new small fires were seen. The CDC was very good at doing this. This matched with the procedures and skills they used to track foodborne illness. Applying those same procedures to SARS-CoV-2, the CDC investigators were able to track down the source of the outbreak to precise institutions within the county.
In early May, the vast majority of viral spread was most often isolated cases at meat-packing plants, LTCFs, and prisons. Penetrating deeper, in some cases the CDC’s team was able to find a single individual who was the first person to be infected and who then passed it along. Almost without exception, that person had visited a major metropolitan area that was still confronting high cases, and came back to their local community, likely asymptomatic, and infected others. From this, the CDC personnel, using data they received from the local authorities, tracked the spread and entered into the database a code that indicated the exact source of the infection—so for instance, when cases began in a prison, they were recorded as a P for Prison, since they arose in that particular type of institution. The CDC would support the state in testing everyone at those sites, revealing that hundreds of cases had developed over a week. The CDC would then continue to monitor the situation and continue to test in partnership with the state and local authorities; our data team did as well; soon, data showed that the flare-up had diminished in intensity and was nearly extinguished.
That approach worked well, but it resulted in an unintended consequence. Even though these outbreaks were isolated to a specific site, on some media outlets the entire state would flash bright red as the cases rose dramatically in this one county and then the next week bright green signaling the rapid decline in any additional cases in this county. I was worried that this would give Americans the false impression that in the future we could expect immediate control of the virus across broader geographical areas that quickly. We were controlling facility-based outbreaks and watching for evidence of community spread, but larger-scale outbreaks would definitely take more time to evolve and for our response to evolve along with it. Jumping the gun and raising false hopes too quickly was another aspect of the messaging response we had to guard against. Making sure that what was being conveyed in the media matched the reality our evidence base was showing was essential to managing the public’s expectations and getting them to buy into needed behavioral changes.
It was the “nearly extinguished” that fertilized my sense that we were missing something. So far, in those first few months, with the majority of the cases in densely populated, cramped cities and their surrounding communities, the case incidence curves produced there were large—picture a nearly standard bell-shaped curve, something that has an obvious shape to it. The curves weren’t complete, especially with still inadequate testing, of course, but a clear trend was readily apparent. In early May, along with those obvious curves, we were also seeing something like blips on an oscilloscope, small isolated bursts and tiny waves, which we identified and worked with the states and the CDC to immediately control, but was there something else lurking beneath the surface.
Based on the available data, for those institutional outbreaks, additional testing was done in the household associated with the worker. This broader testing in many cases also showed little community spread. Consequently, it seemed as if that outbreak was contained. (In addition to coding exactly the type of institution, the CDC also used C to indicate where community spread was occurring.) With these spikes at the start of May, that community component accounted for less than 10 percent of the total codes in counties where these institutional flare-ups occurred. Slowly, incrementally, but still perceptibly, that number increased for the next two weeks, rising at first to as much 30 percent of the counties’ codes, attributable to a mix of institutional and, in some counties in the South, community spread.
What was the source of that spread? Overall the situation seemed to be in hand, even at this local level, but still the thought nagged at me that we were missing something. As May went on, my growing sense was that some seed had been planted beneath the surface, and had germinated, sprouted, and grown from a single seedling into a field of invasive weeds.
While I was wondering about that missing component, other aspects of the ongoing struggle to wrestle with so many challenges became more obvious.
The first week of May, I learned that both our task force data team and FEMA/HHS were running parallel data teams tracking the pandemic, including hospitalizations. That figure was critical in determining how the limited U.S. supply of remdesivir, the antiviral medication that was proving highly effective at treating Covid-19 disease, would be distributed. Given that we had the promise of approximately only a million donated doses over the next months, with a six-month wait before new doses could be produced, allocating wisely was top priority. Having this kind of parallel systems and duplicated data could potentially cause problems and wouldn’t do anyone any good.
The remdesivir would come to us in weekly batches of twenty thousand to twenty-five thousand doses. The plan was to monitor the situation and adjust the allocation numbers based on rising new hospital admissions of Covid-19 patients. The CDC had improved its reporting system, increasing from 40 percent to 75 percent of the hospitals in the country reporting. My internal data teams were calling hospitals and tracking new Covid-19 admissions; the FEMA/HHS data team was tracking total hospitalized Covid-19 patients. The FEMA/HHS figure wouldn’t help us determine where the remdisivir shipments needed to go. To be effective, this intravenous drug must be administered immediately after a patient is admitted to the hospital—at worst, within the first twenty-four to forty-eight hours.
Since my arrival to the task force, I’d been asking the CDC (for many reasons) to get all six thousand hospitals to report daily new Covid-19 admissions, current Covid-19 patients, and newly admitted intensive care unit patients; this was the only way to identify current needs as well as project future areas of increased need so we could be proactive in our responses rather than reactive. With the game-changing remdesivir, whose efficacy depended so much on the timing of its administration, we needed new admissions data now more than ever.
The problem I’d feared resulting from having two different data streams materialized. Despite my instructions that shipments of remdesivir go to hospitals with the highest new admissions, the initial week’s supply didn’t go to these locations. Rear Adm. John Polowczyk at FEMA had used the data it had: total Covid-19 inpatient status. As a consequence, we wound up sending supplies of remdesivir to facilities where patients, weeks into their illness and with long-term complications, still lingered. They would never benefit from the drug. Newly diagnosed patients who urgently needed the drug didn’t get it. Shipments were sent to hospitals that lacked the refrigeration units needed to preserve the drug, and therefore ran the risk of spoiling what we’d sent them. In one instance, a batch of the drug went to the wrong “Columbia Hospital” because no one had checked the address.
I was furious.
The next day, I walked into the White House at 7:15, sleepless and unsettled. At 8 a.m., I attended the daily morning meeting held by Chief of Staff Mark Meadows. This meeting was an opportunity for all the major players in the administration to convene to devise top-level strategy on various issues, including the pandemic. I had only been asked to attend over the past couple of weeks while we were drafting the reopening of America guidelines. Also present were Joe Grogan; the deputy chief of staff, Chris Liddell; Jared Kushner; White House senior counsel Pat Cipollone; Marc Short; Katie Miller; two members of the president’s communications team, Kayleigh McEnany and Alyssa Farah; and the stuffed pheasants that appeared to be a prominent part of the décor in Meadows’s office.
When it was my turn to speak, instead of doing my usual daily data summary, I recited, chapter and verse, the story of the remdesivir debacle. In closing, I said passionately, “This is the kind of unbelievable level of fuck-up that ends up killing people. We can’t keep doing this!”
“Dr. Birx!” Mark Meadows’s tone and volume nearly matched mine. With my attention grabbed, he spoke more calmly: “We understand. We need to move on now.”
I remained livid. I knew that if I continued in this way, I’d become the bitch who couldn’t let things go instead of someone with the balls to tell it like it is.
As the meeting resumed, my anger at the remdesivir mess-up and at being shut down by Meadows simmered. Afterward, I went to Vice President Pence. I told him about the remdesivir problem and recommended that he integrate the FEMA/HHS and the task force data team parallel data streams into one single system that we could all use for decision making. This wasn’t just about remdisivir allocations and distributions. This was a significant miscommunication, I reminded him, that resulted in the wrong hospitals getting the potentially lifesaving drug, and it needed to be fixed. Throughout all levels of the response we had to struggle with inefficiencies, duplications, and parallel data systems like this. We couldn’t continue to make mistakes by using the wrong data or wrong data source. We needed all agencies to use a single comprehensive integrated system, of which Irum would oversee the continued evolving development and implementation. The vice president agreed that was what was needed, and we added that to our list of responsibilities. More immediately, Vice President Pence contacted Secretary Azar to get the distribution of remdesivir on track.
I tried to focus on the positive. With Irum in charge of that data centralization issue, we’d avoid repeating the same mistakes. Bob Kadlec and John Redd and Rear Adm. Polowczyk, after that single misstep, worked beside me week after week to make sure the drug got to the sites that needed it, and together we saved lives.
That night at home I listened patiently as Meadows went off on me over the phone. Angrily, he was demanding to know why a shipment of remdesivir he had requested be sent to a Florida hospital had not arrived. Six days earlier, he’d promised Democratic congressman Ted Deutch the supply, and his request still hadn’t been met.
Dismayed and disappointed by another remdesivir delivery problem, I let him vent. He had a legitimate gripe; new admissions were rising in Florida, and I’d already taken steps to resolve the larger issue. After Meadows ended the call, still fuming, I checked the distribution sheets and then contacted Steve Hahn and Bob Kadlec, who verified that the shipment had gone out that day and would arrive the next. I then relayed to Mark Meadows the news he was hoping to hear. Another fire put out, I retired for the night.
The next day, I was called into the chief of staff’s office. Mark cut straight to the point: “We have someone in that group leaking stories to the press. I’m certain of it.” He was referring to the attendees at yesterday’s daily chief of staff meeting. “I’m not certain who.” He paused, as if to let the implication sink in. “I think you understand how damaging it would be for everyone if what you said yesterday ever got out publicly. In case you don’t understand, hear me now: You will never say anything like that again in any meeting.”
I was dumbfounded. Instead of fixing the leak problem, I was going to have to censor myself? In light of what had just happened with remdesivir and how I’d managed to find an effective solution to the problem, Meadows was still focused on managing personalities and leakers. Why not allow people to speak freely in a crucial internal meeting? I knew the answer: because appearances mattered. I imagine Mark Meadows was also worried about appearances this close to the election. He didn’t want the administration to look like it wasn’t on top of things—but what about addressing the real problem? Remdesivir distribution was in disarray. That’s what the focus should have been on—optimizing operations, not optics. By this point, I had long understood that, for a lot of people in the White House, political concerns outweighed specific public health concerns. This most recent incident was merely a variation on that theme. My priority was clearly not aligned with theirs.
In the end, how I spoke in future chief of staff meetings became a moot point. My admin, Tyler Ann McGuffee, told me that the daily meeting had been “canceled.” Since the meeting would no longer be held, my presence was no longer required. Of course, a new invitation to the meeting went out to all the prior attendees but not to me. Business went on as usual in there, I supposed, but losing the one time I felt I had an opportunity to speak frankly about the complexities of the pandemic and the federal response with senior White House leadership who could make things happen and, critically, had access to the president was yet another obstacle. The doctors and the task force had already been marginalized enough, and most doctors weren’t free to openly communicate to the American people. Losing one more chance for direct access to the president’s chief influencers would further marginalize me from the president’s inner circle. So be it. I’d figure some way around that and concentrate more of my energies on the main task at hand—the COS meeting covered so many other topics unrelated to the pandemic, and I could use that freed-up, non-Covid discussion time to strategize ways around the other roadblocks.
On the other hand, I couldn’t let go of the thought that if one of the men in the room had similarly gone off as I had, he would have been looked up to for his passion and fiery commitment. I was a liability—one that they thought they could easily dismiss by exclusion from a meeting. They underestimated me. I wouldn’t be on their list of attendees, but I was always going to be attendant to sharpening the response at the ground level.
I understood from the outset that with this president, with this combination of senior advisors, during this election year, my impact on the executive branch was never going to directly produce the results we all wished for. Believing that I could directly move the president, the CEA, Mark Meadows, Marc Short, Derek Kan, and others not just to take the virus seriously, but to immerse themselves fully in understanding how data-driven messaging and mitigation practices would be effective was an impossible errand. I had spent decades moving presidents and prime ministers across the globe to enact critical policies—policies that many of them not only didn’t personally believe in but also perceived as detrimental to them politically—to ensure the most vulnerable and marginalized residents had access to lifesaving prevention and treatment services. But unlike those other leaders I was able to convince, some of the West Wing group were proving to be implacable, immovable. Now, after all this time, I saw better which people were inert, and to what degree. I couldn’t focus most of my energy on trying to move the unmovable; the strategy needed to shift. Just as I knew that in a pandemic getting people to change their behavior was very hard, that was true of those shaping the pandemic response as well. Better to leverage those who could help me impact the response than those who resisted me. There was Jared and there was the vice president, and those two men would be my go-to people in the White House, then and for the next nine months, to move the pandemic response forward.
Outside the White House, I had other allies. Those county outbreaks the CDC handled gave me greater confidence in our ability to coordinate task force efforts and theirs. FEMA was critical to all of our efforts as well. Bringing that kind of coordinated effort to scale was possible, and we were working toward that. I also heard in our calls with governors that, by and large, regardless of party affiliation or partisan divide, they were very committed and, I believed, willing to take additional guidance to ensure that citizens of their states were safe and their economies could recover. (I didn’t usually do this directly myself; I’d create call lists for the vice president and provide him with talking points to ensure that the states were getting consistent messages.) In the military, you look for places where a force multiplier can have the best effect—in other words, any factor that can produce an effect greater than its size or apparent strength might reveal, to fight on a par with a larger force. I was always on the lookout for those and when I could I’d deploy them. This was the kind of thing I’d been doing for years with PEPFAR and before. I felt comfortable having that level of engagement. I didn’t need to be among the generals or the chiefs of staff; working with the lieutenants and sergeants might prove to be more effective. I was learning.
The story the virus was telling continued to evolve. As we moved deeper into May, some of those blips on the radar of minimal spread into the community increased in frequency to match the rise in cases. Now nearly 40 percent of the counties’ rising new cases had a component of community spread. Though we weren’t seeing explosive growth on the scale of what we’d seen in March and April in the metros, case incidence and hospitalizations in those pockets were growing. In messaging directly to specific governors, in the report to all governors, and in my daily report internal to the White House and agencies, I sent out the alert: this was new; this was community spread in rural counties, not just large metro areas. Unfortunately, for several reasons, this didn’t carry as much weight as I would have liked. For one, previous numbers coming out of the metros were large. That set a kind of bar then. If we weren’t seeing those kinds of figures, then that likely meant that things were still better. And they were better in the metros, but not as better as we all hoped for everywhere.
All states have areas of population concentration. The data coming out of them carries a disproportionate weight when looking at state averages. I always tried to make this point and was frequently frustrated that after reopening, on the national and state level reports a troubling game of red light/green light was being played. When using those statewide averages, and applying them to the status maps that became more prevalent in the media, it became common to see states flipping from one of our color-coded indicators to another with great frequency. Those maps were misleading because they didn’t reflect what was happening in individual communities, including rural towns. Our internal maps were finally being produced with color-coded counties. But in May and into early June, too many were still at the state level rather than for individual counties. I spoke with some media off the record, this time asking for them to move toward a more countywide account of the state status in the graphics being used. I never wanted a distorted picture of the reality we faced to perpetuate a false sense of security.
To one degree or another that’s what a WHO and a subsequent CDC announcement about asymptomatic spread did. Once again, we were back in the debate about the level of asymptomatic spread. Dr. Maria Van Kerkhove, the head of the WHO’s emerging diseases and zoonosis unit, announced that it was “very rare.” The WHO’s statement created a mini-firestorm of controversy in the scientific community, which challenged this assertion. The WHO tried to walk it back, but by that point it was too late. It could not unsay what had been said.
Shortly after this, the CDC stated silent spread was occurring, but it accounted for only 5 percent of the cases. The CDC did say that asymptomatic spread was “plausible” and that it “meaningfully contributed to ongoing community transmission,” but these vague, cautious terms indicated that it still didn’t believe, as I did, that silent spread was responsible for as much as 50 percent of the cases and the majority of infections in those under thirty-five. Testing wasn’t as robust as it needed to be and children, for the most part, weren’t being tested at all because many didn’t have symptoms. Consequently, many still thought that children weren’t being infected, or if they were they would only develop mild disease, and that they played a minimal role in transmitting the virus. Without more comprehensive data, the CDC wasn’t fully accounting for the breadth of asymptomatic spread, and its 5 percent figure was far out of line with what I was seeing and projecting. I could see it in the trends and the numbers. I could see it in the rising test positivity in young people without any symptoms or clinic visits.
This difference in opinion had existed from the start of my tenure as response coordinator, and now, here we were at the beginning of June, with nearly two million Americans infected, and the public health agencies had yet to break out of their bubble of testing only those with symptoms or exposure to a symptomatic individual.
I had to do something to counter the too prevalent perception the administration was creating that Americans could reduce their level of vigilance. In line with what I’d told myself earlier about utilizing my go-to guys, on June 10, I sent Jared Kushner an email with the subject line “The One Thing the President Can Do that Will Drop Cases by 4 July.” In it, I told Jared that I could see the storm clouds gathering across the South: we needed the president to come out strongly for masking. We could have an impact if we aggressively mitigated now. The next day, I spoke up in the task force meeting, making the same point: we needed mask usage in public indoor spaces to be at 100 percent. This would require a cultural and personal shift, and White House leadership needed to set the tone. I can’t say I heard crickets in response, but it certainly wasn’t a chorus of voices chiming in with their support.
Ultimately, Jared heard me, and I believe it was he and Hope Hicks who schemed to get the president to wear a mask for the cameras when he visited Walter Reed. That was one visual. But we needed such visuals consistently, day after day. Masking in the White House would set the example that masks worked—but only if they were worn regularly. I would have to see if my attempts to reinforce that main pillar of the response would be effective.
I turned my attention to another of those pillars—testing. I knew that the WHO’s and the CDC’s statements would come back to haunt me; they did. President Trump continued to assert that testing led to more cases. Like a trial attorney who makes an assertion knowing the judge will ask the jury to disregard it but also that those in the box couldn’t unhear, on June 15, the president repeated his May 15 assertion that it was more testing that was the cause of higher case rates. Some in the administration used tools like this, misdirection, and labeling things “fake news” while producing their own, to effectively change public perception. Call it bizarre, call it brilliant—whatever you called it, the intention was always the same: hope that the doubt or alternative reality would find fertile ground somehow, somewhere.
Here’s the truth I experienced in this schizophrenic environment: that doubt may have flowered in the public sphere, but those anti-testing statements fit another pattern. The president would say one thing, but in the pandemic response in general, and in this case specifically, testing efforts weren’t interfered with. Neither the president nor anyone in the administration, to my knowledge, ever exerted undue pressure to limit the number of tests being performed or critically interfered with the production and distribution of testing supplies. Instead, the White House, through the task force, aggressively expanded testing using the Defense Production Act, and Brett Giroir used all mechanisms to increase tests and testing supplies. No one ever advocated for closing or limiting the number of testing facilities; instead, the reality was that we funded and supported new testing concepts, helped implement new testing strategies, and then moved them to state-run sites. Throughout the months we continued to scale testing and we continued to buy and distribute supplies across the country. I may not have always agreed with all elements of the specific testing strategy and the oversized priority given to testing those with symptoms; I also wanted to do more specific cohort testing, as universities and sports teams did to find the earliest infections.
Even if Trump wasn’t actively taking steps to reduce testing, the confusion his tweets and public comments sowed on the issue was damaging. As evidence of the power and influence Trump wielded, many people were left with the impression that what the president was tweeting about testing was true when, in reality, it was the opposite. The more tests performed would drive the test-positivity percentages down as infections were rapidly identified and community spread and household spread mitigated. In fact, more testing, and more awareness of one’s status, leads to a more effective response to that status, driving down transmission and therefore cases.
As simple as that math is, it was surprisingly difficult to make it understood. Time after time, throughout May and June, both Democratic and Republican governors would report their state’s increase in cases was due to increased testing. But because their positivity rate was rising, it meant not just increased tests but increasing viral spread. While Trump’s words on testing may not have altered the federal execution, they were absolutely detrimental to public perception.
I believed then and still do now that the president’s assertions on testing were a by-product of his belief that the CEA’s initial estimate of twenty-six thousand deaths was still accurate. Obviously, we had exceeded that number of deaths, but those extra deaths could be explained away through a number of right-wing theories floating around: The reporting structures weren’t efficient. Doctors were mislabeling non-Covid-19-related deaths as Covid-19 deaths. Testing more made rates of infection go up. Just as testing drove up cases, testing in hospitals drove up cases of incidental Covid-19, not real Covid-19 disease. And so on . . .
The fact that President Trump himself apparently didn’t want to know what was really happening spoke volumes about how far down into a facts-don’t-really-matter hole we’d fallen since I’d convinced him to announce the fifteen and thirty days to slow the spread. He was getting his information on the pandemic from others, others who were cherry-picking data, others who were convinced this virus was not severe and we were overreacting. Telling him the Covid-19 hospitalizations were exaggerated. The deaths were exaggerated. He was hearing from doctors who told him we were lying and purposely misrepresenting the pandemic to him to do damage to him and his reelection. Words word words. But the actions actions actions to combat the pandemic continued.
MORE WORDS CAME AT me. In early June, I was provided with the “White House Coronavirus Task Force: Report to President Trump.” A summary report of some considerable length that I was to review, it was essentially a victory lap for the White House Task Force on its handling of the pandemic crisis. Probably initiated at the time when the talk was to end the current task force, this was the kind of document you might expect to get when a project is winding down or has already ended, not in the middle of a crisis that’s still actively being managed. It had been clear back then and was clear now that the end wasn’t in sight.
Just two days before receiving that report card, I’d noted in my daily report to the White House that seventeen states were seeing rising rates of infection, and I highlighted that seven of those (North and South Carolina, Arizona, Arkansas, California, Texas, and Florida) were experiencing the highest case numbers since the beginning of the pandemic. Things were getting worse, not better. The spring had been awful, chaotic, and we were scrambling. Now, with remediation recommendations in place (some of them well considered, others less so) and a summer surge that would lead to an even worse fall and winter, some in the White House were actually looking at this ongoing calamity as if it were over, as if they believed that if they said it was over enough times, perhaps that would make it so.
The report was another reminder that the testing pillar had to be fortified. Even if the president wasn’t directly attacking it, he was engaging in a kind of propaganda effort to win popular support to his side. He could achieve three things: he could make a claim based on a wrong interpretation of the data that things were better than the testing evidenced; through his public messaging campaign he could get fewer people to test to drive down the numbers; and he would still not directly interfere with testing, in order to demonstrate American superiority. It was a marvel of a communications strategy, to demonstrate that demonstrably contradictory things could all be true. While that is sometimes possible, in this case it wasn’t.
To a great degree of certainty, tests don’t lie. They do produce false negatives, but that’s not intentional, as a lie is. The data we gathered from testing didn’t lie. It was subject to different analyses, and it was my job to counteract the false narrative(s) being told. That was a battle I had to wage on many fronts, and I believed that being as data driven as I was, I was the best person with the best team to win that intense skirmish. As immovable as some people in the administration were on some aspects of the response, I was equally immovable on my belief that testing and the data it revealed was essential to showing us the way forward. The president, that report, could use whatever words they wanted to, but the evidence told a truer story.
The testing kerfuffle, and the administration’s premature claim of mission accomplished, was a case of collective farsightedness. While images of the awfulness of late March and April consumed my thoughts, the administration had its eye on election victory parties and the start of a new term. To make those visions real, they needed to get the American people’s minds off the pandemic and onto to the administration’s economic achievements—anything else but the rising death toll. This was a vision that many, regardless of party affiliation, shared. The White House and many members of the public mirrored each other’s desires. They wanted to redirect their attention from the pandemic elsewhere—to Memorial Day weekend; to the Fourth of July; to November and the election; to adjusting to the “new normal” so many were talking about.
The sad truth, one I was still struggling so hard to make clear, was that the new normal would look a lot like the very recent past. We were on the edge of a new surge, a product of our collective Memorial Day start of summer activities.
I was still working hard to communicate what the present rising numbers of test positivity actually showed: they always projected what we would see three weeks later: illness and hospitalizations; and six weeks later, deaths. Still, with the CDC’s and the WHO’s pronouncements regarding asymptomatic spread echoing down the halls and in the minds of so many, the White House wasn’t listening to me and remained stuck playing defense, reacting rather than attacking. If this report were released it would be akin to claiming victory in the middle of the first quarter.
It also became even more difficult for me to publicly counter that message. Ever since the disinfectant debacle and the president abandoning the daily press conferences, the Trump administration had effectively banned me from speaking publicly for weeks. I kept pressing for the resumption of regular press briefings. I believed the comprehensive presence of the task force members presenting on the state of the pandemic and the actions needed by both the federal government and American citizens was important. Making it clear what we knew and what we didn’t; what we were learning together about the virus. I still believed it was important to connect directly with the American people, where I could cut through some of the clutter and confusion the White House and CDC messaging had created. Then there were the individual pressers that Bob, Tony, Steve, and I were doing. Most of these were stopped. None of us thought that wise. In a perfect world, CDC guidance and task force recommendations would have been in perfect alignment. Because they weren’t, having a means to clarify our position was crucial. The CDC had its public platform, and now we were being denied our own.
I never knew who was responsible for this change. In my case, I believed that Marc Short and the vice president’s communications team were primarily responsible for my being silenced, but it was never clear from whom this was coming. Had I been allowed to do more national press when states reopened throughout May, my message would have been largely unequivocal: Follow the gating criteria in the guidelines. We are seeing outbreaks in specific counties that the CDC is tracking carefully. We are looking for evidence of community spread. At the end of May I would have said: Here is where we are starting to see increasing community spread in the rural counties in Mississippi and Alabama. We see significant community spread in the Navajo Nation and we need to increase support there across the three states. Be more cautious. Protect the vulnerable in your household. Expand mitigation in these areas. Test more strategically, looking for those who are unknowingly infected as well as those with symptoms. The outdoors is safe for you to gather and have your children play. Instead, I could say little to nothing publicly.
Of course, I could have taken my thoughts to the air the way so many people in the Trump White House did: by leaking them anonymously, telling the public through other people what was going on with me inside the White House. For ethical reasons, I would never do that.
Eventually, the president’s communications staff stepped in and cleared me to do more local media—revealing the likely motivation behind the virtual gag order: They hadn’t wanted me shaping or influencing the national conversation in any way. My words would almost certainly have made it harder for the president and them to keep turning the page, effectively closing the book on Covid-19. I had, it seemed, benefited from a combination of benign neglect and “out of sight, out of mind.” I sensed the president and some of his inner circle had already moved on from me and the elements of the pandemic response I was coordinating, making it easier for his communications team to grant approvals for media requests—as long as I didn’t appear on the screens he was watching.
ON JUNE 16, VICE President Pence had an op-ed piece run in the Wall Street Journal. It was published with the unfortunate title “There Isn’t a Coronavirus ‘Second Wave.’” The subtitle was, “With testing, treatments, and vaccine trials ramping up, we are far better off than the media report.” It was true that we were making progress in all the areas the subtitle mentioned. Although I wasn’t involved in the decision to do, or the writing of, the op-ed, I did see it only in passing in hard copy, literally hours before it was submitted. I can only surmise that when the op-ed was composed, we were primarily seeing the institutional outbreaks that were being rapidly detected and controlled with rapid engagement of the CDC throughout the majority of May. But after Memorial Day, in retrospect, the second wave was silently moving through the Sun Belt undetected then exploding in the second wave by the beginning of July. The vice president had to endure heavy criticism for presenting an inaccurate assessment of the current situation. This op-ed moment stood in contrast to the seriousness he brought to the summer surge response, including in that time pushing us to provide the Sun Belt states the support they needed. He would also support and accompany me on visits to the region that would begin just days after the op-ed.
Some in the administration’s wishful thinking about the pandemic’s end overlapped with the start of the summer surge I’d anticipated and warned about in the White House. My What are we missing? question regarding the isolated outbreaks throughout May that the CDC was diligently addressing in state after state transformed after Memorial Day, due to widespread travel from areas in the north of the United States where the virus lingered, into a full community spread across the Sun Belt. We had underestimated the depth and breadth of Americans’ movement. The resulting viral spread that went with them, primarily with eighteen-to-twenty-five-year-olds and then twenty-five-to-thirty-five-year-olds, created a new phase in the invasion. In days we went from isolated specific institution outbreaks to broad community viral invasion. Even with all the guidance we’d created and the numbers we had provided to help the governors best manage their states, some were still far too slow to react.
This was especially true for the states that had reopened in late April and early May and did not see a substantial initial rise in cases. After several weeks open, they saw their situations deteriorate rapidly following Memorial Day. Studying the numbers carefully, I saw clearly that states like Arizona, Mississippi, Louisiana, Alabama, and Florida were on the precipice of their own New York–style catastrophe in July. But it would be worse in those states than it had been in the Northeast. Their populations had higher rates of comorbidities like obesity, diabetes, hypertension, and heart disease. Critically, the virus was moving into rural areas and rural hospital systems, which lacked equipment and had fewer health care providers and less capacity. The very places that needed stringent mitigation steps immediately (mask mandates, reduced indoor dining, among others) had shown themselves to be the least likely to impose them. They hadn’t experienced the destructive forces of this virus in the March to May time frame and thought they wouldn’t now.
Up to this point, the vice president had been an important conduit for communication with the governors. Though I didn’t have as much access to him as I had when I first arrived, I adapted. I asked for ten minutes of the vice president’s time to make certain he understood the gravity of the situation As always, he was receptive to the idea of making direct calls to those governors. I got around the Oval Office roadblocks, but the vice president ran into another.
With every call, independent of party affiliation, governors all reported that their states were fine—their hospitals were not filling. Most equated viral spread with rising hospitalizations as they had seen in the media from New York City. As a result, they would wait until hospitals began to fill to act with increased mitigation. They still weren’t getting the message about the three-week lag time, that testing of younger cohorts and finding asymptomatic infections was important, that small outbreaks could be mitigated but that the silent spread that was a part of them was still at work. There were earlier signs and signals of viral spread in their states, and not just the later-rising hospitalizations.
But calls from Vice President Pence to the governors alone would not be nearly enough. Increasingly, as the doctors on the task force ran into the limits of what could be accomplished from Washington, DC, I saw a need for more ground-level intervention that could carry our message directly to the decision makers in the states and cities—not over the phone or on Zoom, but in person.
During my first week with the task force, I had noted down, “It was clear that states needed more on the ground support and wanted us to travel and leave a fulltime team behind to support the states in their response and address any issues immediately.” Someone from the federal government needed to go out into the field. I believed that was the role of the CDC.
I sent an urgent message to Bob Redfield, asking him to send CDC personnel to North Carolina and Arizona, two states at most immediate risk of a surge, to speak with local health authorities and the community. It has long been my experience that a situation looks very different up close than it does from behind a desk or from a computer screen. I was continually frustrated by the CDC’s apparent unwillingness to put more people out in the field for long periods, not just a week or two. These surges were lengthy, and we needed boots on the ground continuously for months, not days, to understand what was working and what wasn’t from messaging to supplies.
They could be the force multiplier. Outside the United States we had found that CDC effectiveness was greatly increased when actively embedded with and in close coordination with the Ministries of Health. Working right alongside the public health officials in each country day after day. Out of the office in the embassy and into the offices of the host government. I believed this was critical for the United States. CDC health officials needed to be permanently embedded alongside their counterparts in the state and county health offices. Learning from each other, listening and adapting best practices learned from other states and rapidly translated to other states. Using the CDC network to actively move information in real time and actively learn and share.
Early on in the pandemic, those scientists were informed that, if they chose, they could volunteer their efforts for thirty days to Covid-19, and a portion of them did so in some capacity as a part of their usual responsibilities. Many, many more did not. (The same applied to uniformed public health personnel at the NIH.) Their employment agreements with the CDC, in my mind, should have stipulated that, in the event of a national public health emergency, they would become a first responder, deploying to various places across the country.
So, in response to my urging Bob to deploy the CDC personnel, he said his hands were tied. He couldn’t force anyone to go to one of the Covid-19 hot spots, or anywhere else for that matter. He had to ask for volunteers. I wanted people from both agencies to join in an all-hands-on-deck effort to manage this crisis. Nothing but their goodwill could compel them to do so. I applaud those who did.
Brett Giroir and the Public Health Service did answer the call, as did the Department of Defense, sending health personnel out to the states not for a few days, but for weeks and months at a time to support testing, hospitals, and nursing homes. The real secret sauce in many states, though, was the National Guard. They answered every call, took on every mission, and saved many lives.
To this day, though, I can’t imagine why there isn’t a provision in the public health safety plans to deploy every available health professional, both those in uniform and not, from all the federal agencies in the event of a pandemic. When we face a military threat, those who work for the Department of Defense, including our frontline soldiers, don’t have the privilege of opting in or out. They are told where to go and what to do, and they go there and they do what they were instructed to do.
These structural and personnel limitations to our federal health agencies inherently constrained our reach, negatively affecting what we could accomplish in Washington. As the Trump administration’s focus drifted from the pandemic response to the economy, those limitations had been revealed. The states where Trump’s attention would have helped the most, those that leaned conservative, were precisely the states less inclined to accept our mitigation message from afar. We needed to meet these governors, mayors, and lawmakers on a more level playing field. Simply making pronouncements, placing phone calls, and filing reports was not allowing our ideas to break through.
With the hindsight of the nearly two years since June 2020, it’s easy to forget just how much confusion there was back then about how SARS-CoV-2 behaved, who was at risk, how the virus spread, and why it was so hard to detect. At the time, it was difficult for us to discern from Washington what was behind the objections from the governors. Sure, it could have been political, and in some cases it was. But it could also have been that they, understandably, were having a hard time reading the muddled and at times contradictory statements coming from the Trump administration or the confusing and complex guidance from the CDC. The task force would say one thing, President Trump would say another, the CDC would put out an ambiguous statement loosely supporting the task force but leaving itself some wiggle room. Meanwhile, Tony was on national media trying to push back against the contradictory messaging, to break through the noise; and President Trump was tweeting his own personal truth. Honestly, I can understand why some governors were legitimately pulled in different directions, facing opposing impulses about how to move their states.
We needed to act. To enhance our communication with the governors, we created a weekly executive summary report to provide every governor with county-level data, showing where their state was at present in the pandemic and what that meant for the near future. With these reports, I was trying to simplify things for them: using the type of language and graphics that would make the picture as clear as possible, so they could get ahead of what was coming not to neighboring states, not to the region, not to states a thousand miles away, but to their state and specific counties within their state—as well as a whole-of-country analysis so they could understand how this virus was moving around the country.
While we received some positive responses to these state-specific reports, the sheer distance between the governors and Washington, and the lack of a full understanding of the virus and how to read the data, made it difficult to chart a course for each state. The economy-versus-health conversation defined this uncertainty. Lost in the debate over economic recovery versus public health response was any sense of nuance regarding the kinds of mitigation strategies appropriate to a given state. The media, often led by President Trump himself, seemed to frame the issue as a zero-sum game—either you’re entirely on the side of the economy, or you’re entirely supportive of public health. Either everything is open, or nothing is. You impose mask mandates, or you ban mask mandates. When it came to actual implementation of these policies and ideas, where the rubber met the road for the governors and their states, the reality was far more complicated, and it deserved a more in-depth and nuanced conversation. Unfortunately, no one in the administration, the CDC, or elsewhere seemed willing to go directly to the states in person and have that conversation face-to-face.
Ever since I’d been okayed to do local media, I had been trying to spread the message in individual states that way. Over time, I’d learned a few things about the media and its role in the pandemic—most notably, that while many people turned to cable networks to see reality painted with a broad national brush, a lot of them relied on their local affiliates. Generally, when I appeared on local news, the journalists there were interested in getting accurate information specific to their community. They weren’t trying to make headlines themselves. They weren’t asking “gotcha” questions. It didn’t matter if they were broadcasting in a red state or a blue state; they wanted to be of service to their viewers, who were interested more in protecting themselves, their communities, and their loved ones than anything else. As I began this smaller-scale outreach—appearing on dozens of news programs in early summer—I began to feel that bringing my case directly to the people, state by state, city by city, could actually work. It wasn’t efficient, but I felt it was having an effect.
Still, the list of moves the White House was making to project victory and return to normal continued. I heard the ticking clock sounding the approach of a very, very difficult fall, while the CEA pushed to have the European travel ban lifted. I wasn’t the only one who pushed back on the CEA’s idea, and the vice president, Jared, and the task force did listen to reason and the data. Partially as a result, restrictions on leisure travel from Europe wouldn’t be eased until late fall 2021.
Besides the looming summer and then the fall/winter surge, another specter was on the horizon: the general election. As much as the vice president remained fully engaged with me, took an active interest in what I was reporting, and did his best to support me, he would soon be on the campaign trail. The window on his constant daily availability to me was closing. As an indication of the White House’s shift in focus, instead of meeting every day, our task force sessions had been cut to two to three times per week.
The election represented an entirely new variable, one that had me even more concerned. Indeed, if made public as seemed to be the intention then, the administration’s “victory lap” report fit a narrative tailor-made for election season. With the election on the horizon, it would be that much harder to get the White House to raise the alarm about anything related to the pandemic. Any message that could interfere with President Trump’s reelection message would be scrutinized, watered down, and weakened potentially to the point of irrelevance. As much as President Trump’s and the political elements of the administration’s focus had waned since April, the fall would represent something far worse. Not only would they be distracted by the campaign, but the virus would be poised for its most lethal stage yet.
AND SO, ON THOSE meditative mornings when I tended to my garden, I considered other options. I knew myself and my natural inclination to always hang in there and do more. Find a way or make one. I knew that, with one phone call, I could have the biggest megaphone in the world for a second through which to shout that the Trump administration had lost its sense of urgency; that it was moving on from the pandemic response; that a specific state had reopened too fast; that Americans choosing to travel across the country revealed that as far as they were concerned the pandemic was over; that we stood on the brink of a summer surge that would hit many states incredibly hard and kill a hundred thousand people, some unnecessarily.
I played out the going to the press scenario more fully. I would have done it eagerly, if I had honestly believed it would have produced some kind of course correction from the White House; I would have sacrificed my job and returned to my PEPFAR position in a heartbeat. It was true that Tony, Bob, Steve Hahn, and I had agreed that if one of us was fired the others would resign in protest. We were all still on board with that promise and were all still on the task force. I was neither hoping to be fired nor willing to resign independent of the others being let go.
The problem was, I didn’t believe my departure would change anything for the better. Accusing the Trump administration of negligence wasn’t going to suddenly produce a different response to the pandemic from them. And it missed the point that there were people every day within the very walls of the West Wing who were helping me get things done, moving policy, and ensuring action. So, it was never that simple. To the outsider it may have looked that black and white, but behind the scenes critical progress was being made using data to drive federal support. The machinery of the federal response was more focused and more data driven in decision making week after week. Progress could still be made. We needed to respond to the summer surge and be ready for the fall.
It was also obvious that the American public could already see that President Trump had staked out a position that opposed specific science, that opposed masks, that opposed testing. But behind the scenes we were still moving the ball down the field and mobilizing the vast federal resources to the right intervention. We still struggled with communicating effectively to motivate the American people to do what was needed when the virus came to their community. Communities would need to take steps to protect their larger circle. They had to act together and not divisively.
The evidence for the president’s obstinance had always been in full view—he’d tweeted much of it himself. Leaving wouldn’t bring much to light that wasn’t already visible. My message of warning would last a news cycle, two at most, and then everyone would move on—except the people suffering and the states on the verge.
Moving policy is always more complicated than it appears. In the case of this pandemic, navigating the states’ versus the federal government’s role made things inherently more complicated. What constituted “support” and what was “interference” wasn’t always as clear-cut as some liked to believe. The states would determine which mitigation policies to enact.
At first, in the beginning of the pandemic, the federal government’s approach had been to focus on the whole of the country. Gradually, we began moving away from that to a more state-specific emphasis. This was a good thing, but I wanted to make it a much better thing. As much as we communicated with governors throughout the early spring, we couldn’t address the feeling many Americans had: that the government was out of touch with how the pandemic was being experienced where they lived.
What overrode any other consideration was this: that other question in my mind about what was missing had now been answered. I knew that what we’d seen with those institutional outbreaks had now expanded beyond the confines of those buildings, beyond the people who worked in them, into their homes, and beyond into the community linked to our summer travel plans. I didn’t want to spend too much time regretting not connecting all the dots, I wanted to do everything in my power to prevent that from happening again. We had not effectively foreseen the vast spread from the advent of summer. We needed to learn what we had missed so we didn’t miss it in the fall. I had to get out of the White House and to the states. I had to cut through all the interference the president’s words were creating. I had to look governors and state and local public health officials in the eye, read their expressions, know when I needed to provide greater clarification, and show them the data and the graphics to give them an evidence base to support the measures I had seen working elsewhere and that had been so effective in other places.
I might be starting from point zero with some of the governors, but our understanding of the pandemic and my own understanding of why so many people believed that this time would be different had evolved. The hope that we’d endured the worst of it was rooted in many causes. I’d have to do what I could to uproot them, but also learn from the experiences of states who’d been most effective in mitigating against the virus as well as the mistakes that had been made. We’d started with a whole-of-government approach; that would continue, but it had to be modified so that the whole could support the parts. That was what I was hoping to do and to discover, but this was moving into new territory, taking the approach I’d used elsewhere to see how effective it could be transplanted to American soil.
This on-the-ground effort should have been made by the CDC. For so many reasons, that agency was the right representative of the federal government to be leading such an effort. Yet, the CDC wasn’t yet doing it, despite my urging. They were still only going to states for a week or two. They weren’t meeting with most of the decision makers like the governors nor were they meeting with communities. So, rather than encourage them with words, I decided to show them with my actions. Get out there! Do this kind of fieldwork. Learn from it. Data at a distance was helpful. Data and experience and feedback from those on the ground were invaluable. A pandemic is a lived experience as well as a subject of scientific inquiry for future publication. Perhaps our visits to the states would help bridge the divide between the CDC’s academic approach and our frontline public health one. We hoped they’d take notice of our example. The CDC and other agencies did have people out in the field, but those in the field often conducted their work remotely from hotel rooms, conducting Zoom meetings, creating another barrier.
I knew, from years of being on the road 40 percent of each and every year for decades, that I would be able to stay on top of my task force and coordination responsibilities and still visit the states. I broached the subject with the vice president, who was fully supportive. He turned the matter over to Tucker Obenshain, and the great team at the Office of Intergovernmental Affairs led by Doug Hoelscher and William Crozier.
So, the data team and I came up with an idea: Irum and I would travel together to states whose hot spots had put them in the red zone. We’d be risking our own health and safety, but face-to-face seemed the way to go. Just as it’s easier to hang up on a telemarketer calling your phone than to close the door on the flesh-and-blood canvasser standing on your porch, we decided we needed to meet in person with the governors and others at the state and local level. We would take our message to them and learn what they needed, what was and wasn’t working. We needed to see, listen, and learn.
I let Tucker know it was important that we get to Arizona, a real hot spot. It turned out that Vice President Pence and HUD secretary Ben Carson already had a trip to Texas scheduled for the last weekend in June. Irum and I could join them on the flight to Dallas. Tucker also arranged additional visits for us there, before Irum and I drove on to New Mexico and then Arizona. This was the blueprint for the months ahead. By December, with Irum, I’d travel to forty-four states, some several times, sometimes coordinating with the vice president’s travels and other times hitting the road independently, covering thousands and thousands of miles visiting communities large and small. We would be on the road nearly 50 percent of the time.
Along with meetings with the governors, Tucker arranged sessions with state and local health officials, hospital associations, doctors, nursing associations, nursing homes, individual frontline workers, community members, and tribal nations. This first itinerary was a matter of convenience and happenstance, but ultimately, it would prove providential. We’d learn a lot in Texas, New Mexico, and Arizona, and I’d be able to use what we learned as Irum and I tracked hot spots and then went to where the virus had announced its presence. It wasn’t enough to sit in state capitol conference rooms. We had to get out on the front lines and get a closer look at how this pandemic was being lived every day by people outside the government.
A big part of the reason I felt comfortable leaving Washington was I had recently supported the hire of Dr. Moncef Slaoui to head Operation Warp Speed (OWS), the public-private partnership to hasten the development of a vaccine against SARS-CoV-2. Dr. Slaoui would oversee Covid-19 vaccine development. His presence and guidance proved to be a strong hand the country could all grab on to, and he would carry us to the vaccine finish line.
Dr. Slaoui had retired in 2017, after working for thirty years at the pharmaceutical company GlaxoSmithKline. He spent several of those years as the head of its vaccine development division. The company had created vaccines against malaria and Ebola, something that had resonated with me during our interview. At the time, Dr. Slaoui was still on the board of directors at Moderna, but he resigned that post when he accepted the job to lead OWS, to avoid any conflict of interest. In so doing, he had signaled to all that private industry and the government could work cooperatively.
In the case of Operation Warp Speed, there was full White House engagement. Jared Kushner and HHS secretary Azar, invoking the Defense Production Act, made sure vaccine developers had all the critical raw materials and could conduct the trials and manufacture without delays. Over the course of the next months, we would see cooperation and mutual respect among all the groups involved. Had there been this kind of focused commitment in all areas of the pandemic response, including communications, the science of behavior change, ensuring that all Americans understood the science and data and were empowered to act, we might now be viewing our efforts as an across-the-board success, not just the patchwork one it was. With its unique partnership between the White House, HHS, and the private sector vaccine and therapeutic developers, Operation Warp Speed, I felt, was one instance where we didn’t overpromise or underdeliver.
I was encouraged by one of the first moves Dr. Slaoui made, immediately bringing on board Carlo de Notaristefani, an expert in the vaccine manufacturing processes. It is one thing to develop a safe and efficacious vaccine; it is another to be able to make it in the quantity required. Proactive production and working out all the scaling from thousands to millions of doses would be key to the rapid rollout we all were hoping for and that was eventually delivered.
I was also pleased when another person with a long career in the military, particularly in supply and logistics, came on board. Gustave F. Perna, a four-star U.S. Army general, took command as chief operating officer of the federal Covid-19 response for vaccines and therapeutics. In July, he’d transition over to become COO of Operation Warp Speed, where he would coordinate logistics for the CDC’s distribution plan developed in coordination with states for the yet-to-be-produced-or-approved vaccines. Getting out ahead of the approval process was a key move that was lacking in other areas. Like Dr. Slaoui, General Perna brought a wealth of experience and expertise to both those jobs. Similarly, Rear Adm. Polowczyk followed by General Stafford brought a similar data-driven, no-excuses, now-now military discipline to logistical supply chain matters and worked with Jared on the next-generation federal stockpile. Collectively, we were committed that no matter who won the election of 2020 they would inherit a fully stocked federal stockpile.
This whole-of-government approach that tapped into the expertise of the military and the deep partnership with the private sector was and is a new approach to pandemics and pandemic preparedness and should be integral to the full planning and execution. The depth and breadth of this type of partnership was unique to the Trump administration and not only saved lives but should transform future thinking and planning.
Technical advances certainly aided the rapid development of vaccines, but technology as a tool must be employed efficiently and thoughtfully. If there was one thing to be learned from vaccine development, it was that a shared vision, a balance between competition and cooperation, and an enormous investment of capital can do wonders in a pandemic. Operation War Speed is a road map of success for future critical vaccines and therapeutics.
As Irum and I prepared for our trip, I was well aware of what we had missed. That was the incessant pulse I felt beating in my chest. I was having my own “Never again” moment, vowing that we’d not miss any nuance in the data again, and that we’d translate this new learning into words and actions. Too much was at stake to do anything but. One more, two more, a dozen more times when we had to work through, around, or over whatever lay in our way, we’d do it.
I was pleased when, in late June, we made progress on the communication front. I was being allowed to meet with medical correspondents in the media, which gave me a chance to correct the president’s message on decreasing testing. I could also utilize them to lay the groundwork for my upcoming work in the states. To counter the president’s false claims about test positivity rates, I explained what the administration wasn’t accounting for, “the two-week sequence of events.” Two to three weeks after you see an increase in positive tests, you will see an increase in hospitalizations, followed two weeks later by an increase in fatalities. If you cherry-picked data from a particular point or from a specific state on this time line—you would be ignoring the longer-term trend. If fatalities from a past surge were decreasing in one area of the country, but test positivity was rising in another, what you would be seeing was evidence of another surge in another region. As the president preached his false gospel on the role testing was playing in the rising case numbers, he was ignoring what the data was showing us about the inevitability of more cases. More cases = more hospitalization = more deaths, as the virus always found its way to the vulnerable Americans living in communities and there was no vaccine yet to protect them from severe disease.
During these meetings with medical correspondents, I made the case that things were getting far worse for the summer and that this trend would continue into the fall and winter. One month after the April 15 release of the reopening guidelines, Covid-19 cases had increased by 125 percent and deaths by 174 percent. We couldn’t yet see that, after the forty-five days we’d been granted had elapsed, by Labor Day, we would go from approximately 675,000 cases and 33,000 deaths to 6.2 million cases and nearly 200,000 deaths, combining the 100,000 fatalities from the spring surge and the 100,000 lives lost in the summer surge. Cases increased by 827 percent from April to September, while fatalities rose by 544 percent.
The summer surge was deadly, but if we had mitigated earlier with increased testing and masking and with decreasing social gatherings with the first increase in test positivity, lives would have been saved. But in talking with states then and now, every time the test positivity and cases began to rise they would say “this time the outcome will be different,” “this time we have more tests,” “this time it’s a different variant,” “this time we have vaccines”—yet the outcomes continued, and continue, to be the same. That will change over time but as long as there is widespread community spread and Americans who aren’t protected, due to a poor response to the vaccine, due to age or immunosuppression, or due to the number of unvaccinated vulnerable Americans, lives will be lost.
I made the same case about the summer surge and the prospects for fall and winter in our doctors’ group and with the larger task force: We needed to prepare for the coming heightened crisis. By the third week in June, I changed this message a bit: The crisis isn’t approaching. It’s here.
Tony wrote me privately to let me know he got it and that, in his view, “the wheels are coming off.” The response from others was muted.
The president had publicly stated that he would intervene in pandemic matters as necessary. So, I tried to make the case through Jared that this was one of those necessary moments. During the last two weeks of June, I sent him several emails encouraging the adoption of universal mask mandates among members of the administration while in public, more sentinel testing (testing performed across a community, even of people with no symptoms), and the usual laundry list regarding supplies and therapeutics. He said he was working on it. I needed the president to talk to the American people and raise awareness and the need for them to act to protect their vulnerable family members. We had tools—we could blunt the impact of the surge.
As I counted down the days until my road trip with Irum, Vice President Pence updated me on his progress with the governors. I’d asked him to make clear that a significant surge was under way.
“Debbi I’m sorry to say this. I’m not having much success with these calls.” He sounded discouraged. “They’re hearing me, but I don’t think they’re really listening. They say they are fine, the hospitals are ‘fine.’” But, I said to the vice president, the hospitals won’t be fine—they will be overwhelmed again soon.
I read in his expression the same question I’d been asking myself for so long: What are we missing in our communication with governors? We can see it—why can’t they?
It was the silent spread issue rearing its ugly head. Without demonstrable evidence that sentinel testing could provide, without hospital admissions rising, the waters appeared calm. But farther out at sea, rapidly approaching swells were rising. The tsunami was building.
We’d have our work cut out for us once we started to sit down with the governors.
Saturday, June 27, was spent packing. I’d gone to Jared Kushner, Tony was sounding the alarm, and the vice president was well aware of the situation. A surge was coming. Had he communicated it to the senior advisors and the president? I believed that he had, but I couldn’t know for sure. Without direct access to the president, and with trust in me at a low ebb among his inner circle, I did the only other thing that I could.
In the top lines of the opening page of the daily summary document for that day, I heavily emphasized that if we didn’t act now, the summer surge could see our reaching as many as one hundred thousand new cases a day—in the end, we reached “only” eighty thousand—and an additional one hundred thousand American lives would be lost. They were. The refrain I sang was the same: We needed to mandate the wearing of masks in public indoor places. We needed to close or vastly reduce occupancy indoors where people were unmasked, like in bars and restaurants.
As a kind of coda to that shared report, I wrote the doctors’ group a postcard from home before hitting the road:
I have tried for 2 weeks to get acknowledgment of our situation and with current log phase. I am pushing as hard as I can. In local media I push for masks and testing but I am not scheduled for any national media and I know I will remain sidelined. Would be good to connect over the weekend if someone can get a line. Don’t forward this to anyone.
In retrospect, I see how desperate that sounds. But when you can see the approaching tsunami and there are still people on the beach you need to run out to the beach and be clear about the warning. We needed to get to the beach. I continued to send out emails over that weekend. In one 5 a.m. missive to the doctors’ group, I tried again to hammer home my point. At the beginning of the week, we were at twenty-six thousand new cases a day. Six days later, we were at more than forty-six thousand a day—the largest percentage increase in the United States up to that point.
We needed to act now.
We needed states to institute stricter mandates now—not wait.
I sent a separate but similar email to Jared Kushner. He was out of pocket, but he told me to contact his former college roommate Adam Boehler and Adam’s associate Brad Smith. Both were young, successful contemporaries of Jared’s serving in various advisory capacities within the White House and in other federal agencies. On a phone conference call for the four of us, I felt like a talking head, delivering again, at the top of the hour, the news of the day. I reiterated every point of the message I’d been trying to refine over the course of the previous weeks.
It’s here.
It’s going to be bad.
It’s going to be VERY BAD.
They offered assurances that they got it. They’d work on it. They’d get back to me.
I ended the call hopeful, but nagged by the Ghost of Overpromise and Underdeliver. A scant few hours later, I was back meeting with Vice President Pence, doing yet another version of my (legitimate) doom and (legitimate) gloom presentation.
The next morning, trusting that I’d done as much as I could to make clear what we were facing in the coming months, I set out. I’d entrusted the care and feeding of my plants and flowers to my husband. They’d be well taken care of, and I knew my family would take good care of one another.
Irum and I exchanged a look as we used disinfectant wipes on all the touchable surfaces of the car. I surmised that some spots were simply unreachable, but that didn’t matter, you went after them anyway.