For the last two decades, whenever I’ve heard of a new pathogen emerging, my first thought has been the risk to Africans. In the United States, we have many different layers of public health protection. Americans receive support from the states themselves and from the CDC, with thousands of public health officials in positions to shape and support the public response. Africa, though—whether you’re talking about the entire health care system or just the number of health care providers—is in a fundamentally different position.
I love Africa and the people PEPFAR serves, but even with the substantial support that many nations, including the United States, had put into bolstering its health care system, sub-Saharan Africa was one of the most vulnerable parts of the world. Throughout the region, we were still confronting HIV, TB, and malaria, and any new threat to the region was a threat to the progress of our work and the very people we served. I have always believed that, in life and especially in public health, a proactive approach is best. The commerce and travel between China and Africa had increased logarithmically over the past two decades. China was in deep trouble; Africa needed to be prepared for this new threat.
The entire time I was tracking, observing, and calculating the possible dimensions of the novel coronavirus outbreak in China to other parts of the world, I was in the midst of planning for one of the most important events in my yearly calendar: PEPFAR’s annual meeting to evaluate the progress in all the African programs we support. It was at this meeting that we’d help plan the effective use of the more than six billion dollars in U.S. taxpayer money we’d receive for the next year. The meeting was to be held over three weeks in Johannesburg from mid-February 2020 to the beginning of March, commencing on February 17. We’d been working long hours in preparation for it since late fall 2019, reviewing data and writing the “Technical Considerations” section we put together each year for our report “Country and Regional Operational Plan Guidance for All PEPFAR Countries,” to ensure that the most recent science and data were available across all our programs.
PEPFAR represents what is best about humanity and, in particular, the United States. We enjoy a privileged position in the world and often lead the way in doing good, impactful work in global health. PEPFAR is an expression of the American people’s compassion for those less fortunate than us. It is an ambitious and highly successful program. It has to be, to take on the many challenges of HIV/AIDS—its diagnosis, treatment, and, critically, its prevention. Working in deep partnership with impacted and concerned communities and governments, we partnered to take on directly the structural issues of inequality; human rights; gender-based violence; and the access and availability of services for young women, the LGBTQ community, and others marginalized by host governments. All these fall under the umbrella, some at the edges, of public health. At PEPFAR, we’re always driving, above all, to make possible what many have viewed as impossible: controlling the HIV pandemic without a vaccine. I liken this to the ethos of the special operations community in the military. Among its slogans is the creed “These things we do, that others may live.” You don’t work for organizations like PEPFAR because the work is easy and the financial rewards are great. You do it because it is a calling.
I thrive on being around like-minded individuals whose dedication to making a difference is their true north. We all come from different backgrounds, cultures, and training, but we are united in our goals. We share a real sense of community and action. It’s all about now, now, now—doing what we can to have an immediate and lasting impact on people’s lives. That’s been the ethos under my watch and since President George W. Bush and his administration worked to get PEPFAR funded and implemented. The president and the First Lady, Laura, had a shared world vision and a deep understanding that to whom much is given much will be required. This included addressing HIV/AIDS in Africa. At the same time, the legislation that helped create PEPFAR created the position within the State Department of global AIDS coordinator, the other hat I was wearing as ambassador-at-large.
Normally, PEPFAR’s annual meeting would have commanded all my attention. But 2020 was only three weeks old, and already it was abnormal. Whenever I wasn’t planning for the meeting or evaluating our programs on the ground through intensive data analysis, my mind was squarely on the exploding coronavirus cases in Asia and the implications for Africa.
To make sure that the people of Africa, particularly sub-Saharan Africa, weren’t going to be caught flat-footed due to the WHO’s lack of urgency on the new virus, I wrote to Erin Walsh at the National Security Council on January 20. Erin was the head of the Africa region at the NSC, but I wasn’t looking to get any insight or intel from her; instead, my focus remained on what I knew. The threat of the virus jumping from its home ground in Asia to elsewhere in the world was very, very real.
I based my serious threat assessment on the number of cases and deaths and on another factor—one that was more behavioral than biological. While it was true that in 2002/3 the damage SARS did outside Asia was minimal, we now lived in a vastly different world. The SARS outbreak had originated in China, but it was spread primarily to other countries through outsiders coming into China and then returning to their home countries, bringing the virus with them. Back then, only a trickle of Chinese nationals traveled outside the country. Now, Chinese nationals traveled around the world in the millions. The timing of the outbreak also couldn’t have been worse. It coincided with the Lunar New Year, when even more Chinese would be traveling both within and outside their country. The distribution and spread of the virus would be far greater and far quicker due to the undetected silent invasion I fundamentally believed was taking place across the globe.
The collective effort to track the novel coronavirus outbreak was made much easier in the third week of January, when a professor at Johns Hopkins Whiting School of Engineering unveiled a dashboard she and her graduate students had put together that allowed so many of us to track global cases in real time. The dashboard was wonderfully easy and accessible. With a frequency bordering on the compulsive, I would click over to it throughout the day and in the early hours of each morning, when the aggregated data for Asia appeared. It was through this data that I watched the alarming speed of the virus’s advance. Watching SARS spread back in 2003 had been like watching a house fire consuming one home and seeing a single ember land on the roof of another house and slowly smolder for a bit. But watching the novel coronavirus outbreak was like watching satellite imagery of many, seemingly unrelated blazes popping up in different areas of the globe independent of an originating source.
I used the Hopkins dashboard’s numbers to demonstrate to Erin Walsh why it was important to immediately hold a meeting with all African diplomats in Washington, where I would speak. They needed to be informed of the dangers posed to their areas of concern. I would be in Africa in three weeks, but that would be too late. We needed to put out an alert now, through the African Diplomatic Corps in DC.
Walsh agreed to schedule the meeting.
In that first week, once the Johns Hopkins data went live on January 22, I watched as the cases mounted: 314 . . . 581 . . . 846 . . . 1,320 . . . 2,014 . . . 2,798 . . . 4,593 . . . By the end of the month, in just nine days, they were up to 9,826. Going from 314 to 9,826 reported cases in nine days is a large increase. More worrying was the doubling—from 2,798 to 4,593 to 9,826—every twenty-four to forty-eight hours. And these were the visible cases; testing was not widespread yet. So, I believed there weren’t nearly 10,000 cases but—based on my silent-spread arithmetic of three to ten times—potentially, 100,000 cases and growing, spreading unrelentingly, community by community.
The number of countries reporting cases also increased to twenty-four, including some in the Middle East, North America, and Europe. Rapid geographic spread was evident, and what had taken SARS weeks and months to travel was taking this novel coronavirus hours and days. In my mind, I kept seeing the bull’s-eye on Africa.
BY THE LEAD-UP TO my meeting with the African Diplomatic Corps in DC, the fifteen-member WHO Emergency Committee still, apparently, hadn’t seen enough evidence even to declare that the Wuhan cases constituted a public health emergency of international concern. This didn’t make any sense—unless you understood the bureaucratic logic of the World Health Organization. The WHO has historically never wanted to appear wrong or to seem to rush to judgment, an instinct that, in this case, was already costing lives. My responsibility was to the African countries, and by meeting with their ambassadors and having them relay my message to their capitals and on to their public health officials, I’d be doing what the WHO wasn’t—giving them adequate time to prepare for a worst-case (but reality-based) scenario.
I wasn’t just raising the alert for the African countries; I was providing them with solutions and options. We at PEPFAR had spent the last nearly two decades investing in all aspects of the health systems in sub-Saharan Africa, not only to address HIV/AIDS, TB, and malaria, but also to ensure that those same systems would be there in the event of the next pandemic. I planned to let those critical laboratories, the broad array of health personnel we were funding for the HIV response—everything and everyone at their disposal to assist in the response to this new pathogen. I believed that the United States, as it so often did, could serve as a model for the proper procedures to implement to combat this outbreak. To act as a guide for various public health operations on the African continent, I asked two of the people primarily responsible for shaping the U.S. domestic response, Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases (NIAID), and Dr. Robert Redfield, head of the CDC, to share their expertise with the African representatives. Whatever plan was in place for the resource-rich United States, I wanted it replicated in Africa.
Getting Fauci and Redfield to speak was an easy ask. I’d known Tony Fauci for more than three decades. I consider him one of my mentors. More than anything else, I learned from Tony the importance of listening and then adjusting your responses based on listening. He really heard what his patients had to say. I can’t tell you how rare that is. He was super smart about disease pathology, but it was his decency and his empathic nature that truly set him apart. He spent many long hours doing research and then evening rounds, and even if we were working a twelve-hour day, a fifteen- or sixteen-hour day, Tony listened, and his patients felt his concern for them. Combine that with his mission focus, and you have as formidable a presence as there could be without his ever coming across as intimidating, except to us junior members of the team. Tony combined the attributes I most admired: He was a brilliant thinker and a highly capable communicator. He could move easily between the world of science, with its many introverts, and the public realm, where extroversion makes it more likely you will be listened to.
Along with being the director of NIAID, Tony was the chief medical advisor to President Trump, but more than that, he was someone I trusted implicitly to help shape America’s response to the novel coronavirus. He agreed to present at the African Diplomatic Corps meeting to let the African ambassadors know what the United States was doing to prepare for the novel coronavirus regarding treatments and vaccines.
Bob Redfield, the director of the CDC, also quickly answered my request for help. Bob and I also had a long history of working together. As was the case with Tony, Bob and I both worked at Walter Reed Army Medical Center in the 1980s and with renowned NIH researcher Dr. Robert Gallo, who co-discovered the HIV virus. Like Tony, Bob was an innovative, out-of-the-box thinker—something I had never been before I met them. I like to have data, to question that data, and to push the data. I worked in support of both Tony and Bob, attempting to design clinical trials and evaluate the results of these two men’s leaps of intuition. Bob and I worked in the trenches together, and we developed the kind of we’ve-got-each-other’s-back mentality that comes only from being tested under the most challenging circumstances. We were also a good pair—Bob was focused on HIV from a virology perspective, while I focused on the body’s response to the virus, the immunity perspective.
For years, long after we spent hours in the lab or on the ward, Bob and I, joined by another colleague, Dr. Craig Wright, would sit in the residents and fellows’ room late into the night running through the possible causes of the disease that had suppressed our patients’ immune response. Those were the darkest days of my medical career, and I was fortunate to have shared them with Bob and Craig. Not only were we haunted by the gaunt faces and the ravaged bodies of our patients, but we had to deal with the stigma attached to what was then perceived as a “gay disease.”
I can still hear a surgeon, the general in charge of Walter Reed, berating us because he believed we ran the risk of having his hospital known as “an AIDS hospital.” He was concerned, he said, that active duty soldiers and retirees with health problems wouldn’t want to come there because of that reputation and fear of infection. Bob and I were united in the fight against this kind of thinking. That some people stigmatized AIDS patients made all those hours I spent poring over the literature searching for a cause even more worthwhile. Unraveling the mystery and then eradicating the disease became a lifelong passion. For decades, Bob and I would both do anything we could to prevent even one more person from suffering the way so many of our patients already had.
Back then, Bob was willing to be aggressive and take chances. For AIDS in the 1980s, the stakes were high, and the field was relatively wide open. Bob brought both brilliant thinking and fearlessness to problem solving. As for me, I worked as a kind of translator, the strategist, the get-things-done-behind-the-scenes implementer.
Since leaving Walter Reed, Bob and I had remained in contact. Working with him now, I had every confidence, based on past performance, that whatever path the virus took, the United States and the CDC would be on top of the situation. We weren’t going to talk about containment. We were going to discuss mitigation efforts—early testing, available therapeutic measures to back up diagnostics, preventative measures. We had one advantage over those in China: They had faced a sneak attack. We had systems in place within our public health care services to deal with viral outbreaks. We had the CDC and the NIH. The scientists working in the United States were among the best in the world.
ON JANUARY 28, AFTER meeting with Erin Walsh to solidify the planning and schedule for the upcoming African Diplomatic Corps State Department meeting, I received a text from Yen Pottinger. Aside from being the wife of my friend Matt, the deputy national security advisor, Yen was also a former colleague at the CDC and a trusted friend and neighbor.
Like me, Yen was among the many outside researchers who were now tracking the virus. A brilliant woman, she had recently played a key role in developing a new assay (test) for diagnosing whether an HIV infection in someone was recent or old. In our three years working together at the CDC, I had marveled at her abilities in the lab. As early as mid-January, Yen and I had been in communication about the outbreak in China. As events unfolded, we shared whatever insights, information, and anxiety we had.
Her husband, Matt Pottinger, was one of the good ones in the Trump White House. A former journalist turned highly-decorated U.S. Marine who served as an intelligence officer for part of his time, Matt had deep experience in China (including during the 2002–2003 SARS outbreak there) and was fluent in Mandarin. Matt took a position in the National Security Council in the earliest stage of the Trump administration, while still serving in the Marine Reserves. Unlike many in the White House, particularly in the security services, Matt managed to survive the rash of dismissals, scandals, and changing of the guard that took place over the course of the Trump administration, and in September 2019, he was appointed to the post of U.S. deputy national security advisor.
In November 2019, shortly after settling into his new role, Matt had communicated to me that he wanted me to work at the White House in some capacity as a public health security advisor. I told Matt I appreciated his thinking of me, but I was declining. I needed to remain focused on controlling HIV around the globe.
Of course, Matt respected my decision, but he reserved the right to ask me to reconsider.
Since he’d made the job offer, I’d had so much on my plate that I’d quietly filed it away, never thinking I would reconsider a job inside the White House. Off and on in early January 2020, I’d share my thoughts with Matt: about the larger picture, about how the virus response in the United States should go, and about how the White House could better manage its messaging around the virus—usually mentioning these things through Yen. She was happy to assist in any way possible.
Yen knew I would be on the White House complex for my meeting with Erin Walsh, and the text she sent me said that Matt had a “proposition” for me. She didn’t know any of the details, but Matt had apologized for the short notice and said he hoped we could meet face-to-face. Yen arranged so that I could meet him in the West Wing, and once we were both there, Matt got to the point quickly.
He offered me the position of White House spokesperson on the virus.
I told him I wasn’t interested because my skill set didn’t match the job title. In truth, I’d never been particularly media savvy—not because I didn’t understand the game, but because I’d never had the patience for playing it. While I’d done plenty of press events when asked to do so by leaders in government, I’d never sought out the media, and I didn’t need or want to be out front. I prefer doing things rather than talking about doing them. I have always felt that if you do the right thing for the right reasons, you don’t need to be validated in public.
Of course, I understood quite well the necessity of messaging and how important a role rhetoric plays in shaping and implementing policy, but there were others more suited to that role than I. I offered to provide Matt with the names of better candidates, while continuing to give him some unofficial guidance about this virus through Yen. Matt accepted my declining the post, took me up on the list of other candidates, but he again reserved the right, he said, to ask me to reconsider later.
Along with feeling a mismatch between my skills and the spokesperson role, I had another reason for saying no. For nearly forty years, throughout the course of my career, whether in the U.S. Army or as a public servant, I’d chosen not to align myself with a specific political party. I had been careful to keep my political leanings personal. Instead, as long ago as the Carter presidency, I’d worked as a public servant across Republican and Democratic administrations. I had served the people—not a party or administration. I was not a DC or a White House insider who spent her hours plotting how to ingratiate herself with the right people to make sure she had the president’s ear. And I didn’t want to spend my time cracking the code to gain entry, only to be dismissed because I’d worked for one administration and not another. I also didn’t want to be merely a mouthpiece, having to restate what senior officials in the White House had decided or believed. In doing so, I would be seen, by implication, as affiliated with that party or administration.
What I wanted to do was define the actions being taken on the emerging virus based on the data. In my years of working with high-level leaders around the world, I had wielded metrics to move minds and formulate policies, standing behind data to justify the changes and encouraging political figures to make the hard decisions needed to save lives—even if those decisions didn’t help them politically. A number of times, I’d been able to move world leaders who didn’t have their people’s best interests at heart.
I wasn’t certain I could move President Trump. It would take someone with much more political savvy than I to do so.
IN MY BACK-CHANNEL COMMUNICATIONS with Matt, I pulled together all the publicly available data I’d been compiling and analyzing, connecting the dots to create a concerning picture, and sent it to Yen to forward to him. For privacy and security reasons, I wasn’t ready to use official White House email. I trusted that Matt would share the information with those who needed it and not reveal that I was his source. In communicating with Matt, I had ensured they would have everything I was seeing, to use during White House meetings. I let Yen know that the earliest data available showed that the Wuhan outbreak and subsequent spread would be, at a minimum, ten times what SARS had been.
I also passed along communication strategies. At this early stage in the crisis, communication would be key. If we were truly going to engage in a campaign to mitigate the spread of the virus, and not rely solely on containment, then people were going to have to change their behavior, as they were already doing in the Asia region. Accounting for and then containing those who were symptomatic, rather than definitively determining them through testing, would be inadequate. With so many people already silently infected, it would be nearly impossible to mitigate effectively without other efforts, ones that involved individual behavioral changes.
In any health crisis, it is crucial to work at the personal behavior level. With HIV/AIDS, this meant convincing asymptomatic people to get tested, to seek treatment if they were HIV-positive, and to take preventative measures, including wearing condoms; or to employ other pre-exposure prophylaxis (PrEP) if they were negative. Prevention and knowledge were crucial to slowing the spread of HIV. We expended enormous amounts of time, energy, and money devising campaigns to get this message across.
We also understood that people needed to have information tailored to their age and sex. We knew that the platform used to convey the message, and who delivered that message, was also important to changing behavior and getting people to act. This level of detailed analysis and action-oriented messaging meant relying on those outside the public health field to assist us. In the private sector, companies hire advertising and public relations firms who specialize in communicating effectively to influence behavior (get consumers to purchase goods), and we relied on their expertise to help us get those at risk for HIV to “buy into” our message around safe sex practices and preventing infection. Those public relations and advertising firms taught us crucial lessons. They conducted focus groups that helped us hear what our target audience thought, believed, and felt. We had to learn to listen better to better address the needs of the people we wanted to help. We were scientists, but we weren’t behavioral scientists, and accommodating human action and cultural perception is important in all things to do with public health.
Well before I came onto the task force, I knew the government agencies would need to do the same thing to have a similar effect on the spread of this novel coronavirus. The most obvious parallel with the HIV/AIDS example was the message of wearing masks. Because the novel coronavirus was airborne, wearing a mask limited the amount of aerosols or droplets an infected person could spread and reduced the number of these particles others could inhale. One of the things that had kept the SARS case fatality rate from being worse was that, in Asia, the population (young and old alike) adopted the wearing of masks routinely, to protect themselves from air pollution and infections in crowded indoor and outdoor spaces when social distancing wasn’t possible. Masking was a normal behavior. Masks saved lives. Masks were good.
In the United States, however, we didn’t have that same history of successful mitigation fresh in our minds. Independently from me, Matt became the self-appointed White House prophet of mask wearing. Having also been in Asia during the SARS epidemic, he’d seen how the Chinese people and those throughout Asia had adopted wearing masks as an antidote to the government’s initially flat-footed response to the outbreak. He and I had also seen that, across Asia, N95 respirators (those masks that form a seal around the nose and mouth) weren’t readily available or used outside hospitals. For this reason, people regularly wore cloth masks. This distinction would loom large later on.
At the White House, Matt’s message about wearing masks to prevent silent spread had fallen on deaf ears. The consensus there, and among some in the United States, seemed to be that masks weren’t necessary because people were at low risk of getting the disease. The other reason wearing masks didn’t gain traction among Americans was that, besides not having a history of success to fall back on, masks required the wearer to make multiple commitments—to purchase them, to keep them in various locations, to remember to put them on, to deal with the physical and mental discomfort, to get over the stigma attached to wearing them. Simply put, wearing a mask required more effort than most Americans were accustomed to putting in. Change is hard. Behavioral change, and remembering that change later, is really hard.
Another strategy that suppressed the 2003 SARS outbreak was social distancing guidelines—limiting how close you got to other people, especially indoors, but also how frequently you gathered with others indoors and, critically, reducing the number of people with whom you interacted by reducing the frequency and size of gatherings. Along with wearing masks, these behavioral changes had the greatest effect on mitigating the SARS epidemic by limiting community spread and not letting the virus claim more lives.
In those early days of the novel coronavirus, when few were acknowledging the role of silent spread, I knew it would be extremely difficult to begin a public campaign touting these three measures. With no clear-cut numbers to convince people of an obvious need for them, who would engage in behavioral changes as drastic as wearing masks and reducing the size and frequency of gatherings? This was not new: Back in the 1980s, even when it was clear that many, many people were dying of AIDS, it was still difficult to get the message across about the use of condoms and the other behavioral changes needed to decrease the spread of HIV. Similarly, if you hadn’t yet seen anyone in your family or your community getting sick from the coronavirus, or if the number of those infected was very small, it was far too easy to shrug and say, “I don’t see the need.”
This was a variant of the “Not in My Backyard” phenomenon. Unless this virus was actively affecting people’s lives or the life of someone connected to them, getting people to adopt a precaution above the most basic level would always prove to be difficult. Also, here in the United States, we are not particularly attuned to the idea of prevention, especially as it pertains to our own health and even when it comes to a virulent disease. Even “CDC,” the abbreviation for our most trusted health agency, the Centers for Disease Control and Prevention, leaves off the P, which represents the most crucial word in its name. This says a great deal about what we value. Prevention, in many people’s minds, takes far more effort than treatment. While we’re sometimes reluctant to do the latter, most people loathe doing the former.
Also, good and effective preventative interventions are often invisible. If you take care of yourself and don’t get sick, there are no real markers you can look back on to say, “That was a near miss.” It is extremely difficult to prove a negative, to show that a “non-event” happened. Individuals’ tendency to place treatment over prevention is one of the greatest challenges our public health officials face all the time.
One way to convince people of the need for behavioral change is to develop a consistent messaging strategy. When public health measures are centered on behavioral change as the primary intervention, communication is key, and consistent communication is critical. To date, the statements on the novel coronavirus from health officials, and from President Trump himself, had centered on containment and not prevention of community spread through mitigation. This was the wrong approach. This focus on containment would lead the American public to believe that the virus was primarily outside the United States and that, if it crossed our borders, it could be stopped immediately. Comparing the new virus to SARS and MERS would also feed the American people the false expectation that it would be limited in spread, as was the case with those viruses. Meanwhile, comparing it to ordinary seasonal flu would give the public the sense that not only was this coronavirus fairly harmless, but that it could be treated like the flu—which is diagnosed by its symptoms and which doesn’t deeply impact families and communities. It trivialized the virus and its threat.
I communicated to Matt that we needed to break this chain linking the novel coronavirus to SARS and the seasonal flu and reprioritize testing, full mitigation, mask wearing, improved hygiene, and more social isolation. To that end, a coordinated, concise, and carefully worded series of communications would be necessary to get the messaging right both within the White House and, more crucially, to the American people. The private sector had taught me the importance of message segmentation based on demographics. Communication must constantly evolve based on continual feedback from the community you are addressing.
I was giving Matt a lot of ideas, and I was glad to be able to help him, and the country, but I had one lingering regret. I texted Yen: “Every time I turn something down, I feel like I am making yours and your children’s lives more difficult, as Matt has to work more. But I am trying to support behind the scenes.”
She responded: “That’s funny, because it’s not true. Don’t feel bad. Our lives will continue to be difficult until he finds a new job. He thinks you should take over Azar, Fauci, and Redfield’s jobs, because you’re such a better leader than they are. He has been underwhelmed thus far.”
Though I would come to see in Matt’s comment the sense of foreboding it carried, I dismissed it in that moment, taking the statement as hyperbole. Yen was a sympathetic spouse, expressing Matt’s frustration, the depth of his worry, and the inaction he was seeing out of the Department of Health and Human Services, which includes both the NIH and the CDC.
Though Matt was unnerved by what he was seeing from the federal public health officials, I trusted Bob and Tony. This trust was reinforced at my meeting on January 31 with the African Diplomatic Corps. Everything Drs. Fauci and Redfield said about their approach made sense based on the information available to me at that point. While President Trump had casually dismissed the coronavirus’s potential threat to the country, there were good people with great minds and effective strategies at work on it in the United States. Two of them had just shared further evidence of that: at the meeting with the African Diplomatic Corps, Tony presented on the work being done to accelerate therapeutic treatments and vaccines to combat the potential pandemic, and Bob talked about the work the CDC was doing to test and confirm cases. Neither of them spoke specifically of asymptomatic silent spread or of the role testing should play in the response, but I didn’t read too much into this omission. And I didn’t have time to speak to either of them specifically about testing, as they had time only to run into the meeting, make their presentations, and then run out. Later, it would become clear they were working on the China travel ban that day.
As the first month of 2020 came to a close, I believed that those with the most acute vision with regard to the virus would prevail and that the United States was in good hands. I could sleep well knowing that the full force of what the nation had at its disposal—the public health agencies, researchers, laboratories, and medical professionals—was in place. I wanted to be certain that I could say the same for Africa. For the foreseeable future, I would ally my interests with where my duties called me. As far as I could assess, my focus on Africa was not misplaced. The threat to an already vulnerable region was far greater than it was to the United States, with its expansive, and expensive, medical industrial complex.
Still, it was hard to shake that trained sense of worry that came from experience. I found myself thinking back to a call I had taken two days earlier, on January 29, from my deputy, Dr. Angeli Achrekar. Right away, something in her voice quickened my pulse. She had called me from beneath a stairwell at the airport in Addis Ababa, Ethiopia. She confirmed what I’d suspected: A tide of Lunar New Year celebrants from China inundated the lounges and departure areas.
The levy that had kept SARS largely isolated to Asia almost two decades ago hadn’t just broken; it didn’t even exist anymore.