Flying thirty thousand feet above the Atlantic with no view of the earth below me, I was struck by an analogy. That I could envision what was below me but couldn’t see it was pretty much how I’d experienced the Trump administration’s response to the outbreak thus far. All this would change soon enough. In less than a day, on Monday, March 2, I’d be on the ground, walking into my new role as White House coronavirus response coordinator. Then I’d be able to see if perception aligned with reality.
I had my reservations about working in what looked like, from the outside, a dysfunctional White House. Before agreeing to come on board, I’d shared my thoughts with only a few people, primarily my PEPFAR deputy Angeli Achrekar, Irum Zaidi, and Yen and Matt Pottinger. In fact, Yen and I had a bit of a laugh when she asked me what my husband thought of my taking on a new role. I’d told her that, given that I was still in South Africa and he was in the United States, I hadn’t yet told him (not to mention my adult daughters) about the possible White House move. I was that concerned about information being leaked. Who knew who was monitoring our communications? I’d committed, and I was going, but in those long hours on the flight home, I found myself reassessing just what I was actually entering into.
From my perch at the State Department, I had seen three years of high turnover and continual news reporting of chaos in the White House. A pattern emerged: talented and respected people went in and then abruptly left. Some of them wound up testifying at congressional hearings. More concerning, I saw too many political casualties among retired military members serving in the White House. H. R. McMaster, John Kelly, James Mattis—none had survived that undisciplined environment, not one. I didn’t know these men personally, but I’d served under men like them. Worldwide, they had overseen high-stakes life-or-death situations where events went sideways, where rules of engagement had to be funneled through Department of Defense lawyers, and where different agendas, military and political, conflicted. If those experienced, never-give-up-on-the-mission leaders hadn’t survived, what chance did I have?
From the outside, this administration seemed too disorganized, too negative, too chaotic, too disrespectful, too vindictive, too scattered, and too mean. Because I wasn’t a political person, I had only two connections, besides Matt, to the people in the White House. The place was filled with business-oriented people who were tight with one another and who had made millions, perhaps billions, in their careers. Prior administrations, and the country, had become increasingly partisan and distrustful of civil servants. Add to that volatile mix a looming presidential election.
I wanted to do what was best for my country, but I also had to consider what would happen to me. Accepting this position would end my federal civil service career. That was a precondition of taking the job that I forced myself to accept, especially given the polarization of the political parties and, particularly, the broad negative view of the Trump administration. That end was a tough pill to swallow. I’d had a great career, one that I was justifiably proud of. I was helping to control the HIV pandemic by using granular data and by driving the policy reforms necessary to establish equity, remove barriers, and ensure access to services for everyone, independent of tribe, race, gender, sexual orientation, wealth, political party affiliation, age, or geography. This was all a dream no one had previously thought possible, but it was made real through many people constantly pushing. My colleagues viewed me as a hard-driving force focused on those who needed our help the most, addressing both the social and medical reasons for vulnerability.
Of course, there was also my selection itself. I had to consider the possibility that I was a “gendered” choice, the lone female medical doctor on a team that had six male doctors already on board. I also worried that ulterior motives had been at work in the selection process. Would I, as a multidecade civil servant, become a victim of the civil servant/politician divide? Were people like me and Tony, who had an even longer career in civil service than I did, being positioned as scapegoats in case things went sideways? Those with long-term Trump connections could insulate themselves from the president’s hot-tempered wrath. (Not to mention that the roster had already changed, with Secretary Azar out as head of the task force and Vice President Mike Pence in. What this foretold was still to be determined.) By having us around, the “politicals,” when things went awry, could say they’d gotten bad advice from the “public health experts.” They could easily blame the civil servants and characterize us as members of the “deep state.” These were realistic possibilities.
From past experience, I was clear-eyed about what I might face in working with this administration. In 2019, I faced off against President John Magufuli of Tanzania. The previous president, Jakaya Kikwete, had been very supportive of our comprehensive response to the HIV pandemic, but when President Magufuli came in, he replaced the minister of health and enacted a series of regressive policies that, if allowed to stand, would have severely limited our ability to help not just gay men, but the highest-risk group, ten- to twenty-four-year-old girls. We had worked hard for many years and had made significant progress. President Magufuli staunchly opposed our programs for the most vulnerable and reversed laws that required young women to be at least eighteen years of age before being allowed to marry. Magufuli seldom seemed to have the best interest of his most vulnerable Tanzanians at heart. Still, over time, we’d been able to claw back all but one of the losses we suffered under his administration. After that experience, I wasn’t going into the White House task force afraid of hard work or dealing with those who didn’t prioritize best public health practices.
I had dozens of reasons not to do this job, and only one reason to do it: Matt seemed certain I was the missing piece. He knew I had worked on RNA viruses like SARS-CoV-2, from the laboratory bench to the community, developing tests, therapeutics, and vaccines. He knew I had practical on-the-ground experience in what was needed to combat a pandemic. He knew I had convinced other presidents and prime ministers around the globe to enact politically unpopular policies crucial to saving their constituents’ lives. He also knew that, being ex-military, I was mission-oriented and that service mattered deeply to me. He also knew my focus on data and my relentless drive to use it for decision making to drive policy change.
More than all that, I think he believed I was resilient enough not to get distracted by the constant political swirl around 1600 Pennsylvania Avenue and beyond. He thought I could survive in this White House. I wasn’t so sure. I was confident in my abilities, but less sure of how they would be received in a potentially hostile environment.
For the rest of the flight, I focused on the mission. This began with considering my first interactions with members of the task force and what elements of the response to prioritize most. I had to better understand who and what I would be coordinating. The task force had been meeting since the end of January, and like any new kid showing up after the start of the semester, I was already behind on some of the social aspects—how the various personalities in the room were meshing and what was happening behind the scenes at the agency level. The task force members must already have established a working rhythm and relationships.
To that point, Matt had offered only somewhat vague impressions about Tony and Bob and his general sense that the task force’s lack of urgency was problematic. I’ve always trusted my ability to read a room, but the stakes here were very high. I was confident that I could present a plan of action for how to proceed, but I certainly wasn’t going to be able to come in and dictate terms to anyone. Any whiff of overbearing leadership would be detected instantly, and I’d likely find myself backed into a corner. Forcing myself into a defensive position would serve neither mine nor the country’s interests.
As for what we were up against, as the jet carried me across my Rubicon, I reviewed all available past U.S. pandemic preparedness plans. Fundamentally, crisis management problems already existed. The pandemic preparedness plans could clarify which agency under HHS was the lead. Was it the CDC or the Office of the Assistant Secretary for Preparedness and Response? This was the first time the United States had faced a substantial pandemic with both ASPR (which was formed in 2008) and the CDC (established in 1946) in place. Having competing factions within the same department could foster execution and accountability, but would the two agencies play well together? If not, how was that failure already impacting the situation?
Not having a clear sense of who was leading on what front could cripple coordinated preparedness efforts. Similar confusion over agency oversight existed when it came to developing vaccines and therapeutics (Biomedical Advanced Research and Development Authority [BARDA] vs. the NIH). Knowing who was responsible for what aspect of a mission was essential to successful planning and execution. So was agreeing on a core set of principles to guide the response. The lack of urgency and task confusion (as we’d seen already with the testing debacle) had put us behind, but the lack of consensus on this virus’s silent spread as a guiding principle could prove crippling.
I wrote a list of action items and charted a way forward. Gaps existed, but from thirty thousand feet in the air, my perspective was distorted. I needed to see how large those gaps really were. I’d devote my first week, then, to on-the-ground reconnaissance.
Testing and communication were two of the largest gaps to be filled immediately. Scaling production to meet the needs of the entire United States required aggressively enlisting the private sector. One of my priorities that first week would be meeting with commercial test developers to close that capacity gap with a rapid increase in testing production. I assumed that some version of this conversation with the commercial test developers had already taken place with someone on the task force or at the White House, but I wanted to make sure this partnership with the private sector was being prioritized.
To communicate more accurately, we had to replace two of the administration’s persistent damaging messages with correct ones: Covid-19 was not the flu, and the risk to Americans was not low. The risk of death may have been lower depending on age and underlying conditions, but the risk of infection was not. Also, the healthy and young were unknowingly spreading the virus. That the CDC was relying on its flu model approach behind the scenes was bad enough; but the White House’s rhetorically comparing the risk of this virus to the seasonal flu was far worse. Most Americans heard this claim, and once that low-risk flag was planted, it was going to be hard to remove it. I was determined to do so.
My initial reconnaissance mission would also prioritize understanding the administration’s views on masking. Matt had told me that there was little to no support within the task force for their use. I couldn’t tell precisely from where in the White House the resistance was coming or what form it was taking. Certainly, the administration’s public statements weren’t making clear what its stance on masks was. If the administration, following the CDC’s lead, believed that this was a flu-like event, then any type of intervention that didn’t fit a flu scenario would become a harder sell. We had to make that sale, but it would be like getting a car buyer to opt for the extended warranty before buying the actual car. Communications, testing, and masking were important, but first things first—we had to sell the car and get awareness of asymptomatic spread driving the response.
With the assistance of my PEPFAR colleagues and others, I’d gathered, to that point, international data. The task force would be basing its approach on domestic data, and I wouldn’t know until I got to the White House precisely what that looked like. Further complicating things, I had no idea how quickly I’d be able to get domestic data in order to make clear the charts and graphs I would use in lobbying for action. I always made my own graphics and PowerPoints to convey critical concepts visually, using PowerPoint for its graphs, not text. I had always found that a graphic could tell a complex story it would take hundreds of words to convey.
For all the logistical issues that testing would present, it would be far more challenging to change entrenched positions in the medical professionals at the CDC and elsewhere in the administration about what this virus actually was: a silent spreader. I couldn’t begin to win over the politicians to the idea of silent spread, or of the drastic actions we would need to take to curb it, if I didn’t even have the doctors on my side. My sense, my hope, was that the doctors would see what I was seeing and what it revealed about silent spread. Even if, publicly, they weren’t in a position to act on it as aggressively as I felt they should have, at the very least, they had to recognize its role. Maybe they hadn’t seen it as soon as I had, but by now, they must have seen it. Either that or they had access to numbers they believed would prove their case, numbers that, from my vantage point on the outside, I hadn’t yet seen.
Still, in the back of my mind, I continued to hear Matt’s voice—his sense of urgency, how hard he’d worked to get me on board. The foreboding behind his words was palpable, and the sooner I was behind the curtain, the sooner I could begin to understand firsthand what was motivating his concern. I desperately wanted to arrive at the White House and learn that Matt’s fears were misplaced, that the machinery behind the scenes was functioning, albeit slowly, much as it should have been, or that, perhaps most optimistically, I was simply wrong about the silent spread.
In fact, at no time in my life had I ever wanted to be wrong about something as I wanted to be now.
I LANDED IN DC at around noon on March 1. That evening, as I prepared for the next day, I realized I had no idea how one was supposed to dress for this job. I spent considerable time thinking about the impression I wanted to make on the president, the vice president, and the other members of the task force the next day. Though I was ridiculously jet-lagged from my all-night flight, I managed to think clearly. I picked a black dress with a black jacket emblazoned with buttons. It looked very much like a military uniform, and that was the image I wanted to project. With that outfit and my highest heels (which made me more than six feet tall), I wanted to send a serious and commanding signal: I might be the only female physician on the task force—indeed, I might be one of only a few women in the room—and the odds might be stacked against me, but I would look like I was in command-and-control mode.
That first day, I was greeted by two representatives of the vice president—his chief of staff, Marc Short, and an aide named Olivia Troye—before meeting with Vice President Pence. Going in, I anticipated feeling a bit of kinship toward him. He was in a somewhat similar situation to mine, having been appointed to head the task force just seventy-two hours earlier. The vice president and I had met very briefly once, when I asked him to speak at an AIDS Day event in 2018. But for me, he was still essentially only an outline. Once in his presence, I quickly filled in the details. I looked around his extraordinarily organized office. Photos of different family members surrounded him on the north and west sides of the room. Biographies of leaders filled the bookshelves on the east side of the room, while the south side contained a working fireplace. The room reinforced my previous impression of him as the prototypical reserved, solid, down-to-earth, family-oriented midwestern man.
We exchanged brief greetings and very few pleasantries before I got down to the business at hand. As the head of the task force, the vice president, above all others, I believed, had the president’s ear. Sticking to my plan, I addressed the major points immediately: the president had to understand that we weren’t facing the flu and that the risk to Americans was not low. Again and again, I emphasized with the vice president, and with many others that first week, that any comparisons of Covid-19 to the seasonal flu, any references to its case mortality rate in relation to the flu’s, any belief that detecting SARS-CoV-2’s presence solely through symptoms in an individual or in a cluster would be a real blow to the safety of the American people. Testing was key.
I was pleased to hear Vice President Pence set the tone in that first meeting with me, and then later with everyone else, by saying bluntly and unashamedly “I don’t understand that” whenever he didn’t fully grasp some medical or technical concept. In an environment where bluster and stubborn know-it-all-ness too often prevailed, Vice President Pence admitted that he was no expert and that much of the material I was presenting to him about virology and epidemiology was foreign to him. He also impressed me by trying to contextualize my points: “Why is that important? Explain to me why you think this way.” From the outset, I greatly appreciated this kind of honesty and directness. Even better, throughout the eleven months we worked together, he kept this spirit of inquiry and active curiosity alive in himself and encouraged it in others. He was willing to listen, to learn, and to act. Because I was willing to take the time to consider all questions, and had come in prepared with a plan, he listened to me and seemed to trust me. I received no signal that he was resistant in any way to my presence or to my specific recommendations. He grasped my sense of urgency and committed his staff to translating the priorities I listed into immediate actions.
I didn’t have a team at this point; it was just me in the White House. Although Matt and NSC staff were supposed to find me office space that first day, it was the Office of the Vice President that found me a place. Within hours, they had moved Olivia Troye, who now worked directly for Marc Short, into that same space, four feet from me. Later, I’d learn that Olivia had been part of the National Security Council, detailed from DHS, but she was now an aide to the vice president’s White House Coronavirus Task Force.
At the time, I didn’t think much about what this shift from NSC quarters to the vice president’s locale meant. Later on, I’d learn that the move was not about space allocation, but was politically motivated. It was the opening salvo by Marc Short and his team to “protect the vice president and the president,” to scrutinize my possible impact. Olivia Troye would be responsible for monitoring my every move and reporting back to Marc Short.
As I bounced from one meeting to the next that first week, I tried to get a feel for the dynamics at play. In getting to see the personalities in action, I gathered that my fears about the vice president’s and my dual entrance into the task force, combined with Alex Azar’s perceived demotion, would complicate matters further. As head of HHS and the task force, Azar had been in power. Now on board as the coordinator, I was unsure where I fit in or, critically, where Azar thought I did.
From the outset, Alex Azar’s hostile body language and clipped verbal responses to me revealed his dissatisfaction with the roster shuffling. As he spoke, he often leaned back with his arms folded—a defensive posture. People on the defensive, or people who feel they have been slighted, can become vindictive and don’t always act logically or stay focused on the task at hand. We all needed Alex and his leadership, and I needed to find a way to make things work. From using data collection and analysis to structure the public health response (CDC), to developing therapeutics and vaccines (NIH and the private sector), to having these therapies and vaccines approved (FDA)—the Department of Health and Human Services and its agencies were central to the Covid-19 response and to protecting Americans. As it turned out, one of the reservations I’d expressed to Matt from the beginning, my relative lack of experience in navigating unfamiliar domestic and highly territorial waters, was going to be an enormous challenge. I knew global; I didn’t know domestic.
While operating in the shadows I had intuited from the ambiguously written pandemic response that a struggle within HHS was occurring. The task force meetings I attended that first week revealed that conflict was playing out in real time. In a large bureaucracy, interagency squabbles can, obviously, be very counterproductive. This particular border war was between two agencies geographically distant from each other: the CDC in Atlanta, headed by Bob Redfield, and ASPR in DC, headed by Dr. Bob Kadlec. The gap to be bridged was between the CDC technocrats and the ASPR bureaucrats; it was between who would plan the response and who would execute those plans. That HHS had to be in charge was undeniable. The question was: Would it be the CDC or ASPR that took primacy in ensuring a comprehensive response and continual course correction in real time as the pandemic evolved?
Geography matters, and ASPR personnel and leadership were in the same building where HHS and its secretary resided. From the start of the pandemic response, this meant that ASPR was in the best position for face-to-face conversations between HHS and the task force simply by our walking down the hall. Meanwhile, the CDC’s team was mostly on a conference line. I considered all CDC personnel as essential frontline workers whose efforts would be enhanced by working on-site in Washington, DC, and in all states. In times of crisis, when data moves quickly and responses need to be fast and agile, physical presence can be critical. As so many of us have discovered as a result of living our work lives digitally during the pandemic, the dynamics of in-office and remote work environments are not the same. Although there was some rotating of CDC personnel in DC and a handful of them on C Street, 99 percent of that agency was in Atlanta and, like many white-collar Americans, working from home. This lack of continuity would hamper their efforts.
Worse, I would soon realize that the most senior CDC technical people overseeing the pandemic were not in the room at HHS. Instead, they were manning their own Emergency Operations Center in Atlanta. The CDC senior technical people were the ones we needed available long term in Washington. They could be responsible for explaining to the bureaucrats the more difficult-to-grasp, technical, scientific details of the current crisis. Their absence there made a hard situation even harder.
In those initial days, because I didn’t know all the players, I relied heavily on people I knew I could trust—mainly Matt Pottinger, Tony Fauci, and Bob Redfield. When I had questions or concerns or important information to relay, I went to those I knew best, Bob and Tony. Conversely, I felt certain that others on the task force had their reservations about me. Could they trust this outsider? No, they didn’t know me. They weren’t thrilled that I had come along, they didn’t believe they needed coordination, and they potentially believed that my very presence had knocked their agency down a peg or two. Pecking orders and territorial boundaries mattered.
Vice President Pence appeared to be one of the few people who was fine with my being there, but his staff, accustomed to protecting their boss’s self-interest, didn’t appear to trust me. Marc Short, the VP’s chief of staff, headed the list of those whose antennae seemed to be up. At that early stage, I didn’t know Short nor understand his motivation, but I knew he was political and that he was there to closely monitor the political aspects of the response. I couldn’t tell if he was protecting the vice president or, ultimately, the president. In the end, it didn’t matter. The men’s interests were intertwined. Vice President Pence was my direct report, and whatever role Short played with the vice president, it didn’t interfere with me having access to Pence, and we worked closely and well together.
I SPENT MOST OF my first week observing where things actually stood relative to where I thought they should be. I asked questions. I listened. I didn’t want to come in pushing from the get-go. I wanted to learn where we were on crucial fronts like testing and masks, but more important, I wanted to discern how the task force was (or was not) building the role of silent spread into their thinking.
At one meeting early that first week, Bob was presenting to us on the state of the epidemic. He handed out an Excel spreadsheet printed on a single double-sided page. It summarized case data and deaths by state—just those generalized numbers, which came from the states themselves. This thirty-thousand-foot view was not what I had expected or what was needed. I was hoping that the task force would at least have had more precise data by county and zip code by now, something that would show us exactly where the virus was in the states, counties, and municipalities, so we could plot from those coordinates and focus attention and resources in real time. I was looking for numbers that would allow us, at worst, to project where the virus was likely to emerge next or, at best, through testing, to spot the early onset of clusters in precise locales.
Instead, what we had been handed was without interpretation, analysis, or projection. It simply showed where we were twenty-four hours before. To me, numbers alone, without interpretation or projection, don’t mean anything. All this data would show us was where the sickest of the sick were now. Without more granular data, like test positivity and new hospitalization rates, we couldn’t see which hospitals would need support, where the hardest-hit communities were located, and who was most susceptible to severe illness. What we had wasn’t enough to project into the future or prevent future community spread elsewhere. Numbers that don’t contribute to a solution mean nothing.
While I didn’t say anything to Bob at this point, I knew we needed more precise data points than just case totals. There had to be secret data somewhere in the CDC’s Emergency Operations Center, data coming in from the states that was being used to model the next move. This single piece of double-sided paper couldn’t be the extent of what the federal government knew and believed about cases of Covid-19.
After that meeting with Bob, I quietly started to inquire about getting the raw data, shaking the trees a bit to find out who had access to it. I asked Bob Redfield and others where the data was that I could really sink my teeth into. Where was the demographic data on the infected—broken down by race, ethnicity, underlying conditions, age? These figures wouldn’t just identify the infected; they would identify how this virus operated, an essential component to formulating a pandemic response. Knowing whom a virus infected led to understanding how it behaved.
From the onset of the outbreak, other countries, like Italy, despite being in the midst of their own Covid-19 crises, had been continually providing comprehensive hospitalization and fatality data, aggregated by age and gender, in real time to Irum and me. That is the way global support is supposed to work, and that is how Europe had responded to this crisis: with the specific demographic information necessary for us to understand how this virus was acting in ways that were different from previous viruses. Changing the narrative so that we all agreed that this was not the flu required my knowing (by race/ethnicity, age, comorbidities, and so on) who was getting seriously ill, where, and when.
I felt tension tightening my neck and shoulders. I had to unclench my jaw. How was this really happening? How in the world could we not have clear data at this point? What the—? It was March. Bob and the CDC had heard about this two months ago, and this was all we had? A static, partial thirty-thousand-foot awareness. I pressed the flats of my hands into my eyes and shook my head. I had expected something very different, but now I could see not only that the data-reporting structures that had taken years to build in Africa weren’t present in the United States, but that we had days to get the same job done here. I thought of those photos of the Chinese building hospitals in ten days. That kind of construction was easy compared to what we now had to undertake.
Had the United States really been flying this blind for this long? We had known about this virus for weeks. We had all seen the overrun hospitals at ground zero in China. How was it possible that we had so little understanding of what was unfolding on our own shores? Following the science actually requires getting the data to develop the evidence base that creates the “science”—we didn’t have that critical data.
My notes from March 4 say it all: “The White House Task Force has no unified source of truth to understand the scope, scale, and spread of Covid-19 in near/real time. The CDC has an incomplete subset of information (CDC case data) among multiple fragmented efforts on various legacy (on-premise hardware) infrastructure. A significant wealth of critical information exists distributed across the state/local, public and private entities and requires White House direction to centralize.”
To cut through this immunologist-speak: we were dangerously behind the eight-ball on this one. The CDC had precious little systematic data, and what it did have had not been curated efficiently or effectively. It existed on outdated hardware, using software not meant for this kind of pandemic. Things were so bad in fact that, in 2020, the exchange of information within some states was often transmitted by fax. Hand-entered data was then passed along to the CDC electronically or by fax. Clearly, data collection at the CDC was inadequate.
One of the gaping holes in the U.S. pandemic preparedness plan was not having a capable data collection system. Data is everything in a pandemic. Data shows your gaps; it shows where communities have an effective response; it lays bare the truth, where things are deteriorating and where they are better. It allows you to stay laser-focused and develop evidence-based policies. Without comprehensive data, you won’t have a comprehensive response. Without data, you don’t know what is working and what isn’t. You can’t see who needs help and who doesn’t. And you can’t manage what you don’t measure.
I knew that hospital data existed in deep detail elsewhere. Once the coding of illnesses became how health care providers were paid, they had developed or purchased highly sophisticated data systems. Whether it was in doctors’ and nurses’ notes or in barcoded entries for medicine and supplies dispensed, in tests conducted or results confirmed, real-time data did exist.
Despite the Health Insurance Portability and Accountability Act (HIPAA), which ensured the confidentiality of these records, we had been extracting this data globally for years. With the patients’ personal information removed, the remaining data allowed us to see what was happening without breaching patient privacy. In all the years of pandemic preparedness, certainly we had the ability to protect patient information while getting real-time data around specific symptoms and laboratory results. Where was it? Why didn’t the CDC have access to all of it from every hospital and clinic and not just from a select few? I didn’t give up looking.
In the meantime, I continued to monitor the more demographically specific global data that Irum was collecting through her international contacts. I also reached out to the HHS Office of Global Affairs to help me get data from Europe. This wasn’t going to be sufficient to convince those in the White House, but it would help me build the case. Most notably, I thought it could move Bob and Tony toward my belief in silent spread. In my mind, the biggest red flag was the older age of those admitted to hospitals with serious disease. Given that everyone infected did not go on to become seriously ill, hundreds of people would not be showing up to hospitals seriously ill, as they currently were, if there weren’t community spread. There had to be a lot of asymptomatic younger people and people in their forties and fifties with much milder infections driving the spread to these more vulnerable individuals.
Before one task force meeting that week, I turned to Bob and Tony. The task force meetings often started five to ten minutes late, and we had arrived early, so we used the extra time to confer. Huddled together, the three of us discussed where we were on silent spread.
“Our people tell me that it’s not greater than twenty percent of total cases,” Bob said.
“Based on what?” I asked.
“The Diamond Princess, for one.”
“But that data isn’t accurate,” I said, incredulous. “Those numbers were based on primarily the symptomatic cases and the roommates for the symptomatic cases. I’m not telling you anything you don’t know, Bob, but the older passengers were mostly symptomatic. They didn’t account for the younger, asymptomatic cases, the crew members.”
“Those are the numbers we saw. We can’t project based on what we didn’t see.”
This was a real sticking point. We knew how many people were on board that ship. That was the denominator. But we didn’t know the full numerator—the total number of cases—because not everyone on board had been tested. You can’t derive an accurate percentage that way. If you have a bag of ten apples and bite into one that’s rotten, you can’t say that 90 percent of them are bad based on that one sample. Your estimate will, more than likely, be wrong. How would we produce an accurate projection? By sampling all ten of the apples, of course. But if your belief is based only on appearance and not on core empirical evidence, then your percentage estimate will be close to useless.
And then there was the surface sampling on the Diamond Princess. It was bad enough that not everyone on board her was tested every day, but after passengers disembarked, surfaces on the ship were swabbed for the virus. Of course, the PCR test showed SARS-CoV-2 everywhere. RNA fragments can survive on surfaces where the full-length infectious virus may not. What was left behind, therefore, couldn’t infect people. Experts should have understood this immediately, or investigated it quickly. By doing that, they would have eliminated the possibility that surface contamination was contributing to spread. Inadvertently this swabbing led to the “surface transmission” theory of Covid-19 spread, producing the run on disinfecting wipes across the globe, the religious quarantining of packages, and the habitual wiping down of all groceries for weeks. And it was another distraction from the true source of continued spread: the infected experiencing no symptoms and transmitting the virus to others.
In this case, though, it wasn’t solely the CDC that had underestimated the silent spread figure. They were basing their number on what their Japanese colleagues had calculated. The CDC’s rank-and-file scientists and researchers accepted the Japanese numbers and used them in their own silent spread projection. I saw the initial calculation as flawed; therefore, any projection based on it would be equally flawed.
I felt that silent spread could account for as much as 50 percent of total cases; the CDC believed it was closer to 17 percent. This lower figure would make silent spread far less of a concern for them. Their estimate would have had me sleeping better at night—only, I didn’t agree with it.
As it turned out, Bob and Tony didn’t agree with the CDC’s number, either. While they weren’t willing to go quite as high as my 50 percent figure, their thinking was closer to 25–30 percent—still high, but not quite as dire as I saw things. Also, I believed the spread was distinctly age-related, with younger adults more likely to be asymptomatic. Though I was somewhat disappointed that Bob and Tony weren’t seeing the situation as I was, at least their number supported my belief that this new disease was far more asymptomatic than the flu. I wouldn’t have to push them as far as I needed to push the CDC. Silent spread demanded dramatic action outside the task force, and I would need both Tony and Bob fully behind me to build support for any action needed to address it.
Despite disagreeing on the numbers, Tony did totally support aggressive action based on Italy’s data. So, until I gained access to (or, in the end, had to create) the full range of data we needed domestically, I relied on Italy’s data to make my case. Tony knew a lot about the Italian public health care system and its researchers. Both were part of one of the most sophisticated and advanced health care systems on the European continent. Tony had worked with a number of prominent Italian doctors and researchers over the years. I curated all the global data and presented all of it—from South Korea, Japan, Spain, and France. But to make the most important and specific points I needed to, I chose the Italian data because it offered the best opportunity to get Tony farther down the path toward accepting my conclusion regarding silent spread.
From the Italy data in particular, I was able to see that we were about ten to fourteen days behind where the Italians were. And at that moment in Italy, things looked grim. By early March, the virus had already spread to all regions of the country, and by March 9, all sixty million of its residents would be in lockdown. An Italy-like surge in cases was coming to the United States. We needed to prepare now for what Italy was experiencing, even though it seemed likely we were already too late.
WHATEVER SUSPICIONS THE VICE president’s staff had about me, they helped when I asked for it. One of my requests within the first two hours of my arrival was that I be able to meet with representatives from the private sector’s laboratory test developers and heads of commercial labs, to scale up testing and processing immediately with their high-volume, high-throughput systems. It still wasn’t clear to me whether any such meeting had already happened, but better to be redundant than let something slip through the cracks. By Wednesday of that first week, I was sitting down with private developers.
I’d been envisioning this meeting ever since I recognized how flawed the first tests were and how misguided solely relying on the Public Health Laboratories had been, and it didn’t take long to confirm my fears about private-sector testing: this encounter, incredibly, was the first time they were meeting with a federal representative about testing. Sometimes the federal government keeps the private sector at arm’s length and engages with it sparingly; some in the public health field are inherently distrustful of the private sector’s for-profit motivation. I’d had a very different experience in Africa and Asia with the pandemic response to HIV and TB/HIV. Approaching the private sector strategically had helped us address the gaps we were unable to fill ourselves. When fully supported and allowed to operate without political constraint, the public and private sectors can move mountains together.
In our conversation that day, it became clear that by using every available testing platform, from Roche, Abbott, ThermoFisher, Hologic, Cepheid, and Becton-Dickinson, we could increase testing capability by a factor of one hundred, and then one thousand, within weeks. I trusted these developers because they were the backbone of PEPFAR’s viral load monitoring and point-of-care HIV and malaria testing across sub-Saharan Africa. Using their tests and equipment, we had moved very quickly from presumptive diagnosis and treatment in rural areas to full, definitive diagnosis of each and every patient. If these companies could create high-throughput nucleic acid tests and point-of-care tests for Covid-19—simple tests that could be used in communities here and overseas—we’d diagnose people on the spot, and not in days. How to deliver and then process those tests was still a sticking point—a typical distribution and collection problem, but on a massive scale—but the developers’ representatives felt it was achievable. Likewise, these companies could resolve another major problem with testing: production. They could manufacture as many tests as we needed. The only problem was that manufacturing—indeed, all these things—would take time we didn’t have. And then there was the need for swabs to take samples from the nose, transport media to move the samples to the lab, and then test tubes, pipettes, and PPE for the laboratory workers.
This was the essence of the problems we faced. The testing manufacturers offered solutions, but this meeting should have happened weeks ago, and it might not have happened at all if I hadn’t asked for it. We should have already had in place the tests I was requesting. If, four weeks earlier, when the first CDC tests failed, the White House, the CDC, or ASPR had sat down with the testing developers, we would already have had hundreds of thousands of daily tests by this point. We could have seen the silent spread. We could have been more proactive. We could have warned the American people.
Instead, with testing availability limited and processing so slow, we were still seeing only a small fraction of the cases, the sickest and the hospitalized. We were still weeks away from conducting a significant number of tests. Losing those early weeks of full proactive preparation because of the CDC’s failed tests had been troubling, but learning that we’d also lost the four weeks since then was devastating. We were weeks behind in seeing the silent invasion that I believed was already occurring.
In many ways, this was close to a worst-case scenario. In later conversations, I asked one of the manufacturers critical to the production of high-throughput and point-of-care tests if anyone in the administration or from the CDC had called them in January and February 2020. Their reply was that, in fact, it had been the other way around: the manufacturers were the ones calling the CDC to understand what it was doing and how they could help. The manufacturers were held at arm’s length by the CDC, ASPR, and HHS. They were told their assistance wasn’t needed. At a congressional hearing on March 13, Bob Redfield was asked who was in charge of testing. He said the CDC’s responsibility was to ensure state Public Health Laboratories had access to the tests. When pressed on how much funding was needed to bring public health infrastructure up to speed, he wouldn’t commit.
It was difficult for me to understand why the CDC wasn’t aware of who was in charge of this important aspect of the response. Testing was baked into both the prevention and the control of any disease. Overseeing state Public Health Laboratories access wasn’t enough. Reluctance to private-sector involvement compounded the problems the agency was creating.
When I eventually asked Bob Kadlec of ASPR and Steve Redd, who was at the CDC before joining me in an advisory role, why there had been no prior conversations with the private sector on testing, they essentially pointed fingers at each other and their respective agencies, saying it was the other guy’s job. While institutional ambiguity was obviously a problem in other areas of the response, the lack of follow-up likely stemmed from the CDC’s remaining committed to the flu model, which relied not on testing but on symptomatic diagnosis. Also, not securing private industry assistance was part of a larger pattern of CDC behavior. For years, those in charge at the highest levels believed that as the premier public health agency in the country, the CDC didn’t need much outside help, occasionally engaging a few university scientists and researchers. For the most part it believed that it could manage and lead on its own.
On March 14, Alex Azar assigned Admiral Brett Giroir, MD, to lead the comprehensive testing effort—that is, to be the “testing czar.” Brett immediately focused on all aspects of testing, but he was behind and could only react as one crisis after another complicated his efforts. The CDC/ASPR conflict had resulted in an absence of stockpiles of swabs, pipettes, and transport media (solutions that keep viral samples alive until they can be tested). Although I didn’t know her well at the time, task force member Seema Verma, the administrator of the Centers for Medicare and Medicaid Services (CMS), would be instrumental in ensuring that testing was prioritized and readily available to the public. She did this by getting CMS to pay for the tests and to pay enough for the tests to drive expanded use of them.
The private sector also needed to be engaged with mask production. Within the first forty-eight hours of my arrival, I found out we didn’t have a significant stockpile of the N95 masks and other PPE we needed for health system personnel. This was a stunning and disturbing realization, given how vital N95 masks were for keeping frontline health care workers safe. In January and February, U.S. manufacturers had shipped millions of dollars’ worth of masks and PPE to China. The federal government had encouraged them to do so. Because the leadership believed that the virus could be contained, they didn’t proactively increase the supply of vital equipment. That should have been one of the top priorities in January and February. So was developing a needs-based distribution system for those supplies, which also didn’t happen until after I came on board and rectified an inequity I saw. Fifty percent of the needed stockpile had already been distributed to states based on their populations rather than their need—another flaw in the pandemic preparedness plan. This meant that we distributed based on equality (the same amount for every state), not equity.
Equity means getting the right things in the right amounts to the places where they are most needed. Many of the states that received those supplies never saw significant Covid-19 cases in the first March-through-May surge. Triaging supplies is always a problem in pandemics, and this costly mistake substantially depleted the stockpile without adequately addressing need, worsening an already critical supply chain issue. Those precious supplies needed to go to the ten largest metropolitan areas seeing significant hospitalizations. Reducing health care worker exposure to risk in a timely manner would have gone a long way toward reducing stress on the system and on those on the front lines, reducing some of the trauma those workers experienced. Health care workers should never have had to reuse, ration, or only use partial PPE. We should have never had the surgeon general urging us to not purchase masks (and creating all kinds of mask-related messaging problems down the line) as a result of that early failure to see the clear signs that indicated to me the enormity of what we faced.
I didn’t know if anyone had even gone to the states to assess their level of preparedness. Surely, some states had their own plans in place and may not have needed the same level of federal intervention. Would public health officials in those states make it clear that they actually didn’t need what the feds had to offer? No. Everyone took what ASPR and the Federal Emergency Management Agency (FEMA) sent them.
To help address the N95 shortage, on March 5, I boarded Air Force Two with the vice president and the FDA’s Stephen Hahn to meet with PPE maker 3M, in Minneapolis. Steve was new to federal service in the way I was new to the task force. He had come to the federal government to lead the FDA only in December 2019. Smart, dedicated, articulate, and passionate, he didn’t take himself too seriously and was easy to talk to. We immediately connected.
With 3M, we learned that the United States’ shifting of protective mask manufacturing and production overseas over the past two decades had had unintended consequences. Almost all the surgical masks, hospital gowns, and gloves used in the United States came solely from overseas, mostly from China and Malaysia. We did not have any real domestic production except of N95s, but we could ramp up domestic production of these only so much. We didn’t make any of the essential medicines or critical PPE in this country anymore. This needs to change. The United States needs a secure and independent supply chain.
Shockingly, most of the N95 masks (those that filter out 95 percent of airborne particles) are produced for and used by construction workers. We make thirty-five million of them in the United States each month, but only four million go to health care workers. Those made for construction workers don’t have the fluid barrier on the outside layer that is meant to prevent a large volume of blood or other body fluids from penetrating the mask. Otherwise, they are identical to medical-grade N95s in all their components, including, crucially, the ability to filter out the same size aerosols and droplets responsible for this viral outbreak.
If the FDA approved the use of these construction-grade N95s by health care workers, we would have nearly ten times more masks available immediately for those on the front lines. On top of everything else, most of the supplies of medical-grade masks, gowns, and gloves ASPR had ordered wouldn’t be delivered until June. The FDA’s Steve Hahn understood this and immediately took action, and overnight, under FDA emergency use authorization, the newly approved construction masks increased availability by a factor of ten. This would help, but we still needed more.
Looking back now, I believe this shortage of critical PPE (especially N95 and surgical masks) in February, at the very beginning of the crisis, had pushed the task force to think of masks as a scarce resource that had to be hoarded, instead of a public health measure that could slow the spread. This projected scarcity put masks in the wrong category—they were reserved for health workers only. And because N95 and KN95 masks (the latter certified in China) became precious, it was harder to advocate for broad adoption of them. Meanwhile, those responsible for the shortage weren’t going to press for the use of masks of any kind, given that it would only expose to the public the depth and breadth of the issue and the lack of proactive preparedness by the leadership. Now, with masks in short supply, anyone in the White House or the federal agencies who was innately opposed to masking had yet another rhetorical crutch to prop up their position. Frontline health care workers needed them, the thinking went, not the general public. The former was true; the latter was not. The government’s own long-term failings, fourteen years of underfunding the active stockpiling of needed pandemic supplies, was secretly being used to justify a suboptimal health care approach.
To be clear, recommending that masks be reserved for health care workers did not solve the supply shortages that had health care facilities rationing masks and other protective gear. The lack of masks and PPE for workers treating infected and high-risk patients created a secondary health crisis among those essential medical personnel. Compounding one mistake with another dug us deeper into a hole.
We could have climbed out of that hole if the CDC and other researchers had immediately started to test the effectiveness of other types of masks—cloth ones or less robust surgical masks. People in Asian countries had used cloth masks to prevent viral spread. But because the CDC had not studied other types of masks, it wouldn’t formally recognize them as an effective mitigation tool. N95 and KN95 masks are named for the percentage of particles they block. They are the most effective masks readily available, able to screen out the smallest of particles, such as aerosolized ones. But surgical masks can be nearly as effective against respiratory droplets, which are larger than aerosolized viral particles. Their level of effectiveness varies, but they are still effective. The same is true for cloth masks, including ones made in the home.
The minute ASPR and the CDC knew that N95 mask supplies were limited, they should have sought alternatives and tested those, using simple lab experiments. Those studies could have been done in days. (Eventually, in early fall, the mask material tests were done, but by then, too much damage had been done, too many minds hardened.) In the absence of definitive homegrown studies of mask efficacy or mask materials, the CDC wasn’t going to commit to recommending masks one way or the other.
Scarcity, plus this lack of verification of effectiveness, shaped much of the ambiguous initial messaging on masks. Had mask tests been done in February, we would have carried a consistent message about the initial effectiveness of cloth masks from early in March. (The more infectious variants that followed over a year later required an upgrade to KN95 and N95 masks, which by then were plentiful.) Instead, the messaging was mixed and confusing—as evident in the tweet that task force member and U.S. surgeon general Jerome Adams tweeted on the day I joined the task force: “Seriously people. STOP BUYING MASKS! They are NOT effective in preventing the general public from catching #Coronavirus but if health care providers can’t get them to care for sick patients, it puts them and our communities at risk!” Adams was used to working in the hospital trenches. He wanted to make sure his frontline colleagues were protected. Just weeks later, he corrected his position and even showed Americans how to make their own masks.
Still, not only was there no evidence to support his “NOT effective” claim, but every piece of anecdotal evidence we had at that point—from SARS in 2003 to Asia during early Covid-19 in 2020—showed us that masks of all kinds effectively slowed the spread of the virus. However, unless this narrative evidence were “validated” by researchers and approved by the CDC, the task force couldn’t fully refute the surgeon general’s position. Even in the absence of definitive studies, the CDC could have said what was clear to the naked eye: Throughout Asia, people have adopted the wearing of cloth masks in public, and the case numbers there are low and their outbreaks more quickly controlled. Based on this, we think cloth masks could be effective here in the United States. We recommend you make use of cloth masks in public spaces while we work with our scientists to study their full effectiveness in the laboratory.
The American people would have understood clear messaging that laid out what we knew, what we didn’t know, and what we were recommending until we got the data we needed.
But the CDC didn’t do this. More frustratingly, it didn’t even say, “Wear a mask. It might save your life.” Those at the CDC held themselves back. They didn’t value learning from others around the globe. They didn’t make commonsense recommendations while they waited to obtain the laboratory data so critical to their process.
Without a cultural memory of masks having been effective in the past, and with no governmental efforts to work around this, the public was, initially and very understandably, confused. To their credit, many people cut through the noise and wore masks regularly. Many more would have if we’d been clearer.
The CDC prides itself on being a preeminent medical and scientific authority. Historically, its adherence to scientific rigor has suited it well, but if a level of rigor isn’t adaptable to the moment, it can become an Achilles’ heel. In the midst of an enormous health care crisis, you can’t wait until a definitive, tightly controlled, randomized, replicable, peer-reviewed study has been done to make a recommendation that will likely save lives while costing none. Telling people to wear masks early on had little downside. Even so, the CDC couldn’t bring itself to make a less-than-precise statement on mask efficacy, just as it couldn’t bring itself to rely on data and studies from other countries.
The push and pull in research are often between rigor and speed. But during a pandemic, when days and sometimes hours matter, when time truly is of the essence, you can’t worship at the altar of rigor at the expense of speed. Yet this was exactly what the CDC did.
For many weeks and months to come, I fretted over how many lives could have been saved if the CDC had trusted the public to understand that it would take time to get the science right, but that, in the meantime, masks would do no harm and could potentially do a great deal of good in preventing people from transmitting or contracting the virus. Were masks 100 percent certain to work? No. Would cases go down to zero if masks were worn? No. But were masks doing something to slow the spread? I thought so, and clearly China, South Korea, Singapore, Thailand, and Vietnam agreed, because they were all aggressively promoting mask wearing, and their case numbers fell.
But this simply wasn’t enough for the CDC, because the United States had no historical data to rely on to validate masks’ effectiveness. Anecdotal evidence wasn’t going to be enough for them to make a recommendation, and what anecdotal evidence there was didn’t come from experiences in this country. An outbreak of this severity had never occurred in the United States during the CDC’s lifetime. Collectively, the CDC, other agencies, and the public had no historical memory of the 1918 Spanish flu outbreak. The belief seemed to be that this early twentieth-century tragedy was then and this was now. Science and medicine had advanced to such a degree that we didn’t need to rely on past practices or what had worked elsewhere. We could apply a modern, fully American response and evolve it based on data derived from cases on our own shores. Sometimes, common sense butts heads with scientific certainty, and that was the case here.
Relying nearly exclusively on data native to the United States was wrongheaded, and this problem was made worse by the CDC’s lack of a fully integrated data collection system that gathered data from all hospitals and clinics. Because some in the CDC used the most rigorous research standards for evidence-based recommendations and analyses, the lag time between data collection and analysis was too great to support proactive responses.
The CDC never wanted to use so-called dirty data—that is, unvalidated numbers, even those from reliable sources in real time. The figures might have come from hospitals or clinics that weren’t perfect about every granular detail. Though the basic information needed to see the big picture and formulate a response might have been there, data entry personnel, the CDC worried, might not have gotten every element right. The CDC also wouldn’t use data from sources they believed hadn’t met their highly exacting standards before. This is best practice when conducting a clinical trial or producing a scientific paper for publication, but in a pandemic crisis, “dirty data” has its uses in showing a general trend. It can be reflective of what is happening in the general population, not just within a select subset of individuals. Population data from all sources is frequently better than so-called clinical data, which is more narrowly focused. Indeed, sometimes, highly controlled data collection like that exhibited by the CDC, as compared to looking at the entire community in real time and real life, can result in significant bias.
Many times, at PEPFAR, data on our efforts in Africa was shared with the domestic HIV response team at the CDC. Our hope was that those responsible for the domestic program on prevention could learn from our work abroad. But the CDC scientists wouldn’t verify it because they themselves hadn’t done the work to create the program or collect and analyze the data. Instead, they took the time, often years, to gather and report the U.S.-based data on which to base recommendations. Wasting time and effort in a public health crisis like HIV/AIDS, which had been well managed, was inadvisable. Doing the same in an emergent and, likely, long-term public health care crisis was unconscionable.
Bob and I would talk about this throughout the spring of 2020. He recalled what it had been like for him to come to the CDC in 2018. He had a passion to change the course of the opiate epidemic in the United States, which CDC teams had been working on for years, but when he asked for the current data, he was given two-year-old statistics.
“‘Where are the current figures?’” he told me he asked them. “‘We’re still validating it. It’s still under review.’ Two years after the fact and not reflective of what the present circumstances were.”
“That’s crazy,” I replied.
“That’s the reality,” Bob said. “So, do you really think I can push my people on Covid-19 data and get anything close to real-time analyses and recommendations? We’re not built for that, as much as I would like us to be.”
In a crisis, you need to get all the data you can to integrate it into actions and improve and validate your response over time. You need to improve the actual data and data collection rather than merely improving the modeling of the data to fill in the gaps where data was not collected.
I could have, and should have, done better myself to push the importance of masks, testing, and data collection. I saw all these issues, many of them predating my arrival, but I was uncertain how to change the dialogue. I knew it would take years to reverse the institutional current flowing against me. Still, institutional intransigence was no excuse. I should have found a way to push harder. I did push for tests to be performed on the effectiveness of various mask materials, but I was never able to overcome the collective resistance to doing so, and in the end, the testing came from studies in Japan published in October 2020. This took far too much time and energy than it should have. I believed that masks were effective as a mitigation tool, but I didn’t yet have the evidence needed to convince the skeptics, and I couldn’t see any way around these obstacles other than pushing federal agencies to test non-N95 alternatives, which I did. Even so, I should have found other ways over, around, and through. This was the ethos that drove my mission.
After that trip to 3M in Minneapolis, the vice president, Steve Hahn, and I continued on to Seattle to get an on-the-ground reality check on what was happening in the first city knowingly dealing with Covid-19. The schedule was packed with meetings with state and local officials, public health leaders, and frontline health care workers. We met with Washington governor Jay Inslee and various U.S. representatives for the state. We also toured the State Emergency Operations Center and then did a press prebrief, followed by a press statement.
The meetings were critical for outlining what I had already been hearing. The state was already short on tests, testing supplies, and all forms of PPE. Just a few weeks in, and they were short on everything. We had become a country of just-in-time, expecting packages of supplies to arrive on our doorstep or to our hospital supply room or clinic overnight, and if not overnight, then within forty-eight to seventy-two hours. Critically, even in those early days, Washington State’s hospitals and clinics were short-staffed. Caring for Covid-19 patients was time intensive and complicated. We went through the nursing home data. The state’s nursing homes were ground zero for our most vulnerable Americans—elderly and often with comorbidities, everything that, as we had learned from Italy, Spain, South Korea, Japan, and China, put them at the highest risk.
The Washington State Emergency Operations Center was filled with dedicated personnel working around the clock—coordinating among FEMA, HHS, the federal agencies, and local officials to determine implementation and equipment requirements. Governor Inslee made some political statements during the press conferences, but the vice president didn’t take the bait. He understood the pressures the governor was under. He knew governors didn’t have deep expertise in public health, let alone with the deadly virus they were now confronting. It was scary and unnerving. For me, seeing the stress in the eyes of Washington State’s public health leader haunted me over the next many weeks as what began in Washington began to play out elsewhere in the country. I stayed in touch with the Washington State health leader over the next several weeks to get his insights and take them to the task force.
Flying back home that day, I thought of something that had happened earlier that morning. In the task force call prior to our visit to Seattle, Joe Grogan, a senior advisor in the Executive Office of the President, had expressed his concerns about what was transpiring in that city with regard to the virus. He had been worried about the severity of the pandemic from the beginning, but on that morning, his political comment was representative of what I would later see. Joe understood that we were at the beginning of a massive increase in infections. As he put it, we would see a “massive surge in new cases reflecting community spread.” He wanted to make it clear that, while in Seattle, we shouldn’t imply that things were okay. This pandemic was serious.
I agreed with him. I didn’t intend to say anything of the kind, and I certainly didn’t make any such misleading statements during our visit. But I didn’t agree with his rationale. Joe was afraid that if, after we left Seattle, the cases there increased, “We will own the new increase in cases reported.” He didn’t want it to appear that we, as representatives of the White House, were in any way accountable for the rise. He didn’t want White House fingerprints anywhere around Seattle’s outbreak.
During that phone call, he had recommended that we announce new measures while in Seattle. He would have preferred that this be done with Governor Inslee’s support, but “if we have to jam him, we have to jam him,” he said. He concluded by reiterating, “We will own it.”
In that moment, I think Joe was clearly verbalizing what some were already saying behind the scenes in the West Wing—that is, this was not what he personally believed, but something others believed. Joe was an ally who understood how serious the crisis was and would become. He wanted me to hear what others were thinking, and he gave voice to those thoughts.
The message from those others seemed to be: The more we did, the more we would “own” the response—all the good and all the bad. I should have paid more attention in the moment to what he was trying to tell me. He’d issued a warning. Some roaming the halls of the West Wing believed that the less we did, the less we would be accountable for whatever was about to happen.
Too late. I believed we already owned it. Now I just had to make them realize it.