Sunday, March 8, marked the start of daylight savings time. We sprang ahead, and I felt the loss of that hour more profoundly than ever before. Still working on jet lag and a series of late nights, I had woken up at 2 a.m. to do my usual review of the worldwide numbers that had come in overnight. In the United States, the seven-day average had gone from seventeen cases at the beginning of the week to sixty-three by Saturday. Slowly, the numbers had crept up linearly day after day, even without the testing we needed. We were “seeing” only the very sick. This slow linear growth was the prelude to the leap I had been envisioning and fearing for us: the exponential phase of the surge, signaled by a doubling of the daily cases we had witnessed in Italy, Spain, France, and Germany.
These numbers were only one concern among many. Normally an optimistic person, I wouldn’t have taken the job if I didn’t believe I could effect some positive change. But sitting there in the dark, the room cast in shadows by the glow of my computer screen, I felt the doubt and fear brought on from my first full week finally creep out of the shadows and into the light. They had unmasked themselves; I smiled regretfully at the thought.
Joe Grogan’s statements during the Seattle trip about our “owning it” weighed heavily. Acknowledging the need to be held accountable and fearing the consequences of being accountable are two very different things. Suspecting that Joe had voiced the prevalent attitude throughout the White House, one that Matt had also identified, was disconcerting. Up to that point, no one else had flown these colors so blatantly. To counter this desire to evade responsibility, in my response to him then and at every opportunity moving forward, I refocused the message.
The federal government was responsible. Only it could perform certain functions, one of the most critical being comprehensive data collection in real time across all the states and territories. Only the federal government possessed the enormous resources required to accomplish all facets of the response. We were accountable, and we needed to act.
To counter the mixed messaging reaching the American public when we had fewer than one hundred cases, I asked the vice president to bring the media’s medical correspondents into the White House that first week so I could articulate for them my initial core messages:
This is not the seasonal flu.
This disease, in specific age groups, is deadlier than flu. In others, its presence is invisible.
We cannot completely contain this outbreak. It is out there. It is spreading.
We need your help in communicating this message effectively.
In particular, CNN’s Sanjay Gupta was a key component of my strategy. From the onset of the outbreak, while I was in South Africa, I had watched as Dr. Gupta served as the senior CNN medical correspondent and the network’s chief Covid-19 correspondent. He specifically spoke about a mild disease—another way to describe silent spread. I saw this as a sign that he got it. As a doctor himself, he could see what I was seeing. He could serve as a very good outside-government spokesperson, echoing my message that family members and others they were in close contact with could unknowingly bring the virus home, resulting in a catastrophic and deadly event. It would be important messaging going forward, but it could do nothing to slow the spread that had already been set in motion.
The truth was: we were behind on everything. I’d been in the White House a week, and in that time, I had not heard a single piece of news that placed us on track with where we should have been—save for a single meeting the president had convened about vaccine development that put the time line at twelve to eighteen months. We also spoke with the pharmaceutical companies creating therapeutics. These would be available within months. I felt that the vaccine estimate was fairly conservative, one that we could almost certainly beat with the right approach and constant attention to the details of each phase of the clinical trial enrollments. The president was actively engaged with the vaccine companies, repeatedly pushing them for more faster. He had also attended the testing meeting with the commercial developers and urged them for faster and more. The vice president continued to prod them during our weekly calls.
Best case, though: a vaccine was a long way away, too far in time to take any consolation from that one meeting. The concern I’d heard in Matt Pottinger’s voice was now running through my own mind. There was no way around the fact that the response to date had been an interrelated series of failures, starting with the unfounded belief that the virus was being, and would remain, contained.
Seattle, and the on-the-ground realities I had heard and seen there, had driven home the hard truth of the consequences of these failures. Insufficient supplies of PPE, severely limited testing, the imposition of a death sentence on many nursing home patients as the virus was silently brought to them unknowingly by the staff—all this amounted to a specter of death hanging over the coming weeks. I was suddenly brought right back to those dark days at Walter Reed dealing with AIDS. What was happening in Seattle would soon be happening all across the country, in larger cities that were just as unprepared—New York, LA, Chicago, Houston. When the relentless wave hit in a little more than a week, every shortage, every misstep, every failure of vision, would be laid bare. And there would be no way to change course without drastic, seismic action that would be as unpopular as it was essential to saving lives.
The question I wrestled with was how to change minds within the DC bubble, how to point out the groupthink that was shaping the faulty response. I needed those in the White House to switch strategies on everything, from masking to testing to silent spread. But more than anything, I needed to figure out how to make them accept and prepare for the unacceptable: a shutdown to flatten the curve, to prevent every hospital in the United States from being overwhelmed. We were weeks into silent community spread. Containment measures had inevitably failed, so, the next logical step was to protect hospitals in states with community spread. In the other states, we could actually prevent the silent invasion and the initial community spread that eventually led to the vulnerable.
I SPENT THE BETTER part of that Sunday formulating my plan. While I had prepared for a lot of eventualities and had sketched out many plans before arriving at the White House a week earlier, I had not accounted for the dire scenario we were now in. Had this outbreak occurred under any other administration, I would have gone into work the next day and stated the best course of action immediately, no matter how painful or extreme it sounded—because any other president would have wanted to know just how bad things were going to get and what could be done to prevent the worst case.
Except, this wasn’t any other president or any other White House. This was President Trump and the Trump White House. I was standing on constantly shifting sand, among political players I didn’t know and a president who apparently liked his news served good and upbeat, or not at all. The right approach here would be as important as the right pandemic response plan—perhaps even more so.
I had always prided myself on being a hard-charging, get-shit-done public servant. Complacency doesn’t suit me; I’ve always been a doer. And I’m not always patient. Recognizing my own tendencies and flaws was nearly as important now as assessing the current situation. Unlike the CDC, which had approached the novel virus with a standardized response, I had to modify my approach to meet the situation I had found on the ground.
I’d expected some level of resistance coming into the job. But what I encountered wasn’t just different thinking, but a different attitude toward action. I believe in proactive intervention, but the response to date had been stuck in reactive mode. I was always in prepare-now mode. I’d have a Plan A, B, and C ready in case Plan A didn’t work. But the Trump administration and the government agencies had been in a wait-and-see mode. When they acted, they made mistakes, and they didn’t like being seen making mistakes. This made them gun-shy.
For this reason, charging hard wouldn’t move either the politicians or the doctors. That things had been allowed to get to this point spoke volumes about how deep the dysfunction ran. Because negative patterns of behavior had already been established, they would be that much harder to reverse. I wasn’t starting at zero; I was starting at negative twenty. I was the one who was going to have to adapt, not them.
I would do this, I decided, by several means. The first was to continue the same global numbers drumbeat. I had to be selective, however. I would emphasize Europe, given that many in this White House and on the task force understood Europe better than they did Asia.
That Sunday, March 8, as I was wrapping my head around how to make myself heard, Italy announced, with a screenwriter’s timing, the shutdown of its northern provinces. Its strict measures affected sixteen million people living there, more than 25 percent of its population. The spread there was placing significant strain on hospitals; Italy’s sophisticated health system was faltering.
National government decrees banned movement into and out of areas in the north except for emergencies. The message was clear: stay home to stay safe. They meant it, and they would enforce it. Festivals, football (soccer) matches, church services, and other large-scale events were canceled. Italians needed passes just to go to the grocery store. (Researchers, by tracking cell phone signals, showed that mobility dropped by 90 percent.) Those who violated the decrees were subject to fines and imprisonment.
Because the Italian situation was rapidly deteriorating, I pushed the rest of the task force to acknowledge that, as Italy went, so went the United States. I believed that we were already into the same viral spread Northern Italy was experiencing. Our hospitalization rates were rising, but with testing still mired, case rates painted an inaccurate picture. Our projections put us where Italy had been ten to fourteen days earlier. They were now in lockdown, where we likely should have been and would need to be in a week’s time.
At this point, I wasn’t about to use the words lockdown or shutdown. If I had uttered either of those in early March, after being at the White House only one week, the political, nonmedical members of the task force would have dismissed me as too alarmist, too doom-and-gloom, too reliant on feelings and not facts. They would have campaigned to lock me down and shut me up.
Little did I know.
I had been the only woman in the room before and was familiar with the slippery slope of being pegged as “hysterical” and “overreacting.” I’d experienced having every point I made followed by statements like “You know how she is. It’s not that bad.” This response had been my constant companion throughout my career—as a woman, I was primarily dubbed too aggressive, too pushy, or too direct. I had been in the room when this was said about other women, and I knew the same was said of me when I was not present.
Spooking anyone with extreme scenarios wasn’t going to work in those early days. I couldn’t use Italy’s actions as a model for our own, but I could use them as a canary in the coal mine to demonstrate how bad things could, would, get. The virus’s current crushing impact in Europe had its roots in the early steps those countries had taken, many of which were very similar to our own. Their leaders’ efforts were largely ineffectual because they missed the early silent spread. As a consequence, the virus was in full, exponential growth across Europe. I needed to use these European facts to get the White House to act quickly, as Italy had now acted.
Still, it would be a tough sell. During the conversations I participated in that first week, I saw that “American exceptionalism” was a very real problem, one that was making the situation harder. People in the White House thought the United States was special, that our health care system was special, that the biological rules this virus played by didn’t apply to us. This misguided sense of infallibility would prove deadly. Every task force member needed to understand that our hospitalization numbers and deaths wouldn’t be better than those coming out of Europe. They would be worse. This would be difficult for them to accept.
To counter this, the second front of my plan was to use the time allotted to Tony, Bob, and me at our task force meetings over the next week as strategically as possible. I would build toward an end-of-the-week pitch to this administration for the most aggressive mitigation steps possible. Knowing it would never fly, I wouldn’t seek a “shutdown” in the Italian sense, but the closest possible thing I could get from this administration.
Unfortunately, this would mean not taking the full measures necessary at that point. I had to accept this reality. Some would think they were too drastic; some would say it was up to the states; some would just ignore the issue. Still, anything short of a similar, flattening-the-curve-type shutdown would leave us exposed to the fully overrun hospitals and fatalities seen in Italy. We needed to act, but the worst possible thing I could do at this stage would be to push too hard and end up with our doing nothing. We were so far into community spread that we now had to flatten the curve. By enacting any mitigation strategies, we would be acknowledging that the continuous rise in cases was inevitable. Spreading that increase out over a longer span of time would keep the rate of rise lower, so cases wouldn’t overwhelm health services, supplies, and health care providers. This wasn’t an optimal mitigation strategy, not even close, but it was the best outcome we could hope for at this moment, with where we were heading, and with whom I was dealing.
What I would pitch to the vice president at the end of the week would function like a circuit breaker. It would be a set of measures designed to slow the spread and buy us time. I wouldn’t use the alarmist language that could set off the economic team’s and the president’s tripwires. I didn’t yet know how my proposal would make its way to President Trump—whether the vice president would bring it to him or I would. Ultimately, it didn’t matter who the messenger was; all I cared about was the time line.
In a week, we had to sell our version of a shutdown. Together, Bob, Tony, and I needed to take a step-by-step approach to lead everyone to the eventual conclusion that this makeshift shutdown was the only option to protect every metropolitan area in the United States from that initial surge. If we moved too quickly to get them to that point, we’d lose the narrative and our audience. Regardless of how I dressed up the language, shutdown was a terrible outcome for any White House, but in this one, it would be anathema. The resistance to it would be overwhelming.
That’s why the third, and perhaps most crucial, part of my approach was to try, once again, to get more of the medical establishment to acknowledge the greater degree of silent spread. The fundamental disagreement over the role of silent spread was the common denominator for all the problems that had led us to this moment. I had to find a way to change minds on this—starting with the rank and file at the CDC. Thought leaders in Atlanta had continued to discount the role of silent spread, and the cascade effect of the CDC’s “flu-like” characterization, along with its influence on states’ responses, could do great harm. And unfortunately, Bob could only do so much to influence the CDC rank and file.
The CDC is populated with many talented and gifted professionals, many of whom also happen to hold liberal political points of view. As a political appointee, Bob was stained by his association with a Republican/conservative administration. The rank and file would question everything that came from Bob and this White House. Whether it was because of my background in the military (once considered a bastion of conservatism) or because I was now part of the White House response team, I suspected that my views would be examined skeptically through these two political lenses, traditional conservatism and Trumpism, as well. Fair or not, scientifically objective or not, this was the reality.
To begin to confront this, the day before, on Saturday, March 7, I’d spoken to Tom Frieden, the CDC’s director under President Obama from 2009 to 2017. I wanted another CDC ally, and Tom was well respected within CDC circles specifically and in the field of public health generally. Though Tom was no longer the head of the CDC, he still had some influence—considerable influence, I thought—over the opinion leaders there and those in positions of power within the agency. I was direct with Tom: I needed the CDC, most notably its most senior officials Anne Schuchat, Nancy Messonnier, and Dan Jernigan, on board the silent spread train. I also needed the CDC’s talent and reach. Critically, I needed the agency to evolve beyond temperature checks and symptoms to see the silent spread and to move to proactive testing as a pillar of the public response.
Tom wasn’t quite there yet on the magnitude of the silent spread. On our call, he mentioned that same 17 percent figure derived from the CDC’s interpretation of the Diamond Princess. I wasn’t deterred. I believed we could bridge that gap. I sent him the analyses Irum and I had done of the data. He promised he’d review them. I knew he’d look at the data without bias, and I was confident that this would get him to my side eventually. I couldn’t say the same for the folks at the CDC, given how entrenched their position was, but Tom could prove to be a large weight on the scale, tipping those flu model hard-liners in my direction. Getting Tony and Bob was key, but getting Tom was arguably more important, given that the climb up the medical mountain would be insurmountable without more support from inside the CDC.
To do this—to tell this story for Tony, Bob, and now Tom—I needed numbers, all the numbers. I needed access to whatever data Bob and Tony and the CDC had. I needed to understand the full breadth of what data was being used to make decisions. Based on what I’d seen that first week, the data was far less than I had hoped for and much less than I needed. But I was still convinced there had to be something more granular, something that could tell me with greater specificity who was getting sick, how old they were, and precisely what areas of the country they lived in. Digging around for this data became one of my main priorities for the week ahead, so I could marry the U.S. data with the European data to show clearly where we were and where we were headed. Once I had the data, I could become more aggressive with my lobbying efforts, because by then, the math would be incontrovertible. Patience. I wrote the word at the top of a report I’d been reading. I didn’t like approaching problems too slowly, too stealthily, but I had to do what was needed.
As I shut down my computer the Sunday night prior to the task force meeting the next day, I reminded myself that this administration had spent the last three years railing against the “deep state,” accusing professional civil servants like me of supposedly undermining President Trump’s leadership. Weeks of inaction had gotten us here, but once again, I reminded myself that I couldn’t risk falling farther behind by rushing too hastily. At this early stage, marching in with bold pronouncements was only going to get me fired or, worse, ignored.