No sooner had we convinced the Trump administration to implement our version of a two-week shutdown than I was trying to figure out how to extend it. Fifteen Days to Slow the Spread was a start, but I knew it would be just that. I didn’t have the numbers in front of me yet to make the case for extending it longer, but I had two weeks to get them. However hard it had been to get the fifteen-day shutdown approved, getting another one would be more difficult by many orders of magnitude.
In the meantime, I waited for the blowback, for someone from the economic team to call me into the principal’s office or confront me at a task force meeting. None of this happened. Maybe it was because the stock market had stopped its plummet; I didn’t know then, and I still don’t. As governors around the country began to respond and implement a version of our recommendations, I waited for President Trump to see that what we’d recommended was shutting down the country. This explosive response didn’t happen. Instead, the virus pummeled New York City and the bedroom communities in Northern New Jersey and Connecticut and on Long Island just outside it.
Since February, I’d been envisioning a catastrophic scenario—lurid images born of what we’d all seen first in China and then in Italy—here on our shores. At first, it was a point in the distance. By March 16, that point had grown much closer and was taking shape in New York City. On February 29, a man from Queens became the first confirmed case of community transmission in New York City. On March 1, the first confirmed case was identified in Manhattan. Two days later, there was the first recorded person-to-person transmission. Less than a week later, the number of cases in New York City rose to sixteen. Governor Cuomo had declared a state of emergency on March 7 for the entire state.
If any place in America needed fifteen days to slow the spread, it was New York City. The virus had staked its claim on an urban center that was a prime candidate for extensive community spread. Highly populated, densely packed, New York City was a place where people jammed into buses and subway cars, where even at the best of times your personal space was reduced to a tissue-thin layer. What we were beginning to see as a highly transmissible virus was in its optimal environment. Looking at the cities of Europe and doing the math, I feared it was already far too late to prevent what was going to happen in New York City. All we could do was work to prevent the hospitals from being overwhelmed. Indeed, later research into the virus antibodies of infected people would show just how vast the spread was in New York City: the virus had been spreading silently in the city at least since early February. For the coronavirus pandemic in the United States, New York City became the tip of the spear in a life-or-death battle that hadn’t been seen in America in over a hundred years.
The weekend of March 14–15, while I had been preparing my pitch for what became 15 Days to Slow the Spread, New York City had closed its public schools and was already encouraging businesses to allow employees to work remotely. Mayor Bill de Blasio and New York City’s health commissioner—who, just two weeks earlier, had encouraged people to go about their daily lives—were justifiably sounding the alarm.
On Monday, March 16, the day after our guidelines went into effect, I stood outside the Vice President’s Office watching TV footage of Mayor de Blasio stating that the city might need to shut down and residents might have to “shelter in place.” De Blasio expected to make the difficult decision over the next forty-eight hours. It seemed the message of the circuit-breaker, flatten-the-curve strategy had connected with his administration. Perhaps that’s why I was surprised when, not long after, New York State governor Andrew Cuomo implied that no such thing was in the works—de Blasio lacked the authority to implement a shutdown, Cuomo said, and such a move was unnecessary. As Governor Cuomo said himself, “I would have to authorize those actions legally. It’s not going to happen.”
At that time, I got the impression that the White House was surprised that Governor Cuomo wasn’t taking more drastic action, especially given that, on the day we announced 15 Days to Slow the Spread, Cuomo had called for more federal leadership. But rather than taking our recommendations and guidance right away, he waited several more days, until March 20, to order that, statewide, all nonessential businesses had to close, effectively beginning New York State’s shutdown.
Seeing this back-and-forth unfold, I was astounded. Here was a mayor who maybe could have moved a bit sooner, but who was now trying to do the right thing for his city, and there was the state’s governor interfering. This squabble resulted in days of delay and put a huge number of people at greater risk. Losing those days of lockdown proved costly to the city, but what was even more detrimental would be the long-simmering rift in the leadership between the governor and mayor. A feud that predated Covid-19 by years suddenly had much higher stakes, now that human lives were on the line. Yet, not even a crisis of this magnitude could overcome their apparent political pettiness. This was the first real indication I had of the power governors possessed in such situations. Later, I used this awareness to appeal to governors directly, but at the time I was confounded (and still am) by why Governor Cuomo, at this early and precarious point in the pandemic, would use his power to undermine Mayor De Blasio and the people of New York City.
Almost overnight, New York City came to dominate the news cycle, and as the third week of March elapsed, I came to see the big role New York had played in why I hadn’t received any immediate pushback from the shutdown. My presentation to the vice president, which was relayed to the president, had predicted that things would become dire. And now, I was proven correct—with wall-to-wall media coverage, no less. The tragic events in New York had, it seemed, shown the president and vice president the wisdom of the path they’d already chosen. When the picture I’d painted started coming true in New York City, it immediately had an impact on them—especially given that this president, born in Jamaica, Queens, was a native of New York City.
I recognized that when, in two weeks, I asked for an extension of the flattening-the-curve shutdown, tragic events beyond my control might again help my case. On March 15, when I’d pitched the shutdown to Vice President Pence, the United States had just shy of five thousand cases and seventy-four deaths; for most people in America, especially those in the White House, the virus was still fairly abstract. Something would be needed to stop people in their tracks—the CDC, the president, the media, the American public—and convince them once and for all that this virus was for real. With the rate of spread we were now seeing out of New York, my fear was that whatever was beginning there would be that thing.
FOLLOWING THE PRESIDENT’S MARCH 16 announcement of the guidelines, the frenzy that had characterized my first two weeks took on an even greater pace. Whereas my initial two weeks had been shaped by trying to put our slow-the-spread approach in motion, now I had to use my time as effectively as possible to gain any new ground we could, while also figuring out how to extend the slowdown.
A massive array of issues, constituencies, and areas of need had to be addressed, and as coordinator of the White House Coronavirus Task Force response, that was my job. Members of the task force spoke with grocery store executives, encouraging them to offer special seniors-only hours in places where home delivery wasn’t possible. I reviewed the medical literature about various therapeutic treatments that might be effective against Covid-19 and studied the mitigation protocols that health officials in China, South Korea, and elsewhere had followed, to determine their efficacy and applicability in the United States. I prepared for and then participated in phone calls with physicians and nurses groups and public health officials responsible for tribal lands and prepped for media and press conference appearances. We reviewed the guidelines that the CDC was putting out regarding foreign travel, cruise ship excursions, child care facilities, long-term health care facilities, and hospitals and clinics. We spoke with five thousand state and local officials on a conference call—including governors, attorneys general, secretaries of state, mayors, city council members, country commissioners, and local public health officials. We were going as fast as we could to make the biggest impact we could.
On March 16, in tandem with the White House announcement of our guidelines, the task force began holding daily press briefings. These quickly took on increased importance and visibility, as events were moving at such a high speed, and we were conveying important information in the briefings. For each press event, I’d review the remarks that those in the Executive Office of the President or the Office of the Vice President had prepared. Following a brief preparation with the vice president, we would go down the hallway, past the Oval Office, to the Press Briefing Room. Once inside, Seema Verma, Bob, Tony, Steve Hahn, Surgeon General Jerome Adams, and I, and sometimes HHS secretary Alex Azar, would stand together for several hours not moving. We were the supporting players, with first the vice president and then the president as the leads.
No matter my role, I was in an unfamiliar setting. Cameras, still and video, were everywhere. The members of the press, who were carefully seated at a distance from one another, conducted themselves professionally. At these briefings, I always felt not quite put together as I gazed out at these perfectly dressed journalists—smartly put together even in the midst of a pandemic. When statements were made by, or questions asked of, the president, I had to figure out how to look serious and not react to what was said, no matter my inner feelings. I asked my colleagues how they were able to stand and keep their facial expressions so unmoving. They told me to focus on a distant point at the back of the room and think of other things while still paying attention.
Most of these press conferences were incredibly serious in tone, as we went through what we knew from Europe and our own country and what we could do together to slow the spread. When I had to speak, I carefully tried to use my time to convey what I was seeing in the numbers, something I thought was especially important to contribute. One evening, I spoke directly to Millennials, who, I believed, were critical to our slowing the spread. Millennials, usually the children of Baby Boomers, were uniquely positioned to communicate both to Gen Z about the risks of the virus and to their own parents and grandparents (Boomers and the Silent Generation) about protecting themselves. Frankly, I was worried about the Baby Boomers and how they might discount the risk of the coronavirus and continue to gather, but I knew they would listen to their concerned children. Millennials were the backbone of communicating many of the mitigation elements. Members of Generation X, those in their ’50s and ’60s, were a bridge demographic, sharing characteristics and points of view with Millennials and Baby Boomers depending on a variety of factors.
I wasn’t always perfect at communicating data or what the data meant. One evening, while speaking about where the virus was and where it had been successfully prevented from spreading in the community using the recent measures we’d recommended, I turned to the U.S. map we’d set up nearby to point out Montana. My mind went blank. Which of those two large, rectilinear shapes was Montana and which was Wyoming? While I could name every country, capital, and most of the cities, counties, or provinces across the globe, especially in sub-Saharan Africa, I couldn’t identify the state by shape. I turned to the vice president for help.
“Montana or Wyoming?”
“Montana, Dr. Birx.”
I could tell he was surprised. I should have known this, and before the next presser, I made a point of learning not only all the states, their capitals, and their large metropolitan areas, but also most of the more than three thousand counties in the country. There were times I might not have gotten the pronunciation quite right—such as when I pronounced the x in “Bexar County” when it’s supposed to be silent, like “bear”—but I learned, and I tried not to make the same mistake twice.
Limited testing for the virus remained one of my foremost sources of anxiety, as it would for some time. We still didn’t have enough tests, we didn’t know how to test thousands of Americans quickly, and we were already seeing problems with the supply chain for all testing supplies.
After our initial meeting during my first week on the job, I communicated regularly with the test developers and commercial laboratories. They were very responsive. Day after day and week after week, Abbott and Roche continued to provide me with daily information on where test kits were being shipped, the volume of tests being performed, the test positivity rate, and how many tests were going to large reference labs (labs that receive specimens or samples from other labs) versus hospitals. They weren’t required to send me this data, but they did, filling in some of the gaps the CDC had created. The private sector was able to move at speed far better than the governmental agencies. Time and time again, it was the private sector that responded rapidly to save the country. They were the backbone of our ability to respond to the crisis in real time, whether with tests, PPE, therapeutics, or vaccines. Yet, nothing they did would overcome the months-long head start the virus had over our testing capabilities. We were still months away from having the volume of tests and the processing speed we needed.
In the meantime, we were coordinating with state and local governments to expand testing sites to sports stadiums, community centers, churches, and retail parking lots and getting mobile testing facilities up and running. We were preparing to utilize personnel to collect thousands of samples efficiently and were figuring out how to get the results back in forty-eight hours or less. From mid-March and into April, we had thousands of labs across the United States fully qualified to use FDA-approved testing platforms. To ensure that we had readily available data, we built in a requirement that test results would go not just to the client and their physician, but also to the state and federal health agencies. We’d also made headway on test production, with the FDA agreeing to allow commercial manufacturers to distribute their newly developed tests without an emergency use authorization. The FDA also issued new guidance that would allow states to develop tests independently, but it would take time to get those tests and sites fully functional.
This was the good news. The bad news was that stocking those facilities and making testing more accessible were still problematic. As a consequence of the testing shortfall, the case data we needed in order to see the true extent of the spread would rely on people voluntarily going to testing facilities, being evaluated at emergency rooms, or being admitted to hospitals. The shortages were so acute that HHS discouraged people without symptoms from getting tested unless they had been exposed to someone positive or had traveled to a global hot spot like China. As necessary as rationing tests was at this point, this emphasis on symptomatic testing had the unintended negative effect of appearing to confirm the CDC’s bias toward symptomatic spread while simultaneously underrepresenting the true number of people infected.
Even so, with a testing data system up and running, and with required reporting, the daily testing rate was rising rapidly. Still, using the CDC’s testing recommendations, I calculated that probably only 30 percent of the cases were being accounted for. As time went on, following CDC recommendations, hospital administrations and public health agencies began asking people to stay away from emergency rooms unless they were critically ill. Hospitals were being overrun, becoming hot zones. Again, as a result, fewer and fewer people were being tested at the community level, a fact that further obscured the reality. We’d eventually figure out how to test outside traditional medical facilities, but this early in the pandemic, at a time when I needed the most accurate numbers reflecting the breadth and depth of the outbreak, I was not going to get them.
PERIODICALLY, IN BETWEEN ALL the meetings, conference calls, and other responsibilities, I would stop by my data team’s little conference room each day and reengage in the ongoing, rambunctious debate about just how much silent spread there was. I was still trying to chip away at the CDC’s position, but more than that, I was trying to overcome my own team’s doubts. Getting an extension of the shutdown depended on my winning over at least one of them.
In my efforts to get the CDC on board, my meeting with Tom Frieden on March 14 was a helpful start. I was mildly heartened four days later, on March 18, when I read a “CDC Daily Key Points” document that finally acknowledged that community spread of coronavirus was present in the United States. In reading the CDC’s assessment of the initial major U.S. outbreak, at a nursing home in King County, Washington, I came across, and highlighted, this line in its analysis of why the response there had been less than optimal:
5. Delayed recognition of cases because of low index of suspicion, limited testing availability, and difficulty identifying persons with COVID-19 based on signs and symptoms alone [my emphasis].
I didn’t know who had written this analysis, but it was clear that someone, either at the CDC or on the ground in King County, was acknowledging that relying solely on signs and symptoms alone wasn’t working. Unfortunately, this acknowledgment still wasn’t in general circulation at the CDC. All the right language was there—“community spread” and “difficulty identifying” and “based on signs and symptoms”—but they weren’t recommending the actions needed to address the silent spread. What we needed now was massive, proactive testing, especially in hot zones among people under age thirty-five—those most likely to be asymptomatically infected. And we needed to limit all gatherings.
When I put my data team together at the end of my first week on the job, I hadn’t been looking for Irum or anyone else on it to be a yes-person (not that Irum, Chuck, or Steve ever would be). In fact, I was hoping for the opposite from all of them. The team served as an important critical and scientific sounding board. We trusted one another; even then, we had each other’s back. We didn’t always agree, but we valued the critical thinking and insights each of us brought to the table. None of us was always right, and we didn’t dwell on the mistakes of the past, but instead, ran forward on as little sleep as we could manage. They would listen to my ideas, evaluate the numbers I proposed would reflect the number of possible fatalities, and rebut what didn’t make sense to them.
And this was where the lack of testing and the lack of data converged. Not only were our domestic numbers lower than what was actually happening on the ground, they were also less precise, lagging far behind in the complete demographic details that were needed. We were working on it, but commissioning new software would take time—time that, it was increasingly clear, we didn’t have. Yes, the people at Johns Hopkins were doing their best to provide the most comprehensive statistics, but like everyone else, they were at the mercy of the virus: Hospital staff and agency staff at some locations were becoming overwhelmed with patients. When hospitals become inundated, data gathering, and ensuring that the data is complete and is shared promptly, becomes a lesser priority. As a result, the evidence that would make the best case for extending the shutdown was precisely what we lacked. The clock was ticking toward the end of the fifteen days, and I felt every second of it. We needed more.
On March 18, Irum convened a virtual summit with ten statistical experts from around the globe, including the United Kingdom, the Netherlands, and the United States, representing institutions such as Imperial College London, Columbia University, Harvard, and the CDC. Each expert produced two models, the first of which assumed no further intervention after the two-week shutdown ended. This so-called unmitigated response—which would constitute no further mitigation and would allow the infectious virus to move unconstrained across the country—produced some dire figures, with between 1.5 million and 2.5 million estimated deaths in the United States over the next several months as the virus ran rampant, unabated. Without an extension of the shutdown, this would likely be the scenario we’d face.
With their second models, the experts produced predictions of deaths based on a variety of mitigation assumptions and their level of effectiveness: school closures, social distancing, and a strict lockdown. Though the models produced different percentages, full lockdown was estimated to reduce the number of cases by 60 to 90 percent. This was with 100 percent compliance, a theoretical possibility but a real-world impracticality. A million and a half to 2.5 million deaths was horrifying to contemplate, but equally disturbing was that reducing that number between 60 percent and 90 percent would still result in a huge death toll, approaching 150,000 to 500,000, and this was just modeling this surge—not future surges.
We needed to refine these projections, as the death of 150,000 to 500,000 people was too much of a numerical spread to take to the vice president. The bottom line was that mitigation could be an overwhelming “success,” and yet it would still result in more than 100,000 people dying over the next few months. By hearing what other experts had determined, by seeing these extreme figures, the task force and White House, I hoped, would be driven to further definitive action. These numbers, which represented deaths on a then-unimaginable scale, had laid bare just how far behind we really were.
As the case numbers from around the world and in the United States rose, I inched my team closer and closer to consensus on my 50 percent–asymptomatic figure. (While lots of research was being done at the time, a more exhaustive and conclusive study in May 2021, by the University of Chicago, would put that figure over 50 percent.) By the end of the third week in March, Italy had enacted its strictest measures, with 90 percent of the country shut down. On March 11, three days into the nationwide Italian lockdown, and on the day all bars and restaurants were ordered closed, Italy had 9,172 cases. On March 22, when the country closed all factories and ended nonessential production, they had 59,138 cases, a sixfold increase. They weren’t close to flattening the curve—the worst was still ahead for them. Interventions take time to work, but we wouldn’t have that data from Europe before we needed to ask for an extension of our shutdown.
In comparison, New York City, still the hardest-hit area in the United States, had 1,263 total cases on March 11. By the twenty-second, that figure was up to 33,073—a twenty-five-fold increase in eleven days. It wasn’t just the absolute number of total cases that was troubling; it was the rate of the rise. New York City was going from 300 to 1,000 to now 3,000 cases per day. This hundredfold increase in cases was the kind of exponential growth, a day-over-day doubling, that lets you know community spread is rampant. This rate of rise couldn’t be explained by symptomatic spread alone; most cases were being missed. New York City was in full exponential growth, precisely paralleling what we’d seen in Italy.
If there’d been any doubt before about the extent to which asymptomatic spread was a significant contributor to the rise in case numbers, the New York City numbers convinced the team that my estimate of at least 30–50 percent asymptomatic spread was likely accurate and possibly even conservative. Even though the testing issues prevented us from having the quantity and type of data we needed, a preponderance of numerical evidence, the picture was crystal clear. For those of us in that tiny room, doubt had been replaced by a communal sense of dread.
We asked the modelers to change the assumptions in the models to reflect a New York City–like outbreak, with an agreed-upon 30 percent of silent spread cases reflecting the rate of case increases in the New York metropolitan area. Irum and I wanted to model what the fatality forecast would be if ten to twenty-five of the largest metropolitan areas in the country (those with more than a million residents in the city and immediate outlying suburbs) were affected. It was important that our scenario closely reflect reality—these places would be affected serially over time, not simultaneously. Modeling for them would allow us to see how the pattern would impact the allocation of precious supplies.
I did not mention this “metropolitan area” approach to predicting the numbers in the task force meetings. Introducing this kind of complex modeling to the whole team would have been too fraught with potential bones of contention and arguments for one methodology over another. No real good could have come from our getting wrapped up in the minutiae of how New Orleans and its demography (population density, age makeup, racial breakdown, percentage of comorbidities) was different from, say, Detroit or Milan. Keep the focus on the most salient point—the serial nature of the viral invasions across the country and how to prevent it.
My numbers team and the other modelers were at work adapting the Italian data to fit with U.S. demographics to produce a projection. All the task force needed to understand was that the virus (and its disease) was progressing rapidly in the New York metropolitan area. Also we had cases in all fifty states, and that without intervention, all states and all major metropolitan areas could end up staring down the barrel of what New York City residents currently were. To paraphrase the old expression, as New York City went, so might go every major metropolitan area.
Strong as they were, these models and projections couldn’t account with certainty for how willingly Americans would comply with the recommendations compared to Europeans. So many factors went into calculating compliance that we could use only an estimate. It was here that I best understood Tony’s reluctance to rely on models, but I also believed that when it came down to it, what we were determining was the potential fate of hundreds of thousands or even millions of people. Better to go with the best calculable estimate than nothing.
I didn’t want the press finding out about all of our different modeling scenarios. I couldn’t risk having every pundit on TV preemptively tearing into the cornerstone of the case I was building for the president. It wasn’t perfect—and the press would point that out—but I couldn’t let the perfect become the enemy of the good. Whatever our differences regarding the extent of asymptomatic spread, I was fairly confident that Bob, Tony, and I remained solidly in one another’s corner. I also believed that Steve Hahn, another ally and someone who truly understood data, would see the wisdom inherent in an extension of the fifteen days.
Yet, in the final week of March, Bob and Tony disagreed with some aspects of my strategic approach. We were all in alignment about the need for continuing the current mitigation. I was seeing Tony, Bob, and Steve in our daily task force meetings, and I emailed, texted, or was in phone contact with Tony nearly every day, frequently more than once. There was no aspect of the response on which Bob, Tony, and I didn’t consult one another. We each served as the others’ sounding board and support system when inevitable frustrations set in. We provided one another with both wise and effective counseling.
We went back and forth on the length of the extension; we were all in agreement that one was needed. I felt it should be thirty days, but when I broached the subject of asking the president for this, Bob and Tony both felt that it would be more prudent to ask for another fifteen, wait, and then ask for another fifteen after that. I disagreed. I didn’t believe the president would have the patience or the political will to go to the American people and say, Here we are again, asking you to do this one more time. But those thirty days would give us a chance to limit the kind of exponential growth we’d seen in New York from expanding across the entire United States. Anything shorter would be seriously inadequate, and we couldn’t take the chance of the president agreeing to only fifteen more days and then stopping short of what was actually required.
In the end, I held firm to my gambit. Go for the thirty. Tony, Bob, and Steve accepted. Tony worked with me on the graphics and the wording. Time compressed, and anxiety levels rose—I didn’t need any data to confirm that. I felt it in the thumping of my heart and in my worried, exhausted sighs.
WHILE I WAS GETTING modelers to help project the impact of mitigation, members of the Council of Economic Advisers were modeling the pandemic’s effects on the economy for the second quarter. Jared Kushner shared these forecasts with me.
In one, Tyler Goodspeed, a member of the CEA, had written, “I am not a public health expert. But in discussion with the brightest epidemiological modelers in recent weeks [read: not us], it has become clear that while interventions may alter the path of critical cases, optimistically they can attenuate the cumulative case load by maybe 20%.” In essence, he was saying that the most by which mitigation could lower cases was 20 percent. Once there was wide community spread, this could be true, but we were trying to prevent that initial community spread from occurring in the first place, to protect the main metros across the United States that weren’t yet into community spread. Goodspeed went on to add that there was a need to be very clear-eyed about the staggering economic costs of mitigation and about what any mitigation might do from a public health perspective.
To the best of my knowledge, the CEA and the White House senior advisors who supported their view had been silent about our initial fifteen-day ask; I doubted they would be again. They’d planted their flag on the hill they’d chosen to die on, declaring (without supporting data) that any solutions the medical people produced would be only 20 percent effective.
In another email Jared shared with me, a member of the CEA noted that one forecast didn’t account for the economic effects of shutting schools down, pointing out that education expenditures at the state and local level accounted for 3.35 percent of GDP. By March 18, 79 percent of schools in the United States had been shut down without federal recommendations. If that educational spending decreased by 79 percent over a three-month period, the annual rate of real GDP growth would be reduced by 10.2 percent. Later, more references were made to economic devastation, “an unprecedented economic contraction—more than double the magnitude of the worst quarter of the post-war period to date.” You didn’t have to read between the lines: The economic people didn’t think a 20 percent reduction in fatalities was worth the cost to the economy.
These reports were having an impact on the president, I could tell. On March 24, at the halfway point of our 15 Days to Slow the Spread campaign, President Trump stated that he hoped to lift all restrictions by Easter Sunday, April 12. He wanted the country “opened up and just raring to go.” Otherwise, the economic toll would be too great. Lives versus livelihoods were on the line, and he was siding with the latter.
I was shocked when he said this. With those words, it became clear just how far I’d have to move him in a matter of days.
In many ways, the economic figures felt just as scary as what we were modeling, but we could never forget that the figures we were tracking weren’t just numbers—they represented human lives. I didn’t have the time to think much about the assumptions being made in their models about the value of human life, but each time I walked into our little conference room, I had to remind everyone on my team that we all needed to be at our best, given the forces we were up against.
I was troubled by the sense that everyone in the White House seemed to have their own data stream and interpretation of that data. Some didn’t understand the reporting cycles—over-the-weekend data reporting was always incomplete, and the Monday figures I provided tended to be lower than the actual case and fatality counts. Fatality reports were notoriously delayed by weeks in the United States. You didn’t just need to use the data; you needed to understand the nuances of that data and how easy it is to under- or over-interpret the data at one point in time. Yet, every Monday, the economy people would report up the chain to West Wing personnel that things were improving. They’d cherry-pick a single positive data point and use that to produce a general, overly sunny forecast. I tried to align the data sources and their interpretation, but day after day, new emails would arrive with a summary of the state of the pandemic that I would then have to refute. Everyone was looking for “better” data—data that would make the pandemic look more “flu-like,” less deadly, less of an issue.
During the first few days into the 15 Days to Slow the Spread campaign, I had begun to hear whispers from those within the CEA and elsewhere about my data.
Where is she getting her information?
Are these sources reliable?
I have different data than she does.
Of course, data was unstable, and we were still trying to develop comprehensive reporting for cases, hospitalizations, and deaths. The kind of data I was getting easily from European colleagues seemed to be elusive in the United States.
I didn’t know the source of the whispers, but I knew that if I could turn those whispers into a normal conversation, so much the better. I decided to sit down with the other data-interested personnel inside and outside the task force to find out the sources for their statistics. I figured we could go through them together, to improve both mine and theirs. Perhaps they had a source I wasn’t aware of. Did they have a better source for daily Covid-19 hospital admissions? Where were they getting their laboratory data?
We didn’t want to dismiss their work out of hand, so Irum and Daniel Gastfriend met with Tyler Goodspeed from the CEA and Derek Kan from OMB to discuss it. If, when I later made my assertions, the economic-leaning members of the task force knew that some of what I’d calculated had come from their camp, they and others in the administration might be less likely to raise objections.
Meanwhile, Irum was continuing her work with the outside modeling experts. She and they were refining the graphs they’d created on viral spread without mitigation measures, so that they best represented the data and were accessible to the nonmedical eye. While I was satisfied with the work the modelers had done on this first task, the more important task was presenting the impact of a mitigated response. None of the models adequately represented what I believed the country’s infection and mortality status would be with various levels of mitigation.
Consequently, I continued to work on these myself and engage in active debates with the data team. I’d assess and assess and assess what I was seeing happening in the United States and in Europe. I took the current mitigated Italian case, hospitalization, and death curves and applied these one by one to the ten to twenty-five largest major U.S. metro areas we thought could see community spread. I then adjusted each calculation to reflect the future weeks when each area would see a peak. Crucially, I was projecting a figure based on each metro area having its own curve serially, not simultaneously, displaced two to three to four weeks into the future. I assumed a ratio of hospitalizations to deaths similar to the Italian experience. I did that because the quality of the Italian health care system was similar to ours, but whereas Italians were an older population, we had more comorbidities; I believed these two factors would balance each other. I then combined this data and projected over the next two months to predict the possible impact on the United States. I produced a range, with a low end and a high end based on whether ten or twenty-five of our largest cities evolved as Italy had. Our domestic reporting was so inadequate and late that I didn’t even have enough data from New York City to make clear projections; so I had to use Italy’s data.
My first projections put us at eighty thousand to two hundred thousand people dead just during April and May, the first surge.
I had my sights on fully briefing the vice president on the weekend of March 28, just three days before the expiration date of the original fifteen-day Slow the Spread campaign. In anticipation of this, on the day before the meeting, I would reveal the projections I’d come up with to members of the task force for the first time—including to Bob and Tony. I needed the vice president to be ready to brief the president over the weekend, to ensure that we could announce the extension before the end of the first fifteen days.
Then, much to my sadness, other supporting evidence for an additional thirty days of restrictions began presenting itself in the real world. My initial wake-up call back in January had been the graphic footage from that Wuhan hospital; for many Americans, including those in the White House, similar images coming out of Elmhurst Hospital in Queens produced the same startling effect. Pictures and stories of what was happening in New York City began to appear in various media outlets in the days before my Friday meeting with Vice President Pence. One twenty-seven-year-old doctor there described the situation to the New York Times, characterizing it as “apocalyptic.” Over the previous twenty-four hours, they’d had thirteen patients die.
Across the city, nearly 4,000 Covid-19 patients were hospitalized, and FEMA believed that, over the next days, all 1,800 intensive care unit beds in the city would be occupied and would likely remain so for weeks. Two city hospitals were already reporting that their morgues were full. Mortuary space was expected to reach capacity, and the state had asked for eighty-five refrigerated trailers from FEMA to receive the dead. Soon, those trailers would be parked outside various hospitals in the city. Online, photos showed nurses using plastic trash bags as personal protective equipment. Reports circulated of two patients being hooked up to the same ventilator due to the shortage of equipment. These kinds of visceral reminders of what Covid-19 could do visually reinforced the data, filling in the gaps and telling a story that numbers alone couldn’t tell.
The president received a very personal reminder that week when he learned that Stanley Chera, a New York City entrepreneur, had been diagnosed with the disease, was hospitalized, and was faring poorly. Very soon after Chera was first hospitalized, he was placed in a coma on a ventilator. President Trump described Chera as a friend and began publicly remarking on how vicious Covid-19 could be. I saw this as the president’s recognizing that people like him not just in age—Chera was only a few years older—but also in similar economic circumstances couldn’t count on wealth as a form of immunity. Initially, I did not press this point in any of my presentations. I heard the president mention Chera several more times that third week. He also talked about Elmhurst Hospital; he knew that hospital. Suddenly, this pandemic was not abstract to him, but very real and personal. Hearing and seeing the president grow more somber, I sensed he might be more receptive than I’d initially thought to dropping his position on relaxing the guidelines by Easter.
Add to this the scenes being broadcast out of New York: the ambulances hurtling down abandoned streets, the cacophony of multiple sirens blaring, the lines of sick people outside hospitals, and the dire, excruciating tales of suffering, survival, and loss—the story and the numbers together presented a vivid picture not of what was to come, but of what was already here. Worse, the scenes in New York City pointed to what was likely to take place in other metro areas around the country. If we didn’t extend the shutdown, a New York–type outbreak in every major city across the country would be our future—the kind of future that would see one or two million people dead by the fall.
I walked into my meeting with Vice President Pence on March 28 confident that I could make my case. As usual, Pence responded soberly to my presentation. His chief of staff, Marc Short, was unusually quiet, not pressing me on any points.
At various intervals, the vice president did ask, his urgent tone revealing far more than his poker face did, “Deb, do you really believe it’s going to get this bad? Do you really believe that this many people will die? Do you really believe the hospitals are going to get in this much trouble?”
At each point, I told him that I was certain about what I had concluded.
It was hard for anyone to swallow the notion of the United States going from fewer than 5,000 deaths to between 80,000 and 200,000 over the next eight weeks as the best-case scenario.
My meeting with President Trump was scheduled for Sunday morning. Prior to meeting with him, I consulted again with Tony.
“I think you need to up your numbers,” he told me.
I blanched at this. “Really? I’ve already told the vice president eighty thousand deaths at a minimum.”
“Tell the president one hundred thousand. That’s a big, round number and will resonate with him in a way that eighty thousand won’t. I also think that’s more accurate.” He then went on to say that the upper limit should be 240,000, not 200,000.
Still, these were projections, and the difference he was recommending wasn’t that substantial. After I met with Tony, who made great edits to the text to make the bullet points clearer, it was back to work, revising the slides and documents I’d present to the president. Tony might not have liked models, and he might have wanted a higher degree of rigor and certainty, but he recognized, just as I did, that we had to move with what we had, not what we wanted. Waiting for perfection would have doomed us all.
As I walked through the White House on Sunday, March 29, I immediately sensed a different vibe. Instead of the manic flurry of aides coming and going, the clamor of televisions from outer offices, the general hum and buzz of a busy office space, the scene was subdued. Its having been a Sunday contributed to this, but the place was by no means empty. The atmosphere wasn’t quite somber, but watchful.
Before, I’d been able to walk the hallways and feel nearly invisible, just one of so many others whose degree of importance, influence, or insight wasn’t particularly noteworthy. That day, though, eyes diverted from desktop screens to follow me. I wasn’t sensing fear so much as anticipation.
Unlike in the past, I didn’t have to wait long before being led into a room in the Residence known as the Yellow Oval. I was nervous. I had never been in the Residence before. I stood and waited for the vice president to signal where I should put myself. I sat on the yellow couch next to the chair the president usually occupied. The others, including Vice President Pence and Marc Short, either stood making small talk or sat. We waited.
I saw Tony Fauci looking pensive. This was a small group, not the task force. This was a different room, not the Situation Room. This meeting had been specially arranged, most likely by the vice president. I wasn’t sure how much detail he had gone into, if any at all, in briefing the president. But our presence here in the Residence signaled that the vice president believed me and the numbers I had presented to him. I honestly didn’t know what to expect from the president. A couple of days earlier, I’d landed myself in the media’s crosshairs for praising the president’s ability with numbers and data in an interview with the Christian Broadcast Network, but up to that point, he had taken my guidance and respected the data I’d given him. Now I needed him to do that again, and I had no idea if he would.
The president walked in. He was dressed in more casual clothes than I was used to seeing him wearing in the Oval, a pair of slacks and a polo shirt.
The vice president looked at me and signaled me to speak.
Despite my nerves, I plunged right into the deep end. Opening with my PowerPoint graphics, I said, “Mr. President, we need to take additional action immediately. I’m recommending that we extend the Slow the Spread measures by thirty days.”
“What will happen if we don’t do the thirty days?” he asked. He had cut to the chase.
I paused for a second, then decided to hit close to home: “If we don’t, I’m certain that we’re going to have fifty, a hundred, and potentially a thousand Elmhurst Hospitals. That means more trucks outside those facilities. That means more bodies inside those trucks. We’re going to see city after city looking like what New York does right now. It will only get worse.”
“I know that hospital,” Trump said. “What’s going on there, it’s horrible.” His eyes narrowed for a moment and his brow furrowed. He relaxed and tensed these facial muscles as he continued to take my words in. The sense I had had about the watchful atmosphere outside the Yellow Oval was now inside it. I’d been in the president’s presence at only a few meetings by now, though many more press conferences. I’d noticed how he frequently held on to the lectern stiff-armed, his shoulders spread, making himself even larger a presence.
He didn’t do this as he looked at me. He seemed to contract rather than expand.
“My friend is there. I’m younger. Don’t weigh as much as him.” He recovered quickly: “What are you basing this on?”
I explained to him how the United States was tracking as Italy had: we were two weeks behind where they were. I hit hard on Italy’s case fatality rate, the toll it was taking especially on people over seventy, people with other health issues—the overweight, the hypertensive, those with known cardiac or other respiratory or systemic issues. I showed him one of the charts we’d created. It literally and figuratively demonstrated the graphic nature of the reality. It showed a steep and inexorable rate of rise of infections, hospitalizations, and deaths.
“That fast?” he said.
“Yes, Mr. President.”
“How many?”
“One to two hundred thousand dead by the end of May. Best-case scenario.”
Again, he seemed to deflate. “Do you mean that there will be body bags there? Refrigerated trucks? Just like at Elmhurst?”
“Yes, Mr. President. Hundreds of hospitals.”
“Worst case?”
“If we do nothing?”
He nodded.
“Millions. Somewhere between one-point-five and two-point-five million.”
He flinched as if I’d struck him. He looked up from the graphs I’d handed him and then back at me. Back to the charts and then back to me. “Are you sure?”
“I am, Mr. President,” I replied without hesitation. I held his gaze.
“One hundred thousand to two hundred forty thousand dead even with another thirty days?” For the first time, his voice had lost its matter-of-fact tone.
“Yes.”
Hearing those words come out of his mouth made what we were talking about even more real for me. I sensed then and in the preceding week that the president had a grasp of the enormity of what our country faced. I tried to imagine what it must be like for him and some of the others in the room to hear these numbers. I’d been operating on the front lines of the decades-long HIV/AIDS pandemic, which was still taking the lives of nearly a million people per year. He, and most Americans, didn’t have my perspective.
We sometimes use the term sobering to describe the kind of Covid-19 mortality numbers I was talking about. For anyone without my background, projections like mine might have been seen as the kind of hyperbole spewed by a barfly in a rambling, incoherent denouncement of governmental malfeasance. Still, I could understand others being up in arms at the apparent impossibility of what I was suggesting.
Now, as I write this nearly two years later, the numbers are no longer impossible; they are our reality. Ultimately, with the additional thirty days in place, my forecast for the three-month period proved to be accurate:
March 28: 139,732 cases
May 31: 1,889,000 cases
March 28: 2,844 deaths
May 31: 109,058 deaths
No reasonable person, when talking hopefully in March 2020 about adjusting to a new normal, could possibly have imagined this included accepting that, by February 2022, as I write these words, we would already have seen nearly 6 million deaths around the world, with another nearly 10,000 people dying globally by today’s end. In the United States today, there were “only”—and it breaks my heart to use that word—over 100,000 daily new cases and over 2,000 daily deaths. We have surpassed 930,000 Americans lost, with the potential to reach over 950,000 by March 1, 2022. Those 2,000 or so—who among us wants their lost loved one to be part of that “or so”?—brought the death count to an unfathomable and avoidable 950,000 Americans lost.
At the time of our meeting in the Yellow Oval, all these numbers were in the future, hypotheticals that none of us knew would come to pass, hypotheticals I wanted desperately to avoid. I had no idea then how inured the president would become to the growing numbers, nor that so many of us would come to see them as an acceptable consequence of a collective reluctance to do the right thing—whether that was to wear a mask, avoid large social gatherings, refrain from dining indoors, or get vaccinated.
As I sat there, waiting for the president to speak, the words running through my mind were This has to happen. We have to get the additional thirty days. As I sit here now, the words running through my mind are This didn’t have to happen. This shouldn’t have happened. This can’t go on happening.
The president continued to sit, one hand covering his mouth. He dropped it to join the other one folded in his lap. I didn’t dare scan the rest of the room. I kept my eyes on him, gauging. He wore the same expression he had worn while discussing his very sick real estate developer friend.
“Tony, what about you?” He turned to Dr. Fauci. “Do you see it the same?”
“Yes, Mr. President, I do.”
The president nodded. “Okay, okay.”
We thanked the president and rose to leave the Yellow Oval Room. As I gathered my things, the sense of relief was palpable. The last thirteen days had been the most stressful, anxiety-inducing, and busiest of my life. Making the case for 15 Days to Slow the Spread on March 15 had been difficult; creating this pitch for an additional thirty days had been harder by many orders of magnitude—and of course, the president hadn’t even committed to anything at that point. But I read his “Okay, okay” as acceptance of the additional thirty days.
But the truth was, as much as I had wanted the extension, I also recognized that regardless of this win, the situation remained dire. We weren’t going to somehow snatch victory from the jaws of defeat with a last-minute miracle. This was about limiting the damage, doing just what “flattening the curve” implies. No one likes to think in such pessimistic terms, but after effectively losing January, February, and part of March, this was our reality.
What mattered most today was that the president—perhaps surprisingly to many—had done the right thing, though I suspected his decision wasn’t one that pleased most of his trusted advisors in the economy wing of the task force and elsewhere. Whatever my view of him as a politician or a person was immaterial. In this one instance, he had listened to the data, looked at the graphs and the evidence, and had made the only choice he could—and in doing so, he was helping us deliver a crucial message to the American people. These mitigation policies were needed. It wasn’t a question of economic vitality, but of individual lives. I just hoped he had the political will to keep them in place.