Losing President Trump’s support for the countrywide measures so early in April had other detrimental consequences—mainly, that he and others in the administration quickly turned to reopening the country as quickly as possible following the end of the thirty-day Slow the Spread extension period.
As early as April 7, at the direction of the White House senior advisors, some on the task force and many others in the administration were at work on a parallel mission: to develop a plan to reopen the country as soon as possible. As task force coordinator, I was to be part of this “tip-of-the-spear” staff work group. We were given until April 15 to draft and submit to the Executive Office the plan that became known as “Opening Up America Again.”
Not only was the timing tight, but how we were moving forward exemplified the problems inherent in any group enterprise, particularly at the level of the federal government. Simply put, too many chefs in the kitchen. Initially, at least three separate groups were duplicating efforts to develop this guidance: HHS, OMB, and the task force. In addition, OMB was being aided by an outside agency, the Boston Consulting Group. Wisely, Joe Grogan saw that this hydra-headed approach, the kind that had failed before in other endeavors, needed to be streamlined.
To avoid interagency squabbling and turf wars, Joe and I worked to consolidate the three working groups into one, placing specific people I trusted in leadership positions on core topics and assigning tasks to the various groups. In our first meeting, I shared with the larger group which tasks each subgroup would be responsible for. No one pushed back on their assignments; it was obvious I was trying to strike a balance in each group between the public health–minded and the economic/politically–minded—the latter with high political interest in reopening businesses, schools, churches, and other institutions. I also placed Bob in this group, along with White House senior advisors, to ensure that the guidance would be embedded in public health messages.
This was one of the important things I could accomplish in my role as coordinator. I wasn’t the secretary of HHS, I wasn’t the director of OMB, and I wasn’t a cabinet member. The heads of the agencies were still in charge of their people in the larger working group. Though I couldn’t directly persuade everyone around the table to agree with me, I could at least ensure that knowledgeable personnel acting upon strong, evidence-based data were present in each work group. We had less than a week, so we all needed to work independently and full-out. I also internally organized my data team to ensure that we moved forward deliberatively based on the best information, data, and science at the time. Remember, we lacked a historic road map to show us what had or hadn’t worked in the past.
If I stacked the deck in my favor in any way, it was by putting myself in charge of drafting the “gating” criteria for a deliberative, safe, data-driven reopening in the states. I did my research, relying heavily on the work of Drs. Tom Frieden, Scott Gottlieb, and Zeke Emanuel. At this point in the evolution of the response, we’d be moving past the emergency “flattening-the-curve strategy” that had blunted the initial surge and toward the crafting of guidelines that reflected where we were currently in our understanding of the virus and the specifics of proactive mitigation to prevent immediate viral surges across the country. My goal was to make the reopening of the states a data-driven exercise: as each state moved toward reopening, it would have to pass through one phase, or gate, before moving on to the next, thus ensuring the greatest degree of public health safety. This was my way forward within the context of the president’s “never again.”
To move from one phase of reopening to the next, states would have to demonstrate a fourteen-day continuous decline in new cases and test positivity, clearly demonstrating that its community spread was under control. Within my gating criteria was a clear call for weekly “sentinel testing” (that is, testing across a community, even of people who appear well) to serve as an early alert of asymptomatic community spread. This was very important to me, as I fundamentally believed that community spread began silently among the eighteen-to-thirty-five age group, who were more social and more likely to gather together indoors. Seeing the first signs of silent spread and responding with mitigation would protect the vulnerable and ensure decreased hospitalizations and fatalities. Early mitigation with masking, reduced indoor dining, and limiting friend and family gatherings would ensure that businesses, schools, and critical community engagements could continue operating and that the virus would not reach the vulnerable. I was scrupulous in making sure the benchmarks for proceeding from one gate to the next were as stringent as possible. Any early setback would drive a state back to an earlier gate and prevent further deterioration.
Along with the hard-and-fast fourteen-day rule and the hard stops, hospitals had to be absolutely capable of handling patients. They had to have enough PPE and staff and a robust testing program in place for their health care workers and the community, to detect early community spread among their staff. With these stopgaps, my goal was to ensure that most states wouldn’t get to phase three (fully open) until late summer. That way, we could use the summer to prepare for the devastating fall and winter I foresaw.
I needed direct control over this dimension of the guidelines. With these gating criteria, governors had a simple, straightforward, usable, and modifiable template to guide them and to adjust to their unique situations. States without significant community spread in April would be able to move forward cautiously in May and would serve as an early road map for what was and was not working. We could continually monitor the on-the-ground situation for any evidence of community spread and mitigate it immediately where needed.
Each reopening task group worked on drafting a portion of the two documents. The first was a brief list of bullet points that would live on the White House website and that the president would use during the press conference announcing the reopening guidelines. We’d refer to this as the framework document. The second, a CDC document, would be a far more detailed guidance document paralleling each aspect of the bullet points and would be posted to that agency’s site. Also, I wouldn’t have the final say-so over what was included in either document. The framework document would have to go through the Office of the Staff Secretary (Staff Sec), which managed the stream of documents that flowed into and out of the Oval Office and was considered by many the nerve center of the White House.
Staff Sec was run by Derek Lyons, an attorney admitted to the bar in Texas and DC. Derek and I engaged in a lot of back-and-forth over the framework document. While he was very helpful in streamlining and clarifying the language, I met with strenuous resistance from him in mandating that masks be worn everywhere indoors and in all outdoor public places where social distancing wasn’t possible. I’d submit the framework document with the mask mandate included, and he’d send it back with it removed. I’d reinsert it, and again he’d reject it. Back and forth we went, until eventually, I got an approximation of what I wanted and the American public needed. It was frustrating. “Strongly consider using face coverings while in public, and particularly when using mass transit” clearly isn’t a mandate, but a suggestion. It shouldn’t have been that difficult to get the administration to recommend simple masks, but it was.
While I had been dealing with the White House’s push to reopen, the CDC, after weeks and weeks of discussion, finally provided the guidance on masks we had needed back in February. On April 3, it recommended that the public wear cloth masks. Perhaps naïvely, I thought that the CDC’s having come out in support of masks would make mandating them much easier. Masks were critical to any chance of our reopening the country, making indoor spaces safer and ensuring that schools and businesses could fully open. Yet, that same day, in a briefing announcing the recommendation, the president said, “It’s going to be, really, a voluntary thing. You can do it. You don’t have to do it. I’m choosing not to do it, but some people may want to do it, and that’s okay. It may be good. Probably will. They’re making a recommendation. It’s only a recommendation.” In equivocating in this way—instead of making a strong statement about the CDC and its experts being world leaders in public health care—the president essentially gave the American people carte blanche to ignore the guidance, as he would be doing.
At the same time, President Trump, without using the terms asymptomatic or presymptomatic, urged all people to behave as if they were infected, even if they exhibited no signs of being so, and to exercise a level of care accordingly, a practical, straightforward way to open safely and remain open. This was the closest we got to a formal acknowledgment of silent spread. If only this type of statement had continued to be made day after day, offering a practical, straightforward way to open safely and remain open.
Instead, the overall message was muddied. For one thing, the president’s stating that he wasn’t going to wear a mask became a huge problem then and throughout the response. Also, the CDC guidelines made no mention of masks preventing the wearer from infection. Summarizing the rationale for wearing simple cloth masks, the president said, “In other words, if a person has the disease without knowing it, wearing a very basic mask can help prevent that person from infecting others.” This was true, but it was also confusing, as many Americans I met over the coming months would tell me.
Americans have common sense, and the CDC recommendation on masks did not pass the commonsense test. How could the material absorb what they exhaled but not what they inhaled? If there were two layers, and the layers were the same on each side, how could it be that only one side was effective? I believed from the beginning that masks could partially prevent the wearer from transmitting and receiving the virus. How effective were they at doing both? Simple tests could be done to determine this. For weeks in task force meetings, we’d discussed the need to get these inexpensive fabric tests performed (especially on the Hanes masks being made in coordination with HHS and ASPR), to ensure that we were distributing effective protection. If the country didn’t have a large enough supply of surgical masks, we needed to know how well cloth masks worked—at least in the laboratory. It would have taken a matter of mere hours to get such tests done and analyzed.
Regulations prevented the White House (to which the task force was attached) from entering directly into contracts with vendors. As coronavirus response coordinator, I therefore wasn’t empowered to execute or fund such tests. Worse, I couldn’t direct anyone else to get them done by private laboratories, either. I could ask, and I did. I asked the CDC, the NIH, ASPR, and the FDA to move on testing the efficacy of various cloth, surgical, and N95 masks so the American people would have the clear, definitive information they needed to inform their actions.
Unfortunately, territorial stickiness again gummed up the works. The CDC was the logical choice for carrying out such tests, but the agency seemed paralyzed on this point. Why it didn’t devise and then execute tests on masks remained a constant frustration, and a mystery to me. I prodded and prodded, but never received a satisfactory answer.
As for the NIH, ASPR, and the FDA, they didn’t believe that pursuing this kind of testing was part of their job. So, definitive tests on masks didn’t get done by the federal agencies. Instead, university labs, private-sector labs, and even CNN had the tests performed—but these tests weren’t systematic enough for the CDC or the task force to make data-driven recommendations. Without a definitive statement one way or the other about the effectiveness of masks as two-way protectors, the public became confused, frustrated, and, ultimately, angry and distrustful.
I don’t know even now why these simple tests were not done and the public informed of the results so they understood that masks worked in both directions. This clear information gap and lack of definitive data allowed others to fill the void with their own interpretation of mask effectiveness, which continued to create confusion.
In October 2020, a Japanese team of researchers did what we had been asking for since March. They studied the effectiveness of various kinds of masks and published the results, finding cloth masks 20–40 percent effective and N95 masks 80–90 percent protective for the wearer from infectious viral particles. The percentage increases to 50 percent and 99 percent in preventing escape of viral particles from the infected wearer. So if both the uninfected and the infected wore masks, the protection from infection was magnified. The CDC briefed the HHS secretary on this at the beginning of November, hours before the general election and months past the spring and summer surge of the virus, and weeks into the third and deadliest surge. He immediately brought it to the task force’s attention, but this whole episode was months too late. If the CDC had followed the model of the Japanese study, the data that might have emerged could have changed America’s perception of masks.
Americans wanted and needed clear, evidence-based guidance on masks, and they weren’t getting it. The cumulative effect of this? While plenty of people took the CDC’s guidance as a call to start wearing masks, that guidance also cast doubt on masks’ efficacy among much of the American public. Inadvertently, it fed the fire of those in the camp who believed masks were unnecessary and uncomfortable and required too much thought and preparation and who were otherwise predisposed against wearing them.
In contrast, the FDA, in the face of an enormous public health emergency, was allowing compassionate use of safe, promising therapeutics that allowed doctors to try new and old medication to combat the deadly virus. The FDA also issued emergency use authorizations without complete and final data. It lowered the level of definitive evidence required to make decisions, while still carefully balancing safety needs. The CDC needed to be just as aggressive in its prevention science and data collection leading to evidence-based advice. The agency needed to lead America in the study of prevention interventions, from masks to indoor physical distancing to vaccines. Americans were willing to learn with us, but our lack of evidence and our inability to tell the whole story led to confusion and distrust then and today.
The CDC’s mask guidance also undercut the critical message on silent spread that had already been so hard to convey. When people read or heard about the mask guidelines, they likely thought, I’m not infected. I don’t have any symptoms. I’m not going to infect anyone else, so why do I need to wear a mask if it isn’t going to keep me from getting infected?
Beyond being counterintuitive, the mask guidance also appealed to people’s self-interest—but in the wrong way. People are more willing to take precautions they believe will protect them. The idea of wearing a mask to protect others while doing nothing for them made the guidance much easier to ignore. Of course, ideally, we want people to act foremost in the interest of others, but this, sadly, does not always align with real-world behavior.
For all the legitimate issues I had with the CDC’s new position on masks, pushing back against it in public or in the media would have been equally fraught. The highly respected CDC had spoken; attacking its guidelines as insufficient or incomplete seemed too risky. Its reputation largely insulated it from criticism, especially any emanating from this White House—in the face of any criticism with a whiff of politics to it, the media’s fallback position was to side unquestionably with the CDC. Besides, it had taken so much to get the CDC to put out even this muddled guidance on masks that the drawbacks to further undermining the guidance were far too great. The CDC wasn’t clear enough, it didn’t pass the commonsense test, but at least it had made a small step forward. Perhaps the clearest indication of this was how many people started wearing masks in specific areas of the country. Overnight, groups and individuals sewed masks for themselves, their families, and their communities. Even if it wasn’t as dramatic or uniform across the country as it could have or should have been, progress was progress.
Still, an unfortunate downside to the new guidance was that when I pushed the White House to include a more aggressive masking mandate in the reopening guidelines, I lacked the CDC’s full backing; without definitive data, it could only be “recommended,” which made the mandate even more of a long shot. The pushback from Derek Lyons on this point was especially forceful.
I thought I would get significant pushback on the phased reopening described in the framework document, with my strict gating criteria for states. I doubted the White House would approve the criteria, but I was helped by an unlikely source. Another modeler not associated with the task force shared her projections with Derek Kan and the senior White House advisors. Even before we’d “reopened,” as many as forty states, she said, were already in phase three, the green, most open phase. According to her calculations, those states could already reopen fully. This was music to the ears of most in the White House, and the message became: Go ahead and set up your system. It will look good but will be essentially meaningless and unnecessary, since only ten states will be in the most restricted phase. It was great that they thought this was the case, but it wasn’t. Because no one in the administration had bothered to look closely at the gating criteria, and with the modeler’s “forty states” misinformation fed to them from outside our group, they had failed to understand fully how the gating system worked. According to the now-approved gating criteria, all states had to go through a mandatory two-week period just to prove they could start phase one.
But because of this failed understanding, I was able to get our strict gating criteria and framework plan approved and posted to the White House website as official policy. Just as important, we’d effectively extended the Slow the Spread campaign for two additional weeks, to mid-May, as each state demonstrated its control of the virus in their state.
The CDC’s own “Guidance for Implementing the Opening Up America Again Framework” (not to be confused with the framework document posted to the White House website) was bound up in bureaucracy and oversight issues. While the briefer, White House document essentially provided a list of what needed to be done for the states to reopen safely, the CDC’s document would provide the even more critical component: the specifics of how those things could be done. The states were relying on this more detailed document to establish the best practices and protocols for reopening safely. The CDC document was to be posted to that agency’s website as a single complete document—but this never happened, and it went up piecemeal over weeks, providing the states with fragmented, disconnected guidance.
This delay was hugely problematic. Because the CDC didn’t get this document done quickly enough, governors and state health officials had to scramble to find answers, frequently relying on the task force for any kind of guidance that should have come from the CDC. The CDC blamed OMB for the delay, but I’m dubious of this; drafts of the CDC document were still being circulated well after the April 15 deadline. I suspect that some of the CDC’s lateness was a result of its typically cautious approach and of the glacial pace at which internal processes and reviews moved, exacerbating these institutional tendencies. Some of the delay was due to editing related to asymptomatic spread. Perhaps there were other reasons, but bottom line: posting implementation guidelines for reopening weeks after the reopening officially “began” limited the guidelines’ effectiveness. It was one more misstep that eroded state-level confidence in the federal support they needed.
But I had other concerns with the CDC’s guidance. In the early drafts, I edited one section of their document to push to make clear, again, that silent spread was at work in producing early silent community spread, highlighting the importance of testing. I placed bullet points to that effect front and center. When the CDC finally posted the guidance, these explicit statements had disappeared from the opening paragraph. Though a close reading of the document’s entire one-hundred-plus pages and various addenda would have explained the role of silent spread, it should have been explicitly stated at the beginning of the document, highlighting the importance of proactive testing of sentinel cohorts, as it appeared in the White House Framework. Instead, it was implied, and, consequently subject to possible misinterpretation.
This guidance wasn’t just for state health officials; it was for the governors and their staff, nonmedical people who would have benefited from a clear explanation of my strong, foundational beliefs about testing that would allow us to act proactively and not reactively to prevent a hot spot from expanding into a larger hot zone. When we saw test positivity rates rising in a specific area we needed to expand the “sentinel cohort” testing program. That meant intentionally routinely testing those under thirty-five—community college students, nursing students, EMS students, all health care workers, and potentially high school students. People who were in the community but also at sites where they could be routinely reached and tested. If any of those asymptomatic people tested positive, they would isolate for ten days, thus cutting off the transmission route that might eventually lead to the most vulnerable group—the elderly and those with comorbidities or compromised immune systems. Testing those with symptoms was helpful, but it would never effectively work as well as sentinel testing in speedily reducing the chances of spread throughout a larger community.
The discussions in task force meetings and within the reopening work groups remained contentious on this point. The FDA, HHS, and the CDC were aligned in disagreeing with aspects of my position. They all believed, to one degree or another, in testing more, but they remained highly focused on, and prioritized, the symptomatic individuals who present later on in community spread.
But with tests approved by the FDA for symptomatic individuals only, the Centers for Medicare and Medicaid Services was able to pay for testing only of people with symptoms, people who had been in close contact with someone with symptoms, or people known to be infected. The CDC then recommended testing priority to only these cases, making it hard for the states to proactively test for the early asymptomatic cases often found in those under thirty-five. It came down to money. With no payer, either the person being tested had to pay out of pocket or the states had to fund the testing directly. The states needed to use CARES Act monies or other funding to perform this critical step. Eventually, some clever young Americans learned to pretend to have symptoms or exposure, just so they could be tested to protect their family members. This should never have happened, and yet it continues today.
Short of mass available testing at the first evidence of community viral spread, we needed to test weekly all long-term-care facility (aka “nursing home”) workers, those employed in communal transport, and those who lived in multigenerational housing. Seema Verma would do precisely this with a strategic testing “experiment” to prove the efficacy of weekly testing in identifying the role of asymptomatic spread. Because of her position as the head of the Centers for Medicare and Medicaid Services, she was able to mandate weekly testing of staff and residents in long-term-care facilities based on the level of community spread, ensuring we isolated the first cases and prevented onward spread among the most vulnerable. Because these facilities received public Medicare funding and were used to scrutiny by the agencies overseeing them, Seema was able to apply both the carrot and the stick. And with control over policy, she could be proactive. As a consequence, the viral fires that ravaged many long-term-care facilities in the early months of March to May 2020 were eventually brought under some control in many places due to this proactive testing approach. This kind of data-driven policy making would become the model we all needed to follow, and exactly what I was pushing the CDC and others, in mid-April, to enact—with little success.
ON APRIL 16, PRESIDENT Trump announced the “Guidelines for Opening Up America Again.” The messaging on masks wasn’t perfect, but at least the gating criteria would be highly effective. We had provided a framework that could be applied as is or adapted within each state and county.
As with the Slow the Spread campaign’s measures, the Trump administration was fine with not having full authority over the reopening criteria and gating—although, when he announced the guidelines, he did say he would point out any states that opened too quickly. Three days before announcing the reopening guidelines, he’d said unequivocally in a press conference that he had the power to lift stay-at-home orders in the states. As he put it, “The president of the United States calls the shots.” I was in that press conference, again biting my tongue. It wasn’t my role to step in and correct the president about federalism or how, under the direction of the vice president, the working groups on reopening had been conferring with the governors all along. Three days after that “the president calls the shots” statement, the president pivoted on the authority issue, acknowledging that it would be up to the governors, with federal support.
Ultimately, it is true that we couldn’t enforce a strict federal requirement for reopening. The United States of America is a collection of states with independent states’ rights. As much as the president sometimes promoted the far reach of his authority, the states would determine their own reopening. We could only offer guidance and support. But that guidance needed to be clear and consistent, and the support needed to be continuous and adaptive to meet the needs of Americans and the states.
By the time the reopening guidelines were announced, popular resistance to the Slow the Spread campaign was already evident. Initially, I saw the protests to mask wearing and social distancing as an inevitable by-product of the spring surge having affected some metropolitan areas to a greater degree than others—the virus had not yet reached some of the protestors’ more rural counties; many didn’t personally know anyone who’d been affected yet. This was actually evidence that the Slow the Spread approach was working. I sensed that some saw the virus’s absence in their area as evidence that they had never been at risk and would never be at risk. Many viewed the virus as a plague on the large cities—places where they had chosen not to live. I was sure those complaining and actively protesting the mitigation measures felt that they had sacrificed their Main Street to fight a virus that survived and thrived only in places where they didn’t live and would probably never visit: Chicago, New York City, Detroit . . .
What I didn’t expect was that, the day after he announced his own administration’s reopening guidelines, President Trump himself offered support to anti-shutdown demonstrators in Michigan—and later in Minnesota and Virginia, all states that had Democratic governors. As April dragged on, his grievances and frustrations with a science-based approach to combating the pandemic only grew more publicly hostile. On April 17, echoing the protest cries, he tweeted, “LIBERATE MICHIGAN!”
With these words the leader of the United States began encouraging protestors to take back their states and ignore local public health guidance. And the resistance to our message increased throughout the pandemic. His words also signaled an end to the sense of our “all being in this thing together,” to seeing our sacrifices as a shared burden we shouldered to produce a shared benefit. Rather than uniting us around a collective cause, the president was exploiting the differences and divisions between us. It was stunning to see that, only a day after announcing his own administration’s guidelines, Trump was supporting constituents whose chief goal was to undermine them. The juxtaposition infuriated me. It was as if he were determined to erode any progress the reopening guidelines produced.
More practically, the protestors and the president were wrong, of course. “Liberating” Michigan would only have liberated the virus just at the time when Detroit was exploding and the virus was being effectively mitigated, preventing spread throughout the state. At the end of March, Michigan ranked third, behind only New York and New Jersey, in Covid-19 deaths. By mid-April, it was the third state to reach the then-shocking figure of twenty thousand cases. At the time of President Trump’s tweet, cases and deaths were still rising in urban areas. Instead of making an inciting remark, he could have used the opportunity to inform the public. He could have explained why Michigan was in the condition it was in, why the reopening phases were so essential. Instead, the president sought to undo that state’s hard-fought progress.
It was at this point that the “never again” message he’d delivered to me in private finally entered the public square. Having received two divergent narratives about the pandemic, one from me and one from the CEA, President Trump had been ambivalent about what he thought of the policies he had originally endorsed. Now, in siding with the protestors, and in other actions and statements, he had shown where his ultimate loyalty lay. He believed the CEA memo. Never again would he side with us and the data I was providing. His ambivalence had hardened into categorical resolve.
AS APRIL STRETCHED ON, I began to express more of the profound sense of confusion and frustration I was feeling, the alienation—the outsider on the task force; the politically inexperienced one; the less polished, less practiced media type who was used to speaking her mind plainly as often as was possible and practicable.
During one of the informal “doctors’ meetings” we felt were necessary to convene as April progressed, Tony, Bob, Steve Hahn, and I took a moment to reflect on the progress we had made. Yes, we had moved the president to the 15 Days to Slow the Spread, the 30 Days to Slow the Spread, and a careful reopening of America. We were moving supplies and medical personnel to where they were needed, and the New York City surge was beginning to abate. The wonderfully upbeat Steve said, “So, how do you think it’s going?”
I looked him in the eye and said, “We’ll be lucky if we survive this.” I read confusion in his face. I went on: “We’re going to be hated. We will be the ones who’ll be blamed by both sides. We will be hated by the right for not agreeing with the president and hated by the left for staying and trying to support as comprehensive a response as possible under an administration they loathe. Guilt by association.” I let the thought hang there.
Steve nodded.
In encountering all these advances and retreats, I had a gut feeling that so much else was going on beneath the surface. Bob, Tony, and Steve tried to dissuade me. But in that moment, I felt I existed in a nearly overwhelming moment of contradiction. I worried that the four of us wouldn’t survive in this environment, while at the same time I was convinced that we would absolutely need to see this through. Despite the dominant negative impression of us in the press and within the administration, I knew one thing: You don’t abandon the battlefield in the midst of a fight because it’s hard or because it could damage you personally. You stay. You redouble your efforts. Our hope now was that all our efforts to produce the reopening guidance would pay off in fewer cases and fewer deaths. We also needed to ensure we were ready for the fall. We needed better treatments, a full federal stockpile of PPE, therapeutics, tests, and vaccines.
I knew I’d lost the president’s attention. What I couldn’t know was that, after April 21, I wouldn’t have another presidential briefing on the state of the pandemic in the Oval Office until the summer surge was fully raging. I would occasionally, after the CEA report, be called into the Oval from my perch outside in the hallway, to make a point with the president prior to press conferences, but it always felt like he didn’t see me. He didn’t acknowledge me verbally, except for his “never again” reminders, and later he stopped doing even that. I became a nonentity. He appeared to find nothing useful in what I had to offer—which was a realistic assessment of the situation and a reliable, accurate forecast of the disease’s trajectory and toll. If I wasn’t of use, I ceased to exist—except for a few moments as a prop in meetings where the so-called optics required I be present. I didn’t know it at the time, but the infamous “disinfectant” press briefing fit into this category.
“AND THEN I SEE the disinfectant, where it knocks it out in a minute, one minute. And is there some way we can do that by injection inside or almost a cleaning?”
It was April 23. The president was at the lectern in the White House Briefing Room. I was sitting to one side, against the wall. Trump was not speaking to me, but to the Department of Homeland Security’s undersecretary for science and technology, William Bryan, sitting two chairs down from me, closer to the door the president and White House staff used to access the room.
The president moved on to discuss the benefits of sunlight and of disinfectants that were effective against the virus outside and on surfaces—a justification for encouraging people to get outdoors and children onto playgrounds. Then he mentioned the use of light and disinfectants as treatments for Covid-19.
What was happening?
I sat there, unmoving, my hands clasped tightly in my lap. I watched the president’s exchange with Bryan and then looked at the floor, knowing my face would betray me. I kept my breaths slow and shallow. I tried to control my body’s reactions to what the president was saying. My brain whirred as I attempted to track his reasoning. How had he gone from sunlight sterilizing children’s playground equipment and the use of disinfectants on surfaces to using light and disinfectants—injecting disinfectants—to treat the human body?
I wondered where this was going, why he was on this tangent. I would soon get my answer.
This isn’t often reported, but prior to this press conference, William Bryan attended our usual daily task force meeting. We had earlier talked about wanting children to be active, to be able to go outside again, use playgrounds. Many cities and towns had closed their playgrounds and parks, limiting families’ ability to socialize and engage outdoors, especially in cities. We wanted families going to playgrounds and parks. I believed the outdoors was safe, and we had asked the DHS to study the impact of sunlight and disinfectants on surfaces to determine if playground equipment could be made safe and to encourage mayors and governors to reopen these outdoor spaces, parks, and playgrounds.
They could. Sound research had said so.
I had thought the matter was done and dusted, the evidence clear, the conclusions sound. But somehow, between that task force meeting and this press conference, everything that had been made clear had grown foggy again.
After the task force meeting, as I later learned, Bryan was pulled aside and taken to the Oval Office. This kind of post–task force gathering with the president happened infrequently now. In this case, I was not present; nor had I been invited. Instead, as had been so often the case by then, I was already outside the Press Briefing Room, about thirty-five feet from the Oval Office, waiting for the president to arrive. I waited and waited. Minutes passed, then a half hour, and then nearly an hour. What was going on?
During their tête-à-tête in the Oval, as I would later learn, Bryan briefed the president about the impact of sunlight and disinfectant on killing the virus. The president then asked him about the potential use of sunlight, heat, and disinfectant, not to clean surfaces in support of outdoor activities, but as a treatment. Reportedly, Mr. Bryan politely listened to the President’s ideas and said he would discuss them further with his team.
Fast-forward to that awkward press conference moment. Bryan and the president, it appeared, were continuing their off-the-cuff Oval Office discussion, but now it was happening in front of the media and before the eyes of millions of Americans, millions of people around the world.
As the president continued his musings on the use of heat and light, I looked down at my feet and wished for two things: something to kick and for the floor to open up and swallow me whole. With the fifteen- and thirty-day campaigns, we had finally shown that this administration was taking the viral threat seriously and that the American people should, too. The president’s disinfectant remark could unravel all that, and at the worst possible time, when the emphasis should have been on the slow, deliberate, careful reopening of the states. I knew the media would pick up this ball and run with it, discrediting weeks of careful work.
At the end of his long dialogue with Bryan, the president finally turned to look at me, in my chair against the wall, to ask about the benefits of heat and light as a treatment. I replied, “Not as a treatment.” Then, pivoting from the bad science to the good, I pressed on, talking about how the body naturally defended against invaders. I was employing, in my response, a commonplace truth of immunology: the role of fever in the body’s defense against viral infection. I hoped to get the conversation back on track, saying that heat and light couldn’t be a treatment per se and denouncing the tenuous connection between the disinfection of an inanimate object and a true antiviral treatment. But doing so only made things worse for me.
Many people thought I should have run up to the microphone and shouted, Not a treatment! That I should have leapt from my chair, hurled myself between Bryan and the president, and shouted, This is nonsense! I know myself, and I wouldn’t do such a thing even today.
To say that I was caught completely off-guard by the absurdity of what was being said in that room that day is an explanation, but not an excuse. Yes, I should have done better. I should have said “Not a treatment” more forcefully, several times over. I should have ignored my deeply ingrained, military-honed instinct not to publicly correct a superior and followed my instincts.
Instead, in that moment, I thought, Correct what needs to be corrected and move this along.
It wasn’t my reputation or standing I was worried about at this point. The more time and attention this disinfectant nonsense received, the bigger distraction it would be from what we needed to focus on right now: safely reopening the country. The important thing was to get the right message out there: sunlight and disinfectants were not treatment options, but a means to get children outdoors and playing with friends.
In the end, my facial expression, one of worry and disbelief, did the work my words could not. What the president was suggesting was nonsense. It wasn’t worthy of the nation’s attention. The vast majority of the American people, I believed, would see it for what it was: an impulsive statement, as improbable as it was improvised. It said more about the state of the speaker’s mind than about any fundamental scientific truth.
I left that briefing furious. In a matter of minutes, with the uttering of a few words, our credibility had been blown up. None of what the president had said about disinfectant made sense. He needed to recant and recant immediately, before this spun out of control.
Because I didn’t have direct access to the president, I asked Jared Kushner, the next best thing, to make sure the president knew that what he’d implied in raising these bogus ideas with Bryan undermined the serious science we were using to communicate to the American people. I told Jared that the president needed to immediately correct the statements he’d made in the press conference. I know Jared went to the president.
The next day, the president said he had been “joking.”
The media and the public saw through this. Many of us have used the same excuse after saying something hurtful or unwise. But there can be consequences to some “jokes,” especially when they come from the mouth of the leader of a country. They can’t ever truly be unsaid; the damage remains done.
Having the president take an idea from one context and apply it to another fit into a larger pattern I had witnessed. I had the sense coming into the White House that the president’s team had struggled even before the pandemic to filter the information the president so voraciously consumed. Whether or not the information was credible; whether the person who espoused a particular belief, point of view, or “fact” had based it in sound reasoning and evidence, hardly seemed to matter. With the pandemic dominating the news cycle, social media, and other areas of the internet, the White House was awash in conspiracy theories, speculation, and a panoply of perversions of science posited by nonexperts.
The president’s team couldn’t deal personally with all the phone calls, emails, texts, and random mentions the president came across while viewing his four screens or the information his friends fed him. Because of this, his senior advisors and the vice president’s communications team, Devin O’Malley and Katie Miller, often passed these people on to me to speak with. These outside influences ranged from TV doctor Mehmet Oz to pillow salesman Mike Lindell—and they gave oxygen to all manner of ideas that had no business making their way into the White House. The inclusion in the president’s body of information of even the most baseless, suspect ideas created the illusion that all information, no matter the source, was equal and equally trustworthy.
Understanding science can be hard. Nuance is important. Ideas and statements get distorted. And you can’t just “consider the source”; you have to think more deeply and not accept anything at face value, no matter the source.
The disinfectant debacle brought about a fundamental change for the task force. For one thing, the daily press conferences ended. This meant it was harder to communicate, to get our data, concerns, and solutions out there directly to the American people. More than that, though, it codified the shift that had taken place throughout April. The doctors on the task force, especially me, no longer had an audience with the president. He was no longer hearing our analysis of the data, nor the solutions for combating the virus. We were effectively cut out of the Oval Office discussions and the decisions that would come from those discussions. Trump’s senior advisors and outside sources could present their views on the pandemic unchallenged. The days of presenting graphics and analyses to the president were over. The people who wanted to neutralize my influence had won that battle, but the larger war was still raging. While we all had roles to play, and while there was still a lot of good we could do while there, our days of being able to shape White House communications on a large scale were over. We needed to find another way to influence the critical decisions and policy making—in the states.
From that point forward, whenever I felt we needed a press conference to communicate with the American people directly, it would take weeks and weeks of begging the vice president and Marc Short to schedule one. What press briefings were held—which I often wasn’t a part of—had the feel more of campaign events. In them, the message was: Here’s how great we’re doing on testing or therapeutics or vaccines. The White House would never return to the serious message needed on this pandemic: where the virus was and who had to take precautions.
IF APRIL WAS WHEN the economic forces in the White House regrouped against the science of the virus, May saw us increasingly marginalized, solidifying President Trump’s, and his administration’s, resistance to our efforts. As the tide turned, the mood grew darker, more sinister. Death threats and warnings of attacks (sometimes sexual in nature) against me and my daughters had begun in April and were occurring with a frequency that was hard to ignore. I took the first set of them to the State Department, since they were my current employer. They were used to these types of threats to ambassadors around the globe. They asked me to continue to track them. Tony got protection, and I got to do more collecting.
To be honest, I couldn’t read the hate mail. The sheer volume of it was overwhelming. I never reported it again to the State Department. I reminded myself that I had been in much more threatening and unsafe areas in my life and had survived. I would survive this. I did get help from the Secret Service, though. They were amazing—at their posts day after day, protecting all of us. I greatly appreciated their work. Once, they did something very kind. Like many households in America, we had a family telephone plan that dated back decades ago, when my daughters were in high school. But now we were getting threatening, sexually violent texts. So, the Secret Service called our provider and got my phone locked, and overnight, the texts disappeared, never appearing again until I left federal service. I will always be grateful for this kindness shown me. Those messages were deeply unnerving to my daughters, and I was so grateful when they stopped. The mail threats didn’t, but at least I didn’t have to open those and read them.
Tony and I had become the avatars for science, both for the White House and for those in the public who disagreed with the shutdown. Science became the enemy, data-driven debates dissolved into threats and expressions of hatred.
On May 6, without fanfare or bluster, the president casually said the White House Coronavirus Task Force would soon be disbanded. In its place, a new task force would be created, one focused on getting the country’s economy fully recovered.
At first, I had no idea what was happening. No one had said anything to me about these changes. I had to find out through the media, when the rest of America did. I couldn’t believe it. Here we were, in May, two months into my coming on board, and the president was essentially declaring victory over Covid-19. Though he’d be keeping Tony and me on board as the lone survivors of the public health wing of the disbanded task force, the economic wing would be getting not just the green light, but the keys to all the cars and permission to detour around the unpleasant realities of the pandemic—all to get to the Promised Land of a revitalized economy.
I stayed—knowing that if I didn’t, no one else would be brought in to replace me, leaving Tony alone to flounder in the wake of the president’s now disregard for public health. I spoke with Tony; he was equally upset. We had looked forward to the day when there would be no need for a Coronavirus Task Force, not to its being prematurely ended as another false signal to the American public that all was well.
Looking back, I see that my public responses to events like this were often muted. But things happened so fast in that environment, and with such great frequency, that instead of flinching or raising your hands to protect yourself, you simply had to let whatever was incoming bounce right off you, so you could focus on the task at hand. Given the summer surge in 2020, and the surges that followed, I don’t like to think about how much greater the loss of American lives would have been had we not done what we had up to that point. Without the Coronavirus Task Force:
There wouldn’t have been the hospital database that tracked vital supplies, health care personnel needs, and critical therapeutics, helping get them where they were needed.
There wouldn’t have been the PPE early alert systems that identified and helped resupply every hospital across the United States short on masks, gloves, and gowns.
There wouldn’t have been the amazing behind-the-scenes work of so many to get the message out through local media.
And without the task force, the governors almost certainly would have had to fend for themselves. Instead, they were able to speak directly to us with great frequency, and the governor’s reports we sent them each week gave these leaders—especially of red states, whose populations were more resistant to mitigation measures—the cover to say they were only asking for what the White House had advised. Without those reports and the perception of White House backing for the mitigation measures they provided, there would have been dozens more Michigan-like protests, more open defiance of mask wearing and social distancing regulations. The governors would not have been able to hold the line.
Fortunately, the day after saying the task force would be disbanded, the president tweeted that it would remain in place indefinitely. He also mentioned how many people had contacted the White House to express their positive opinion of the work the task force was doing. He said he had had no idea how popular we were.
I wondered: Popular? I have never been popular. I’m the data nerd. I’m used to doing the hard work behind the scenes. Popular? Does that really matter? Isn’t it about how effectively we’re doing our jobs?
I can’t be sure precisely what went into his changing his mind, especially given how marginalized we’d been for the last month. Perhaps he had realized that in spite of his distaste for the work we were doing, the political optics of disbanding the task force at this stage would not have been good.
He kept the task force going, but he would continue to undermine us publicly just as he had been. Perhaps it shouldn’t have been surprising, then, when he came out against widespread testing. On May 15, he said, “Don’t forget, we have more cases than anybody in the world. But why? We do more testing. When you test, you have a case. When you test, you find something wrong with people. If we didn’t do any testing, we would have very few cases.”
Rightfully, many people in the media seized on this statement, excoriating the president for his incorrect explanation for why the United States’ Covid-19 case numbers were so high. If test positivity is rising despite increased testing, it means that there is ongoing, uncontrolled community spread. Together, both test positivity and tests per capita are the most meaningful metrics for determining the effectiveness of a testing program. (Remember: some people were having themselves tested again and again; while others weren’t being tested at all.) When it came to this important measure, the United States actually trailed Canada, Russia, and other countries in Europe.
I heard what the president said on testing and dismissed it as just another example of his desire to reframe the narrative so that the negative picture (the high case rate) could be replaced with a rosier, more voter-friendly one. I also saw his remark for what it was: President Trump tossing red meat to his base.
As misleading as this rhetoric was, I would have been more concerned about his distortions on testing if his words didn’t stand in direct contrast to what his administration was actually doing behind the scenes. For all his anti-testing statements at this point, the reality was that the task force, under the leadership of Vice President Pence, was pulling out all the stops to rapidly expand testing. Through the agencies, and with clear White House approval, we were spending billions of dollars on tests and testing supplies. We were aggressively testing in nursing homes and asking universities to use testing to bring their students back safely in the fall. We were flying in swabs from across the globe so that testing could be constantly expanded. We were using the Defense Production Act to streamline the manufacture of supplies and raw materials for the private sector, to build more manufacturing facilities, and to expand testing. We had ensured a constant funding stream for the purchase of tests through the ups and downs of the surges to make sure the private sector would continue to expand testing. We were working to increase testing of the most vulnerable, including at the Federally Qualified Health Centers and tribal nations. And we continued to work with the private sector and states to increase testing. And the White House had posted the guidance I had written to ensure broader, more strategic testing—finding the silent spread. Week after week, testing increased, and continued to increase throughout the months that followed. The majority of reported testing was primarily with the PCR nucleic acid test. By January 2021, we had reached nearly two million of these tests per day, and were also sending out fifty million free antigen tests monthly to the states and institutions that needed them most.
At no time did anyone tell us to stop this acceleration in testing. The president was a master at saying one thing to appease his base while his administration did another in support of combating the virus. This was the dichotomy then and throughout the months that followed. One thing was said, while a very different action was taken.
The direct effect of this particular instance of bluster by the president was negligible on me and the task force. However, there was plenty of collateral damage, specifically in its effect on public perception. How people viewed the pandemic response and what personal actions they took—these were the true casualties of Trump’s language. As we moved through the summer and into the fall, we began to see more profoundly the results of the American public’s not having the kind of leadership from the man in the White House that could have led them to do the right thing.
In a town hall on CNN, I was asked if I thought more testing was a bad thing—a question designed to drive an even bigger wedge between me and the president. I wouldn’t rise to that bait; I kept on message. Testing to detect asymptomatic spread was good and necessary. Testing didn’t increase positivity rates. Aggressive, strategic testing allowed you to spot the silent spread early. This kind of testing, in fact, would decrease the number of confirmed cases over the following weeks, because it would stop community spread.
I didn’t want to paint the president’s comments in a simplistic way. In fact, questions on testing were complicated by far more than merely what the president had said. The long-standing “test more or test wisely?” debate was ongoing and expanding. For months now, “testing czar” Brett Giroir, the CDC, the FDA, and I had been unable to agree on the best approach: Whom to test? How many to test? But there was also another wrinkle: Which tests should we be using?
From the outset, there were two different testing options, each with its merits: the nucleic acid test (also known as the PCR test) and the antigen (rapid) test. While the nucleic acid test was the more accurate, it provided a positive result long after the viral infection was cleared—that is, long after the infectious period. The antigen test could be processed and read much more quickly. This difference in turnaround time was no small thing; antigen tests could produce results in a matter of minutes, and could therefore be used to prevent ongoing transmission to others, as opposed to the days and sometimes weeks it was then taking nucleic acid tests to be turned around. The only problem was that the antigen test results were not as reliable. Still, while antigen tests did have acknowledged deficiencies in detecting seasonal flu, I believed the new SARS-CoV-2 antigen test was more reliable for detecting the virus than the previous flu antigen test.
In addition to believing we should test only those people with symptoms, the CDC and the FDA also felt we should use only the more reliable nucleic acid test for diagnosis, even with its longer turnaround time. The CDC and the FDA were okay with antigen tests, but not for official diagnosis and not for diagnosing asymptomatic cases. Meanwhile, asymptomatic testing was exactly what we needed the antigen test for. If you got a rapid answer that you were infected, you could immediately take measures to avoid infecting others. Getting an immediate answer, one that developed right before one’s eyes, would appeal to younger people, who were more likely to be asymptomatic, and would encourage them to increase their personal testing. The CDC thought the antigen test result could be considered only presumptive. This caused incredible chaos in reporting and required reporting. In other words, its results would have to be confirmed by a nucleic test—thus requiring people to double dip, spending more of their time and energy. Also, there was no reason to report the antigen test results, as they weren’t considered definitive. Once again, the perfect became the enemy of the good.
There were also issues of cost. Because of the CDC’s and the FDA’s positions on the antigen test, the Centers for Medicare and Medicaid Services couldn’t pay for them, and thus, private insurance refused to pay, too.
Similarly, states didn’t want to pay for antigen tests because their costs couldn’t be reimbursed; they would use the antigen test only if they were given them for free. Because of all this, antigen tests came with an out-of-pocket cost, whereas nucleic acid tests would be covered. This automatically put antigen tests out of reach of those who needed them most. Brett stepped up and worked to align the fifty million antigen tests sent out per month with the sites that needed them most through the fall.
At the same time, despite Bob and me having pointed to their advantages in phone calls, public health officials across the country united against the antigen tests. It’s difficult to fault the state agencies and public health officials. They didn’t want to break with CDC guidance. But this refusal to strategically embrace antigen tests led to even more community spread.
To advance my case, I devised a strategy for the use of our current testing supplies, one that would increase the rate at which the tests could be processed and that wouldn’t strain our inventory. Early on in the pandemic, the availability of tests had been a major stumbling block. We had wanted to preserve as much of the testing materials we could for use in diagnosing the more vulnerable age groups. From the outset, the message had been that testing younger people widely was not a priority. I didn’t anticipate that “test the older, not the younger” would become set in stone even after the supply strain eased.
For weeks within the doctors’ group of the task force, we worked on a blueprint for strategic testing involving the antigen test, especially since the federal government had purchased 150 million of them. Tony was fully supportive, agreeing that my plan to use antigen tests for screening for silent spread was the right approach: We had a ready supply of them, the rapid tests were likely to be more appealing to younger people, they were proving to be reliable in this application, and by using them instead of the nucleic acid tests, we could reserve these latter tests for the most vulnerable age groups and other higher-risk people. To bolster my argument, I used Seema Verma’s success with long-term-care facilities as a real-time experiment to see if lots of testing would prove effective at identifying the infected (who could then be isolated) before they were symptomatic.
Of course, none of this was different from what I had been saying all along. It’s just that, before, most of the evidence supporting the need for widespread, strategic testing to find asymptomatic spread in the community had come from other, mostly Asian countries. Now we had increasing amounts of evidence from within our country supporting this strategy—evidence that showed clearly how tests could be used to track asymptomatic spread in a community.
And still, it wasn’t enough. While Brett Giroir, the CDC, and the FDA understood the rationale for my position, I struggled to get everyone to shift gears into a proactive mind-set. Their objections were nebulous, insubstantial, nothing I could use to refine my case for a different testing strategy—essentially boiling down to a lack of will and follow-through. The FDA would not approve antigen tests for asymptomatic diagnosis until July 2021.
We should have made these faster tests universally available. This failure put the United States farther behind Europe in testing and made us more vulnerable to surges. I admit that the antigen tests were not as reliable as the PCR tests, but not using them cost us lives. Unknowingly infected, untested sons and daughters spread the deadly virus to their vulnerable parents and grandparents. I suspected—and later on, I confirmed this in personal encounters—that many young people in the eighteen-to-thirty-five age group who were unknowingly in the silent superspreader group hadn’t wanted to wait the twenty-four to forty-eight hours it took, best case, to learn the results of their nucleic acid, or PCR, test—especially when that “best case” often turned into more than a week. They wanted an immediate answer, and frankly, they were right. They wanted a test they could use right before they saw their elderly aunt or their grandmother or their parent receiving cancer treatment. They understood being negative in that moment of interaction was what was important to protect others.
We had in our possession millions of antigen tests and nucleic tests that could have been distributed to more sites so people wouldn’t have to wait for results. We had a quicker test available, one that would have told them within minutes, not days, that they needed to isolate or mask indoors when with their vulnerable family members. Knowledge is power, and we denied Americans that critical power by deciding we needed the perfect rather than the good.