We were about an hour into a meeting in the Situation Room on January 29, 2020, chaired by President Trump’s acting chief of staff, Mick Mulvaney, discussing what appeared to be an emerging new viral illness in China. According to our sources, 7,711 people were infected and 170 had died from their disease, although reliable information from China was scarce. With several Chinese cities locked down, our group of about a dozen mostly top-level National Security Council and HHS appointees were debating how to evacuate U.S. citizens from Wuhan, China, when President Donald Trump walked in.
The first thing he did, to my great surprise, was to look right at me. “Anthony,” he said, “you are really a famous guy. My good friend Lou Dobbs told me that you are one of the smartest, knowledgeable, and outstanding persons he knows.” I gulped and thus began my first extended conversation with the forty-fifth U.S. president.
Dobbs, the then host of the Fox Business Network show Lou Dobbs Tonight, had called me that morning. I knew Lou well because he had interviewed me countless times over the past decades about public health threats—everything from HIV, anthrax, the seasonal flu, and measles to Ebola and Zika. The president wanted to meet me, Lou said. Just a few hours later, here I was with Donald Trump, a big, imposing man who filled the room. He had a New York swagger that I instantly recognized—a self-confident, backslapping charisma that reminded me of my days in New York.
For the next twenty minutes, as we discussed the new virus that we were calling SARS-CoV-2, the president directed many of his questions my way.
Before that day, I had met President Trump only once. The previous fall, I had been one of a group invited to the Oval Office for the signing of an executive order that called for improvements to the manufacturing and distribution of flu vaccines. In the years before the signing ceremony, I sometimes wondered what it would be like if I ever were to interact with him since he shocked me on day one of his presidency with his disregard of facts such as the size of the crowd at his inauguration. His apocalyptic inaugural speech also had taken me aback, as had his aggressive disrespect for the press. But-face-to-face, at that brief signing ceremony in September 2019, I had found him far more personable than I had expected from watching him on TV and reading about him in the newspaper.
After the signing ceremony ended and we were walking out, one of the president’s staffers called me back into the Oval Office, where Donald Trump signed a copy of the executive order for me, the D in “Donald” oversize and looping. As I looked on, he remarked to me that he had never received a flu vaccine until he became president. As someone who is zealous about getting his annual flu shot, I was a little surprised. When I asked him why, he answered, “Well, I’ve never gotten the flu. Why did I need a flu shot?” I did not respond.
Now, more than four months later, in the Situation Room, as President Trump directed his comments to me, the other principal attendees and a handful of presidential advisers, sitting in the crowded spaces against the wall, seemed puzzled and were probably thinking, Who is this guy, and why is the president so interested in him?
“How fast do you think this virus will spread?” the president asked me.
“We don’t know, Mr. President,” I answered, “because the information we’re getting from China is not entirely clear.”
“Do you think we’ll be able to handle this in the U.S.?” he asked.
“Well, if we do identification, isolation, and contact tracing properly, we will likely be able to handle it. But we need to be careful and learn more about this virus to be sure.”
He smiled, and as he was leaving, he called out over his shoulder, “Thanks again, Anthony. We’re counting on you.”
Not since my first day of high school in 1954, when Father Flanagan, the assistant principal and dean of discipline at Regis High School, nicknamed me Tony, had anyone other than my parents, my sister, and Shelly Wolff ever called me Anthony.
But I was not going to correct the president of the United States.
I first heard about a pneumonia-like virus coming out of Wuhan, China, on New Year’s Day. Christine and I planned to take a brisk, four-mile walk on the C&O Canal towpath, along the Potomac River, something we had done together almost every Saturday, Sunday, and holiday since we first met thirty-seven years earlier.
Throughout the Christmas holidays, Greg Folkers, my longtime chief of staff and a human fire hose of information, emailed me updates from the CDC and other sources throughout the world on the current flu season, which was shaping up to be harder hitting than usual, especially for children. My interest was not just professional. Right before Thanksgiving, I had flown home from a medical meeting in Amsterdam, sitting for almost nine hours next to a woman with a wet, violent cough. Even standing in the back of the plane whenever the seat belt sign was off could not save me from coming down with the worst case of influenza I had ever had. And I had had my vaccination!
On January 1, 2020, I was zipping up my fleece to head outside with Christine when the phone in the kitchen rang. I picked it up to find a health reporter on the line. “Dr. Fauci,” he said, “there’s something strange going on in central China. I’m hearing that a bunch of people have some kind of pneumonia. I’m wondering, have you heard anything?”
I thought, He is probably referring to influenza. Or maybe this could be a return of SARS, which in 2002 and 2003 had infected about eight thousand people and killed more than 750. It had been bad, particularly in Hong Kong, but it could have been much, much worse. Thank goodness the SARS virus did not spread very efficiently from person to person. Public health officials in China, where they have a very solid infectious disease infrastructure, had been able to combat the virus by contact tracing and quarantining those who were exposed.
Someone in the press calling me at home on a holiday about a possible disease outbreak was concerning, but it was not that unusual. Reporters, who sometimes had better or at least faster ground-level sources than we did, were often the first to pick up on a new disease or situation. Nor did it automatically trigger an immediate, all-hands-on-deck response from us at NIH. These pneumonia-like cases in China might be a blip, or they might be a wave. We needed more solid information.
“I haven’t heard anything,” I told the reporter, “but the situation should obviously be closely monitored.” And that is exactly what we did.
But monitoring was not easy, because the outbreak was a moving target from the get-go. For one thing, we had a hard time finding out what was really going on in China because doctors and scientists there appeared to be afraid to speak openly for fear of retribution by the Chinese government. One thing quickly became clear: tests were showing that this was different from influenza; it was a novel coronavirus. In the first few days of 2020, the word coming out of Wuhan—a city of eleven million—suggested that the virus did not spread easily from human to human. Bob Redfield, the director of the CDC, was already in contact with George Gao, the director of the Chinese Center for Disease Control and Prevention. During an early January phone call, Bob reported that Gao assured him the situation was under control. A subsequent phone call was very different. Gao was clearly upset, Bob said. The Chinese CDC head told him that it was bad—much, much worse than people imagined.
A full code red, with flashing lights and screaming alarms, went off in my mind during the fourth week of January when I saw photos in a newspaper that revealed the Chinese government had erected a thousand-bed prefabricated hospital over a few days. At that point, the virus was reported to have killed just twenty-five people and infected around eight hundred, according to data the Chinese had released. Time out, I thought. Why would you need that many hospital beds when fewer than a thousand people are infected? There must be a much bigger, very real problem that we are not fully aware of.
That was the moment I suspected we could be facing an unprecedented challenge, and my anxiety index took a sharp turn upward.
By the end of January, we were hearing that the cases in China were increasing by about 25 percent per day. There were now reported to be more than 9,000 people infected and 213 people dead. I was astonished to realize that the number of people infected in a single month had surpassed the original SARS total for an entire year. The United States had its first travel-related case of this novel coronavirus on January 20; a thirty-five-year-old man had returned home to Washington State, from Wuhan, with a severe cough and fever.
Because close to three million people flew into the United States from China every year at the time of the outbreak, the CDC had begun screening these passengers at several U.S. airports, scanning for fever, and asking them about symptoms such as a sore throat or a cough. We had been considering the next step for a few days: Should we recommend closing the United States to travelers from China? After weighing the pros and cons, we concluded that given China’s high rate of infection, a travel ban might buy us critical time to prepare Stateside while our case numbers were still low.
On the last day of January, sequestered in the Situation Room for hours, the coronavirus task force, chosen a couple of days earlier and chaired by the HHS secretary, Alex Azar, devised a proposal to ban all foreigners who had been in China during the past fourteen days. Having reached a consensus, the entire task force plus Kellyanne Conway, counselor to the president, and other White House officials reassembled upstairs in the Roosevelt Room to hammer out how to present our recommendation to the president.
Finally, we were ushered into the Oval Office. Seated in chairs in front of the Resolute Desk, Alex Azar, Bob Redfield, and I explained the details of the proposed travel ban to the president. As in our last meeting, he posed several questions specifically to me about whether I was fully on board with the ban. “It is an imperfect process with some downsides, Mr. President, but I believe it’s the best choice we have right now,” I assured him.
I was relieved that the president wanted my input, because I had the sense that something large and frightening was on the horizon. The American people needed to be reassured, but they also needed to be informed about the real dangers headed our way. The White House communications team began arranging for me to appear on TV news shows. Even though this was something I had been doing regularly for decades with AIDS, anthrax, and other crises, this was different. The entire world was transfixed by this rapidly evolving outbreak and was soon to be directly affected by it.
The upshot: I became the de facto public face of the country’s battle with the disease. This was good, in that I could both calm the country’s anxieties and provide factual information. But it also led to the gross misperception, which only grew exponentially over time, that I was in charge of most or even all the federal government’s response to the coronavirus. This would eventually make me the target of many people’s frustrations and anger.
“We don’t know what’s going on with this virus coming out of China right now,” I told the group assembled in the conference room down the hall from my seventh-floor office on the NIH campus. This was January 3, just forty-eight hours after the reporter had called me at home on New Year’s Day. The scientists sitting around the table, led by the Vaccine Research Center director, John Mascola, and some of whom had been with me for decades, knew exactly what I was going to say next.
“We are going to need a vaccine for whatever this new virus turns out to be.”
Barney Graham, a gentle giant of a man at six feet, five inches tall and one of the world’s foremost vaccinologists, vowed, “Tony, get me the viral genomic sequence, and we’ll get working on a vaccine in days!” His confidence was based on intellect and experience, not bravado. As skilled as he is as a scientist, he was known also for his modesty and mentorship of his students and trainees such as his brilliant young protégé Kizzmekia “Kizzy” Corbett. He was a key player in NIAID’s VRC.
Vaccines comprise a “platform” and an “immunogen.” The platform is the type of vaccine that delivers the immunogen to the body. The immunogen is derived from the pathogen that gets delivered to the body by the platform.
Barney had been leading a collaborative group of scientists for years within the VRC and in medical centers throughout the country. Their goal was to develop the optimal immunogens for vaccines to induce the most effective immune response against a given virus when injected into the body. The name “immunogen” comes from its function of being a generator (gen) of an immune response (immuno). Some immunogens continually change shape, making them inconsistent in their ability to induce an optimal immune response. An immunogen that continually changes is in the correct shape only part of the time. It needs to be set or fixed in the right shape to do its job. Barney and his team at the VRC, as well as two outside collaborators, Jason McLellan and Andrew Ward, figured out a way to accomplish this for some viruses by inducing certain mutations that stabilized the immunogens in the correct form. This was done for the MERS virus and, most important, for respiratory syncytial virus, or RSV, a virus that can cause serious disease and even death in infants and the elderly. The RSV vaccines currently available are derived from their work. The immunogen for the SARS-CoV-2 vaccine is the spike protein, which protrudes from the virus. Barney induced mutations in the spike protein that stabilized it in a form that made it an optimal immunogen.
The challenge for SARS-CoV-2 was to find the right “platform” or vehicle to deliver the stabilized spike protein to the body. Here is where the multiyear collaboration of the VRC with the Moderna company comes in. Barney and the VRC folks and others had been working with Moderna on a vaccine platform called mRNA. It is highly adaptable and can be ramped up quickly and modified as viruses evolve into new variants. This was a sea change from the slow and arduous classic way of influenza vaccine development that includes isolating the virus and growing it in fertilized eggs, with all the uncertainties that we had experienced over the years with influenza.
The mRNA platform technology was largely the result of research conducted over many years by Katalin Karikó and Drew Weissman, who won the Nobel Prize in 2023 for their groundbreaking research. I had been Drew’s mentor when he was a trainee in my NIAID lab from 1991 to 1997, and I am not at all surprised at that accomplishment.
Even though at this point there had never been a licensed vaccine using the mRNA technology and though there remained a lot of skepticism, my VRC colleagues and I were very optimistic about it. Compared with other vaccines, the mRNA process is faster and more precise. When cells in the body make proteins, they do so by sending coding messages (m) to the complex protein-producing apparatus of the cell. The instructions in that message come from RNA, which provides the cell with the information it needs to make the correct protein. With SARS-CoV-2, the part of the virus that binds to cells in the body, particularly the nasal passages and the lungs, is the spike protein. Barney Graham and John Mascola’s team, including Kizzy Corbett, merely needed to know the genomic sequence of the newly discovered SARS-CoV-2 virus to pick out the part that codes for the spike protein (the immunogen) and together with Moderna use it to make the correct mRNA. Then they would be off to the races. That is exactly what Barney meant when he made his bold claim.
Fortunately, we had to wait only a week. I received an excited phone call from Barney on Friday night, January 10, alerting me that two scientists, one from China and the other from Australia, had just uploaded the SARS-CoV-2 sequence to a public database. Barney immediately contacted a company that artificially produces or synthesizes strings of genetic code. He placed an order for the nucleotide sequence, and this lifesaving product was delivered in a small test tube packaged in a FedEx envelope. The modest charge was put on a credit card. But in a meeting in my conference room soon thereafter with John Mascola and some of my other senior staff, Barney brought up a sobering point. “Tony, if we really are going to go after this with a full-blown vaccine effort, including preclinical studies in animals and various phases of clinical trials, we’re going to need a lot of money and my budget is already tight.”
“Barney, don’t worry about that,” I instructed him. “Just let me worry about the money. I’ll move things around in the current NIAID budget for now. If this thing really explodes, I promise you, I will get us more money. You just go and make your vaccine.” As the group left the room, I asked John to stay for a moment. “John, I am not kidding. Pull out all the stops. I will get you what you need. If anyone can do this, your folks can.”
For the next several months, I bounced back and forth between the NIH and the White House, alternately sitting behind my well-worn government-issue desk at NIAID with a treetop view of suburban Maryland and perched in front of the Resolute Desk commanded by Donald Trump in the Oval Office. In early February, I was so consumed by my twin roles I had to cancel a long-planned trip with Christine to Florida to celebrate her birthday. We had been through a few epidemics together over the years; as usual she was understanding, but I still felt terrible about disappointing her.
On February 11, the World Health Organization officially designated the disease caused by the novel coronavirus as COVID-19 at the same time that the task force was working at full speed to deal with its impact. We spent several days talking about cruise ships, particularly the Diamond Princess, a British-flagged ship that had called at Hong Kong, Vietnam, and Taiwan and was currently docked in Yokohama, Japan. Our intense focus was what to do with the roughly four hundred mostly elderly Americans on board among a passenger manifest of several thousand.
Back at my NIAID home base, we were on target with the timeline of my primary mandate—developing a COVID vaccine. Production of vaccine and preclinical testing had started within days of the virus’s genetic sequence publication. In parallel with Moderna, Pfizer and BioNTech, a German company, were on a similar fast track, using Barney’s stabilized spike protein as their immunogen. The first steps toward a vaccine had been accomplished.
COVID was now spreading insidiously and relentlessly around the world. Unfortunately, in the midst of this, the country’s premier public health agency, the CDC, was still suffering from many of the same issues that had hampered it previously.
The reason was more than its geographic separation from HHS central in Washington, D.C. The CDC traditionally had something of a go-it-alone perspective, generally excluding input from outside sources. To be sure, the personnel at the CDC were a group of talented and deeply committed professionals. I respected them and many were friends.
The CDC’s weakness in handling COVID optimally from the start was rooted in its historical method of investigating diseases and illnesses: the syndromic approach. CDC officials traditionally track an outbreak by testing people with symptoms and then interviewing and testing those who have come into contact with the sick person. This is highly effective when, for example, there is an outbreak of a disease that is overwhelmingly spread by people with symptoms—think Ebola.
But the CDC’s syndromic approach was not adequately suited to dealing with COVID, a swiftly spreading disease in which, it would later turn out, more than a substantial portion of the transmissions come from people who are asymptomatic. The CDC was slow to recognize and act on that.
Another vulnerability was the way the CDC was set up to collect data, which in fairness to them was not entirely under their control. Rather than obtaining the data firsthand, the system depended on local public health departments around the country to provide the critically needed information. The result was that CDC figures were often either incomplete, because health departments did not universally provide all the data, or out of date, because the data were not always provided in a timely fashion, thus depicting only what had happened weeks earlier, not the day before. And as the disease kept spreading, what was actually happening was always far worse than what the CDC’s data were telling us at the time.
It seemed that U.S. public health officials were constantly playing catch-up. By the end of January, rather than relying on data from the CDC, we all started tracking SARS-CoV-2 through real-time statistics posted on a Johns Hopkins dashboard, which was plugged into the global information circuit. Countries such as the U.K., Israel, and South Africa were able to collect next-day numbers, providing their public health departments with accurate information.
While my NIAID group was focused on creating vaccines and working with pharmaceutical companies to develop treatments, testing had always been in the CDC’s portfolio. In the past, the CDC had established an outstanding track record for quickly creating tests for diseases like Zika. With COVID, however, the system failed. Instead of immediately partnering with the diagnostic industry, the CDC started from scratch with a test that turned out to be defective. Then the error was compounded by not immediately collaborating with outside private laboratories to make alternative tests. Instead, the CDC tried to fix the defect itself, and valuable time in getting adequate testing was lost during the month of February.
Also, there were regulatory constraints on how the test could be used. At first, the test could be used only on a “person under investigation.” This meant that the person had to have an epidemiological connection to a known case—in other words, known contact or exposure. But with an infection where you had no idea what the connection to a known case was, this approach was inherently contradictory. I called Brian Harrison, chief of staff to Alex Azar, to explain and, I hoped, resolve this dilemma, and he suggested that we both talk to Azar to get the FDA and the CDC together to loosen these constraints. It worked, but that did not solve the deeper and pervasive problem with the initial lack of widely available tests.
Because the only way to determine how many people were infected was through testing, other public health officials and I were advocating to flood the country with tests. Since they were hard to come by and in many places completely unavailable, we were flying blind. Meanwhile, other countries around the world were testing hundreds of thousands of their citizens on a regular basis.
While the CDC struggled with tests and tracking, there was no mistaking the message delivered on February 25 by Nancy Messonnier. A physician and an accomplished public health official who headed the CDC’s National Center for Immunization and Respiratory Diseases, she told reporters on a conference call that a pandemic in the United States was no longer a matter of if but when and that we should prepare to do things like close schools and work remotely. “Disruption to everyday life may be severe,” she announced. “But these are things that people need to start thinking about now.”
There is no doubt in my mind that Nancy, who was in the trenches at the CDC, did the right thing: she told Americans the truth. That is the ultimate obligation of public health officials. But not surprisingly, her statement caused a firestorm. The media erupted, the stock market plummeted by a thousand points, and President Trump was furious.
The next day, the president announced that Vice President Mike Pence would take over as the head of the White House coronavirus task force. Within days, Deborah Birx joined the team as White House COVID-19 response coordinator.
I had known Deb since she was a young army doctor working on HIV, and I had the highest respect for her. I met Mike Pence for the first time the day he ran his initial task force meeting. The soft-spoken vice president always solicited the medical opinions of the physicians on the task force: Deb Birx; Bob Redfield; the FDA commissioner, Stephen Hahn; Surgeon General Jerome Adams; and me. He listened carefully to our answers, often asking astute follow-up questions and never pretending to understand something if he did not. One day months later, while I was sitting outside his office waiting for a press briefing to start and chatting with his chief of staff, Marc Short, the vice president invited me in for a Coke. While I was in the office, I told him that this was a bit of déjà vu because I had often met with Vice President Cheney in that same office during the anthrax saga. “In fact, I have a photograph of Dick Cheney and me in these exact chairs,” I said. With that, in a combination of “not to be outdone” and genuine kindness, Vice President Pence called in his photographer who took a photo of us in a similar pose. A few weeks later I received a signed print with a gracious inscription.
While many things in this White House were the same as they had always been, I also picked up on little things that indicated how differently this administration operated. Vice presidents are always publicly loyal to the president. That is part of the job. But, in my opinion, Vice President Pence sometimes overdid it. During task force meetings, he often said some version of “There are a lot of smart people around here, but we all know that the smartest person in the building is upstairs.”
He was of course talking about the man sitting behind the Resolute Desk in the Oval Office.
Others joined Pence in heaping praise on Donald Trump. When the coronavirus task force held teleconferences with the governors, most of the Republicans started out by saying, “Tell the president what a great job he is doing.”
I have always felt compelled to tell it like it is without being offensive. So, a couple of days after Messonnier’s bombshell conference call when I got a surprise phone call from the president at 10:35 p.m., I did not flatter him. What I did do during our twenty-minute conversation about COVID-19 was to lay out the facts. I encouraged him not to underplay the seriousness of the situation. “That almost always comes back to bite you, Mr. President,” I said. “If you are totally honest about what is happening with COVID, the country will respect you for it.” He was courteous to me, and as we hung up, I felt satisfied that he had heard what I said.
The next day, however, he announced at a rally in Charleston, South Carolina, that COVID was the Democrats’ “new hoax.” This was the first, but not the last, whiplash effect that I would experience in dealing with this complex man.
When COVID hit Italy in February, I started calling up my Italian colleagues. “Tony, we’re getting overrun,” they told me. “We’ve never seen anything like this before. It’s absolutely terrible.” I had trained some of those physician-scientists, and I knew how smart and good they were at their jobs. I also knew that the Italian health-care system is first rate. If they were telling me that COVID was a disaster in Italy, then for sure it was going to be a disaster in the United States. We would have been kidding ourselves to think that we could handle it any better than the Italians.
Deb Birx officially arrived at the White House on March 2 and was installed in an office downstairs from the Oval Office. She immediately proved to be a force of nature, getting up at 4:00 a.m. to review the latest statistics. She began every task force meeting with an update on the current number of U.S. COVID cases. On her first day, there were eighty-nine cases in the United States and six deaths.
What began to worry me at this time was community spread, and I was particularly focused on Seattle. Community spread is when there are infections in the community that are not linked to other known infections or specific exposure. My longtime colleague and close friend Dr. Larry Corey, the leader of our HIV Vaccine Trials Network, called me from Seattle on March 3 and told me that 380 people with flu-like symptoms had been screened in four emergency rooms in the Seattle area. Out of this group, four tested positive for COVID, which translates into about a 1 percent infection rate within that group. Given that the number of people who had clinically obvious infection in the Seattle area was still extremely low, 1 percent of people with documented infection in this sample of 380 people could not all have been infected from one of the very few people with obvious COVID at that time. They must have been infected by someone unaware that they were infected. That is community spread, and the 1 percent was likely the tip of an iceberg.
When I brought this information to the task force meeting, both Vice President Pence and Secretary of the Treasury Steven Mnuchin did not seem to fully appreciate the seriousness of what I was saying. In fairness to them, this was not surprising, because 1 percent sounds insignificant to the untrained ear. But I tried to explain to them that this small number reflected the situation a few weeks earlier and the real number was now probably hundreds of infections.
By this time, I was almost constantly in the media talking about the impending crisis as we saw more and more cases throughout the world that, without question, were caused by community spread. In response to questions by the press, the president hinted or declared outright that the situation was under control at the same time that I was warning of the impending disaster. Without deliberately contradicting him, I kept the message going: things would be getting worse, and indeed they did.
In one Oval Office meeting I had mentioned to President Trump that we were hard at work at the VRC in the early stages of developing a COVID vaccine. This got his attention, and he asked that I show him around the VRC. I was eager for him to meet Barney and Kizzy. On March 3, the president flew up to the NIH on Marine One, and Alex Azar and I were supposed to be waiting there to greet him. A scheduling snafu had Trump arriving before us as we raced up Wisconsin Avenue to Bethesda in Alex’s car, leaving the president waiting in the holding room for several minutes. Yikes! A few more gray hairs appeared on my head imagining how upset he would be. His advance team was clearly unhappy, but Trump seemed fine. Barney and Kizzy described where we were with the vaccine. Barney told the president that within a couple of weeks, a phase 1 trial would likely begin to determine safety and to provide early indications of whether the vaccine induced an appropriate immune response.
After they made their presentation, the president asked them, “Why can’t we just use the flu vaccine for this virus?” Barney said, “Well,” and he picked up a 3D model of the spike protein of COVID and a 3D model of the influenza protein called hemagglutinin, and said, “Mr. President, antibodies recognize surfaces and shapes, and you can see that the shape of the influenza hemagglutinin and the COVID spike are entirely different. So, you can’t use one to immunize against the other.”
President Trump seemed satisfied, I thought. But it was not the first or the last time that he seemed to conflate COVID with influenza.
After the tour, the president invited Alex and me to return with him on Marine One to join him at a press conference. He took obvious delight in explaining to us the flight path from the NIH to the White House and how all air traffic to and from local airports was on hold until he landed. After landing on the South Lawn, the president asked me to explain to the press what we were doing at the NIH. He was in an upbeat mood, and all was good between us. I did not realize that not everyone in the White House shared his feeling about me.
On March 8, 2020, 60 Minutes broadcast a segment about COVID, its first of many. In the segment after the primary show, 60 Minutes Overtime, I told the interviewer in response to a question, “Right now in the United States people should not be walking around with masks.” I was not expressing solely a personal opinion; I was expressing the consensus at the time. Jerome Adams, the surgeon general, and the CDC both recommended that people not wear masks, and I was articulating that point of view. The supply of masks and other PPE was already low. If we told people to go out and buy masks such as N95 or KN95 masks, the fear was that there would be a stampede on the supply, and we would create an even greater shortage of masks needed by the health-care workers taking care of very ill COVID patients. Next, there was no clear evidence at the time that masks were effective outside the context of a health-care setting such as a hospital. Finally, although there was accumulating evidence that the virus was spread by aerosol and in large part by people without symptoms, this was not widely accepted, certainly not by the WHO.
I was not wearing a mask, nor was Christine.
Because I was the doctor whom viewers saw giving advice on 60 Minutes Overtime, I became the public health official who very early in the pandemic instructed them to not wear a mask. Later, my words were twisted by extreme elements in an attempt to show that I and other scientists had misled the public, that we could not be trusted, and that we were flip-floppers. But the controversy over masks illustrates a fundamental misunderstanding among some about science, particularly the biological or health sciences.
People associate science with absolutes that are immutable, when in fact science is a process that continually uncovers new information. As new information evolves, the process of science allows for self-correction. The biological or health sciences are different from the physical sciences and mathematics. With mathematics, two plus two equals four today, and two plus two will equal four a thousand years from now. Not so with the biological sciences, where what we know continues to evolve and uncertainty is common. This uncertainty is magnified in the context of a deadly pandemic when there is already anxiety and suffering. With COVID, our understanding of transmissibility, severity, vulnerability of different people, and level of protection, to name a few, continually evolved, and our medical advice had to change to reflect this.
This is exactly what happened in early March with the question of whether to wear masks and how effective they were.
Right from the start in virtually every interview and TV appearance when given the opportunity, I always added the caveat that things could change, and we must be prepared for that. When additional information became available over subsequent weeks, including that there was no longer a shortage of masks; that when properly fitted and worn, quality masks did work; and that the virus was readily spread by infected people who had no symptoms, we energetically advised the public to wear masks.
March 2020 was the month when COVID became frighteningly real to Americans. March was also when I started waking up with a jolt at 4:00 a.m. to stare at the ceiling with worry after worry going off in my head like a machine gun. Italy was locked down on March 9, and two nights later, during an Oval Office address, the president ordered that citizens from twenty-six European countries be temporarily banned from traveling to the United States. In the meantime, Deb Birx was working nonstop behind the scenes to figure out how to protect the United States even further. She formulated a layered plan of shutting down the country for at least fifteen days to see if we could “flatten the curve” of new COVID cases by limiting people’s exposure. The idea was to prevent hospitals from becoming overwhelmed. I strongly supported Deb as she carefully refined a set of guidelines before taking them to the vice president. If he was convinced the plan was solid, the next step would be for him to present it to the president. All went according to Deb’s well-thought-out process, and on March 16, President Trump committed to a measure that no U.S. president had ever done before, announcing a program that became known as “15 Days to Slow the Spread.”
I was impressed that, although he knew there were economic considerations, the president agreed to the plan. I think Donald Trump thought that COVID would be temporary: a little time goes by, the outbreak is over, everyone goes back to work, and the election cycle can begin. He could not have imagined that the pandemic would go on for such a long time. I believe this explains why he repeatedly asked Deb, Bob, and me whether COVID resembled the flu. He desperately wanted the pandemic to disappear just as flu does at the end of the flu season.
Tragically, COVID was not the flu, and it did not vanish. Just the opposite. And so, with the ghastly reality setting in that COVID was not going to go away, Trump began to grab for an elixir that would cure this disease. Along came hydroxychloroquine. President Trump began hearing from the Fox News star Laura Ingraham and others who were touting the drug as a treatment for COVID. Hydroxychloroquine is a long-established medication that people take to prevent or treat malaria. It is also used to treat inflammatory and autoimmune diseases such as lupus and rheumatoid arthritis. Perhaps this drug would be his magic bullet, the fast way out of COVID. Soon he began touting it at our now daily press briefings. Tuning in were millions of worried Americans, hoping to put the pandemic behind them and get on with their lives.
The fact was, however, there were no clinical studies proving that this antimalarial drug would help people. And it might hurt them. The president seemed unable to grasp that anecdotes of how hydroxychloroquine might have helped some people with COVID did not translate into solid medical advice. This is when I realized that sooner or later I would have to refute him publicly.
During the early months of 2020, after a three-year hiatus following the Obama administration, I had been glad to be back working in the White House, making a difference. Then, gradually, I recognized that even though a contingent of bright and dedicated public servants filled the offices of the West Wing and the Executive Office Building, this was not the White House I had known since the Reagan administration. And the differences were going to dramatically affect the way I could do my job.
The president’s overt hostility to much of the press, particularly many of the White House correspondents from a variety of outlets sitting in front of him in the Briefing Room during task force briefings, was one glaring example. At one briefing, when Peter Alexander of NBC asked what he would say to Americans frightened by the pandemic, President Trump responded, “I say that you’re a terrible reporter.” At another briefing, he called Jonathan Karl of ABC a “third-rate reporter.” I had known Jon for years and considered him a friend, along with Jim Acosta and Kaitlan Collins, both of CNN, whom the president often verbally attacked. But even when I did not know the journalists the president insulted, I was still taken aback by his behavior. I was also concerned that my very presence at the lectern or sitting against the wall of the press room would be interpreted as acceptance on my part of his behavior.
More problematic for me was that I knew some of the things Trump was saying about the pandemic were false, and I had to push back when asked not only there at the lectern but in follow-up interviews. “Hydroxychloroquine doesn’t work,” I told reporters. Inevitably, they would ask me if I agreed with something Trump had said such as “Yesterday, the president said that [COVID] would just disappear like magic.” I would then have to respond with the truth: “Well, that’s not going to happen.”
I have often been asked how I got the wherewithal to publicly contradict a president of the United States. My answer is that I harked back to my identity as a physician who has cared for thousands of patients over my long medical career. I take very seriously a statement in the first chapter of the twenty-first edition of Harrison’s Principles of Internal Medicine, of which I have been an editor for forty years. In one section we quote from the 1950 edition of the textbook: “The patient is no mere collection of symptoms, signs, disordered functions, damaged organs, and disturbed emotions. The patient is human, fearful, and hopeful, seeking relief, help, and reassurance.” Understanding this compels me to abide by the principles to always be honest; to be unafraid of saying that I do not know something; to never overpromise; to be comforting, yet realistic. When I spoke to the American public in the daily White House press conferences, I tried to act as if, metaphorically, the American public were my patient, and the principles that guided me through my medical career would have to apply.
I took no pleasure in contradicting the president of the United States. I have always had a great deal of respect for the Office of the President, and to publicly disagree with the president was unnerving at best and painful at worst. But it needed to be done. I realized I had a critical role to play, the person who showed up and told it like it was. And I not only had to tell the truth to the president; more important, I had to tell the truth to the American people; otherwise, I would compromise my own integrity and relinquish my responsibility to my patients—the American public.
At this point, with hydroxychloroquine and similar topics, I felt that I had opened the gate to go down a perilous road. But as long as reality was being distorted, I could not turn back. I leveled with the American public about the reality of the risk of COVID and calmly encouraged them to take care of themselves and minimize their risk. This feeling of responsibility toward the American public was the reason that I did not walk away from the coronavirus task force even though my closest confidants, Christine, Cliff, and Peter Staley of ACT UP fame, frequently asked me to at least consider stepping down. They feared that my association with this president, even if I objected to much of what he was saying, would taint my reputation. Much to my surprise, I became an instant hero to the millions of Americans who saw me as a physician bravely standing up for science, truth, and rational decision-making. They liked and felt reassured by this pushback against the president’s ungrounded assertions. This is when people began to make donuts with my face on them and to create bobbleheads, T-shirts, candles, socks, and such with my image. I was glowingly profiled in endless articles. I felt good about being a source of comfort to the general public, and one might think that all this adulation was appealing to me. After all, one of my favorite actors, Brad Pitt, played me on Saturday Night Live, and people signed petitions to have me named People magazine’s Sexiest Man Alive. But it was not appealing to me at all. As a serious seventy-nine-year-old physician and scientist who is very much a private person and who instinctively shuns attention, I felt profoundly uncomfortable.
There is a widely circulated photo of me from a White House press briefing on March 20, 2020. I put my hand to my forehead in response to a comment by the president. That day, President Trump was being especially flippant. He was standing at the podium with Secretary of State Mike Pompeo, making one provocative statement after another.
Then Trump said, “Secretary Pompeo is extremely busy, so if you have any questions for him right now could you do that because…I’d like him to go back to the State Department or, as they call it, the Deep State Department.”
I had a moment of despair mixed with amusement. I looked to my left at the first row of reporters, where Kaitlan Collins was sitting. When our eyes met, she gave me one of those “What the…?” looks. I put my hand to my forehead to hide my expression.
The problem, of course, was that while millions of Americans appreciated or admired me, a hard-core group saw me as a nay-saying bureaucrat who deliberately, even maliciously, was undermining President Trump. They loved and supported the president and regarded me as the enemy.
To them, my hand to my forehead moment proved it.
This is when things began to get difficult for my family and me. The HHS Office of Inspector General monitored the dark web, and in late March they started to see a considerable amount of hostility and threats directed toward me. As a result, I was assigned a security detail. For years, AIDS had made me a target, but that was largely before social media. Back then, I used to get one to two insulting letters a month, mostly homophobic rants, sent to my office at the NIH.
This was different. Now my family and I were barraged by emails, texts, and phone calls. I was outraged that Christine, and especially our daughters, were harassed with foul language and sexually explicit messages and threatened with violence and even death. I was consumed with anger and wanted to lash out at the people who were terrifying these innocent young women.
Aside from making me incensed that my family’s safety and well-being were being threatened, these direct expressions of hatred did not distract or frighten me. I did not have time for fear. I had a job to do. This goes back to my training as a physician in a busy New York City hospital. You learn to push through crises and fatigue, to not feel sorry for yourself. Doing your job was what mattered.
Physically, however, dealing with the pandemic was taking a toll. On any given day, I was doing two to ten TV and/or radio interviews depending on the topic or crisis with a wide range of interviewers, from CNN to Fox News to the networks and PBS and NPR. I was also a frequent guest on podcasts, Instagram chats, and Zoom calls, to try to reach a wider, often younger, audience. But most of my time was spent off-screen and behind the scenes on the phone, answering questions from governors and mayors—Republican and Democratic—and with local public health officials and individual clinicians across the country. One governor might update me on the status of the COVID outbreak in their state and talk about whether things were improving or getting worse. A hospital director might use the chance to ask for more specific resources from the Feds (us) such as ventilators or more PPE. I was also able to clarify for them, when needed, a new guideline from the CDC. It was a good way for me to get a direct sense of how the outbreak was affecting individual communities and people, and for local officials and health-care professionals to make their needs known.
Mornings often meant a conference call with the WHO that segued into my daily staff meeting with my NIAID team. I was constantly in touch with the NIAID efforts in the development of a COVID vaccine, and it was not unusual when I was on the phone on one call that two or three other calls would come in. I seemed to be constantly looking for an electrical outlet to recharge my cell phone. What I could not recharge was my voice. I was talking so much that my voice developed a raspy tone that got progressively worse, only to manifest itself as a vocal cord polyp that later would have to be removed surgically. And of course I was inundated with about a thousand emails a day, many of which even with screening by my staff required my immediate attention and a personal response.
I was getting four hours of sleep a night at most, and often less. I was not eating, nor keeping hydrated, and I was losing weight. I felt as if I were back in my medical residency days when we were on call every other night and weekend and did not leave the hospital until our patients were stable, and they were never completely stable. But that was when I was twenty-six years old, and here I was on the cusp of eighty. It took Christine to lay down the law. “You are going to bed at a decent hour, you are going to eat regular meals, and you are going to carry a water bottle,” she said in a way that left no room for argument.
Keeping me up on certain nights, but it was worth it, was my close friend and confidant Peter Staley, who often called at around 10:00 to check up on me, encourage me, and provide thoughtful suggestions about issues I was facing. Peter, who had lost none of his activist intensity over the years and whose intelligence and candor I admire, was someone who I knew always had my back.
There were three other people who I knew had my back: my daughters. Three different personalities that they are, they expressed their concern and support in different ways. Ali, aged twenty-eight, in her soft but firm manner, continually advised me to take care of myself, reminding me that this was a marathon and not a sprint. She would know as she is a devoted marathon runner. Megan, aged thirty-one, the worrier, was particularly cognizant of my age. When she visited from New Orleans, she was chronically afraid of getting infected and infecting me. Before tests were available, when she flew up to Washington, she locked herself in our basement for the full fourteen days of quarantine before she came upstairs to see me. I am a passionate lover of dogs, and my eldest daughter, Jenny, thirty-four, often connected with me through her dog, Lucca, whom I deeply loved. Jenny sometimes reached out to me with photos of Lucca attached to a text message or email that had Lucca saying, “I love you, Tony” or “You got this, Tony.”
During this heated period, one person at the White House continued to remain friendly to me, occasionally asking, “How are things, Anthony?”
President Trump.
I expected that he would have gotten really upset with me by this time, but he did not. I seemed to have a unique relationship with the president, at least for the time being. I attributed this to his perhaps feeling a camaraderie with me because we both grew up on the streets of New York, he in Queens, and I in Brooklyn. He might even have recognized a bit of his own New York swagger in me. Even though I was saying things he did not like, it seemed as if he did not want tension between us.
One thing that seemed to capture the president’s interest were the ratings of his press briefings. After one briefing in March, the president asked me to come into his side office adjacent to the Oval Office, a room with multiple TV screens on the wall, all tuned to different news outlets. He called the Fox News personality Sean Hannity. “Hey, Sean,” he said on speakerphone. “You should see the ratings we have!”
This was not a onetime occurrence. After another packed briefing in the White House Press Room, he left the podium with me and other members of the task force, and as we entered the anteroom, he looked up at the television screen and exclaimed, “Our ratings are amazing! We’ve got to keep doing this. We got better ratings than cable, better ratings than the networks!”
Despite his wishful thinking, two realities, both in our shared hometown of New York City, seemed to hit him hard. One involved a friend of his, Stanley Chera, a successful Brooklyn-born real estate developer who was hospitalized in late March. The president was telling a group of us gathered in the Oval Office about how he had been talking to Chera, asking him how he was doing. A few days later, President Trump called him again, and “I find he’s on a ventilator,” he told us. “Wow. This must really be serious.” Chera died of COVID a few weeks later.
The other reality was in the images coming out of New York City in the fourth week of March. These also appeared to shake the president. By this time, it was the epicenter of COVID in the United States, and videos capturing long lines outside hospitals, the sound of endless ambulance sirens, and emergency rooms with patients on ventilators terrified the nation. There were refrigerator trucks parked outside Elmhurst Hospital, not far from the neighborhood where Donald Trump grew up. Health-care workers were storing the bodies of COVID victims in them because there were too many to fit in the hospital mortuary. More than 1,900 had now died of COVID in the United States, including 728 in New York City. It seemed at that moment President Trump really got it.
It was during these dark days that Deb, I, and the task force recommended to the president that the nation needed him to extend the fifteen-day shutdown for an additional thirty days. Deb worked out the details of the extension.
To his credit, despite a great deal of skepticism on the part of his economic advisers, the president was still listening and acted on our recommendation.
But soon, everything would change.