In new book, Birx describes how data failures, bureaucracy and politics hindered Covid-19 response

Still, as political messages drove out public health messages, Birx wrote, she and some of the doctors in the Covid-19 response formed a pact: If any were fired, Redfield, National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci and US Food and Drug Administration Commissioner Dr. Stephen Hahn agreed they would all resign in protest.

“I was neither hoping to be fired nor willing to resign independent of the others being let go,” she wrote.

“I didn’t believe my departure would change anything for the better. Accusing the Trump administration of negligence wasn’t going to suddenly produce a different response to the pandemic from them.”

The optics of firing her would be bad, she wrote.

After Birx told CNN’s Dana Bash in August 2020 that the virus was “extraordinarily widespread,” Birx wrote, Trump called her and demanded the name of the person who booked the interview, saying “That’s it! Do you understand me? Never again! The virus is under control.”

Although they were making progress, she wrote, “The president was wrong. We didn’t have the virus under control.”

Aside from a “dysfunctional” White House, the United States struggled to keep pace with the fast-moving virus, Birx wrote. Fixing the problems uncovered by the Covid-19 pandemic may help save the country from the next, she says.

Address inadequate data collection and analysis

“Data is everything in a pandemic,” Birx writes in the book. “Data shows your gaps; it shows where communities have an effective response; it lays bare the truth, where things are deteriorating and where they are better. It allows you to stay laser-focused and develop evidence-based policies. Without comprehensive data, you won’t have a comprehensive response.”

Before joining the Covid-19 response, Birx wrote, she thought US health officials were seeing data that she couldn’t access. But once she arrived in March 2020, it became clear to Birx — who had previously worked on the President’s Emergency Plan for AIDS Relief — that the country was “dangerously behind the eight ball” on data collection on the emerging coronavirus.

Birx described a meeting in March at which the task force received a single double-sided page of data that “summarized case data and deaths by state.”

In 2020, she wrote, data in some states was often being sent by fax and then passed along to the CDC.

“How was this really happening? How in the world could we not have clear data at this point?” she wondered.

All the US had, she said, was “a static, partial thirty-thousand-foot awareness. I pressed the flats of my hands into my eyes and shook my head. I had expected something very different, but now I could see not only that the data-reporting structures that had taken years to build in Africa weren’t present in the United States, but that we had days to get the same job done here.”

Understand that a new virus may behave differently

Birx wrote that even before she signed on to the White House team, she suspected that asymptomatic spread was contributing to the quick rise in Covid-19, although the evidence was slim.

“After years of experience seeing asymptomatic, presymptomatic, and mildly symptomatic cases being ignored in tabulations, anytime I read a number indicating a confirmed case, I multiply that by a factor of between three and ten,” she said.

Early on at least, the focus was on those with symptoms, much like in the case of the flu.

But the virus that causes Covid-19 is very different.

That became clear when cases surged in New York City, a dramatic rise that “couldn’t be explained by symptomatic spread alone.”

“If there’d been any doubt before about the extent to which asymptomatic spread was a significant contributor to the rise in case numbers, the New York City numbers convinced the team that my estimate of at least 30-50 percent asymptomatic spread was likely accurate and possibly even conservative,” Birx wrote. “Even though the testing issues prevented us from having the quantity and type of data we needed, a preponderance of numerical evidence, the picture was crystal clear.

“For those of us in that tiny room, doubt had been replaced by a communal sense of dread,” she said of the task force.

Develop tests early

Contributing to the lack of clear, granular data on Covid-19 and the misunderstanding of silent spread was a significant need for testing in the United States. The CDC’s early test was flawed, putting the country weeks behind on testing, Birx wrote. Even then, public health labs weren’t equipped to move fast and handle the volume the Covid-19 response would need.

Writing about a meeting with American Covid-19 testing manufacturers early in her tenure, Birx said that learning that the White House had dragged its feet on meeting with manufacturers, on top of limited tests and slow test processing, represented a “worst-case scenario.”

“In later conversations, I asked one of the manufacturers critical to the production of high-throughput and point-of-care tests if anyone in the administration or from the CDC had called them in January and February 2020,” she wrote.

“Their reply was that, in fact, it had been the other way around: the manufacturers were the ones calling the CDC to understand what it was doing and how they could help. The manufacturers were held at arm’s length” by the CDC, the Department of Health and Human Services and its Office of the Assistant Secretary for Preparedness and Response. “They were told their assistance wasn’t needed,” Birx wrote.

Later on, Trump’s rhetoric on testing shifted — he suggested that the United States had high case numbers because it tested so many people — but Birx said the task force was working rapidly to expand it, spending billions on tests and supplies and implementing serial testing in nursing homes and universities.

“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,” she wrote.

Push for solutions before there’s a problem

Birx’s book concludes with a list of “critical issues” to address in the US around pandemic response and preparedness. It includes clarity on how responsibilities are divided between agencies, ramped-up testing and diagnosis, improvements to CDC data collection and “overarching” improvements for public health coordination.

Some of those changes are still needed to manage the current pandemic.

“One of the most important takeaways here is to not wait until the surge or the holidays are upon us,” she wrote. “We have learned that there are lulls in the outbreaks. During these interludes, we needed to expand testing access. We should have used that time to prepare for the next surge by getting as many Americans as possible to buy into making critical behavioral changes needed to protect their vulnerable family members.”

Looking ahead, Birx wrote that the solutions can’t be pushed into place only when there’s an emergency.

“We don’t need one set of standards and processes for improving public health of the country and another for pandemic preparedness — they need to be integrated and utilized between pandemics to improve the health of the nation,” she wrote.

“We need to stop just observing the problem and begin addressing the problem.”