Opinion | Faust Files: A Talk with Deborah Birx, MD, on the Early COVID Response

In this exclusive video, Jeremy Faust, MD, editor-in-chief of MedPage Today, and Deborah Birx, MD, former White House Coronavirus Response Coordinator, have a candid discussion about Birx’s new book, Silent Invasion: The Untold Story of the Trump Administration, Covid-19, and Preventing the Next Pandemic Before It’s Too Late, which details the American pandemic response from within the White House.

The following is a transcript of their remarks:

Faust: Hello, I’m Jeremy Faust, editor-in-chief of MedPage Today and the author of the “Inside Medicine” newsletter on Bulletin.com. I’m joined today by Dr. Deborah Birx. Thank you for joining us, Dr. Birx.

Birx: Happy to be here.

Faust: Thank you. Dr. Birx was — well, before she became a household name, Dr. Birx ran the CDC’s Division of Global HIV and AIDS and she oversaw PEPFAR, which is the President’s Emergency Plan for AIDS Relief, which is one of the most successful public health interventions that our government has been a part of in recent decades, I would say. And then, of course, everything changed in 2020 when she became the first White House Coronavirus Response Task Force Coordinator.

Her new book, Silent Invasion, is a detailed account of what it was like on the inside, and it is fascinating. I just finished reading it. It is bold. You pull no punches. Thank you for writing it, and thank you for being here.

Birx: Thank you. Obviously, I’ve written a lot of scientific articles and a lot of chapters, but that was my first attempt to translate science into a book format.

Faust: So let’s talk about this book, Silent Invasion. I think I’m the intended recipient of this book in the sense of who I vaguely thought you were and who you are. Tell us about that gulf. What do people think of you and what do I successfully know now that I’ve read it?

Birx: Well if you asked anyone around the globe in HIV, they would tell you who I am: hard driving, data driven, will do anything to ensure people’s lives are saved.

I knew when I was working on HIV that my patient was never the Ministry of Health; my patient was the community at risk for disease. So that’s how I went into the White House. Yes, it was where I was working, but my loyalty was to the communities and the Americans that were at risk for COVID.

Faust: But you strike me in the book as just a complete data wonk.

Birx: Yes, total data wonk.

Faust: And that’s pretty much why you were brought in, is that right?

Birx: I think so. I think two things: one, I had actually battled a pandemic, and successfully — I mean, we have really made incredible strides on HIV and HIV/TB in Sub-Saharan Africa and around the globe.

But secondly, we did that through data. Making everybody visible that needed our help, not just the people we could see, but the people we couldn’t see, and that’s what data allows you to do.

But data is irrelevant if all it does is create an article. Data has to lead to action. Data has to be transparent.

So anytime we would change policy or guidelines or ask the Ministries of Health to change policy or guidelines, we all agreed on the data and the reason that we needed that policy change. I think in this country, we need to make data accessible to every American so they can analyze it themselves.

Faust: Yeah. I mean, this is what I write about in my newsletter, and it’s sort of my little shtick too. I was like, “Oh, okay. She was me in the White House.” That’s what it kind of felt like.

And in fact, there’s this moment in the book where you talk about how you’re on Google using Google Translate to read the Diamond Princess [cruise ship] statistics. I did the exact same thing. I wonder if we could find out, you know, how you can see page views, like how many people translated the Diamond Princess pages from Japanese to English. Well, at least two.

Tell me about those moments and when you started to realize the extent of asymptomatic transmission of this disease.

Birx: I felt like it had to be happening in January, because you don’t build a 1,000-bed hospital in a matter of days, or a 10,000-bed hospital, if you don’t have unbelievable community spread. Because we don’t have any viral diseases that only cause severe illness in one tiny group. Other people have to become infected and not be seen.

But I couldn’t prove it. I think the Diamond Princess, for those like yourself who really took the time to really look at what happened in the Diamond Princess, you knew it had to be the crew. So to me, it was very clear, but not to everybody.

Faust: And also the transmission dynamics are so bizarre.

Birx: Exactly.

Faust: Because you have a spouse living in a cabin and not getting it from their spouse. Yet at the same time, as you mentioned in MMWR — the CDC’s journal on morbidity and mortality — in the report, we see this thing where one person in a choir gave it to dozens of people.

So it’s just a very strange pathogen, right? It exploits our assumptions that we’re gonna hunker down when we get sick, and this virus says, “No, I’m gonna spread right before that happens.”

Birx: “And I’m gonna spread it with young people who don’t know they’re infected.”

I just want to always, always make this clear, as with HIV or any infectious disease, people are not intentionally spreading it. They truly don’t know. And it’s our job as those of us in medicine and science and technology and healthcare to make sure that they have the tools to utilize that successfully to protect themselves and their family.

Faust: So when you talk about kind of realizing the extent of asymptomatic transmission …

Birx: I love that you were doing the Diamond Princess translation too. I just love that.

Faust: Yeah. I mean, it was very frustrating because they wouldn’t update it often enough. And I took home two messages. One was that this is a very contagious pathogen. Two is that this is very, very dangerous for my parents’ generation. And I thought it may be fine for everyone else. It took until later datasets to realize that we’d had excess mortality in young people, which — we just didn’t have a big enough N at that point.

But you talk about in the book, I love this, you said there are somewhere between three and 10 times, if given the tip of the iceberg at the beginning of an outbreak, if there’s a hundred cases, there’s probably 300 or there’s probably a thousand.

So this is the first time we ever heard about an R-naught for this virus. That’s the reproductive number. This is the number of people that the average person who gets infected subsequently infects. That’s called an R.

The first number we were given was 2.58, which was a very alarming number, and then it was upgraded. But actually, when you take into account asymptomatic transmission, it’s far higher. And I was part of a team that actually thought it was much higher.

What do you think the R was? Then I’ll tell you what we thought it was.

Birx: I thought it was between 4 and 5. When I tried to paint that picture in the book — because I had this group of people that I’m so grateful that came and worked with me because I didn’t know what was gonna happen to their careers. I was older in my career, so even though I knew it was going to be terminal for my career, I didn’t want that to happen to other people. But they understood how much I valued data and they understood I would need a team.

So three or four people showed up, and we argued about that and the degree of asymptomatic spread, because those two are so critically linked. So, I thought asymptomatic spread was well into the 50%-60% range — by age group, it could vary up to 85% — and we were able to get that data from colleges when they started testing regularly. But that’s what was driving the doubling and tripling of the R-naught for me.

Faust: I’ll tell you a funny story. So, I was the middle author on a paper and we thought it was more likely in the teens. This was sent to a journal and they sent it back and they said, “Well, that’s impossible because it would have to be an airborne virus.” And that was the end of that.

Birx: Yes! What’s upsetting to me is you and I looking at the Diamond Princess data are like, “This is an aerosol. This is highly contagious. This is being spread asymptomatically. This is going to be a huge problem.” And other people are saying it’s on surfaces, that it’s droplets, not realizing that that is just incomplete, partial RNA fragments.

That results in everybody wiping down their groceries rather than understanding aerosolized spread, which means it stays in the air for a number of hours. I always say to people, it doesn’t matter who’s in that room when you get there. It matters who’s in that room before.

Faust: Turnover, right? And this is the thing, I’m not a domain expert on aerosols, but recognizing that — there were a lot of people who were very territorial saying, “Oh, it’s not airborne.” And I said, “Well, look, I don’t know. All I know is that it’s airborne enough.”

Birx: The data said it was airborne.

Faust: It was moving through the air, and I didn’t want to get into whether it was extended droplets or this or that.

Talking about asymptomatic transmission, and you do talk about testing, and we all know the documentation of how we didn’t do testing right. We have a lot of agreement on the use of rapid antigen tests and the idea that these are tests that might miss an early infection, they certainly will miss a late infection, but they should get you right when you’re contagious, which is really the way you stop things. When did you first understand that?

Birx: Very early. So when we had that first meeting on March 4th with the companies — and these were companies I knew from HIV and I knew their capacity to produce tests — and we asked for PCR tests, antigen tests, and antibody tests because I knew we had to get into the community and it had to be simple and fast because we needed the 20- and 30- and 40-somethings being willing to test.

They were not going to go sit in a drive-through for 4 hours and wait 5 days to get an answer. That wasn’t going to happen, but people would come by quickly to do an antigen test. And they would’ve come back daily if we had asked them to. People were very responsive and really responsible. I never saw in all of my trips people being intentionally irresponsible.

Faust: The rapid story is a little bit murky, but it seems like the FDA didn’t really approve or authorize many. Is that fair to say?

Birx: So here’s the circular reasoning — and you would understand this completely. So, all of the original tests were done on a set of specimens that were collected from people who were symptomatic, because we didn’t have enough tests to test for people without symptoms. So they wouldn’t approve it for asymptomatic use, and that was its value!

And so, because they wouldn’t approve it for asymptomatic use, even though I showed them that the viral load in the nasal cavities were identical between the asymptomatic and the symptomatic, they wouldn’t approve it for that.

And that resulted then in the CDC sending out guidance that it was provisional. Well, no one’s gonna test twice! And we didn’t have the resources to have everybody who was antigen positive go back and get another PCR.

So it just really hampered us, and they didn’t approve antigen tests for asymptomatic testing until the summer of 2021.

Faust: Right. Do you think these tests are still misunderstood?

Birx: Totally!

Faust: A lot of my colleagues, some really smart people, say that it gives people a sense of false security and therefore they go and they infect people.

Birx: Absolutely not. If you explain it correctly and you say to them, “These tests are for that moment in time. You may be negative tomorrow or you may be positive. And so if you’re seeing your grandmother 3 days in a row, you’re gonna have to test 3 days in a row.”

I think we’ve gone through 500 or 600 antigen tests. I mean, we definitively use testing. Even my daughter’s children’s preschool tests weekly. I’m so proud of that because it makes a huge difference.

The colleges that tested weekly had less than 1% to 2% community spread. The colleges that tested only those with symptoms infected 20% to 30% of their population. It’s very clear. You have to find the pre-symptomatics and the asymptomatics.

Faust: Yeah. I think that’s a huge thing that people don’t understand — it’s actionable information.

I had a colleague, a friend, call me a few months ago when there was a concern that maybe they [rapid tests] don’t work for Omicron. And they said, “We had a family reunion” — and this is a really smart person — “and everyone tested before they came. And a couple of days later, everyone got sick.” And I just said, “Well, wait a second. Let’s look at the number of cases there are. The test was good on Wednesday, but by the time you had your little thing on Friday, that was old news.”

Birx: So whenever I walk into an occasion, which I’m sure is a downer, whether it’s a wedding or otherwise, I say, “There are at least two or three people infected in here. So let’s all be respectful and take care. And unless you tested the second before you walked in in the car, I can’t tell that you are negative, and that’s why I’m masking.”

Faust: I asked the audience here today in my session: what would you rather do? Be in a room full of boosted people in the past several months but have not tested, or in a room full of anti-vaxxers who all had a rapid antigen test that was negative a few hours ago. They looked very puzzled, and I’ve asked this question many times to many people, but it’s not close. You want to be with the people who have negative tests regardless of their status.

Birx: Exactly.

Faust: Yeah. But our minds just don’t work that way.

Birx: Well, I think it’s because, and I hold us responsible as public health practitioners and people who have reported on this, and I really appreciate your reporting because you’ve really tried to make it very clear about what we know and what we don’t know.

When we make broad statements, when we say to people that these vaccines are going to protect against infection — one, it wasn’t studied; two, we already knew re-infections were rampant with natural immunity. So the vaccines that were designed to mimic natural immunity are going to have re-infections. We imply that masks only work in one direction.

And you know, Americans have amazing common sense, so when they hear that, they stop trusting the message. I think we are just as guilty for creating that sense that they don’t trust us. We’ve waffled on tests and we haven’t made them clear, we’ve waffled on masking, we’ve not been clear on vaccines, and then we wonder why people are confused.

Faust: Yeah, I agree. And I think we should be humble about what we know at all times. Which is not really our best — we’re not so great at that.

Birx: Well, I think if you had lived through the AIDS pandemic, you would be very good at it because when you’ve lived through that humbling “I don’t know and I can’t fix it,” that makes you very clear on “This is what I know, this is what I don’t know.” And then we have to work in between.

Faust: It’s funny how lived experience matters. Another part of your book that actually really struck home for me was where you talked about the experience at Elmhurst Hospital in Queens, [New York,] which really probably saved millions of lives.

I trained there as an emergency resident at Mount Sinai and Elmhurst. So for me, when I started hearing stories from my colleagues at Elmhurst and hearing the sounds of their voices, I knew that this was real in a way that I hadn’t really understood. And as you say in the book, this landed for Trump, didn’t it?

Birx: Totally. I don’t think I would’ve been able to convince him of the 30 days and the reopening criteria if he hadn’t had the Elmhurst experience combined with his friend being hospitalized and then succumbing to COVID. I think that was so real and personal, and somehow we have to figure out as practitioners how we can make it real and personal without people having to have that kind of level of intimate experience.

I think that’s what we can learn from media training. That’s what we could learn from big marketers, because we have to figure out how to make our messages real for everyone.

Faust: I mean, that’s like the Ryan White approach with HIV, right? Or Tom Hanks doing Philadelphia? That’s really what that’s about.

Birx: Exactly. And I think showing people that that is the experience, and you don’t have to live it.

Faust: Yeah. Megan Ranney and I wrote a piece about this in April or May, and we said, “Look, by the time that everyone statistically knows one person who has died of this virus, there will be a million deaths.” And we don’t want to wait for that.

Birx: We don’t. And we did.