Opinion | Faust Files: A Talk With Deborah Birx, MD, on Fighting White House Misinfo

In the second part of 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 her experience in that position and 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: Let’s talk about therapeutics for a minute.

Birx: Yes.

Faust: So [nirmatrelvir-ritonavir] Paxlovid is really interesting. I was super-skeptical when I first kind of read the studies, and I have to acknowledge that that skepticism was always good to have, but in the unvaccinated high-risk patients, the EPIC-HR study, which is the blockbuster study, you really see this absolutely remarkable effect.

And now, I’m getting texts from my friends in their 20, 30s, and 40s who have no need for Paxlovid and they want Paxlovid — I think that we’re becoming sort of Paxlovid over-reliant.

Birx: Well, that’s how we’re going to get resistance. And so we need to right now be working on next-generation vaccines and next-generation therapeutics, because we’ve been through this with other viruses and, you know, if you have widespread use of it or inconsistent use — I mean, what really worries me is about the rebound. Because clearly 5 days may not be enough for a significant number of patients. That dose may not be enough to get complete suppression of the virus. Then you’re having viral replication in the face of inadequate dosing, and that’s how you get resistance.

So I worry every day that we really need to work on it. And I think the corollary to your 20- and 30-somethings wanting Paxlovid is the lack of ability to get it into the rural counties for the people who need it the most.

Faust: And we’ve already seen this in MMWR this week, I know there’s datasets. Who’s gonna get it? The same folks who got the monoclonals.

Birx: Exactly.

Faust: The wealthy, the young, and the privileged. That’s not where we want to use this. I also worry that it’s sort of like, “Oh, we have Paxlovid? Great, we can let it rip.”

Birx: Yeah. That’s — I call it “pandemic response through polling.” Every time we seem to get close to an election, everybody is like, “Now the theme is: it’s all good. Don’t worry. It’s all good.”

It’s all good if you live in New York City, it is not all good if you live in rural Mississippi. And our responsibility is to make it all good for everybody.

Faust: One place in the book that — I was like waiting for the moment, but it didn’t come and it’s pretty comprehensive — but you did not really go into anything on convalescent plasma and the FDA’s, in my view, incorrect decision to make that available. And I wonder if you would talk about that a little bit.

I will just lay it out on my hand, I think that it’s possible that overusing convalescent plasma, especially in the immunocompromised, can be a breeding ground for variants like Omicron. And it’s likely that Omicron came out of someone who was overtreated.

Birx: I think Omicron comes out of huge populations that are experiencing re-infection and there’s partial immune pressure. I think, you know, there’s a reason for that. We know that exists. We knew all of these things at the start, and that’s what’s upsetting to me. We know how viruses work. We know surges are predictable. We know when they’re predictable in what parts of the country. We know exactly that if a virus is here and goes there, it’s coming to the United States. All of these things are predictable.

I think the convalescent plasma piece is not so simple. And because it’s not so simple, I think with the right — if those groups had titered, if they had selected the right patients, which were in the first 5 days, I think it would’ve [been better].

Faust: Now we see that.

Birx: Yes. It’s just common sense.

But I think that’s why I spend time in the book saying we need a different way to do clinical trials. It can’t just be in the large research institutions. We needed more sites, we needed a CRO [contract research organization] that can work across the United States, and if we had brought therapeutics in a clinical trial to these rural communities and had a community advisory board, people would have stayed up to date with the science and knowledge.

That’s what transformed HIV, is the dialogue between the community that was impacted and those of us who were doing clinical research. And that dialogue is critical to understand people’s circumstances and how to best use therapeutics.

So I feel like we have a roadmap to success, but we’re still not using it. And it’s solvable! If we move from, you know, 30 to 50 premier institutions in the United States to 500, and really ensure that NIH is putting 20% of all of their dollars into clinical trials in rural America, it would change this. Because then rural America would’ve known the study for hydroxychloroquine, they would’ve known the study for plasma, they would’ve known the study for ivermectin.

Now I can tell you, as of Christmas, there were still physicians prescribing ivermectin because they couldn’t get Paxlovid. So all of these things are connected, and we can’t treat them in isolation. We have to fix the core problem, and the core problem is healthcare delivery in both urban areas that are underserved and rural areas and tribal nations.

Faust: Yeah. And I think you spend a lot of time in the book talking about that work, and you were on the road at a time when it was dangerous to be on the road. I think people don’t know that about you.

Birx: It was, because it was not only dangerous for me, it was dangerous for my family. So every time I came back, I had to essentially quarantine and mask indoors because I knew I was constantly exposed.

Faust: So there’s good science, and there are good people, and then there are people that you have trouble with. Your account of Scott Atlas’s influence sort of rang true. It mapped out to what I would’ve imagined. And in a way, your experience is almost a realization of that philosophical hypothetical: what would you do? Would you stay and fight, or would you leave and protest? And if you’re going to stay and fight, how are you going to fight, not just for today, but for the long haul?

But you ran into a foe, certainly with the economic advisors, but really with Scott Atlas. Tell us about that, and tell us about what you did to stop him from doing what he wanted to do.

Birx: You know, it was good to have him come out of the shadows, because I couldn’t figure out where all this counterfactual information was coming from. Clearly it was coming into the White House from March on. I think they were responsible for the Easter thing, and certainly that team — you can see the impact he can have — that team went to Florida and convinced Governor DeSantis that they had achieved herd immunity. I got a call 2 days after that meeting from their health officials saying, “This is what they were told.”

Now, if you’re a governor — I mean, are we expecting them to know all of these nuances of immunology and virology? You have a respected group coming in and telling you you’ve achieved herd immunity and no more people are going to get seriously ill. You want to be the first one that opens completely and does everything. So, what happened in Florida could have happened in the United States across every state.

The teams that really helped me — the communications individuals, Intergovernmental Affairs, who helped me with all the meetings on the road, the communication team that blocked his access to the media — all of these people were working in concert to blunt his influence.

And when I came back and found that he had rewritten the CDC guidance — I couldn’t stop it, because I said in the task force that I can’t support this, so it can’t go out as a White House-endorsed product, but it could go out as a CDC-endorsed product. I mean, I can’t change what CDC is going to put up.

But after, I saw the impact of that guidance nearly overnight. So I called Bob and I said, “We’re just going to rewrite it…”

Faust: Bob Redfield, head of the CDC.

Birx: “…We’re just going to rewrite it and we’re going to post it. You get your people to post it. We’re going to rewrite it.”

Now, I got a very angry call from Mark Meadows, but Mark Meadows had every right to take it down and put the Scott Atlas version back up and he didn’t.

So this is the problem. When people say, “Well, why didn’t you just leave?” I knew behind the scenes what I was blocking and what I was able to do in a positive way. You don’t leave in that. Plus, I came out of the military. That would be like me saying, “I don’t agree with my general. So I’m gonna go on TV one time and let all of my teammates die.” You don’t do that. You work within and you make a change.

Faust: Hindsight is 20/20. Where’s a place where you decided that now is not the time to push, but maybe you wish you had?

Birx: Early on. I had so many balls in the air. I just feel like I should have demanded a meeting with everybody from the FDA testing group and just said, “All right, we’re not leaving this room until everybody agrees on the data. And we come out of this with a plan.” Instead, I wrote new guidance and they would change it and I would edit it back. That was not efficient.

I think I should have been more aggressive in convening outside of the task force, because there were things — from CDC masking guidance, to the whole therapeutic issue, to the issues with the testing — that we got maybe 50% or 60% there, but we needed to be at 90%. I feel like I was pretty aggressive, but I think I could have been more aggressive.

Faust: Your successor, Ashish Jha, what advice would you give him? Or maybe not Ashish, because the atmosphere is not nearly as hostile for science. But for a future administration that’s similar to the Trump administration, what would you give your successor advice on, and on knowing what to do to make the most impact without making it so you get to do it once and then it’s a news cycle and then it’s over?

Birx: And then you can’t do anything. I mean, let’s be very clear: there was no one else in the White House. If I had deserted my post, it would’ve opened it up completely to Scott Atlas being me.

I think that was the plan. I think that’s why articles were leaked to the New York Times and other places in the late spring and summer saying that I was the one saying the pandemic was fine. I clearly was not, but there was someone who was, and that was Scott. So, I think there was a plan to undermine me to the point that I would leave.

But, I think you could see it from the January 6th committee, there were people all through the government, including some of the individuals appointed by President Trump, who understood that you had to stay and fight every day. That was your role. You had to do that.

I think my suggestion to anybody else in the White House is to find a team that you trust. And I think being able to give information to Tony [Fauci] and have Tony be the person that could get out on national news, working with Bob and [Surgeon General] Jerome [Adams] and [FDA Commissioner] Steve [Hahn] to get out to the states because they also went out to the states with me, really establishing that esprit de corps with a team that has your back but also that has really most importantly America’s back. I think that worked.

Faust: You bring up Tony Fauci, and it is interesting, it’s been discussed a lot, that he sort of got this folk hero feeling about him among the public health community and people who really support doing everything we can about COVID. At the same time, he also gets a little bit of special attention from the Rand Pauls of the world.

How do you feel about that? You don’t walk around with the halo that Tony has, and yet also you, as far as I know, haven’t been the recipient of nearly as much …

Birx: Oh God, yes — as much as, if not more. Documented death threats, hate mail, sexual innuendo text.

I just don’t — maybe it makes a difference when you work overseas and you work on HIV and you work in collaboration with the LGBT community in Sub-Saharan Africa and many places where it’s criminalized, you get a lot of death threats and you get a lot of messages underneath your door in the middle of the night. I may not take it quite as seriously.

I mean, there was one instance when the HHS security team called me and said that Tony and I were both on the same list and it was serious. But you can’t let that — people were dying of COVID! So, I just stayed focused on the mission.

Faust: Yeah. I think it’s so interesting. I haven’t read any books that Tony’s written about this yet, but you know, there’s this sense that Tony somehow threaded this needle where he could stay in and fight and also speak out, and people …

Birx: No, he wasn’t inside. He didn’t have to fight — that would’ve been a waste of his time to have him doing what I was doing. I was doing what I was doing and he was doing what he was doing very well.

Faust: And I think that’s the disconnect. I think people don’t realize that you were the coronavirus task force coordinator, you were at the center of this, and I think maybe that’s what people don’t realize, as opposed to an advisor.

Birx: Yeah. I wasn’t a senior advisor in the White House. I made it very clear. I kept my PEPFAR [President’s Emergency Plan for AIDS Relief] hat, so I was dual-hatted the whole time I was detailed into the White House. I never took a special advisor position like Scott or like Jared Kushner.

I have enough respect for Tony that I really saw his skill sets and strengths, and I made sure that he had everything he needed to be successful. That was my job as a coordinator. Everything Bob needed, everything Steve needed, everything FEMA needed, everything Operation Warp Speed needed, to be successful. And then to work in deep partnerships with the states and communities, because that was the other thing that I understood.

So, I think everybody was working towards and for their strengths, and as coordinator, that’s what you’re supposed to do. You don’t try to duplicate what someone else is doing.

I think when people have a minute to step back when all of the emails are released, when people see the depth and breadth of my work in the White House, I think people will have a different vision. But someone had to go inside. Tony and Bob and Steve from probably June on were just calling into task force. I mean, someone had to be at the table, and someone had to be there every day when some of the more strange things would happen so that you could beat those back.