Opinion | Faust Files: A Talk With Deborah Birx, MD, on the Americans Left Behind

In the third 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:

Birx: What matters to me, and the reason I took the effort to write the book, is you have to understand what was good about the Trump response, which was really this deep partnership with the private sector. And without that, not nearly as many lives would’ve been saved. I mean that from the data standpoint of all the hospitals sending me their data, I mean that from the testing side, the therapeutic side, and of course the vaccine side.

That kind of deep partnership — the private sector should be at the table for all pandemic response and preparedness. I think that is new. I think they don’t participate normally in those pandemic responses. And I think that was critical. There wasn’t ever a private sector individual who told me no.

Faust: This is my next question, and you already answered half of it, which is: tell me something good that the Trump administration did, and tell me something bad they did. I think you just did that.

Birx: Number one bad was communication. Because when you have nothing, when you don’t have any tools and what you have to do is communicate behavioral change and the justifications for those behaviors all over the map, that’s a problem. I tried to be very clear, but that is a huge failure of the president.

I do believe that even today, though, that we’re not communicating all of the information in clear ways to the American people. So one, they [Biden and Trump] are not equal in any way. Don’t let me leave you with the fact that I think they’re equal. People should have learned, though, that this is bad and we have to do this better, and it’s not better enough the way we’re doing it yet.

Faust: Yeah. Then, let’s talk about the Biden response. Give me something they’ve done really well. Maybe something that surprised you that they’ve done well, where they exceeded your expectations. And then somewhere where they really needed to improve.

Birx: I’m not surprised that they did a great job with vaccines, because the CDC had a good plan with all of the states. And remember, it is the states. I mean, the federal government is buying and distributing to main distribution sites and the state is really the on-the-ground experience.

I still think we are staying at this level and saying things from a microphone when you should be understanding what the structural barriers are. If we had figured that out with the vaccines, we would know how to do Paxlovid now. So we’re still not engaged at the level of implementation to ensure that our tools have the impact we should have.

Faust: You mentioned that you thought they did well at the vaccine level. One of the talking points that we’ll hear from Trump former officials is, “Oh, no, that was us. They just inherited what we set up.” Who should get the credit for the fact that we did actually have a pretty good rollout?

Birx: You know what I think, and this is — if I was disappointed in anything that the Biden administration did within the first month is, I have seen spectacular programs, but they’re spectacular when both sides work together and build on each other’s success. And I think it was a mistake not to say on January 21st or January 22nd that we’re able to distribute vaccines because of Operation Warp Speed and what happened.

Faust: That’s right.

Birx: When the people talk about how they’re going to be bipartisan and they can’t do that … that would’ve changed, I think, everything in that moment. I think we would’ve had much more vaccination in some of our rural areas. Although I don’t believe it’s anti-vaccine; I believe it’s hesitancy and structural issues that we still haven’t addressed.

I mean, I’m so proud of PEPFAR, the President’s Emergency Plan for AIDS Relief, because President Bush started it. President Obama ensured that it kept going. President Trump, although he kept cutting our budget, Congress kept putting it back. So Congress is key. Bipartisan Congress was key. And then President Biden is key.

So if you want to do things big, right now pandemics today, even battling this current one could take multiple Congresses and administrations. The more we keep saying, “I did this and you did nothing.” It’s not good.

Faust: And I remember when PEPFAR really got funded in the Bush administration, there was a sense of, oh, this can’t be real. Why would George W. Bush want to do this? Is it real? And then everyone was like, “Yeah, this is real money.”

Birx: It’s real money. And it was not only real money. It was real money that expected immediate results and expected continuous program improvement.

What has been disappointing to me is I don’t see continuous program improvement across all of America. I think in certain areas in certain underserved communities they’ve done a good job dealing with vaccine hesitancy, but because they didn’t do a good job in some of the rural areas, it’s going to be a problem with the summer surge that is going to be here very shortly.

I tried to get the information out there early so people could prepare, to give them 8 weeks to figure out how to get testing into every household, and proactive testing and Paxlovid, and we did nothing except send it to pharmacies.

Faust: Yeah. I did argue vehemently with the White House about getting those rapids out, and actually I wonder …

Birx: And we know where to send them! Stop asking for people to do it online. People over 70 are not real fast on their computer. We learned that from the vaccine, where millennials had to step in and fix it.

Right now they could send 10 tests to every single person over 65 — they have their addresses — with instructions on how to use it, how to test during a surge, and the governors would work with them on this in local communities. Go into the churches and say, “I need everybody over 65 testing at a minimum weekly. It would be better if you could do twice a week, so I’d like them to have 20 tests.” And with a hotline number to telemedicine that says, “The minute you’re positive, call this line. We’ll figure out how to get you Paxlovid. It will either be in your pharmacy as a prescription, or it will be sent to your house.”

That is program implementation — “Test to Treat” is a slogan.

Faust: Did you think that the Biden administration kind of was asleep at the wheel? Was afraid to respond to Omicron and say, “Hey, let’s actually do what we achieved in early 2020, which is to flatten the curve.”

People look back at 2020 and think, what was that for? They don’t realize it was so Elmhurst wouldn’t happen again. And it didn’t. But then Omicron comes and my team develops a circuit breaker dashboard, and we’re saying, “Look, the whole country’s going to be full on hospital beds.” Lo and behold, it happened.

Do you think the Biden administration should have said, “Look, can we just please decrease the size and frequency of social gatherings for a while?” Why wouldn’t they say that?

Birx: I think that it built off the fact that in the spring and summer of 2021, they painted vaccines as the miracle.

They stopped testing. Testing fell to its all-time low level; that’s why the south was so blindsided by the Delta surge. Testing was 300,000 PCRs a day; we were up to 1.5 million a day. They really put all of their eggs in the vaccine basket, and that left us vulnerable as a country.

Faust: All right. Let’s finish up by talking a little bit about the future. In the very last pages of your book, you argue for something that I’ve been waiting for someone to say for so long — I’ve actually written a perspective that got rejected from journals saying this, so thank you for saying it with authority — that all these respiratory pathogens that we normally just shrug off, rhinovirus or the seasonal coronavirus, that they all need to be what we call reportable …

Birx: Reportable, definitively diagnosed. It doesn’t have to be reportable outside of the EMRs, but CMS cannot pay for any diagnosis in an infectious disease that is not definitively diagnosed.

Faust: Which we can do.

Birx: We could have done it 20 years ago! I’m doing it in Sub-Saharan Africa right now for HIV, TB, and malaria. It doesn’t matter where you live in Africa, at the longest end of a road, you can get tested with a definitive test.

Faust: So how are we going to get this done?

Birx: Congress. And that’s why that whole last section is 11 pages to Congress. And that’s why yesterday I did the committee briefing. Hopefully you’ll pull down the written testimony, because I go through this again.

Data, laboratory definitive diagnosis, know your baselines because deviation is the way to find new pathogens. The deviation from normal. You see something and it’s not any of those identifiable illnesses, you know something because you’re definitively diagnosing all the other ones and this one doesn’t show up. It will help us to see if any of the tests escape COVID sensitivity, we’ll see again as a deviation.

This is how you control pandemics — not setting up random surveillance sites. Use the system that the United States has in its full capacity. It can be done tomorrow. CMS could put out a rule that says, if you want to code for flu, you actually have to diagnose flu.

Faust: Actually, I meant to ask about this and now you bring it back so I have a chance to sneak it in. We really haven’t incentivized any government to tell the truth. China didn’t get rewarded for doing anything — well, they did a lot wrong. South Africa is a better example. They told us about Omicron. What did we do? We punished them with a travel ban.

I’ve been thinking, we have clandestine operatives all over the world. Instead of spying on scientists, just send us waste water. Why don’t we just collect stuff from around the world and survey it?

Birx: They are doing that stuff. And I just am so proud of South Africa because they sequence and they test. I’m so proud of the U.K. because they sequence and they test.

Here we are in America and we’re not doing either of those to the scale and the ability that we could, and it’s costing American lives.

Faust: So Ashish Jha, who is your successor now, is fighting for money every time he …

Birx: Stop fighting for money. Start using the money we have now effectively.

Faust: Do you think there’s enough money in the package that he has?

Birx: To do the kind of program he should be doing? There’s enough money right now to effectively do it. Prove that you can change the outcome. Prove that you can have the impact with those dollars.

I think you could do it tomorrow across the south. It’s doable. It’s doable with the funding we have. And once you show Congress that you can change it for every American, not just the low-hanging fruit which we’ve been able to do, not just for the rich and the capable that can walk to their pharmacy or have their Mercedes drive them there and get Paxlovid, for every American. Show your numbers and your outcomes and your impact, and Congress will give you the money.

Faust: I think that I’d love to have a follow-up where we get the Deborah Birx pie chart of how to spend these dollars.

Birx: I had to do it every quarter in the PEPFAR program — $6 billion. I only had $6 billion, and I had to reach more Africans than he has to reach in America by a significant number.

Faust: And I’ve told him — we occasionally talk — don’t waste federal dollars getting Paxlovid to me. It’s not worth it.

Birx: But it’s happening. And it’s happening in urban areas. So if you are 20-something, you can get Paxlovid. If you’re 65 with COPD [chronic obstructive pulmonary disease] in rural Mississippi, you can’t.

Faust: What do the next few months look like?

Birx: I’m very worried. I mean, I’m very worried about the south, mostly because the same mentality is happening again.

Remember we had that little Alpha surge last year? That little swell? It was in the Northeast and upper Midwest. It ended quickly just like this current BA.1/BA.2, and everybody goes, “Oh, we’re good.” The media says hospitalizations are stable. Yes. They’re going down in one part of the country, but they’re going up in another part of the country, and we’re not doing anything to help the Southern United States.

It’s looking identical to what it did in the summer of 2020 and the summer of 2021. We’ve got BA.4/BA.5 — highly contagious — and we haven’t prepared the south or our rural communities to get a different outcome and we’re two and a half years in. That’s on the current administration.

Faust: Last question: What’s the next big thing for you? What are you working on and what do you really want to achieve in the next few years?

Birx: I am passionate about ensuring that America looks as good as what I created in Sub-Saharan Africa, and right now it doesn’t.

Faust: Wow. That’s actually a really humbling thing to hear, right? That actually we can do it, but we’ve only done it for others. With collaboration with others.

Birx: With partnerships.

Faust: And it’s sort of like, well, we have to do the same thing with the south.

Birx: Yeah. And with our tribal nations.

Faust: Okay. Well, thank you. Anything else? Have I missed anything you want to get out there?

Birx: No, this was great. Thank you. And thank you for staying on this. Everything is not well in America.

Faust: I agree. I had Francis Collins here just 24 hours ago, and he’s a fairly optimistic guy, but even Dr. Collins says that there are some things that really weigh him down.

I know I said last question, but I lied: 10 years from now in the next pandemic, do we do better, worse, or the same?

Birx: If we fix this one right now in real time, we will have the systems — the health systems, the data systems — to ensure that we’re ready for the next pandemic.

Faust: Okay. I hope you’re right. Dr. Deborah Birx, thank you so much for joining us with MedPage Today and Inside Medicine. Thanks for your work and your great book, Silent Invasion.

Watch Part 1 and Part 2 of the conversation.