By the time I arrived at the end of July 2020, the administration had already developed a massive testing capacity from scratch. Nearly a million tests per day were being conducted. The effort was led by Admiral Giroir, who was assigned the thankless task of overseeing that project.
I understood why the VP was so excited when he had displayed that simplistic chart on my first visit. And over the next weeks the administration continued to successfully facilitate and distribute tens of millions of point-of-care PCR tests and, later, rapid antigen tests. This was a significant accomplishment, but it was clear from the beginning that the White House did not understand how or when to use testing. To my thinking, it was a response to political pressure more than anything else.
From my very first meeting in the Oval Office back in July and again over subsequent meetings, President Trump expressed great frustration about testing. It was easy to see why. You could not turn on the news, even the most superficial talk show, without the lead story admonishing the administration for “the lack of testing.” For months, the country had been inundated with that message—not just from public health types who had now become household names, but from every pundit, talk show host, and news anchor. It became pure groupthink. Celebrities who had no understanding or expertise at all were now stridently opining about the unquestionable urgency of massive, widespread, on-demand testing.
Reminiscent of stock market frenzies, esoteric technical terms that had formerly been unknown to the public like “contact tracing” now became common parlance. Testing for this virus had turned into a national, indeed, international obsession. And to me, that obsession was not just misguided, it was harmful, creating more fear, more frenzy, more irrational policies. Yes, testing was an essential tool in the pandemic. And yes, months before I was involved in any way in Washington, there had been a failure to develop and deliver enough tests when they were needed the most. But by the time I came to DC at the end of July, a massive capacity to test had been quickly developed. The problem now was that it was not being leveraged to save lives. Schools and businesses were closed; people were cowering in their homes. Meanwhile, older people kept dying by the thousands.
Criticizing the administration about testing was more than a natural extension of that obsessive mindset. It was low-hanging fruit for the president’s political opponents. There had been almost no preexisting testing capacity from the outset, so naturally it would take some time to meet the challenge. The obsessive demand for testing rapidly escalated into a hyperpartisan issue. I remembered Pelosi’s mantra—“test, test, test; trace, trace, trace!”—as if she, or any politician for that matter, had any understanding of the appropriate testing policy. She was not alone, though. That mantra was echoed on every news network, regardless of political leaning. No dissenting opinion was even visible to most Americans.
That political heat provoked the expected reaction in the White House. Long before my arrival, testing became Priority Number One. Beyond an important public health policy question, it was an election season, and a contentious one at that. This environment elevated testing into the priority of the president’s closest counselors, his political advisors at the highest levels, and operationally, therefore, the vice president’s Task Force. Presumably, like all politicians, the president was politically motivated, too.
The conflict, the misjudgment about issues like testing and other advice coming out of the Task Force, occurred when the president was swayed too much by his political advisors instead of believing in his own common sense. That advice matched the message of the Task Force, especially that coming from Redfield and Birx, whose decision-making background was tied almost exclusively to testing. That was one of the many problems stemming from the HIV backgrounds of Birx and Redfield. SARS2 had already spread to millions, and it spread by breathing in close proximity; the role and practical application of testing in a virus like HIV couldn’t have been more different. In the end, it was easy to see how the advice to the president was to focus on testing.
Understandable for everyone, that is, except the president. He never agreed, because to him it made no sense. He couldn’t understand why we would test people who were not sick. It was as simple as that. President Trump talked to me privately in the Oval Office about many different things, but almost always, our discussions came back to the subject of testing. The president spoke very bluntly and resorted to common sense rather than any data. He knew nothing specific about the medical rationale for testing. He went with his gut feeling and placed no filter on stating his opinions.
“Why are we testing healthy, younger people? Why don’t we just test sick people?” he would ask.
“And if we test more, we find more cases. But those people aren’t sick!” he would point out, exasperated, echoing what he said many times to the press.
And that seemed rather straightforward, on its face. His point was simple logic—test and you shall discover “cases,” especially with COVID, since a large number, maybe half or more, of infections were asymptomatic. He was also correct that in clinical medicine, the definition of a “case”—a patient—is not generally based on a test seeking out something in a healthy, asymptomatic person.
That is not how medicine is practiced, a point I tried to explain time and again to the Task Force troika of doctors. I had that perspective, because I am a doctor who has been an expert for decades on the significance of diagnostic tests showing abnormalities without symptoms. And wasn’t it also important to consider that the overwhelming majority of people did not have a serious illness, even when symptomatic? As for mildly ill patients with COVID, “standard of care” for them was strict isolation, with or without testing.
Testing, though, was the way—the only way—to find infected people who had no symptoms. In high-risk settings, contagious people with asymptomatic infections would be critical to find, no doubt. But the goal, the rationale for testing, became a key point of confusion and disagreement. We needed to protect high-risk people, absolutely. The question was how. We knew who was at risk, so there were two alternatives: 1) indirectly protecting the “vulnerable” by confining and locking down everyone else, or 2) doing everything to protect high-risk people directly.
By the time I set foot in the White House, the nation, with few exceptions, had already been using the Birx-Fauci lockdown restrictions—the indirect strategy—for months. Why was there no admission that the lockdown strategy did not work? It undeniably failed to protect the elderly. Nursing home deaths were piling up, comprising up to 80 percent of total deaths in some states—and in the meantime the lockdown policy was destroying everyone and everything else. Einstein may or may not have said it, but everyone knew it: “The definition of insanity is doing the same thing over and over and expecting different results.”
Yet the strategy was to continue doubling down on the failed lockdowns that were devastating to so many, especially those outside the “elite.” Reality was being denied, and that remains the case today. Regardless, the answer to the failure, the available tool for those all-in on stopping all cases, was more testing!
Unbeknownst to the White House, several top epidemiologists and infectious disease experts had opined that massive testing of healthy people in settings that were not high-risk was not appropriate at this stage of a pandemic. That was apparent to me from months of lengthy discussions with leading epidemiologists at Stanford and elsewhere. There were already tens of millions of Americans who had been infected; even the CDC estimated a tenfold larger number compared to the confirmed number, as verified by early studies on SARS2 antibodies.
Contact tracing was also “futile” at this point, as Dr. Bhattacharya later wrote in a paper I distributed at a Task Force meeting. Contact tracing was a tool for newly emerging pandemics, new outbreaks perhaps. Oxford’s Sunetra Gupta, a world-renowned epidemiologist, repeatedly stressed the lack of logic in mass testing at this stage and the irrationality of focusing on cases by positive tests. Moreover, PCR tests were detecting virus fragments or dead virus in people who were not even contagious. Yet no one in the Task Force would even entertain this discussion.
The question about the role of testing was fundamental. It wasn’t simply surveillance for the purpose of knowledge—testing was the key to a strategic policy. It was not enough to consider testing through the limited prism of an epidemiologist, the way Birx and Fauci did (even though they, like me, are not epidemiologists). In medical practice, if you referred a patient with low back pain to a neurosurgeon, the most likely outcome was surgery. That’s exactly why I always referred patients to neurologists first—they had more perspective. Some might think of the adage “to someone with a hammer, everything looks like a nail.” Testing was the main tool in the epidemiology toolbox, their only tool, really. That was very limiting in defining its role in overall policymaking.
At this juncture, the testing was not being done to yield statistically valid surveillance information—a legitimate use of testing in the midst of a pandemic. This was diagnostic testing, with broad-reaching policy aims. In this pandemic, a positive test was a major driver of the policy of quarantining and isolating healthy people with low-risk profiles—shuttering businesses, closing schools— in short, a key to locking down the country. That’s why health policy experts like myself with a broader scope of expertise than that of epidemiologists and basic scientists are needed. Because no one with a medical science background who also considered the impacts of the policies was advising the White House. That lack of perspective was the main source of the tunnel-vision focus on preventing the spread of infections to the exclusion of all other considerations.
It was baffling to me, an incomprehensible error of whoever assembled the Task Force, that there were zero public health policy experts and no experts with medical knowledge who also analyzed economic, social, and other broad public health impacts other than the infection itself. Shockingly, the broad public health perspective was never part of the discussion among the Task Force health advisors other than when I brought it up. Even more bizarre was that no one seemed to notice.
The president clearly understood that testing healthy people for a disease that did not make them sick made little sense and would only lead to confining them. I agreed with that common sense view, although with important exceptions, and sitting in the Oval Office I explained the absurd extension of the logic of “test, test, test.” What was the “necessary” number, anyway? One million per day? Not even close. One hundred million per day? Nope. How about everyone in the country—330 million per day, every day.
Even if you could accomplish that goal, the tests themselves were only a snapshot in time. Seconds later, any given person could become infected. So 330 million per day, every fifteen minutes—maybe that would satisfy the testing mania! No matter how many tests were performed, there would never be enough.
The need for increased testing, but in a smarter, more targeted way, still needed to be explained to the president. And I did just that, repeatedly, whenever I had a chance—in concise, short doses. As always, he listened intently. But he had no time or patience for a detailed presentation. That is one reason why we got along well. I was capable of speaking succinctly, articulating the bottom line. More importantly, he knew I spoke directly, no BS.
From day one, I always reminded myself—if, and whenever, the president of the United States asks for my opinion, I am going to give it.
No holds barred—otherwise, what was I there for? Even on my very first visit to the Oval Office, when he complained about wide-spread testing, I bluntly told him, “You are a hamster on a wheel,” knowing that others in the room would probably recoil at hearing that. But President Trump knew it, even repeating the phrase later himself.
There was, I explained, a more nuanced approach to the policy of testing. There were serious reasons to test, important reasons to actually increase testing, but in a strategic way. The question was how to leverage that testing capability to have the most impact—to save the most lives and to facilitate reopening the country, which was the right goal from both a health perspective and the president’s stated policy.
I thought my approach was obvious. This was simple logic, and it reiterated exactly what I had written months before: let’s focus testing on where it really mattered, and increase it. High-risk environments, where high-risk people lived and worked. Nursing homes, a tinderbox of risk for its elderly, frail residents, were an obvious target. Knowing that cases were brought in by the staff, they needed to be tested, and tested far more frequently, perhaps every day. I also pushed for more point-of-care tests in places independent-living seniors frequented, like senior centers; visiting nurses taking care of seniors at home; and historically Black colleges and universities (HBCUs), where high-risk faculty members were more concentrated.
While the president understood and fully supported this, he remained frustrated, as did I, because his most trusted advisors didn’t fully sign on to a strategic approach to testing. At one point he offhandedly remarked, “You’ll have to convince my son-in-law of that.” Naturally, Kushner and everyone else had been deferring to Fauci and Birx on all things medical. To make matters worse, the Fauci-Birx testing strategy was not merely unfocused; their strategy bizarrely prioritized more testing in the lowest-risk people and the lowest-risk environments—students and schools—while letting the deaths continue in nursing homes and assisted living facilities, where a once-per-week schedule was assumed to be effective.
Politics seemed to be the main driver of those in the inner circle advising the president—that was their job. But the politics were irrelevant to me. The frenzy about testing everyone, everywhere, at all times, including low-risk people in low-risk settings, was incorrect, illogical, and harmful.
The funny thing was that while almost everyone assumed the president was only making excuses, somehow covering up for an “inadequate” testing capacity, there were valid reasons to use testing very differently in order to maximize its benefits. Despite the clamor of the “experts” in the public sphere, and almost the entire media narrative pushing the opposite view, the president happened to be correct. Instead of massively testing everyone on demand, testing should be leveraged to do what everything should have been geared toward in the first place—protecting the high-risk, saving lives, and opening society up as soon as possible.
What was most remarkable to me from the inside was that even though the president expressed his points about testing very clearly, and many top epidemiology experts agreed, the COVID Huddles and other strategic operations were run in a different world. The messaging, the public events, the operational strategy, and the communications team pushed ahead with a focus on producing and delivering more testing to low-risk environments, schools, and communities. Reminiscent of Catch-22, when 150 million antigen tests became available weeks later, I was asked by several people in the COVID Huddle, “Well, now that we have these tests, what do we do with them?”