I began writing these comments while on vacation in Wrightsville Beach, North Carolina, and the torpitude of vacation delayed completion for a week. On November 1, I noted that the COVID-19 hospitalization count was still stagnant at 183 for the week of October 25, but test positivity was rising steeply, and case numbers were trending upwards. The ensuing week, hospitalization increased to 218. Colorado appears to be on the verge of a climb in its COVID-19 epidemic curve. The mix of variants is increasingly enriched in Colorado by BA.4.6 and BF.7, which are displacing BA.5. In vitro assessment of immune escape using neutralization antibody titers shows greater immune escape for BA.4.6 versus other omicron subvariants.  As always, new variants are lurking. 

Respiratory syncytial virus (RSV), a seasonal and epidemic respiratory virus, has surged over the last month, figuring prominently in media reports that push the possibility of a tripledemic—SARS-CoV-2, influenza, and RSV. This virus is particularly dangerous for infants and young children because of its propensity to affect the small airways of the lung. Since October 1, there have been 367 RSV hospitalizations in the five Metro counties monitored with a very steep rise over the month. RSV has long been a perennial challenge and one of the viral infections without an effective vaccine. Influenza A has also arrived, but since October 2, there have been only 49 hospitalizations. 

The American Public Health Association (APHA) annual meeting began on November 6 in Boston, and I am at the meeting today (November 7). I was asked by Alfredo Morabia, a friend and editor of the American Journal of Public Health, to participate in a panel discussion on “Modernizing CDC”. The panel includes Michael Fraser from the Association of State and Territorial Health Officials (ASTHO), Julie Gerberding, former CDC director and now with the Foundation for the National Institutes of Health, and me. In anticipation, I had started reading Silent Invasion: The Untold Story of the Trump Administration, Covid-19, and Preventing the Next Pandemic Before It’s Too Late. The title speaks to the author’s ambitions for the book and also explains its length—almost 500 pages.  

The author, Deborah Birx, was the White House Coronavirus Response Coordinator during the Trump Administration. Most will remember her from the press conferences of the Taskforce and most memorably, her demeanor when President Trump proposed that light could somehow be used within the body for killing SARS-CoV-2. Birx brought a strong background in medicine and public health to her role in the White House. She had most recently directed the President’s Emergency Plan for AIDS Relief (PEPFAR). The book begins as she makes the decision to accept the invitation to join the White House team and ends in January 2021. An epilogue offers further reflections, and an appendix lays out issues to be addressed along with her solutions.  

Silent Invasion will jog the memory on key events during the chaotic response to the COVID-19 pandemic. It adds the author’s insider insights through many vignettes. Birx provides readers a view through her personal window, for example into the jockeying among the various players and factions for the attention of the Vice President and President. In a chapter entitled “Scott Atlas Shrugs” she describes the efforts by Atlas to advance his non-evidence-based approaches and her determination to counter Atlas. Recall that Atlas is a radiologist who was added to the Coronavirus Task Force after being noticed by President Trump during appearances of Fox News. Per Birx, she played a key role in marginalizing him. For those wanting Atlas’s side of the story, you might read his book: A Plague Upon Our House: My Fight at the Trump White House to Stop COVID from Destroying America. The Atlas book will not be on my bedside table.  

Much of the message of Silent Invasion can be summarized as “could have” and “should have”. Birx enumerates many of the failings of the initial response to the pandemic and allocates blame to many without pinning responsibility on Trump alone. She highlights the failings of the CDC’s data systems, the initial testing debacle, and the agency's waffling and unclear guidance to the public. The book details the challenges of her interactions with President Trump and the impossibility of swaying him with evidence. Informal “doctors’ meetings” (Birx, Fauci, Hahn, and Redfield) provided a sounding board and maintained a scientific grounding for the taskforce.  

Over the months of the Trump Administration’s response to the pandemic, I often wondered if key players, like Birx, might leave the administration in protest over its chaotic and often politically-motivated strategies. Birx addresses that question, arguing that she could better benefit public health by staying in the administration than by taking a stand on some matter and leaving. Perhaps true. Once marginalized within the White House, Birx took to the road to communicate directly with governors, state and local public health agencies, and tribal nations. I credit her for this effort. Drawing on her travels, she usefully documents the disconnect between what is planned and implemented at the national level and what may be needed and relevant at the local level.  

Other Trump administration players in the COVID-19 response have written books, including former FDA Commissioner Scott Gottlieb’s Uncontrolled Spread: Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic. I have previously mentioned Nightmare Scenario: Inside the Trump Administration's Response to the Pandemic That Changed History, a comprehensive look at the last administration’s failures. There will likely be more accounts.

Turning back to the CDC, the recently released report by staff of the Select Subcommittee on the Coronavirus Crisis provides chilling documentation of the scope of political interference with activities of the CDC. The meddling must have contributed to some of the perceived inadequacies of the CDC’s response. The APHA session is entitled “Modernizing CDC,” but more than modernization is needed to assure that the agency fulfills its mission, free of political interference. CDC has launched a plan for change; it is needed.  

A sad note: Lew Kuller, long-time chair of the Department of Epidemiology at the University of Pittsburgh, died last week at the age of 88. Lew was an unstoppable force and a pioneer of cardiovascular epidemiology. He was continually generating ideas and posing provocative questions. In conversation with Jill Norris, who knew him from her training at the University of Pittsburgh School of Public Health, I noted that I always enjoyed my conversations with him, even if I did not have the opportunity to say anything.  

Jonathan Samet, MD, MS
Dean, Colorado School of Public Health