The book’s subtitle is overly long, and so is the book. We learn over and over her view, which she seemed to have expressed almost daily at White House meetings, that the key to reining in the pandemic was social distancing, testing, masking, limiting the size of indoor gatherings, and—occasionally—lockdowns.
Unfortunately, given the book’s length, she doesn’t give strong evidence for her views. And at times she reveals herself to have a strange view of “proof.” Also, the evidence against the efficacy of masks—evidence that surfaced well before she finished her book—would cause one to hope that she would address this matter. (See “How Effective Are Cloth Face Masks?” Winter 2021–2022.) But she does not; her support for masking is as strong as it was in 2020.
There are other examples of sloppy thinking. Although Birx claims that she carefully looked at the COVID numbers virtually daily, she fails at times to make important distinctions such as the difference between the infection fatality rate and the case fatality rate. She doesn’t address the famous Great Barrington Declaration (GBD), which advocated focusing government attention on high-risk populations while leaving much of the rest of society to function unrestrained, though at one point in the book she seems to endorse that idea.
After reading the book, I give Birx credit on three policy issues: First, she is fairly critical of how the Centers for Disease Control substantially slowed the development of COVID tests and gives the private sector kudos for how quickly it reacted. Second, she shows a real understanding of how the absence of property rights for tribal nations badly hurts the people who live there. Third, although she—like me—favors people receiving the COVID vaccines, she wisely points out that they are not a silver bullet for ending the pandemic.
Questionable choice / One question Birx addresses early in the book is how she got such an important job. She wasn’t an obvious choice to head the U.S. COVID response; when she received the offer, she was in Africa as the U.S. Global AIDS coordinator for the President’s Emergency Plan for AIDS Relief. There’s not a close connection between AIDS and how it spreads and SARS-CoV‑2 (the technical name for the coronavirus) and how it spreads. A key factor in her getting the job was her friendship with Matt Pottinger, a former journalist and Marine who was the deputy national security adviser. In her telling, Pottinger seemed to be very high on Birx’s abilities. But she doesn’t tell the reader what expertise Pottinger had that would have enabled him to make a good choice for such an important position.
And there are reasons to question her judgment on scientific and policy matters. Start with her concept of “proof.” In comparing her and her assistant, Tyler Ann McGuffee, not getting infected in the White House with all the White House people who did get infected, she notes that McGuffee and she consistently used masks, while many of the infected did not. She writes triumphantly: “Mitigation works. Tyler Ann and I are uninfected proof of that truth.” Is their experience evidence that mitigation works? Yes. But is it proof? Not even close.
She makes a similar claim later in the book, writing, “I’m walking proof of the efficacy of masks and other precautions.” After I got vaccinated, I used masks as little as I was allowed to. So, if one person’s experience is enough to constitute proof, then I could just as easily say that I, David Henderson, “am walking proof that masks aren’t necessary,” at least once one is vaccinated. Birx and I would both be wrong; we are simply two test subjects in a large experiment.
Birx vs. Atlas / One non-surprise in the book is Birx’s contempt for her fellow Trump COVID adviser, Dr. Scott Atlas, a colleague of mine at the Hoover Institution. The chapter in which she discusses her conflicts with Atlas in front of then-president Donald Trump is cleverly titled “Scott Atlas Shrugs.” (Disclosure: in the months since Regulation published my review of Atlas’s book on his experiences in the Trump administration, he and I have become friends. See “Atlas’s Case Against the COVID Lockdowns,” Spring 2022.) Birx lists several claims that he made in front of the president. From my understanding of Atlas’s views, I can believe that he did say much of what she claims he said.
According to her, for example, he argued that children didn’t get ill from the virus, that there was no risk to anyone young, and that masks were overrated and not needed. I don’t know if he used nuance at all. If I had been in his position, I would have said that COVID was about as risky to children as the seasonal flu. But the point is that they were at little risk. Certainly, the data back that up. According to the CDC, as of August 19, 2022, after two-and-a-half years of the pandemic in the United States, 1,224 American residents ages 0–17 had died of COVID. That’s about 500 deaths per year. Each death is a personal tragedy, but as a societal matter COVID poses a very low risk to children. For comparison, consider that in 2017–2018, 526 Americans in the same age range died of the flu. Each of those deaths is also a personal tragedy, but no one has described them as a societal problem.
Birx claims that on each of her listed claims, she “refuted” Atlas. She uses that word—as many people now do—to mean that she disputed his views, not that she disproved them. She’s an equal opportunity misuser of the word: in that same chapter, she claims that earlier Atlas had been “refuting her daily reports.”
What she doesn’t say with much detail is how she “refuted” (that is, argued against) his claims. But in one part of the chapter, she does give one nugget. Although she doesn’t specify the particular Atlas claim that she was arguing against, she writes, “We knew the majority of hospitalizations and deaths were from the community, not just nursing homes.” That’s absolutely the case, but it’s not clear what she thinks that shows. Atlas and his Stanford colleague Jay Bhattacharya (who is both an economist and an epidemiologist) were arguing for focusing protection on those most vulnerable. Among those people were residents of nursing homes. She doesn’t disagree with that. Given that the nursing home population in the United States is about 1.5 million and the U.S. population exceeds 330 million, no one would have been surprised about her statement that the majority of deaths and hospitalizations were of people not from nursing homes. But, though the overall number of COVID deaths may have come from the general public, the elderly and nursing home populations were much more at risk. So, it’s not clear why she seems to discount Atlas’s attention to them.
GBD / One issue she never discusses is her thinking about the GBD. The GBD was a short statement that the aforementioned Bhattacharya, along with Harvard University medical school biostatistician and epidemiologist Martin Kulldorf and Oxford University epidemiologist Sunetra Gupta, wrote in early October 2020 and named after the city in which they wrote it. Here’s a key passage from the GBD:
The most compassionate approach that balances the risks and benefits of reaching herd immunity, is to allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection, while better protecting those who are at highest risk. We call this Focused Protection.
The authors of the GBD spelled out the idea of focused protection a little, writing:
By way of example, nursing homes should use staff with acquired immunity and perform frequent testing of other staff and all visitors. Staff rotation should be minimized. Retired people living at home should have groceries and other essentials delivered to their home. When possible, they should meet family members outside rather than inside.
Some of those measures seem, and would have been, costly. But the costs would have been a rounding error compared to the trillions of dollars the federal government spent on extremely unfocused protection.
Interestingly, given that Birx doesn’t mention the GBD, she comes close to endorsing many of its key elements. In describing her trips to talk to health officers and governors in various states (see “Birx Reconsidered,” Summer 2021), she writes:
No matter where we went, we heard two things without fail. Every leader and every American wanted to protect the old and vulnerable while charting a path forward for the young and less vulnerable. The former meant preventing Covid-19 from sickening and killing the elderly and those with severe underlying comorbidities; the latter meant not jeopardizing the education or future prospects of those in schools, small businesses, and working in the hospitality industry. We put the message out that testing and masking brought both these aims together.
In short, “every leader and every American” wanted what the GBD authors wanted. And it seems from context that Birx also wanted what these leaders and Americans wanted. She did differ with the GBD writers on strategy, with Birx pushing for masks and testing more generally and the GBD writers wanting testing of people visiting high-risk residents of nursing homes. Was she concerned that if she referenced the GBD in her book, careful readers might have noticed the similarity between it and her own views? We don’t know and may never know.
Lockdowns / Early in her time at the White House, Birx became one of main champions of lockdowns. We were told in March 2020 that we should lock down for 15 days to “flatten the curve.” This meant slowing the rate of spread so that hospitals would not be overwhelmed. Some observers at the time thought that this 15-day lockdown was just an opening bid and that the government had a longer lockdown in mind. I, naively, didn’t think that. Birx reveals that I should have. In a chapter titled “Turning Fifteen into Thirty,” she writes, “No sooner had we convinced the Trump administration to implement our version of a two-week shutdown than I was trying to figure out how to extend it. Fifteen Days to Slow the Spread was a start, but I knew it would be just that. I didn’t have the numbers in front of me yet to make the case for extending it longer, but I had two weeks to get them.” That’s revealing in two ways. First, she planned for a much longer lockdown. Second, she knew what she wanted to find and she looked for data to make her case.
And surprise, surprise, she found the data. She reports that on March 18, 2020, her aide Irum Zaidi put together a “virtual summit” with experts from various countries, including some from Imperial College, London. Although she doesn’t attach predictions to particular experts, Birx writes that if no mitigation measures were taken, then, according to various experts (I’m guessing she’s including the Imperial College, London experts here), there would be “between 1.5 million and 2.5 million” U.S. deaths over just a few months. With school closings, social distancing, and a strict lockdown, and with perfect compliance, the U.S. death toll over those few months would be 150,000 to 500,000. We know that we didn’t have perfect compliance and that some major states—Colorado, Georgia, and Florida, to name three—backed off from lockdowns between late April and July 2020. Yet we didn’t quite reach 150,000 deaths in that time. Moreover, although Birx doesn’t mention this, a disproportionate number of deaths were in New York, New Jersey, and Pennsylvania nursing homes where state health officials had sent people whom they knew or suspected had COVID. The models didn’t include that. So, performance with imperfect compliance and other questionable policies was way better than the most optimistic of the models predicted. Does Birx acknowledge that? No.
Overriding tradeoffs / Birx has the mentality of an omniscient central planner. Often in the book, she expresses frustration that millions of Americans acted differently from the way she wanted them to. For example, in discussing the fact that people in Texas, New Mexico, and Arizona were very mobile, she writes: “Had they not gotten the message? Had we not made it clear enough? More likely, we presumed, it was a combination of the two.” She seems unaware of a third alternative: they had heard her message clearly enough but found it unpersuasive. That points to something that Birx shows about herself again and again throughout the book: her absolute confidence that she is right and those who disagree with her are wrong.
I shouldn’t leave out a fourth alternative: people want to make their own tradeoffs. Birx seems unsympathetic to people who make tradeoffs different from the ones she recommends, which is strange because she made such tradeoffs in her own life. Recall that in November 2020 she had recommended that people limit their Thanksgiving gatherings to their immediate households. But she refused to follow her own recommendation: she and some in-laws got together in a different household the day after Thanksgiving.
Early in the book and in her time thinking about COVID, Birx had the same insight that both Stanford Medical School epidemiologist John P.A. Ioannidis and Jay Bhattacharya had: the actual infections at any point in time had to be a large multiple of the number of cases, but many infections were so mild that they went undetected. Ioannidis made that point in a March 2020 STAT essay, “A Fiasco in the Making? As the Coronavirus Pandemic Takes Hold, We Are Making Decisions Without Reliable Data.” His reasoning was that many people with COVID who had few or mild symptoms would not bother getting tested while the people who were tested were disproportionately those who were quite sick. The infection fatality rate, therefore, would likely be a fraction of the case fatality rate. The data have borne him out. But in her book, Birx refers to a “nearly 10 percent fatality rate in those over age seventy” and claims that the rate for this group in March and April 2020 was 30 percent. She’s certainly aware that this was the case fatality rate, but she doesn’t bother telling the reader that. One wonders whom else in the Trump White House she didn’t bother to tell.
Conclusion / As noted above, there are several areas in which Birx deserves credit. At various points throughout the book, she criticizes the CDC, although with too little detail about just how bad the agency was for insisting on producing its own tests rather than going with tests produced in other countries or by private or non-federal entities. At one point she even mildly throws National Institute of Allergy and Infectious Diseases director Anthony Fauci and CDC head Robert Redfield under the bus for, early on, claiming without much data that the risk to Americans was low.
Also, she shows a solid understanding of the importance of property rights. She and her aide, Zaidi, visited a number of Indian reservations to understand how they were dealing with the virus and to give their thoughts. She quickly saw a major problem: “As with other tribal nations we’d met, their land was held in trust by the U.S. government, so the tribes couldn’t use it as an investment or for most entrepreneurial enterprises, which exacerbated the cycle of poverty.”
Despite those acknowledgments of the value of private incentives and the problems of government intervention, the book shows that Birx is firmly on the interventionist side. Unfortunately, her successors may well repeat many of these same mistakes in future public health emergencies.
