Birx Reconsidered: The former Trump COVID adviser has been criticized for not leaving the administration, but her efforts saved thousands of lives.

• Author: Harrington, David

In an interview for CNN in March, Dr. Deborah Birx, who was the Trump administration's coronavirus response coordinator, offered a remarkable appraisal of that administration's efforts to contain the virus:

I look at it this way: The first [few months] we have an excuse. There were about a hundred thousand deaths that came from that original surge. All of the rest of them, in my mind, could have been mitigated or decreased substantially if we took the lessons we had learned from that moment. That's what bothers me every day. Her comments quickly drew fire. USA Today editorialized: "Why is she telling us now? And why did Birx persist in her high post, delivering a business-as-usual message, while she knew of so much needless death?" Jonathan V. Last, editor of the Trump-critical The Bulwark, wrote of Birx, "You should be ... haunted by what happened on your watch and shamed and shunned by every peer in your profession, for the rest of your days." Critics quickly posted video of her praising Trump's response to the virus when he was still in office, including her telling the conservative network CBN: "He's been so attentive to the scientific literature and the details and the data. I think his ability to analyze and integrate data that comes out of his long history in business has really been a real benefit during these discussions about medical issues."

To be sure, fair criticisms can be leveled at the Trump administration's response to the disease. But Birx's remaining in Trump's good graces allowed her to make recommendations under the mantel of being his COVID adviser. During the final months of his presidency, she spent most of her time on the road, traveling from state to state, meeting with governors, university presidents, public health officials, and reporters. She delivered an urgent message to everyone who would listen: COVID is surging; it's insidious and dangerous; and people need to start guarding against it now.

Her travels create a unique opportunity to estimate whether people were heeding her advice. More specifically, the variation in where and when she made her recommendations can be compared to outcome variables such as whether people were wearing masks.

As you'll see, the evidence convinces me that she saved thousands of lives. But she didn't save fives everywhere: people were more likely to mask up after her visits, but only in states that Trump won in the 2020 presidential election. Being an emissary of his White House apparently grabbed those state residents' attention and led some of them to wear masks. Governors were also more likely to listen to her in Trump-supporting states and reporters appeared to give more coverage to her visits to those states.

First and foremost, she urged everyone to wear facemasks. Birx always wore a medical mask, which became as ubiquitous as her scarves that the media constantly noted. Early in her travels, she talked about people needing to mask-up when they were "out and about." As the weather turned colder and people moved inside, she broadened her message, urging everyone to wear masks whenever they were interacting with people outside of their immediate households--even in their own homes when friends, neighbors, and relatives were visiting.

She planted the message "Masks work" across the country like Johnny Appleseed planted trees. When nudged by reporters, she would describe studies of salon workers and airline passengers whose masks protected them from catching COVID. One of her favorite studies looked at the passengers of an international flight who were all tested for COVID prior to boarding, though the results were not instantly known. It turned out that eight of the passengers were infected, but none of the others caught COVID because everyone wore masks. Once, after adding a bit too much detail, she chuckled and said, "I won't bore you with all the R-squared values."

During the latter half of her trip, she would sometimes point to herself and say, "I've been on the road," eating at restaurants and staying at hotels, and "I've stayed negative." Like many early pioneers in medical research, she was experimenting on herself, testing whether wearing masks, social distancing, and washing her hands would protect her from the virus.

She had plenty of potential exposures. She interacted with thousands of people as she traveled more than 25,000 miles and visited 40 states, many of them more than once. On a radio show, she described standing in a hotel lobby within a few feet of an unmasked man in a state that had the highest number of new COVID cases per capita at the time. On the counter near them was a sign that said guests must be masked. A few days later, she sat in an hour-long meeting within six feet of a man who later tested positive for COVID.

The danger and drudgery would have been worthwhile if people were listening to her and heeding her advice. But were they? A local reporter in Rhode Island asked her, "Are you satisfied that your message is [being heard]?" Birx paused to reflect on his question, ultimately replying, "You know, I don't think any of us in public health are ever satisfied." She paused again, searching for the right words, and then enunciating slowly said, "We always want our message to be heard and internalized and utilized" by an ever-higher percentage of the intended audience.

Did Birx's efforts have a positive effect? She must have thought so. A month after leaving Rhode Island, a reporter halfway across the country asked, "Knowing what you know today, if you were able to go back in time, say [to] February or March, what would you [have done] differently?" Without hesitation she said she would have hit the road earlier to stress the importance of adhering to the reopening guidelines following weeks of local and state government orders to shelter in place.

This begs the question of whether the Biden administration should now have someone like her visiting with governors and the American people to talk about receiving the COVID vaccine and taking care not to relax mitigation strategies too rapidly as the virus's infection and death tolls fall. Warm weather and the vaccines have certainly curtailed the virus's spread, but there is still elevated public health risk, exacerbated both by virulent new strains of the disease and a significant chunk of the public's hesitancy (and in some cases outright opposition) to receiving one of the vaccines. An official filling the role Birx did last year would certainly be helpful. But will anyone undertake it, and will that person be able to effectively deliver the message to the people who most need to hear it?

HARD RECOMMENDATIONS WRAPPED IN COMPLIMENTS

On her 2020 travels, often to state capitals and university towns, Birx typically began her days in private meetings with governors or university presidents, followed by (sometimes public) roundtable discussions, and culminating in press conferences. She won a bunch of trifectas where the governor came to all three, and was rarely snubbed entirely, though a prime counterexample was South Dakota Gov. Kristi Noem, who turned down repeated invitations to meet with her.

Birx often talked about "carrying messages" to the American people. She didn't actually go door-to-door or hold large public rallies, of course, but she used the press and politicians as her megaphone. She almost always started her press conferences with compliments about what the governor or state residents were already doing to fight the virus. Then she would launch into "the data," characterizing the severity and likely path of a state's COVID outbreak using statistics like COVID cases per capita, positivity rates of tests, and hospital utilization rates. She might say that the COVID-test positivity rate of the state was high enough that the entire state was "red" or that such and such percent of its counties were "red."

Then came recommendations. Wearing masks always topped the list. For example, in her Missouri press conference, she used the name-checking panache of a touring rock star to push the practice:

My fundamental message to everyone [is] that all of us across Missouri, whether you are in Kansas City or Saint Louis, whether you are in Springfield, Joplin, or Jefferson City, whether you are in Branson or at the Lake of the Ozarks, our job in each and every community is to decrease viral spread.... What does that mean? We need every American and everybody in Missouri to be wearing a mask and to be socially distancing. A video clip of her delivering this quote was the lead story on that night's newscast of the ABC affiliate in Saint Louis.

After the recommendations came the questions from the press. Most of the reporters threw her "softballs," but some "hardballs" were mixed in. She swung hard at the former and mostly ducked the latter, which usually had the name "Trump" in them. Several times she was asked what she thought about Trump's campaign rallies of densely packed, unmasked supporters. She would invariably say that she gives everyone, including the president, the same advice to wear a mask and then treated the question like a softball.

She did swing hard at a fastball on a visit to Utah. A reporter asked, sounding incredulous, "Are you saying that families in Utah should not get together with their extended families for Thanksgiving?" She didn't mince her words, although they were a bit garbled: "At your current rate of rise [of COVID cases, that's] correct."

One press conference stands out from the rest. On her second trip to North Dakota at the end of October, she skipped the compliments and went straight to the data. The state was bright red; it had the highest number of new cases per capita in the country. She was more strident than usual, perhaps because she saw little mask-wearing after she checked out of her hotel that morning.

Reporting on what she had observed...