What Happened and Where are we now?

Where does the Science Stand in the US?*
Unfortunately, resources in the National Institutes of Health (NIH) which research disease causes, prevention and treatment have been under budget cut attack. President Trump has proposed cutting the NIH’s budget for four years in a row, by 7% or almost $3 billion in 2021. That is a small compared to the cuts proposed in previous years. To date (03/2020), the congress has rebuffed most of the Trump proposed budget cuts, and congress has even proposed an increase to the NIH budget for the next fiscal year.

Presently, if approved, the biggest budget hit would be taken by the
National Cancer Institute with a 9% cut in 2020. Some departments would get a little more money as they involve the administration’s popular initiatives for pediatric cancer research, $200 million towards a universal flu vaccine and a 4% increase to the FDA to promote cheaper prescription drugs. Pediatric Cancer is a favorite of the Eric Trump Foundation although not all the money it raised between 2011-15 went to St. Jude Children’s Research Hospital as promised, according to Forbes. Another carve out now scheduled for a “smaller” reduction (but no increase) as of mid-February, 2020 is Dr. Fauci’s NIH division. He is the director of many decades of the NIH’s National Institute of Allergy and Infectious Diseases.

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You should know that Dr. Fauci is the short, credible fellow who stands behind Mr. Trump at briefings and is often called on by reporters to “clarify” the president’s statements. Dr. Fauci became famous as the “explainer in chief” for the AIDS epidemic response under President Regan due to his easy to understand language. He’s been with the CDC for decades and is working with five hours of sleep per night, seven days per week on the COVID-19 response. He is on the President’s 12-person
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Coronvirus Task Force because the most appropriate person for the job – who is notably missing – Rear Adm. Tim Zimmer, the director of the National Security Council (NSC) pandemic response team, which oversaw the global response to the Ebola epidemic, quit when his unit was disbanded in 2018. That’s right, the most experienced pandemic-response leader is missing and and his team disbanded, by then National Security Advisor John Bolton, as part of an effort to downsize government and, seemingly, to reduce the influence of science in politics.

Could we have been Ready? What Went Wrong?
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With no pandemic team on the NSC, all planning and carrying out of US coronavirus mission fell to recently appointed Mr. Alex Azar, previously a drug company executive and now Trump’s secretary of Health and Human Services. He heads the small task force on which Dr. Fauci serves, but his expertise is in allergies and disease, not so much in responding to pandemics like Adm. Zimmer. The missing Adm. Zimmer from the task force, and the missing pandemic team from the NSC certainly contributed to the confusion and delay in the US response.

Also, feuding among the members of the task force played a role; e.g., while the president was out of the country his White House Domestic Policy Council director, Joe Grogan, who has fought with Mr. Azar over drug policies, tried to take over the task force essentially omitting health officials. Seema Veema, who came with VP Pence, the administrator for Medicare/Medicaid was excluded from the task force. She has feuded with Mr. Azar so much that President Trump has had to intervene. The chief of the CDC, Dr. Redfield who is also on the task force has been rebuked after telling reporters that there was a looming shortage in equipment to do COVID-19 testing. And so it goes on. Read about the frustrating details here.

Another issue is the ever-shrinking group of scientists and experts at the
National Security Council (NSC) reduces the capacity to provide quick, independent advice based on science to the executive branch. We knew experts on climate change were removed, but who would think have thunk they would eliminate pandemic experts after H1Ni Bird Flu, Ebola, Zika, MERS epidemics and AIDS and SARS pandemics. By the way, President Trump did not “fire” the pandemic expert on the NSC; instead, Adm. Zimmer resigned after his team was disbanded as part of the administration’s effort to downsize the NSC as described above. Neither he nor the unit have been replaced. In hindsight this surely contributed to the slow and ineffective initial response to COVID-19 given the lack of in-house expert advice.

In the beginning it hasn’t helped stimulate the nation to prepare and by calling COVID-19 “corona flu,” suggesting it’s fine for people to go to work, and denying the COVID-19 death rate reported by the WHO because of a “hunch” – all as recently as 03/05/20, well after a pandemic was declared by the WHO and killing thousands in Spain, Italy and brining the “Chinese economy to its knees” according to the right-wing publication
The American Conservative (03/05/20).

Even more damaging to the state of our readiness were the reductions by the current administration in 2018 which have hampered our current response capability; i.e., by eliminating the experienced NSC pandemic response team as described above, and terminating all funding to the CDC for epidemic prevention activity in 39 out of 49 countries including China. They felt any risk in most other countries did not affect the US failing to understand that
pandemic means diseases that affect everywhere people travel, and the US is a prime place people all over the world visit, not to mention leave given huge tourist industry; think cruise ships…

So What’s Being Done Now?
The CDC’s refusal to use foreign COVID-19 test kits, inability to make enough of their own kits, and the fact that when a few kits finally become available they did not work has all largely rested at the CDC director Dr. Redfield’s doorstep. Dr. Redfield, an HIV expert, was a
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professor at the Univ. of Maryland and co-founder of their Institute of Human Virology. As a virologist he should be an ideal member of the COVID-19 task force, but he has been accused in the past of either being sloppy with data (or even fabricating it) about AIDS vaccine research for the Army in 1993. He also comes with political baggage, attractive to some, given his conservative positions on sexual health. Notably he helped implement army procedures to screen and then bar recruits from service if they were positive for HIV, a treatable disease, implying a bias against homosexuality. Perhaps most problematic was his lack of experience in leading a public health agency, before being appointed to lead the still enormous CDC.

Reportedly Mr. Azar is a responsible and efficient healthcare administrator, for a drug company exec., who has tried to investigate internal problems at the CDC. It may come down, as often before, to lack of personnel due to cuts, staff changes and political appointments interfering with mission. There have also been attacks on Mr. Azar for waiting two months before accepting the offers, and cutting the red tape for, from private companies and universities to develop test kits. The 12-member Task Force consists of:
  • Health and Human Services Secretary Alex Azar
  • National Security Adviser Robert O'Brien
  • Center for Disease Control and Prevention Director Robert Redfield
  • National Institute of Allergy and Infectious Diseases Director Anthony Fauci
  • State Department official Stephen Biegun
  • Acting DHS Deputy Secretary Ken Cuccinelli
  • Department of Transportation official Joel Szabat
  • Deputy National Security Adviser Matthew Pottinger
  • Adviser to the chief of staff Robert Blair
  • Domestic Policy Council Director Joseph Grogan
  • Deputy Chief of Staff for Policy Coordination Christopher Liddell
  • Office of Management and Budget official Derek Kan
The infighting and lack of clear leadership has led to VP Pence’s appointment to head the Coronavirus Task Force with some saying
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this is a hopeless task at this point. Is it too cynical to wonder if his appointment is to have scapegoat ready to blame for our national disgrace? Mr. Pence has focused on the larger message to the US and world, as it appears he may not have been given (or be capable of using) the operational tools “to execute specific initiatives” as this POLITICO report states.

To his credit Mr. Pence has been adjusting the 12-member task force to include more health care experts. Here’s an
article from USA Today about the task force now that Mike Pence is in charge. Floating around the committee (in the photo above with the scarf) is Dr. Birx, the White House coronavirus response coordinator, and the aforementioned Seema Veema, Director of the Centers for Medicare and Medicaid which further muddies the picture of leadership. It all seems moot, since the task force briefing became extremely popular on TV, President Trump now shows up and leads the questioning and does all the briefings.

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Were We Warned?
Any belief that there no one could have guessed an epidemic might happen, as Trump has said is false. The Obama administration specifically briefed the Trump transition team on the risk and plans for the next (not if but when) epidemic which was expected by all medical agencies. Here’s an opinion written by the previous CDC director, Tom Frieden, with former Sen. Bill Frist (R-Tenn) published in The HILL, read by all Washington politicians, on 07/13/17. They note a half-dozen examples of what Mr. Trump’s proposed fiscal Year 2018 CDC budget either has or would have done, note #1 below:
  1. Weakening our capacity to prevent or promptly detect epidemics at home and globally
  2. Eliminating research centers
  3. Eliminating CDC’s programs to prevent colon and skin cancer
  4. Cutting immunization programs would result in more childhood illness
  5. Cutting tobacco control and other programs that protect Americans against the leading causes of death: cancer, heart disease, diabetes and stroke
  6. Dismantling HIV prevention programs in the U.S. and globally.
A year ago this March, 2020 ex-CDC Director Dr. Thomas Frieden said “It’s not a matter of if – but when there will be another Ebola or Zika, and right now the world isn’t ready.” The current response (as of late March) is now to create SWAT teams, described in the above POLITICO article. Of interest is that Jared Kushner appears to be leading this effort. His long-term friend Mr. Boehler, director of the Medicare innovation center, who is “viewed as an apolitical Silicon Valley veteran” is on the team. This SWAT team is gaming various response strategies (we’re too far behind for prevention anymore) to deploy testing procedures and quarantine plans as kits become available with the goal of “flattening the curve” or slowing down progression so as to minimize overwhelming our hospitals.

While commendable, it is still an after-the-fact action trying to make up for a lack of any prevention planning or preparedness due given the absence of healthcare leaders in the administration willing to acknowledge a potential pandemic that could affect the US. Mr. Bolton thought he’d just call them back when needed, of course when called after-the-fact it is to late to plan, you can only try to respond. And, that assumes the team is still available which it is not. BTW, Mr. Bolton is no where to be found anymore. Seems he’s been writing a book…

A Warning to All of Us
There are efforts to completely reform the CDC, and no one denies improvements are needed. However, initiatives to reduce funding to the CDC or recreate it as only a purveyor of “block grants” to the states to run their own responses to pandemics and find cures for diseases that affect us all are ill informed at best. Dr. Frieden served under President Obama as the last director of the CDC for 8 years. He resigned the day Mr. Trump was sworn in as president. Among his final statements was, on 01/03/17 in an interview with Reuters:

“We've dealt with Ebola, H1N1 influenza, MERS, fungal meningitis. We're dealing now with influenza and drug-resistant bacteria," Dr. Frieden told Reuters. "We don't know when the next global health threat will come. We don't know where it will come from. We don't know what pathogen it will be, but we are 100 percent sure that there will be a next one.”

And, in the aftermath of the Zika epidemic, he said:

“I really would hope that come April [2017], if a budget is passed, it will include the Rapid Reserve Fund plan that was outlined in the House bill, which ideally would also have some spending authorities that would enable the government to act quickly in an emergency.”

Nothing about COVID-19 is new or surprising. Two months after being briefed on the coronavirus, during a press conference on March 16, 2020 President Trump said “We have an invisible enemy. We have a problem a month ago nobody ever thought about,” Trump went on to say. “It’s just so contagious sort of record-setting type contagion.” We knew, but little was done. Trump was, as reported by people close to him, in previous days making fun Mr. Azar (his own appointee) as an alarmist about his concern over the coronavirus. Of course, two days later on the 18th Trump said at a White House briefing This is a pandemic. I’ve felt it was a pandemic long before it was called a pandemic…All you had to do was look at other countries.” Maybe we’ll heed the warning in time of the next pandemic, when (not if) it comes.

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