As anyone involved in emergency response knows, the early actions you take are crucial—they help lay the groundwork for the months that follow. At the same time, decision-making early in a crisis is difficult: You have to make decisions based on the information you have at the time—and that information was severely limited by the fact that this virus emerged in China and that it was a novel pathogen. With the limited information we had about the virus, we had to act before the situation became a crisis—and that’s exactly what we did.
Thank you, Kay [Cole James], and thank you to the Heritage Foundation for inviting me here today to reflect on the United States' response to COVID-19 and what we've learned over the past year.
It's appropriate this month to discuss what was going on about a year ago, after word of the virus had finally emerged from China, and when the U.S. government began to take action.
As anyone involved in emergency response knows, the early actions you take are crucial—they help lay the groundwork for the months that follow. At the same time, decision-making early in a crisis is difficult: You have to make decisions based on the information you have at the time—and that information was severely limited by the fact that this virus emerged in China and that it was a novel pathogen. With the limited information we had about the virus, we had to act before the situation became a crisis—and that's exactly what we did.
So, what were the tasks that faced America in the early days of the response? Many of these tasks are laid out in the pandemic planning work that has been done at HHS and across the federal government, such as the initial pandemic flu plan we wrote under President Bush and Secretary Leavitt in 2005.
We had to learn about the virus itself by consulting with scientists in China— the country where it originated. We had to educate Americans about the risks of the virus and how it might impact their lives. We needed a coordinated response across the federal government, including containment and mitigation strategies. We had to safely bring home Americans who were abroad and might have been affected by the virus. We had to secure funding to support the emergency response. We had to support the healthcare system with surge capacity.
We had to get real-time data to enable a nimble, science- and data-driven response. We had to spur the development and manufacturing of laboratory tests, vaccines, therapeutics, and personal protective equipment.
All of those tasks were priorities for us in January and February—and we would not have the capabilities we have today if we hadn't begun that work in those early months.
Let's consider when and how the United States became aware of the virus. We learned about an outbreak of pneumonia of unknown origin in Wuhan, China on December 30—not through that country's official channels, as required under the International Health Regulations, but through media monitoring that we do, as well as through a notification from Taiwan's economic and cultural office here in the United States.
That's right: One of the very first ways the U.S. government was notified of a novel virus in mainland China was by… people from Taiwan.
On January 1, CDC began developing situation reports on the suspected novel virus. On January 3, HHS notified the National Security Council, which began holding daily meetings on January 14—just three days after China finally publicly admitted the first death caused by the virus, and the same day that the World Health Organization repeated the claim that there was no human-to-human transmission.
We at HHS immediately recognized the potential danger of a novel coronavirus. Potential, not certain, danger—but definitely potential. CDC issued its first travel warning for China on January 6 and established an Incident Management Team on January 7.
As we worked to learn more about the virus, we at HHS adopted some key strategies and principles grounded in pandemic response planning.
First, we would operate with what we called "radical transparency." The public would know what we knew when we knew it, and they would know what we did not have the answers to.
Second, we would ensure that the American people and top policymakers had direct access to our top infectious disease experts.
Third, we would follow the pandemic action plan, as the situation developed, to contain and mitigate the disease as much as possible, especially with a goal of ensuring that the epidemiological curve and disease burden would remain within our health system's capacity to manage cases.
Fourth, we would act in an anticipatory manner. The mantra that others and I repeated often during this period was a well-known public health adage: You need to take actions now that might seem like an overreaction, because what you are seeing epidemiologically is like looking in the rear view mirror by as much as 28 days. Take actions now to respond to what you think the situation will look like in 28 days.
CDC quickly began working with Customs and Border Protection to start border screening. On January 17, we began enhanced screening of travelers from Wuhan at three U.S. airports that receive significant numbers of travelers from that city, and this effort expanded the following week to five airports, so that 75 to 80 percent of travelers from Wuhan could be screened. That same day, January 17, CDC began media briefings on the novel virus.
Even as we were relaying what we knew to the American people, we suspected we could not trust the reports out of China. Reports from China suggested that the virus had likely emerged there by November, and the Chinese government's explanation for the outbreak did not make sense.
Our CDC director, Dr. Bob Redfield, was told by his Chinese counterpart, Dr. Gao of the China CDC, that the story was that the virus had originated from animals in the now-infamous Wuhan market. Yet in the first week of January, there were several clusters of cases within families, which were very unlikely to have come from close encounters with animals, suggesting human-to-human transmission.
There was so much we needed to know—and so little information coming out of China. That is why, on January 3, at my direction, Dr. Redfield emailed Dr. Gao again and offered to provide a team of CDC technical experts to assist with an investigation. On January 6, at my request, Dr. Redfield sent a formal letter to the China CDC offering full assistance. Throughout January, we continued to make this offer of assistance clear to China. It was not until January 29 that our offer was officially acknowledged.
By that time, one major focus was pushing for an immediate deployment of an international team through WHO, as is customary for potentially concerning outbreaks. I emphasized the urgent need for such a mission in a call with Director General Tedros on January 27, when he'd arrived in Beijing to press President Xi to cooperate and allow entry of an international team. That same day, I personally pressed my counterpart, Minister Ma, and reiterated our offer of full support.
Throughout this time, our diplomatic leaders and staff were constantly pressing their counterparts at WHO on the need for an international mission to investigate the virus. Our teams were also pressing for the Chinese government to send us viral isolates from patients there, and China has still—one year later—failed to provide the first-generation viral isolates.
It was not until February 16 that the international team arrived in China, with two American experts from NIH and CDC on board.
By this time, Chinese intransigence meant that the window of opportunity had passed. Outbreaks of the virus had been seeded around the world. We had been denied the chance to learn about the virus by the country where it originated.
On February 3, I convened the first meeting of G7 health ministers to enable sharing of best-practices and coordination among these key nations. I have now chaired 22 meetings of this group in 2020 under the U.S. presidency of the G7.
People often ask, why was the administration offering any form of praise for China in those early days? There were a few reasons: First, we were always clear that, with China, you don't know what you don't know. Second, we said that China was being more transparent and cooperative than with SARS, because that was the constant refrain from WHO—but that was a low bar. It turns out that, if they got an F for SARS transparency, they deserve at best a D on COVID-19. Third, with China, if you want to get access and cooperation, sometimes a bit of public praise gets you further than hitting them over the head publicly. So we pressed them very hard and firmly in private, but offered muted reinforcement in public, at least while we still thought we might be able to secure their full cooperation and compliance with the International Health Regulations. Unfortunately, WHO never made the shift we did, continuing to lavish praise on China even to this day.
Our concerns were confirmed after the return of the international team organized by WHO, when we learned that the scope of their work had been restricted to observing China's outbreak response—not the origins of the virus itself.
The same bullying of international experts and scientists, sadly, has continued.
In May, member states of the World Health Organization had to authorize by resolution an investigation specifically into the virus's origins. Unbelievably, it was only this week that the investigators were allowed into China. Further, these investigators will largely examine the analyses already done by Chinese scientists. This flawed scope of investigation is the result of months of negotiations over last summer and into the fall between WHO and China, with no input from the WHO Executive Board, through which member states like the U.S. have an actual say. I encourage those China-watchers here at Heritage to continue following China's conduct around this investigation quite closely.
China has spent the better part of this year shamelessly promoting an Orwellian version of events, designed to persuade the world that its authoritarian form of government is best suited to respond to a public health crisis. The facts are, however, that if a novel virus like this had emerged in a democratic nation, a global outbreak might never have occurred.
Contrast what I've just described with how the United Kingdom has handled the recent emergence of a more transmissible variant of the virus: As soon as the new variant was identified by scientists, the news was shared with the world, as was the genetic sequence. The genetic sequence of SARS-CoV-2 in China was not shared until January 9—10 days after the virus was reported in the media and likely one or two months after it had actually appeared.
Being able to investigate the virus in January would have helped the United States and the world develop a science- and data-driven response. Instead, we were flying blind—with human-to-human transmission of the virus not officially confirmed until January 20.
But even without all the data we needed, we were looking at the information we had to prepare and formulate a public health response. China's response, if not their public pronouncements, was making it clear that they faced an extremely serious situation. We needed to buy time to prepare.
But one potential intervention—restricting travel of those coming from the one place where the virus was rampant, China—was not part of any pandemic playbook. In fact, it was intentionally kept out of pandemic flu planning. The theory was that travel restrictions could impede emergency responses and cause economic damage far out of proportion to the benefit from slowing the virus's spread.
I knew this argument well because it was a central principle in the creation of an international framework for pandemic flu response in the 2000s, when the G20 nations agreed not to include travel restrictions as part of our planning. Opposition to the use of travel restrictions was a deeply embedded orthodoxy in the global public health establishment.
But we saw what was happening in China—the lockdown of whole cities—and we saw that it was time to rethink this two-decade-old dogma. On January 30, I had a call with Dr. Fauci, Dr. Redfield, and other public health leaders from CDC. Together, we agreed that the situation had changed, and we formulated a case to present to the President.
Meeting with the President on the afternoon of January 31, I explained the case to him: About 20,000 people were arriving in the United States each day from China. If we dramatically decreased travel, we could slow the spread and buy ourselves time. That, I told the President, was the unanimous recommendation of the public health leaders he had before him.
That evening in the White House briefing room, when there were still just 125 confirmed cases worldwide outside of China, I declared a public health emergency and announced the unprecedented restrictions on travel from China. At the time, we were accused of overreaction, of xenophobia. Yet experts have now concluded that early travel restrictions slowed the spread of the virus, bought us time, and likely saved lives.
We were able to effectively identify and isolate cases originating from or connected to China and Chinese travel. We saw a very early serious outbreak at a nursing home in Washington, but we responded quickly with a team from the Public Health Service Commissioned Corps, and that was not the seeding event for the U.S.
Rather, one of the key drivers was thousands of Chinese workers in northern Italy, which then led to undetected spread of disease in Europe and seeding from Europe into the United States. Genetic data show that the major early outbreaks in the U.S. were from European variants. Ominously, while China had locked down internally, they had done nothing to prevent travel by their own citizens internationally—providing the opportunity to seed outbreaks around the world.
Meanwhile, very early on in the outbreak, a key issue arose from the State Department. There were diplomatic personnel and dependents trapped in Hubei Province, and the State Department wanted to extract them from China on a charter flight. Under the direction of Matt Pottinger, the Deputy National Security Advisor, meetings began of a small deputies committee, of the Deputy Secretary of State, the Acting Deputy Secretary of Homeland Security, the Assistant Secretary of Transportation, and myself, to coordinate this completely unprecedented undertaking.
I insisted that Dr. Fauci and Dr. Redfield attend these meetings, so that we would have their direct advice as infectious disease experts.
In late January, the White House Chief of Staff, Mick Mulvaney, took over leadership of this group, which met on a daily basis, primarily to deal with these repatriation and quarantine measures. After our meeting on January 29, the Chief of Staff and his deputy decided that this would be labeled the White House Coronavirus Task Force, and I was named its chairman.
HHS had a critical role within the task force, as the lead for Emergency Support Function 8, covering public health and medical services under the National Response Plan. But the task force itself was always run by a White House official, since no cabinet secretary orders the efforts of peer cabinet colleagues. That is, and always has been throughout this crisis, a uniquely White House function.
To support the work of the task force, HHS coordinated a staff-level daily operational interagency meeting each morning, in order to implement decisions of the task force regarding the repatriation and quarantine efforts. We also had our own HHS coronavirus working group that consisted of the agency heads within the department, which had come out of the Disaster Leadership Group that ASPR had convened on January 23. By late January, we had integrated FEMA into our work under ESF-8, co-locating their team here at HHS because we knew that at some point, if this became bigger, FEMA would take on operational leadership of the whole-of-government response.
Each of the departments I mentioned was involved in bringing back Americans abroad safely. The State Department, DHS, and the Department of Transportation were the key agencies, of course, for transporting Americans home to our shores. But when Americans arrived home from China through these repatriations, collectively we would need to ensure that they did not spread the virus onward to the community.
We needed to quarantine them. The federal government, through CDC, has authority to quarantine Americans coming from abroad, and CDC has a dedicated office that runs quarantine stations at ports of entry around the country.
What federal quarantine staff do, however, is identify people who need to be quarantined and then ask state and local authorities to implement local quarantine and isolation requirements and procedures. The federal government had not exercised its own quarantine powers since the 1960s—and there was no system set up, at the state or federal level, for physically housing those quarantined.
We had to, and we did, build a quarantine system for thousands of travelers entirely from scratch. On January 29, the first plane touched down at March Air Reserve Base in California with Americans evacuated from Wuhan. Working with the Department of Defense, HHS had housing prepared for them, and provided both arrival medical screenings and ongoing care, as well as every other service they needed, throughout their 14-day quarantine.
Four more repatriation flights later arrived. Over the next month, more than 3,000 Americans would be brought home from China and from the Diamond Princess and Grand Princess, the cruise ships that had suffered outbreaks with large numbers of Americans. There was no documented spread among those quarantined or follow-on spread from those we brought home. This was a remarkable logistical and public health achievement—accomplished without any formal preexisting system to pull it off.
Although there is reason to believe the virus potentially arrived here in December and January, retrospective analysis from CDC has now confirmed that there was not large-scale community spread in the United States throughout February. A study out of Seattle retrospectively analyzed specimens from patients with respiratory disease from January 1 through February 20, and did not find one positive result in 5,270 samples.
There is a myth out there that, if only we'd had a superior testing system, we simply could have caught any cases and isolated them. But given the retrospective analyses we've now seen, that would have been like finding a needle in a haystack. At the time, CDC was using its systems that detect respiratory illnesses, which was the appropriate way to look for the virus given what we knew about it, and that did not show widespread presence of the virus. The same goes for CMS claims data—no evidence of a significant rise in respiratory illnesses. No country had a specialized syndromic surveillance system back in January and February that could have more accurately picked up cases based on symptoms, and given that we now know that up to 50 percent of people are asymptomatic, any such symptomatic screening system would have missed half of the cases.
But we knew—and we told the American people—that we could not hermetically seal the United States, and we would see spread here. We needed the ability to detect where the virus had begun to spread, so that we could take containment and mitigation measures. The problem, however, is that the only test the FDA had authorized for COVID-19 in February was made by CDC and its contractors, which had limited capacity and faced manufacturing problems.
The CDC was always able to test every sample it received, and its testing criterion, based on what we knew about the virus, made sense: It was for symptomatic patients with a potential link to Wuhan.
But, given what we now know about how widely the virus had spread and how it could spread before symptoms develop, what we really could have used was the hundreds of high-complexity labs across America, such as academic and state and local public health labs, developing their own tests to start testing possible cases.
Government rules, however, stood in the way. These labs typically develop tests for viruses on their own, and were starting to use them without ever seeking authorization from FDA. But FDA was now telling them they needed to receive an emergency use authorization, which requires submitting data to FDA for review and performing a number of validation steps.
FDA had announced, without public comment, in a post on its website, that these kinds of tests, which normally require no FDA authorization, would have to receive an EUA during a public health emergency.
Not only was this a new and significant burden for labs scrambling to respond to an emergency, but FDA was not making this requirement clear to HHS leadership or to the public.
Labs weren't used to this process, and now they actually had to do a great deal more work before they could start testing than they would if there weren't an emergency.
On February 29, we agreed with FDA leadership that they would allow labs to start using tests they had developed, as long as they also submitted a completed EUA application within 15 days.
With the EUA requirement out of the way, labs could finally do what labs across the world had already begun doing: developing tests, validating them on their own, and churning out results.
Still, it was not until mid-March that FDA allowed labs to do their own testing without applying for an EUA at all, like they would during a non-public health emergency, as long as they were doing so under state oversight.
These labs could provide more testing capacity, but a nationwide outbreak required enlisting commercial testing companies, the first several of which received EUAs in mid-March.
Parts of HHS had already been working with these private-sector testing partners for weeks. On February 1—when there were still fewer than 10 cases confirmed in the United States—a government-wide working group led by HHS's emergency response arm, ASPR, formalized a strategy for encouraging and supporting test development.
On February 5, BARDA launched a formal solicitation for applications for federal support; and we made the first funding awards on February 25—when there were still just 14 confirmed cases in the U.S. and only 45 deaths from the virus across the world outside of China. These early investments have led to the remarkable technological advances we've seen in testing throughout this past year, such as the development of rapid tests that have been strategically purchased and distributed by the federal government.
In January, we also began work with the private sector to dramatically expand production of supplies available to American healthcare providers, driving more production of crucial supplies like N95 respirators. Just from January to March, we went from about 250 million N95s being made annually in America to a rate of about 640 million a year—and production has continued to increase since.
Early work had begun on vaccines and therapeutics, too. The day after the viral sequence was shared from China, NIH researchers began working on a vaccine candidate with Moderna, and Phase 1 trials for this vaccine began on March 16—a record time to human testing.
On February 4, we announced an agreement with Regeneron to produce a potential monoclonal antibody product.
Thanks to the way that Operation Warp Speed has sped development and manufacturing of vaccines and therapeutics, millions of doses of the Moderna vaccine have now been administered and hundreds of thousands of doses of that Regeneron product have been delivered to the frontlines.
Much of this work, of course, requires money, and I worked to quickly direct financial resources to the response. On January 22, the day after the first U.S. case was confirmed, I signed a memorandum from CDC that allowed us to send a request to the Office of Management and Budget to notify Congress that we needed to access $105 million from the Infectious Disease Rapid Response Reserve Fund, which we did on January 25.
But supplemental funds from Congress would be crucial to supporting more early investment agreements that we needed for PPE and medical countermeasures. On January 30, we began conversations with OMB about the need for a supplemental to continue this work on PPE, therapeutics, diagnostics, vaccines, and federal and state response efforts. Those conversations continued, on an essentially daily basis, throughout February.
We also found funding available in advance of the supplemental. On February 2, I notified Congress of the intent to use my transfer authority to repurpose flexible funds for the response, which we spent throughout that month. We also used existing funds to start partnerships like the one I mentioned with Regeneron, but the supplemental funds passed by Congress in March were essential to continuing and expanding the early investments we needed.
As I mentioned earlier, CDC began briefings on the novel coronavirus on January 17, before China had even confirmed human-to-human transmission. Those CDC-led briefings continued throughout January and February.
The first HHS-wide briefing we held was on January 28, where I was joined by Dr. Redfield, Dr. Fauci, and Dr. Nancy Messonnier, CDC's top respiratory diseases expert.
The focus of that briefing was the radical transparency I mentioned: We were clear with the American people that we faced a potentially serious threat, that we were willing to admit uncertainty about the virus, and that there was much we didn't know.
In each briefing I held at HHS, I was joined by these scientists and doctors. This has always been my approach to public health communications: Ensure that I have clinical or public health experts with me when addressing public health issues. I learned this lesson vividly in the Bush Administration when my boss and friend, then-Secretary Thompson, accidentally speculated about the potential origins of the first anthrax case.
At that first briefing, at a time when we had just 5 confirmed cases in the United States and fewer than 100 around the world outside of China, I said, quote, "Americans should know that this is a potentially very serious public health threat." But we also said, reflecting public health practices and our best understanding of the situation, that Americans should not worry for their own safety at that time. My messaging was always in lockstep with that of Drs. Fauci, Redfield, Messonnier, and Schuchat.
As the virus spread around the world and began to take a foothold here in the United States, we were clear with the American people about what we knew, as soon as we knew it. Throughout January and February, there was no immediate threat to the general American public—but, as Dr. Messonnier said on January 31, we were, quote, "preparing as if this were the next pandemic, but…hopeful still that this is not and will not be the case."
The crucial shift we planned would be from containment measures, aimed to keep the virus out of the United States, to mitigation measures, like school closures, that were intended to slow community spread. On February 5, CDC's telebriefing noted that we might need broader measures to mitigate the spread of the virus in the United States.
On February 14, Dr. Redfield reiterated that we were in containment mode, but that we expected the virus would gain a foothold and we would see community-based transmission.
Since January, we had been working to determine what the triggers would be for moving from one stage of the pandemic plan to the next, and the need for these triggers was becoming clear in mid-February. So, in late February, the White House task force conducted a tabletop exercise with HHS support, to rehearse the escalation through further stages of the pandemic plan.
At that meeting, we determined that community spread of the disease in more than one community was likely—the stage at which we would shift to mitigation measures. We prepared to meet with the President on the evening of February 26, after he returned from a trip to India, to secure his agreement to this escalation of response and new, focused community mitigation measures.
In a February 25 press briefing, I noted that there was now community transmission in a number of countries, including outside of Asia, which was deeply concerning, and I shared that we had begun working closely with state, local, and private sector partners to prepare for mitigation.
We had already begun to set up plans for targeted community mitigation in areas like Seattle, Santa Clara County, and New York City, where the virus had likely begun to spread more widely.
You may remember that, on February 25, in the daily CDC telebriefing, Nancy Messonnier noted that community mitigation measures were in our future, and would include steps like school closures. Certainly, the stock market took notice.
This was exactly what the task force had determined on February 21, but she got a little ahead of the briefing of the President and the official announcement. But she and we were correct, as on February 28, we confirmed the first community spread of the disease in the United States.
By this time, speculation regarding the need for stronger White House coordination and full-time White House leadership had escalated. I fully supported the notion that the White House needed a coronavirus czar or coordinator who could pull together a whole of government approach, as a full-time job, as opposed to just running the task force meetings.
That evening, the President announced that the Vice President would become the White House leader of the Task Force and response, replacing the Chief of Staff.
On March 6, the President signed the first emergency supplemental. Before we had this funding, in late February, ASPR had already begun planning to work with large American clothing companies to make hundreds of millions of sterile cloth masks that could help meet demand. On March 4, anticipating those funds to come, we announced a procurement for half a billion N95 respirators, driving production even higher than it had been. None of this would have been possible without the foundational work with vendors and pre-procurement activities we had led starting back in January.
On March 16, the President announced nationwide mitigation recommendations, the 15 days to slow the spread. That same day, the first vaccine against the coronavirus entered clinical trials, the fastest ever, thanks to the work done in January at NIH and at BARDA.
The work we did throughout those two months bought us valuable time in slowing the spread. It gave us two crucial months to start the development of vaccines and therapeutics and begin working with American manufacturers of PPE.
Today, even as we face daunting levels of cases and deaths in many parts of the country, we have made real progress. That work in January and February is the reason that we now have hundreds of thousands of safe and effective vaccines being administered to Americans every day—which is the reason that we have so much hope this year.
Because of the heroic efforts of Americans from every walk of life—from scientists and public health professionals who've worked so much overtime, to healthcare providers who haven't had a day off in months, to ordinary people making sacrifices to protect loved ones—we will get through this crisis and we will defeat this virus. Thank you for what every one of you has done to support our response so far, and know that, because of your efforts, victory is in sight. Thank you.
