The U.S. was beset by denial and dysfunction as the coronavirus raged

https://www.washingtonpost.com/national-security/2020/04/04/coronavirus-government-dysfunction/?arc404=true

America Wasn't a Democracy, Until Black Americans Made It One ...

From the Oval Office to the CDC, political and institutional failures cascaded through the system and opportunities to mitigate the pandemic were lost.

By the time Donald Trump proclaimed himself a wartime president — and the coronavirus the enemy — the United States was already on course to see more of its people die than in the wars of Korea, Vietnam, Afghanistan and Iraq combined.

The country has adopted an array of wartime measures never employed collectively in U.S. history — banning incoming travelers from two continents, bringing commerce to a near-halt, enlisting industry to make emergency medical gear, and confining 230 million Americans to their homes in a desperate bid to survive an attack by an unseen adversary.

Despite these and other extreme steps, the United States will likely go down as the country that was supposedly best prepared to fight a pandemic but ended up catastrophically overmatched by the novel coronavirus, sustaining heavier casualties than any other nation.

It did not have to happen this way. Though not perfectly prepared, the United States had more expertise, resources, plans and epidemiological experience than dozens of countries that ultimately fared far better in fending off the virus.

The failure has echoes of the period leading up to 9/11: Warnings were sounded, including at the highest levels of government, but the president was deaf to them until the enemy had already struck.

The Trump administration received its first formal notification of the outbreak of the coronavirus in China on Jan. 3. Within days, U.S. spy agencies were signaling the seriousness of the threat to Trump by including a warning about the coronavirus — the first of many — in the President’s Daily Brief.

And yet, it took 70 days from that initial notification for Trump to treat the coronavirus not as a distant threat or harmless flu strain well under control, but as a lethal force that had outflanked America’s defenses and was poised to kill tens of thousands of citizens. That more-than-two-month stretch now stands as critical time that was squandered.

Trump’s baseless assertions in those weeks, including his claim that it would all just “miraculously” go away, sowed significant public confusion and contradicted the urgent messages of public health experts.

“While the media would rather speculate about outrageous claims of palace intrigue, President Trump and this Administration remain completely focused on the health and safety of the American people with around the clock work to slow the spread of the virus, expand testing, and expedite vaccine development,” said Judd Deere, a spokesman for the president. “Because of the President’s leadership we will emerge from this challenge healthy, stronger, and with a prosperous and growing economy.”

The president’s behavior and combative statements were merely a visible layer on top of deeper levels of dysfunction.

The most consequential failure involved a breakdown in efforts to develop a diagnostic test that could be mass produced and distributed across the United States, enabling agencies to map early outbreaks of the disease, and impose quarantine measure to contain them. At one point, a Food and Drug Administration official tore into lab officials at the Centers for Disease Control and Prevention, telling them their lapses in protocol, including concerns that the lab did not meet the criteria for sterile conditions, were so serious that the FDA would “shut you down” if the CDC were a commercial, rather than government, entity.

Other failures cascaded through the system. The administration often seemed weeks behind the curve in reacting to the viral spread, closing doors that were already contaminated. Protracted arguments between the White House and public health agencies over funding, combined with a meager existing stockpile of emergency supplies, left vast stretches of the country’s health-care system without protective gear until the outbreak had become a pandemic. Infighting, turf wars and abrupt leadership changes hobbled the work of the coronavirus task force.

It may never be known how many thousands of deaths, or millions of infections, might have been prevented with a response that was more coherent, urgent and effective. But even now, there are many indications that the administration’s handling of the crisis had potentially devastating consequences.

Even the president’s base has begun to confront this reality. In mid-March, as Trump was rebranding himself a wartime president and belatedly urging the public to help slow the spread of the virus, Republican leaders were poring over grim polling data that suggested Trump was lulling his followers into a false sense of security in the face of a lethal threat.

The poll showed that far more Republicans than Democrats were being influenced by Trump’s dismissive depictions of the virus and the comparably scornful coverage on Fox News and other conservative networks. As a result, Republicans were in distressingly large numbers refusing to change travel plans, follow “social distancing” guidelines, stock up on supplies or otherwise take the coronavirus threat seriously.

“Denial is not likely to be a successful strategy for survival,” GOP pollster Neil Newhouse concluded in a document that was shared with GOP leaders on Capitol Hill and discussed widely at the White House. Trump’s most ardent supporters, it said, were “putting themselves and their loved ones in danger.”

Trump’s message was changing as the report swept through the GOP’s senior ranks. In recent days, Trump has bristled at reminders that he had once claimed the caseload would soon be “down to zero.”

More than 7,000 people have died of the coronavirus in the United States so far, with about 240,000 cases reported. But Trump has acknowledged that new models suggest that the eventual national death toll could be between 100,000 and 240,000.

Beyond the suffering in store for thousands of victims and their families, the outcome has altered the international standing of the United States, damaging and diminishing its reputation as a global leader in times of extraordinary adversity.

“This has been a real blow to the sense that America was competent,” said Gregory F. Treverton, a former chairman of the National Intelligence Council, the government’s senior-most provider of intelligence analysis. He stepped down from the NIC in January 2017 and now teaches at the University of Southern California. “That was part of our global role. Traditional friends and allies looked to us because they thought we could be competently called upon to work with them in a crisis. This has been the opposite of that.”

This article, which retraces the failures over the first 70 days of the coronavirus crisis, is based on 47 interviews with administration officials, public health experts, intelligence officers and others involved in fighting the pandemic. Many spoke on the condition of anonymity to discuss sensitive information and decisions.

Scanning the horizon

Public health authorities are part of a special breed of public servant — along with counterterrorism officials, military planners, aviation authorities and others — whose careers are consumed with contemplating worst-case scenarios.

The arsenal they wield against viral invaders is powerful, capable of smothering a new pathogen while scrambling for a cure, but easily overwhelmed if not mobilized in time. As a result, officials at the Department of Health and Human Services, the CDC and other agencies spend their days scanning the horizon for emerging dangers.

The CDC learned of a cluster of cases in China on Dec. 31 and began developing reports for HHS on Jan. 1. But the most unambiguous warning that U.S. officials received about the coronavirus came Jan. 3, when Robert Redfield, the CDC director, received a call from a counterpart in China. The official told Redfield that a mysterious respiratory illness was spreading in Wuhan, a congested commercial city of 11 million people in the communist country’s interior.

Redfield quickly relayed the disturbing news to Alex Azar, the secretary of HHS, the agency that oversees the CDC and other public health entities. Azar, in turn, ensured that the White House was notified, instructing his chief of staff to share the Chinese report with the National Security Council.

From that moment, the administration and the virus were locked in a race against a ticking clock, a competition for the upper hand between pathogen and prevention that would dictate the scale of the outbreak when it reached American shores, and determine how many would get sick or die.

The initial response was promising, but officials also immediately encountered obstacles.

On Jan. 6, Redfield sent a letter to the Chinese offering to send help, including a team of CDC scientists. China rebuffed the offer for weeks, turning away assistance and depriving U.S. authorities of an early chance to get a sample of the virus, critical for developing diagnostic tests and any potential vaccine.

China impeded the U.S. response in other ways, including by withholding accurate information about the outbreak. Beijing had a long track record of downplaying illnesses that emerged within its borders, an impulse that U.S. officials attribute to a desire by the country’s leaders to avoid embarrassment and accountability with China’s 1.3 billion people and other countries that find themselves in the pathogen’s path.

China stuck to this costly script in the case of the coronavirus, reporting Jan. 14 that it had seen “no clear evidence of human-to-human transmission.” U.S. officials treated the claim with skepticism that intensified when the first case surfaced outside China with a reported infection in Thailand.

A week earlier, senior officials at HHS had begun convening an intra-agency task force including Redfield, Azar and Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases. The following week, there were also scattered meetings at the White House with officials from the National Security Council and State Department, focused mainly on when and whether to bring back government employees in China.

U.S. officials began taking preliminary steps to counter a potential outbreak. By mid-January, Robert Kadlec, an Air Force officer and physician who serves as assistant secretary for preparedness and response at HHS, had instructed subordinates to draw up contingency plans for enforcing the Defense Production Act, a measure that enables the government to compel private companies to produce equipment or devices critical to the country’s security. Aides were bitterly divided over whether to implement the act, and nothing happened for many weeks.

On Jan. 14, Kadlec scribbled a single word in a notebook he carries: “Coronavirus!!!”

Despite the flurry of activity at lower levels of his administration, Trump was not substantially briefed by health officials about the coronavirus until Jan.18, when, while spending the weekend at Mar-a-Lago, he took a call from Azar.

Even before the heath secretary could get a word in about the virus, Trump cut him off and began criticizing Azar for his handling of an aborted federal ban on vaping products, a matter that vexed the president.

At the time, Trump was in the throes of an impeachment battle over his alleged attempt to coerce political favors from the leader of Ukraine. Acquittal seemed certain by the GOP-controlled Senate, but Trump was preoccupied with the trial, calling lawmakers late at night to rant, and making lists of perceived enemies he would seek to punish when the case against him concluded.

In hindsight, officials said, Azar could have been more forceful in urging Trump to turn at least some of his attention to a threat that would soon pose an even graver test to his presidency, a crisis that would cost American lives and consume the final year of Trump’s first term.

But the secretary, who had a strained relationship with Trump and many others in the administration, assured the president that those responsible were working on and monitoring the issue. Azar told several associates that the president believed he was “alarmist” and Azar struggled to get Trump’s attention to focus on the issue, even asking one confidant for advice.

Within days, there were new causes for alarm.

On Jan. 21, a Seattle man who had recently traveled to Wuhan tested positive for the coronavirus, becoming the first known infection on U.S. soil. Then, two days later, Chinese authorities took the drastic step of shutting down Wuhan, turning the teeming metropolis into a ghost city of empty highways and shuttered skyscrapers, with millions of people marooned in their homes.

“That was like, whoa,” said a senior U.S. official involved in White House meetings on the crisis. “That was when the Richter scale hit 8.”

It was also when U.S. officials began to confront the failings of their own efforts to respond.

Azar, who had served in senior positions at HHS through crises including the 9/11 terrorist attacks and the outbreak of bird flu in 2005, was intimately familiar with the playbook for crisis management.

He instructed subordinates to move rapidly to establish a nationwide surveillance system to track the spread of the coronavirus — a stepped-up version of what the CDC does every year to monitor new strains of the ordinary flu.

But doing so would require assets that would elude U.S. officials for months — a diagnostic test that could accurately identify those infected with the new virus and be produced on a mass scale for rapid deployment across the United States, and money to implement the system.

Azar’s team also hit another obstacle. The Chinese were still refusing to share the viral samples they had collected and were using to develop their own tests. In frustration, U.S. officials looked for other possible routes.

A biocontainment lab at the University of Texas medical branch in Galveston had a research partnership with the Wuhan Institute of Virology.

Kadlec, who knew the Galveston lab director, hoped scientists could arrange a transaction on their own without government interference. At first, the lab in Wuhan agreed, but officials in Beijing intervened Jan. 24 and blocked any lab-to-lab transfer.

There is no indication that officials sought to escalate the matter or enlist Trump to intervene. In fact, Trump has consistently praised Chinese President Xi Jinping despite warnings from U.S. intelligence and health officials that Beijing was concealing the true scale of the outbreak and impeding cooperation on key fronts.

The CDC had issued its first public alert about the coronavirus Jan. 8, and by the 17th was monitoring major airports in Los Angeles, San Francisco and New York, where large numbers of passengers arrived each day from China.

In other ways, though, the situation was already spinning out of control, with multiplying cases in Seattle, intransigence by the Chinese, mounting questions from the public, and nothing in place to stop infected travelers from arriving from abroad.

Trump was out of the country for this critical stretch, taking part in the annual global economic forum in Davos, Switzerland. He was accompanied by a contingent of top officials including national security adviser Robert O’Brien, who took an anxious trans-Atlantic call from Azar.

Azar told O’Brien that it was “mayhem” at the White House, with HHS officials being pressed to provide nearly identical briefings to three audiences on the same day.

Azar urged O’Brien to have the NSC assert control over a matter with potential implications for air travel, immigration authorities, the State Department and the Pentagon. O’Brien seemed to grasp the urgency, and put his deputy, Matthew Pottinger, who had worked in China as a journalist for the Wall Street Journal, in charge of coordinating the still-nascent U.S. response.

But the rising anxiety within the administration appeared not to register with the president. On Jan. 22, Trump received his first question about the coronavirus in an interview on CNBC while in Davos. Asked whether he was worried about a potential pandemic, Trump said, “No. Not at all. And we have it totally under control. It’s one person coming in from China. . . . It’s going to be just fine.”

Spreading uncontrollably

The move by the NSC to seize control of the response marked an opportunity to reorient U.S. strategy around containing the virus where possible and procuring resources that hospitals would need in any U.S. outbreak, including such basic equipment as protective masks and ventilators.

But instead of mobilizing for what was coming, U.S. officials seemed more preoccupied with logistical problems, including how to evacuate Americans from China.

In Washington, then-acting chief of staff Mick Mulvaney and Pottinger began convening meetings at the White House with senior officials from HHS, the CDC and the State Department.

The group, which included Azar, Pottinger and Fauci, as well as nine others across the administration, formed the core of what would become the administration’s coronavirus task force. But it primarily focused on efforts to keep infected people in China from traveling to the United States even while evacuating thousands of U.S. citizens. The meetings did not seriously focus on testing or supplies, which have since become the administration’s most challenging problems.

The task force was formally announced on Jan. 29.

“The genesis of this group was around border control and repatriation,” said a senior official involved in the meetings. “It wasn’t a comprehensive, whole-of-government group to run everything.”

The State Department agenda dominated those early discussions, according to participants. Officials began making plans to charter aircraft to evacuate 6,000 Americans stranded in Wuhan. They also debated language for travel advisories that State could issue to discourage other travel in and out of China.

On Jan. 29, Mulvaney chaired a meeting in the White House Situation Room in which officials debated moving travel restrictions to “Level 4,” meaning a “do not travel” advisory from the State Department. Then, the next day, China took the draconian step of locking down the entire Hubei province, which encompasses Wuhan.

That move by Beijing finally prompted a commensurate action by the Trump administration. On Jan. 31, Azar announced restrictions barring any non-U.S. citizen who had been in China during the preceding two weeks from entering the United States.

Trump has, with some justification, pointed to the China-related restriction as evidence that he had responded aggressively and early to the outbreak. It was among the few intervention options throughout the crisis that played to the instincts of the president, who often seems fixated on erecting borders and keeping foreigners out of the country.

But by that point, 300,000 people had come into the United States from China over the previous month. There were only 7,818 confirmed cases around the world at the end of January, according to figures released by the World Health Organization — but it is now clear that the virus was spreading uncontrollably.

Pottinger was by then pushing for another travel ban, this time restricting the flow of travelers from Italy and other nations in the European Union that were rapidly emerging as major new nodes of the outbreak. Pottinger’s proposal was endorsed by key health-care officials, including Fauci, who argued that it was critical to close off any path the virus might take into the country.

This time, the plan met with resistance from Treasury Secretary Steven Mnuchin and others who worried about the impact on the U.S. economy. It was an early sign of tension in an area that would split the administration, pitting those who prioritized public health against those determined to avoid any disruption in an election year to the run of expansion and employment growth.

Those backing the economy prevailed with the president. And it was more than a month before the administration issued a belated and confusing ban on flights into the United States from Europe. Hundreds of thousands of people crossed the Atlantic during that interval.

A wall of resistance

While fights over air travel played out in the White House, public health officials began to panic over a startling shortage of critical medical equipment including protective masks for doctors and nurses, as well as a rapidly shrinking pool of money needed to pay for such things.

By early February, the administration was quickly draining a $105 million congressional fund to respond to infectious disease outbreaks. The coronavirus threat to the United States still seemed distant if not entirely hypothetical to much of the public. But to health officials charged with stockpiling supplies for worst-case-scenarios, disaster appeared increasingly inevitable.

A national stockpile of N95 protective masks, gowns, gloves and other supplies was already woefully inadequate after years of underfunding. The prospects for replenishing that store were suddenly threatened by the unfolding crisis in China, which disrupted offshore supply chains.

Much of the manufacturing of such equipment had long since migrated to China, where factories were now shuttered because workers were on order to stay in their households. At the same time, China was buying up masks and other gear to gird for its own coronavirus outbreak, driving up costs and monopolizing supplies.

In late January and early February, leaders at HHS sent two letters to the White House Office of Management and Budget asking to use its transfer authority to shift $136 million of department funds into pools that could be tapped for combating the coronavirus. Azar and his aides also began raising the need for a multibillion-dollar supplemental budget request to send to Congress.

Yet White House budget hawks argued that appropriating too much money at once when there were only a few U.S. cases would be viewed as alarmist.

Joe Grogan, head of the Domestic Policy Council, clashed with health officials over preparedness. He mistrusted how the money would be used and questioned how health officials had used previous preparedness funds.

Azar then spoke to Russell Vought, the acting director of the White House Office of Management and Budget, during Trump’s State of the Union speech on Feb. 4. Vought seemed amenable, and told Azar to submit a proposal.

Azar did so the next day, drafting a supplemental request for more than $4 billion, a sum that OMB officials and others at the White House greeted as an outrage. Azar arrived at the White House that day for a tense meeting in the Situation Room that erupted in a shouting match, according to three people familiar with the incident.

A deputy in the budget office accused Azar of preemptively lobbying Congress for a gigantic sum that White House officials had no interest in granting. Azar bristled at the criticism and defended the need for an emergency infusion. But his standing with White House officials, already shaky before the coronavirus crisis began, was damaged further.

White House officials relented to a degree weeks later as the feared coronavirus surge in the United States began to materialize. The OMB team whittled Azar’s demands down to $2.5 billion, money that would be available only in the current fiscal year. Congress ignored that figure, approving an $8 billion supplemental bill that Trump signed into law March 7.

But again, delays proved costly. The disputes meant that the United States missed a narrow window to stockpile ventilators, masks and other protective gear before the administration was bidding against many other desperate nations, and state officials fed up with federal failures began scouring for supplies themselves.

In late March, the administration ordered 10,000 ventilators — far short of what public health officials and governors said was needed. And many will not arrive until the summer or fall, when models expect the pandemic to be receding.

“It’s actually kind of a joke,” said one administration official involved in deliberations about the belated purchase.

Inconclusive tests

Although viruses travel unseen, public health officials have developed elaborate ways of mapping and tracking their movements. Stemming an outbreak or slowing a pandemic in many ways comes down to the ability to quickly divide the population into those who are infected and those who are not.

Doing so, however, hinges on having an accurate test to diagnose patients and deploy it rapidly to labs across the country. The time it took to accomplish that in the United States may have been more costly to American efforts than any other failing.

“If you had the testing, you could say, ‘Oh my god, there’s circulating virus in Seattle, let’s jump on it. There’s circulating virus in Chicago, let’s jump on it,’ ” said a senior administration official involved in battling the outbreak. “We didn’t have that visibility.”

The first setback came when China refused to share samples of the virus, depriving U.S. researchers of supplies to bombard with drugs and therapies in a search for ways to defeat it. But even when samples had been procured, the U.S. effort was hampered by systemic problems and institutional hubris.

Among the costliest errors was a misplaced assessment by top health officials that the outbreak would probably be limited in scale inside the United States — as had been the case with every other infection for decades — and that the CDC could be trusted on its own to develop a coronavirus diagnostic test.

The CDC, launched in the 1940s to contain an outbreak of malaria in the southern United States, had taken the lead on the development of diagnostic tests in major outbreaks including Ebola, zika and H1N1. But the CDC was not built to mass-produce tests.

The CDC’s success had fostered an institutional arrogance, a sense that even in the face of a potential crisis there was no pressing need to involve private labs, academic institutions, hospitals and global health organizations also capable of developing tests.

Yet some were concerned that the CDC test would not be enough. Stephen Hahn, the FDA commissioner, sought authority in early February to begin calling private diagnostic and pharmaceutical companies to enlist their help.

But when senior FDA officials consulted leaders at HHS, Hahn, who had led the agency for about two months, was told to stand down. There were concerns about him personally contacting companies regulated by his agency.

At that point, Azar, the HHS secretary, seemed committed to a plan he was pursuing that would keep his agency at the center of the response effort: securing a test from the CDC and then building a national coronavirus surveillance system by relying on an existing network of labs used to track the ordinary flu.

In task force meetings, Azar and Redfield pushed for $100 million to fund the plan, but were shot down because of the cost, according to a document outlining the testing strategy obtained by The Washington Post.

Relying so heavily on the CDC would have been problematic even if it had succeeded in quickly developing an effective test that could be distributed across the country. The scale of the epidemic, and the need for mass testing far beyond the capabilities of the flu network, would have overwhelmed Azar’s plan, which didn’t envision engaging commercial lab companies for up to six months.

The effort collapsed when the CDC failed its basic assignment to create a working test and the task force rejected Azar’s plan.

On Feb. 6, when the World Health Organization reported that it was shipping 250,000 test kits to labs around the world, the CDC began distributing 90 kits to a smattering of state-run health labs.

Almost immediately, the state facilities encountered problems. The results were inconclusive in trial runs at more than half the labs, meaning they couldn’t be relied upon to diagnose actual patients. The CDC issued a stopgap measure, instructing labs to send tests to its headquarters in Atlanta, a practice that would delay results for days.

The scarcity of effective tests led officials to impose constraints on when and how to use them, and delayed surveillance testing. Initial guidelines were so restrictive that states were discouraged from testing patients exhibiting symptoms unless they had traveled to China and come into contact with a confirmed case, when the pathogen had by that point almost certainly spread more broadly into the general population.

The limits left top officials largely blind to the true dimensions of the outbreak.

In a meeting in the Situation Room in mid-February, Fauci and Redfield told White House officials that there was no evidence yet of worrisome person-to-person transmission in the United States. In hindsight, it appears almost certain that the virus was taking hold in communities at that point. But even the country’s top experts had little meaningful data about the domestic dimensions of the threat. Fauci later conceded that as they learned more their views changed.

At the same time, the president’s subordinates were growing increasingly alarmed, Trump continued to exhibit little concern. On Feb. 10, he held a political rally in New Hampshire attended by thousands where he declared that “by April, you know, in theory, when it gets a little warmer, it miraculously goes away.”

The New Hampshire rally was one of eight that Trump held after he had been told by Azar about the coronavirus, a period when he also went to his golf courses six times.

A day earlier, on Feb. 9, a group of governors in town for a black-tie gala at the White House secured a private meeting with Fauci and Redfield. The briefing rattled many of the governors, bearing little resemblance to the words of the president. “The doctors and the scientists, they were telling us then exactly what they are saying now,” Maryland Gov. Larry Hogan (R) said.

That month, federal medical and public health officials were emailing increasingly dire forecasts among themselves, with one Veterans Affairs medical adviser warning, ‘We are flying blind,’” according to emails obtained by the watchdog group American Oversight.

Later in February, U.S. officials discovered indications that the CDC laboratory was failing to meet basic quality-control standards. On a Feb. 27 conference call with a range of health officials, a senior FDA official lashed out at the CDC for its repeated lapses.

Jeffrey Shuren, the FDA’s director for devices and radiological health, told the CDC that if it were subjected to the same scrutiny as a privately run lab, “I would shut you down.”

On Feb. 29, a Washington state man became the first American to die of a coronavirus infection. That same day, the FDA released guidance, signaling that private labs were free to proceed in developing their own diagnostics.

Another four-week stretch had been squandered.

Life and death

One week later, on March 6, Trump toured the facilities at the CDC wearing a red “Keep America Great” hat. He boasted that the CDC tests were nearly perfect and that “anybody who wants a test will get a test,” a promise that nearly a month later remains unmet.

He also professed to have a keen medical mind. “I like this stuff. I really get it,” he said. “People here are surprised that I understand it. Every one of these doctors said, ‘How do you know so much about this?’ ”

In reality, many of the failures to stem the coronavirus outbreak in the United States were either a result of, or exacerbated by, his leadership.

For weeks, he had barely uttered a word about the crisis that didn’t downplay its severity or propagate demonstrably false information. He dismissed the warnings of intelligence officials and top public health officials in his administration.

At times, he voiced far more authentic concern about the trajectory of the stock market than the spread of the virus in the United States, railing at the chairman of the Federal Reserve and others with an intensity that he never seemed to exhibit about the possible human toll of the outbreak.

In March, as state after state imposed sweeping new restrictions on their citizens’ daily lives to protect them — triggering severe shudders in the economy — Trump second-guessed the lockdowns.

The common flu kills tens of thousands each year and “nothing is shut down, life & the economy go on,” he tweeted March 9. A day later, he pledged that the virus would “go away. Just stay calm.”

Two days later, Trump finally ordered the halt to incoming travel from Europe that his deputy national security adviser had been advocating for weeks. But Trump botched the Oval Office announcement so badly that White House officials spent days trying to correct erroneous statements that triggered a stampede by U.S. citizens overseas to get home.

“There was some coming to grips with the problem and the true nature of it — the 13th of March is when I saw him really turn the corner. It took a while to realize you’re at war,” Sen. Lindsey O. Graham (R-S.C.) said. “That’s when he took decisive action that set in motion some real payoffs.”

Trump spent many weeks shuffling responsibility for leading his administration’s response to the crisis, putting Azar in charge of the task force at first, relying on Pottinger, the deputy national security adviser, for brief periods, before finally putting Vice President Pence in the role toward the end of February.

Other officials have emerged during the crisis to help right the United States’ course, and at times, the statements of the president. But even as Fauci, Azar and others sought to assert themselves, Trump was behind the scenes turning to others with no credentials, experience or discernible insight in navigating a pandemic.

Foremost among them was his adviser and son-in-law, Jared Kushner. A team reporting to Kushner commandeered space on the seventh floor of the HHS building to pursue a series of inchoate initiatives.

One plan involved having Google create a website to direct those with symptoms to testing facilities that were supposed to spring up in Walmart parking lots across the country, but which never materialized. Another centered an idea advanced by Oracle chairman Larry Ellison to use software to monitor the unproven use of anti-malaria drugs against the coronavirus pathogen.

So far, the plans have failed to come close to delivering on the promises made when they were touted in White House news conferences. The Kushner initiatives have, however, often interrupted the work of those under immense pressure to manage the U.S. response.

Current and former officials said that Kadlec, Fauci, Redfield and others have repeatedly had to divert their attentions from core operations to contend with ill-conceived requests from the White House they don’t believe they can ignore. And Azar, who once ran the response, has since been sidelined, with his agency disempowered in decision-making and his performance pilloried by a range of White House officials, including Kushner.

“Right now Fauci is trying to roll out the most ambitious clinical trial ever implemented” to hasten the development of a vaccine, said a former senior administration official in frequent touch with former colleagues. And yet, the nation’s top health officials “are getting calls from the White House or Jared’s team asking, ‘Wouldn’t it be nice to do this with Oracle?’ ”

If the coronavirus has exposed the country’s misplaced confidence in its ability to handle a crisis, it also has cast harsh light on the limits of Trump’s approach to the presidency — his disdain for facts, science and experience.

He has survived other challenges to his presidency — including the Russia investigation and impeachment — by fiercely contesting the facts arrayed against him and trying to control the public’s understanding of events with streams of falsehoods.

The coronavirus may be the first crisis Trump has faced in office where the facts — the thousands of mounting deaths and infections — are so devastatingly evident that they defy these tactics.

After months of dismissing the severity of the coronavirus, resisting calls for austere measures to contain it, and recasting himself as a wartime president, Trump seemed finally to succumb to the coronavirus reality. In a meeting with a Republican ally in the Oval Office last month, the president said his campaign no longer mattered because his reelection would hinge on his coronavirus response.

“It’s absolutely critical for the American people to follow the guidelines for the next 30 days,” he said at his March 31 news conference. “It’s a matter of life and death.”

 

 

 

 

The Navy Fired the Captain of the Theodore Roosevelt. See How the Crew Responded.

The Navy Fired Captain Crozier After His Letter on the Coronavirus ...

The rousing show of support provided another gripping scene to emerge from the coronavirus pandemic: the rank and file cheering a boss they viewed as putting their safety ahead of his career.

It was a send-off for the ages, with hundreds of sailors aboard the aircraft carrier Theodore Roosevelt cheering Capt. Brett E. Crozier, the commander who sacrificed his naval career by writing a letter to his superiors demanding more help as the novel coronavirus spread through the ship.

The rousing show of support provided the latest gripping scene to emerge from the coronavirus pandemic: the rank and file shouting their admiration for a boss they viewed as putting their safety ahead of his career.

The memes were quick to sprout on social media. On Reddit, one depicted Captain Crozier forced to choose between rescuing his career or his sailors from a burning building; he chooses his sailors. On Twitter, a slew of videos showed Captain Crozier’s walk down the gangway in Guam, most of them depicting him as a hero struck down by his superiors for trying to save the lives of his crew. “Wrongfully relieved of command but did right by sailors,” wrote Twitter user Dylan Castillo, alongside a video of Captain Crozier leaving his ship.

But in removing Captain Crozier from command, senior Navy officials said they were protecting the historic practice that complaints and requests have to go up a formal chain of command. They argued that by sending his concerns to 20 or 30 people in a message that eventually leaked to news organizations, Captain Crozier showed he was no longer fit to lead the fast-moving effort to treat the crew and clean the ship.

His removal from prestigious command of an aircraft carrier with almost 5,000 crew members has taken on an added significance, as his punishment is viewed by some in the military as indicative of the government’s handling of the entire pandemic, with public officials presenting upbeat pictures of the government’s response, while contrary voices are silenced.

The cheering by the sailors is the most public repudiation of military practices to battle the virus since the pandemic began. At the Pentagon, officials expressed concern about the public image of a Defense Department not doing enough to stay ahead of the curve on the virus.

Notably, the defense of the firing offered by senior Pentagon officials has centered around Captain Crozier not following the chain of command in writing his letter, which found its way to newspapers. In a circuitous explanation, Thomas B. Modly, the acting Navy secretary, said that Captain Crozier’s immediate superior did not know that the captain was going to write the letter, offering that act as an error in leadership and one of the reasons the Navy had lost confidence in the Roosevelt captain.

But a Navy official familiar with the situation but not authorized to speak publicly about it said that the captain had repeatedly asked his superiors for speedy action to evacuate the ship. His letter, the official said, came because the Navy was still minimizing the risk.

Mr. Modly insisted that his firing the captain for writing a letter asking for more help does not mean that subordinate officers are not allowed to raise criticisms and ask for assistance. “To our commanding officers,” Mr. Modly told reporters on Thursday, “it would be a mistake to view this decision as somehow not supportive of your duty to report problems, request help, protect your crews, challenge assumptions as you see fit.”

But the removal of Captain Crozier will likely have a chilling effect on the willingness of commanders to bring bad news to their superiors.

“There’s no question they had the authority to remove him,” Kathleen H. Hicks, a former top Pentagon official in the Obama administration, said in an email. “The issue is one of poor judgment in choosing to do so. They are fueling mistrust in leader transparency, among service members, families, and surrounding/hosting communities.”

 

 

 

Anthony Fauci’s security is stepped up as doctor and face of U.S. coronavirus response receives threats

https://www.washingtonpost.com/politics/anthony-faucis-security-is-stepped-up-as-doctor-and-face-of-us-coronavirus-response-receives-threats/2020/04/01/ff861a16-744d-11ea-85cb-8670579b863d_story.html?utm_campaign=wp_news_alert_revere&utm_medium=email&utm_source=alert&wpisrc=al_news__alert-hse–alert-national&wpmk=1

Nation's top coronavirus expert Dr. Anthony Fauci forced to beef ...

Anthony S. Fauci, the nation’s top infectious-diseases expert and the face of the U.S. response to the novel coronavirus pandemic, is facing growing threats to his personal safety, prompting the government to step up his security, according to people familiar with the matter.

The concerns include threats as well as unwelcome communications from fervent admirers, according to people with knowledge of deliberations inside the Department of Health and Human Services and the Department of Justice.

Fauci, 79, is the most outspoken member of the administration in favor of sweeping public health guidelines and is among the few officials willing to correct President Trump’s misstatements. Along with Deborah Birx, the coordinator for the White House’s task force, Fauci has encouraged the president to extend the timeline for social-distancing guidelines, presenting him with grim models about the possible toll of the pandemic.

“Now is the time, whenever you’re having an effect, not to take your foot off the accelerator and on the brake, but to just press it down on the accelerator,” he said Tuesday as the White House’s task force made some of those models public, warning of 100,000 to 240,000 deaths in the United States.

The exact nature of the threats against him was not clear. Greater exposure has led to more praise for the doctor but also more criticism.

Fauci has become a public target for some right-wing commentators and bloggers, who exercise influence over parts of the president’s base. As they press for the president to ease restrictions to reinvigorate economic activity, some of these figures have assailed Fauci and questioned his expertise.

Last month, an article depicting him as an agent of the “deep state” gained nearly 25,000 interactions on Facebook — meaning likes, comments and shares — as it was posted to large pro-Trump groups with titles such as “Trump Strong” and “Tampa Bay Trump Club.”

Alex Azar, the HHS secretary, recently grew concerned about Fauci’s safety as his profile rose and he endured more vitriolic criticism online, according to people familiar with the situation. In recent weeks, admirers have also approached Fauci, asking to him sign baseballs, along with other acts of adulation. It was determined that Fauci should have a security detail. Azar also has a security detail because he is in the presidential line of succession.

Asked Wednesday whether he was receiving security protection, Fauci told reporters, “I would have to refer you to HHS [inspector general] on that. I wouldn’t comment.”

The president interjected, saying, “He doesn’t need security. Everybody loves him.”

HHS asked the U.S. Marshals Service to deputize a group of agents in the office of the HHS inspector general to provide protective services for the doctor, according to an official with knowledge of the request.

The U.S. Marshals Service conveyed the request to the deputy attorney general, who has authority over deputations for the purpose of providing protective services, with the recommendation that it be approved, according to the official, who spoke on the condition of anonymity to reveal sensitive plans that the person was not authorized to discuss.

A Justice Department official signed paperwork Tuesday authorizing HHS to provide its own security detail to Fauci, according to an administration official.

An HHS spokesperson declined to discuss details of the doctor’s security but said: “Dr. Fauci is an integral part of the U.S. Government’s response against covid-19. Among other efforts, he is leading the development of a covid-19 vaccine and he regularly appears at White House press briefings and media interviews.”

At the briefings, Fauci, who has advised presidents of both parties as director of the National Institute of Allergy and Infectious Diseases, has spoken authoritatively about the spread of the coronavirus and the sacrifices involved in mitigating its effects.

He has at times corrected the president, in particular when prompted by reporters. After Trump said a covid-19 vaccine would be available in a couple of months, Fauci said it would in fact be available in about a year to a year and a half, at best.

His role has turned him into a hero for some. When he was absent from a briefing last month, followers who had grown accustomed to his frank assessments of the outbreak were alarmed that he might have been sidelined for his forthrightness. Many took to Twitter to ask, “Where is Dr. Fauci?” causing the question to trend on the platform.

He gained viral attention two days later when he placed his hand in front of his face in a gesture of apparent disbelief as Trump referred to the State Department as the “deep state department” from the White House briefing room.

Fauci has also given several interviews in which he has tempered praise for the president with doubts about his pronouncements, including about the viability of anti-malarial drugs as a treatment for the novel coronavirus. Most notably, he told the journal Science that he attempts to guide Trump’s statements but “can’t jump in front of the microphone and push him down.”

These moves have inspired fandom. But they have also drawn scorn from some of the president’s most vocal supporters, even as both men have sought to tamp down the appearance of tension.

“The president was right, and frankly Fauci was wrong,” Lou Dobbs said last week on his show on the Fox Business Network, referring to the use of experimental medicine.

Right-wing news and opinion sites have gone further, launching baseless smears against the doctor that have gained significant traction within pro-Trump communities online.

Outlets such as the Gateway Pundit and American Thinker seized on a 2013 email — released by WikiLeaks as part of a cache of communications hacked by Russian operatives — in which Fauci praised Hillary Clinton’s “stamina and capability” during her testimony as secretary of state before the congressional committee investigating the attacks in Benghazi, Libya.

The headline in the American Thinker referred to Fauci as a “Deep-State ­Hillary Clinton-loving stooge.” The author, Peter Barry Chowka, didn’t respond to requests for comment. When asked about the relevance of Fauci’s emails to his role in advising the White House’s coronavirus response, Jim Hoft, the editor of the Gateway Pundit, said, “I don’t have a problem with more information being shared about the doctor.”

The outlet has continued to criticize Fauci in recent days, saying that by offering new predictions about the possible death toll, Fauci and others were “going to destroy the U.S. economy based on total guesses and hysterical predictions.”

Several senior administration officials said that Trump respects Fauci and that the two generally have a good working relationship. Trump heeded the guidance of Fauci and Birx this week when he announced his administration would extend social-distancing guidelines for another 30 days. Last week, many health officials and experts grew worried when Trump said he hoped to reopen the country by Easter, even as coronavirus cases in the United States continue to rapidly climb.

The immunologist, who graduated first in his class from Cornell’s medical school, has been the director of the National Institute of Allergy and Infectious Diseases since 1984. Between 1983 and 2002, he was the 13th-most-cited scientist among the 2.5 million to 3 million authors worldwide and across all disciplines publishing in scientific journals, according to the Institute for Scientific Information.

 

 

 

The Lost Month: How a Failure to Test Blinded the U.S. to Covid-19

The Lost Month: How a Failure to Test Blinded the U.S. to Covid-19 ...

Aggressive screening might have helped contain the virus in the United States. But technical flaws, regulatory hurdles and lapses in leadership let it spread undetected for weeks.

Early on, the dozen federal officials charged with defending America against the coronavirus gathered day after day in the White House Situation Room, consumed by crises. They grappled with how to evacuate the United States consulate in Wuhan, China, ban Chinese travelers and extract Americans from the Diamond Princess and other cruise ships.

The members of the coronavirus task force typically devoted only five or 10 minutes, often at the end of contentious meetings, to talk about testing, several participants recalled. The Centers for Disease Control and Prevention, its leaders assured the others, had developed a diagnostic model that would be rolled out quickly as a first step.

But as the deadly virus spread from China with ferocity across the United States between late January and early March, large-scale testing of people who might have been infected did not happen — because of technical flaws, regulatory hurdles, business-as-usual bureaucracies and lack of leadership at multiple levels, according to interviews with more than 50 current and former public health officials, administration officials, senior scientists and company executives.

The result was a lost month, when the world’s richest country — armed with some of the most highly trained scientists and infectious disease specialists — squandered its best chance of containing the virus’s spread. Instead, Americans were left largely blind to the scale of a looming public health catastrophe.

The absence of robust screening until it was “far too late” revealed failures across the government, said Dr. Thomas Frieden, the former C.D.C. director. Jennifer Nuzzo, an epidemiologist at Johns Hopkins, said the Trump administration had “incredibly limited” views of the pathogen’s potential impact. Dr. Margaret Hamburg, the former commissioner of the Food and Drug Administration, said the lapse enabled “exponential growth of cases.”

And Dr. Anthony S. Fauci, a top government scientist involved in the fight against the virus, told members of Congress that the early inability to test was “a failing” of the administration’s response to a deadly, global pandemic. “Why,” he asked later in a magazine interview, “were we not able to mobilize on a broader scale?”

Across the government, they said, three agencies responsible for detecting and combating threats like the coronavirus failed to prepare quickly enough. Even as scientists looked at China and sounded alarms, none of the agencies’ directors conveyed the urgency required to spur a no-holds-barred defense.

Dr. Robert R. Redfield, 68, a former military doctor and prominent AIDS researcher who directs the C.D.C., trusted his veteran scientists to create the world’s most precise test for the coronavirus and share it with state laboratories. When flaws in the test became apparent in February, he promised a quick fix, though it took weeks to settle on a solution.

The C.D.C. also tightly restricted who could get tested and was slow to conduct “community-based surveillance,” a standard screening practice to detect the virus’s reach. Had the United States been able to track its earliest movements and identify hidden hot spots, local quarantines might have confined the disease.

Dr. Stephen Hahn, 60, the commissioner of the Food and Drug Administration, enforced regulations that paradoxically made it tougher for hospitals, private clinics and companies to deploy diagnostic tests in an emergency. Other countries that had mobilized businesses were performing tens of thousands of tests daily, compared with fewer than 100 on average in the United States, frustrating local health officials, lawmakers and desperate Americans.

Alex M. Azar II, who led the Department of Health and Human Services, oversaw the two other agencies and coordinated the government’s public health response to the pandemic. While he grew frustrated as public criticism over the testing issues intensified, he was unable to push either agency to speed up or change course.

Mr. Azar, 52, who chaired the coronavirus task force until late February, when Vice President Mike Pence took charge, had been at odds for months with the White House over other issues. The task force’s chief liaison to the president was Mick Mulvaney, the acting White House chief of staff, who was being forced out by Mr. Trump. Without high-level interest — or demands for action — the testing issue festered.

At the start of that crucial lost month, when his government could have rallied, the president was distracted by impeachment and dismissive of the threat to the public’s health or the nation’s economy. By the end of the month, Mr. Trump claimed the virus was about to dissipate in the United States, saying: “It’s going to disappear. One day — it’s like a miracle — it will disappear.”

By early March, after federal officials finally announced changes to expand testing, it was too late. With the early lapses, containment was no longer an option. The tool kit of epidemiology would shift — lockdowns, social disruption, intensive medical treatment — in hopes of mitigating the harm.

Now, the United States has more than 100,000 coronavirus cases, the most of any country in the world. Deaths are rising, cities are shuttered, the economy is sputtering and everyday life is upended. And still, many Americans sickened by the virus cannot get tested.

In a statement, Judd Deere, a White House spokesman, said that “any suggestion that President Trump did not take the threat of Covid-19 seriously or that the United States was not prepared is false.” He added that at Mr. Trump’s direction, the administration had “expanded testing capacities.”

Dr. Bruce Aylward, a senior adviser at the World Health Organization, led an expert team to China last month to research the mysterious new virus. Testing, he said, was “absolutely vital” for understanding how to defeat a disease — what distinguishes it from others, the spectrum of illness and, most important, its path through populations.

“You want to know whether or not you have it,” Dr. Aylward said. “You want to know whether the people around you have it. Because you know what? Then you could stop it.”

“You can’t stop it,” he warned, “if you can’t see it.”

The first time Dr. Robert Redfield heard about the severity of the virus from his Chinese counterparts was around New Year’s Day, when he was on vacation with his family. He spent so much time on the phone that they barely saw him. And what he heard rattled him; in one grim conversation about the virus days later, George F. Gao, the director of the Chinese Center for Disease Control and Prevention, burst into tears.

Dr. Redfield, a longtime AIDS researcher, had never run a government agency before his appointment to lead the C.D.C. in 2018. Until then, his biggest priorities had been fighting the opioid epidemic and the spread of H.I.V. Suddenly, a man who preferred treating patients in Haiti or Africa to being in the public glare was facing a new pandemic threat.

At first, Dr. Redfield’s agency moved quickly.

On Jan. 7, the C.D.C. created an “incident management system for the coronavirus and advised travelers to Wuhan to take precautions. By Jan. 20, just two weeks after Chinese scientists shared the genetic sequence of the virus, the C.D.C. had developed its own test, as usual, and deployed it to detect the country’s first coronavirus case.

“That’s our prime mission,” Dr. Redfield said later in an interview, “to get eyes on this thing.”

Assessing the virus would prove challenging. It was so new that scientists had little information to work with. China provided limited data, and rebuffed an early attempt by Mr. Azar and Dr. Redfield to send C.D.C. experts there to learn more. That the virus could cause no symptoms and still spread — something not initially known — made it all the more difficult to understand.

To identify the virus, the C.D.C. test used three small genetic sequences to match up with portions of a virus’s genome extracted from a swab. A German-developed test that the W.H.O. was distributing to other countries used just two, potentially making it less precise.

But soon after the F.D.A. cleared the C.D.C. to share its test kits with state health department labs, some discovered a problem. The third sequence, or “probe,” gave inconclusive results. While the C.D.C. explored the cause — contamination or a design issue — it told those state labs to stop testing.

The startling setback stalled the C.D.C.’s efforts to track the virus when it mattered most. By mid-February, the nation was testing only about 100 samples per day, according to the C.D.C.’s website.

Dr. Redfield played down the problem in task force meetings and conversations with Mr. Azar, assuring him it would be fixed quickly, several administration officials said.

With capacity so limited, the C.D.C.’s criteria for who was tested remained extremely narrow for weeks to come: only people who had recently traveled to China or had been in contact with someone who had the virus.

The lack of tests in the states also meant local public health officials could not use another essential epidemiological tool: surveillance testing. To see where the virus might be hiding, nasal swab samples from people screened for the common flu would also be checked for the coronavirus.

The C.D.C. announced a plan on Feb. 14 to perform the screening in five high-risk cities: New York, Chicago, Los Angeles, San Francisco and Seattle. An agency official said it could provide “an early warning signal to trigger a change in our response strategy.” But most of the cities could not carry it out.

“Had we had done more testing from the very beginning and caught cases earlier,” said Dr. Nuzzo, of Johns Hopkins, “we would be in a far different place.”

The consequences became clear by the end of February. For the first time, someone with no known exposure to the virus or history of travel tested positive, in the Seattle area, where the U.S.’s first case had been detected more than a month earlier. The virus had probably been spreading there and elsewhere for weeks, researchers later concluded. Without a more complete picture of who had been infected, public health workers could not do “contact tracing” — finding all those with whom any contagious people had interacted and then quarantining them to stop further transmission.

The C.D.C. gave little thought to adopting the test being used by the W.H.O. The C.D.C.’s test was working in its own lab — still processing samples from states — which gave agency officials confidence. Dr. Anne Schuchat, the agency’s principal deputy director, would later say that the C.D.C. did not think “we needed somebody else’s test.”

And the German-designed W.H.O. test had not been through the American regulatory approval process, which would take time.

Throughout February, Dr. Redfield shuttled between Atlanta, where the C.D.C. is based, and Washington, holding multiple calls every day with Mr. Azar and participating in the coronavirus task force.

Mr. Azar’s take-charge style contrasted with the more deliberative manner of Dr. Redfield, who lacked the kind of commanding television presence that impressed Mr. Trump. He was “a consensus person,” as one colleague described him, who sought to avoid conflict. He relied heavily on some of the C.D.C.’s career scientists, like Dr. Schuchat and Dr. Nancy Messonnier, the director of the agency’s National Center for Immunization and Respiratory Diseases.

Under scrutiny from Congress, Dr. Redfield offered reassurances. Responding on Feb. 24 to a letter from 49 members of Congress about the need for testing in the states, he wrote, “CDC’s aggressive response enables us to identify potential cases early and make sure that they are properly handled.”

Days later, his agency provided a workaround, telling state and local health department labs that they could finally begin testing. Rather than awaiting replacements, they should use their C.D.C. test kits and leave out the problematic third probe.

Meanwhile, the agency’s epidemiologists were growing more concerned as the virus spread in South Korea and Italy. On Feb. 25, Dr. Messonnier gave a briefing with a much blunter warning than usual. “Disruption to everyday life might be severe,” she said.

Mr. Trump, returning from a trip to India, was furious, according to senior administration officials. Later that day, Mr. Azar seemed to be tamping down the level of concern. All Dr. Messonnier had meant, he said at a news conference, was that people should “start thinking about, in their own lives, what that might involve.”

“Might,” Mr. Azar repeated emphatically. “Might involve.”

Dr. Stephen Hahn’s first day as F.D.A. commissioner came just six weeks before Mr. Azar declared a public health emergency on Jan. 31.radiation oncologist and researcher who helped turn around MD Anderson in Houston, one of the nation’s leading cancer centers, Dr. Hahn had come to Washington to oversee a sprawling federal agency that regulates everything from lifesaving therapies to dog food.

But overnight, his mission — to manage 15,000 employees in a culture defined by precision and caution — was upended. A pathogen that Mr. Trump would later call the “invisible enemy” was hurtling toward the United States. It would fall to the newly arrived Dr. Hahn to help build a huge national capacity for testing by academic and private labs.

Instead, under his leadership, the F.D.A. became a significant roadblock, according to current and former officials as well as researchers and doctors at laboratories around the country.

Private-sector tests were supposed to be the next tier after the C.D.C. fulfilled its obligation to jump-start screening at public labs. In other countries hit hard by the coronavirus, governments acted quickly to speed tests to their populations. In South Korea, for example, regulators in early February summoned executives from 20 medical manufacturers, easing rules as they demanded tests.

But Dr. Hahn took a cautious approach. He was not proactive in reaching out to manufacturers, and instead deferred to his scientists, following the F.D.A.’s often cumbersome methods for approving medical screening.

Even the nation’s public health labs were looking for the F.D.A.’s help. “We are now many weeks into the response with still no diagnostic or surveillance test available outside of C.D.C. for the vast majority of our member laboratories,” Scott Becker, chief executive of the Association of Public Health Laboratories, wrote to Mr. Hahn in late February. “We believe a more expeditious route is needed at this time.”

Ironically, it was Mr. Azar’s emergency declaration that established the rules Dr. Hahn insisted on following. Designed to make it easier for drugmakers to pursue vaccines and other therapies during a crisis, such a declaration lets the F.D.A. speed approvals that could otherwise take a year or more.

But the emergency announcement created a new barrier for hospitals and laboratories that wanted to create their own tests to diagnose the coronavirus. Usually, they faced minimal federal regulation. But once Mr. Azar took action, they were subject to an F.D.A. process called an “emergency use authorization.”

Even though researchers around the country quickly began creating tests that could diagnose Covid-19, many said they were hindered by the F.D.A.’s approval process. The new tests sat unused at labs around the country.

Stanford was one of them. Researchers at the world-renowned university had a working test by February, based on protocols published by the W.H.O. The organization had already delivered more than 250,000 of the German-designed tests to 70 laboratories around the world, and doctors at the Stanford lab wanted to be prepared for a pandemic.

“Even if it didn’t come, it would be better to be ready than not to be ready,” said Dr. Benjamin Pinsky, the lab’s medical director.

But in the face of what he called “relatively tight” rules at the F.D.A., Dr. Pinsky and his colleagues decided against even trying to win permission. The Stanford clinical lab would not begin testing coronavirus samples until early March, when Dr. Hahn finally relaxed the rules.

Executives at bioMérieux, a French diagnostics company, had a similar experience. The company makes a countertop testing system, BioFire, that is routinely used to check for the flu and other respiratory illnesses in 1,700 hospitals around the country. It can provide results in about 45 minutes.

“A lot of us said, you know, your typical E.U.A. is just much too demanding,” said Dr. Mark Miller, the company’s chief medical officer, referring to the emergency approval. “It’s going to take much too much time. And can’t you do something to shorten that?”

Officials at the F.D.A. tried to be responsive, Dr. Miller said. But rather than throw out the rules, the agency only modified the regulatory requirements, still requiring weeks of discussions and negotiations.

After conversations with the F.D.A. in mid-February, the company received emergency approval for its BioFire test on March 24. (The company also began talking to the F.D.A. in January about another type of test, but decided not to pursue it in the United States for now.) Dr. Miller said that while he was ultimately satisfied with the F.D.A.’s actions, the overall response by the government was too slow, especially when it came to logistical questions like getting enough testing supplies to those who needed them.

“You’ve got other countries — and I’m sorry, unfortunately, the U.S. is one of those — where they’ve been slow, disorganized,” he said. “There are still not enough tests available there to test everybody who needs it.”

In an emailed statement, Dr. Hahn maintained that his agency had moved as quickly as it safely could to ensure that tests would be accurate. “Since the early days of this pandemic,” he said, “the F.D.A.’s doors have always been and still remain open to test developers.”

Alex Azar had sounded confident at the end of January. At a news conference in the hulking H.H.S. headquarters in Washington, he said he had the government’s response to the new coronavirus under control, pointing out high-ranking jobs he had held in the department during the 2003 SARS outbreak and other infectious threats.

“I know this playbook well,” he told reporters.

A Yale-trained lawyer who once served as the top attorney at the health department, Mr. Azar had spent a decade as a top executive at Eli Lilly, one of the world’s largest drug companies. But he caught Mr. Trump’s attention in part because of other credentials: After law school, Mr. Azar was a clerk for some of the nation’s most conservative judges, including Justice Antonin Scalia of the Supreme Court. And for two years, he worked as Ken Starr’s deputy on the Clinton Whitewater investigation.

As Mr. Trump’s second health secretary, confirmed at the beginning of 2018, Mr. Azar has been quick to compliment the president and focus on the issues he cares about: lowering drug prices and fighting opioid addiction. On Feb. 6 — even as the W.H.O. announced that there were more than 28,000 coronavirus cases around the globe — Mr. Azar was in the second row in the White House’s East Room, demonstrating his loyalty to the president as Mr. Trump claimed vindication from his impeachment acquittal the day before and lashed out at “evil” lawmakers and the F.B.I.’s “top scum.”

As public attention on the virus threat intensified in January and February, Mr. Azar grew increasingly frustrated about the harsh spotlight on his department and the leaders of agencies who reported to him, according to people familiar with the response to the virus inside the agencies.

Described as a prickly boss by some administration officials, Mr. Azar has had a longstanding feud with Seema Verma, the Medicare and Medicaid chief, who recently became a regular presence at Mr. Trump’s televised briefings on the pandemic. Mr. Azar did not include Dr. Hahn on the virus task force he led, though some of the F.D.A. commissioner’s aides participated in H.H.S. meetings on the subject.

And tensions grew between the secretary and Dr. Redfield as the testing issue persisted. Mr. Azar and Dr. Redfield have been on the phone as often as a half-dozen times a day. But throughout February, as the C.D.C. test faltered, Mr. Azar became convinced that Dr. Redfield’s agency was providing him with inaccurate information about testing that the secretary repeated publicly, according to several administration officials.

In one instance, Mr. Azar appeared on Sunday morning news programs and said that more than 3,600 people had been tested for the virus. In fact, the real number was much smaller because many patients were tested multiple times, an error the C.D.C. had to correct in congressional testimony that week. One health department official said Mr. Azar was repeatedly assured that the C.D.C.’s test would be widely available within a week or 10 days, only to be given the same promise a week later.

Asked about criticism of his agency’s response to the pandemic, Dr. Redfield said: “I’m personally not focused on whether they’re pointing fingers here or there. We’re focused on doing all we can to get through this outbreak as quickly as possible and keep America safe.”

For all Mr. Azar’s complaints, however, he continued to defer to the scientists at the two agencies, according to several administration officials. Mr. Azar’s allies said he was told by Dr. Redfield and Dr. Fauci that the C.D.C. had the resources it needed, that there was no reason to believe the virus was spreading through the country from person to person and that it was important to test only people who met certain criteria.

But even in the face of a crescendo of complaints from doctors and health care researchers around the country, Mr. Azar failed to push those under him to do the one thing that could have helped: broader testing.

In a statement, Caitlin Oakley, Mr. Azar’s spokeswoman, said that the secretary had “empowered and followed the guidance of world-renowned U.S. scientists” on the testing issue. “Any insinuation that Secretary Azar did not respond with needed urgency to the response or testing efforts,” she said, “are just plain wrong and disproven by the facts.”

By Feb. 26, Dr. Fauci was concerned that the stalled testing had become an urgent issue that needed to be addressed. He called Brian Harrison, Mr. Azar’s chief of staff, and asked him to gather the group of officials overseeing screening efforts.

Around noon on Feb. 27, Dr. Hahn, Dr. Redfield and top aides from the F.D.A. and H.H.S. dialed in to a conference call. Mr. Harrison began with an ultimatum: No one leaves until we resolve the lag in testing. We don’t have answers and we need them, one senior administration official recalled him saying. Get it done.

By the end of the day, the group agreed that the F.D.A. should loosen regulations so that hospitals and independent labs could move forward quickly with their own tests.

But the evening before, Mr. Azar had been effectively removed as the leader of the task force when Mr. Trump abruptly put Mr. Pence in charge, a decision so last-minute that even the top health officials in the White House learned of it while watching the announcement.

Previous presidents have moved quickly to confront disease threats from inside the White House by installing a “czar” to manage the effort.

During an outbreak of the Ebola virus in 2014, President Barack Obama tapped Ron Klain, his vice president’s former chief of staff, to direct the response from the West Wing. Mr. Obama later created an office of global health security inside the National Security Council to coordinate future crises.

“If you look historically in the United States when it is challenged with something like this — whether it’s H.I.V. crises, whether it’s pandemic, whether it’s whatever — man, they pull out all the stops across the system and they make it work,” said Dr. Aylward, the W.H.O. epidemiologist.

But faced with the coronavirus, Mr. Trump chose not to have the White House lead the planning until nearly two months after it began. Mr. Obama’s global health office had been disbanded a year earlier. And until Mr. Pence took charge, the task force lacked a single White House official with the power to compel action.

Since then, testing has ramped up quickly, with nearly 100 labs at hospitals and elsewhere performing it. On Friday, the health care giant Abbott said it had received emergency approval for a portable test that could detect the virus in five minutes.

The president boasted on Tuesday that the United States had “created a new system that now we are doing unbelievably big numbers” of tests for the virus. The U.S., he said, had done more testing for the coronavirus in the last eight days than South Korea had done in eight weeks.

Yet hospitals and clinics across the country still must deny tests to those with milder symptoms, trying to save them for the most serious cases, and they often wait a week for results. In tacit acknowledgment of the shortage, Mr. Trump asked South Korea’s president on Monday to send as many test kits as possible from the 100,000 produced there daily, more than the country needs.

Public health experts reacted positively to the increased capacity. But having the ability to diagnose the disease three months after it was first disclosed by China does little to address why the United States was unable to do so sooner, when it might have helped reduce the toll of the pandemic.

“Testing is the crack that split apart the rest of the response, when it should have tied everything together,” said Dr. Nahid Bhadelia, ​the medical director of the Special Pathogens Unit at Boston University School of Medicine.

“It seeps into every other aspect of our response, touches all of us,” she said. “The delay of the testing has impacted the response across the board.”