Dr. Harold Bornstein should have been our first clue that President Donald Trump might not fully respect what physicians do. Yet, here we are, on the cusp of a risky “reopening” of our country’s social and economic life, hoping that physicians and scientists are driving federal policy.
Among other things, Trump has used his daily COVID-19 press events to launch new attacks on American journalists, oversell the prospects of untested treatments he claimed might help COVID-19 patients, and misrepresent the possibility that a vaccine would soon be available. Trump’s occasional reminders that he is “not a doctor” were of little solace.
Throughout the pandemic, many Americans have been buoyed by the thought that competent professionals with fidelity to available scientific evidence were working in the background in the White House. As Coronavirus Response Coordinator, Dr. Deborah Birx brought a glimmer of professionalism to the administration’s otherwise maddening daily COVID-19 press events.
Then came the disinfectants.
As we all know, on April 23, the U.S. President publicly wondered about the possibility that Americans might inject disinfectants into their veins:
THE PRESIDENT: Right. And then I see the disinfectant, where it knocks it out in a minute. One minute. And is there a way we can do something like that, by injection inside or almost a cleaning. Because you see it gets in the lungs and it does a tremendous number on the lungs. So it would be interesting to check that. So, that, you’re going to have to use medical doctors with. But it sounds — it sounds interesting to me.
So we’ll see. But the whole concept of the light, the way it kills it in one minute, that’s — that’s pretty powerful.
Trump would later say he was being sarcastic (readers can decide for themselves), but the comments were said with such seriousness, on a supposedly serious public stage, such that public health officials around the nation, as well as disinfectant companies such as Lysol, issued statements reminding Americans that it is never safe to put disinfectants in their bodies. There were multiple reports of Americans dying from ingesting disinfectants over the subsequent 24 hours.
The comments are well-known, and I quote them not to rehearse familiar outrage, but to raise a different question: What do we expect from physicians serving this or any administration in the face of such dangerous comments? My primary concern is with Birx, since she heads up the COVID-19 taskforce.
Asked by CNN’s Jake Tapper if she was bothered “as a doctor” by the dangerous “musings” the president had offered on national television, Birx responded, “It bothers me that this is still in the news cycle.”
This is Trumpology 101. When in doubt, blame the media.
Birx has increasingly failed to speak as a physician. Instead of working behind the scenes to keep the president from issuing poorly-informed orders, which would be a service to the public, she appears now to be serving as a buffer between the president and the public, which is a service to the president. As a result, her voice has diminished at a critical moment in our national policymaking.
Even as we celebrate the heroic work health care workers are doing around the nation, Americans are increasingly inured to seeing physicians fall short of their Hippocratic charge. After all, just as Birx was becoming a household name, new light was cast on the indefensible opportunism of television’s Dr. Mehmet Oz, who wondered aloud whether “the opening of schools,” which “may only cost us 2 to 3% in terms of total mortality…might be a trade-off some folks would consider.” Like Trump, Oz subsequently walked the comments back. He claimed to have misspoken, but it was hardly believable.
Birx’s drift is different. Unlike Oz, a charlatan who has long capitalized on his fame to advocate for (and benefit financially from) unfounded treatments, Birx is an accomplished and highly-respected physician-scientist. An expert on HIV/AIDS immunology, vaccine research, and global health, among other things, Birx led one of the most important and formative HIV/AIDS vaccine trials in history. Birx served as Director of the Centers for Disease Control’s Division of Global HIV/AIDS for almost a decade, and has by any measure attained the highest levels of scientific and public health achievement.
Which, again, is what makes this hard to watch.
Leaders, from mayors to governors to presidents, need to surround themselves with advisors who possess a steely fidelity to science, and then — and here’s the crucial part — listen to those advisors. For example, in Ohio, Gov. Mike DeWine has largely deferred to Dr. Amy Acton, Director of the Ohio Department of Health, on health matters, thereby allowing her to do…her job. On days when Director Acton is not present at the governor’s daily briefings, there is a notable nervousness around Ohio. Many Ohioans see Acton’s presence on the stage as a reassurance that evidence-based public health thinking, and not capitulation to protests or even anxiousness, is driving decisions made by the DeWine administration.
To be sure, at this time, there are cracks in Ohio’s confidence that fidelity to science will be maintained under immense political pressure to reopen. For example, if appears that DeWine’s about-face on wearing masks was a result of pressure from Republican lawmakers. But, on balance, so far, Ohio has done better than most.
It’s notable in our current political culture that DeWine has treated his health director with respect, affording her a prominent role in his administration. Acton’s experience and knowledge are being deployed in a serious manner. And the visuals are important: there is Acton, in her white coat, a picture of authority. And there is DeWine, listening to her and not reinterpreting her words to fit his agenda.
Contrast this with the role that Birx has been afforded in the Trump administration. Birx dispenses expert knowledge in one moment, only to have the President — who reminds us he is “not a doctor” — mansplain to the public what he thinks he heard her say. More times than not, what he says he heard is not what she said, but rather a spin that fits the president’s agenda. And finally, gender is critical here. While much has been said of Birx’s seemingly endless supply of fashionable scarves, it is unthinkable that Trump would allow Birx to wear a white coat. Imagine the optics.
These reflections present two possibilities. The first assumes that Birx is sitting in the wings, quietly directing the ship of state to safer waters, possibly in a way that we will never know. In this picture, an understandably exasperated Birx is operating out of civic obligation by holding her tongue, which makes her unfazed by the public perceptions that accompany her not speaking up when the president spews dangerous nonsense from the podium of the White House press room. But she is doing it for the good of the country, even at the expense of her own reputation.
A second possibility is that Birx is in fact enabling Trump and that no plan is being executed behind-the-scenes. In this case, in protecting the president from himself, Birx has violated both her Hippocratic and civic obligations, which is frustrating during normal times, but indefensible during a pandemic.
In medical education we teach students about the importance of doing what is right, even when it is hard. We counsel them to always put the health of patients and populations first. Sometimes this requires standing up to powerful people and institutions. We had another illustration of a failure along these lines when the Mayo Clinic allowed their policy of wearing masks to be shredded by a vice president whom they were apparently afraid to confront, and risking their patients’ health along the way. This is a dangerous trend.
As Coronavirus Response Coordinator, Birx is not only an expert, but a leader. Future health care professionals are watching to see if the celebrated admonition to “first, do no harm,” will hold. Subtle clarifications of the president’s dangerous words must sometimes give way to a higher stakes decision to tell the American people, with clarity and purpose what is happening in the White House. One hopes that Birx is carefully considering where she draws the line between serving her country, even at the risk of being ushered off the presidential stage, and complicity in a president’s dangerous words and deeds.
Dan Skinner is Associate Professor of Health Policy at Ohio University, located at the Heritage College of Osteopathic Medicine’s Dublin campus. He is the host of Prognosis Ohio, a health care podcast affiliated with the Central Ohio NPR station, WCBE. Follow Dan at @danielrskinner.