Has Deborah Birx Crossed the Line?

What was the moment that might have permanently undermined the long and distinguished career of Deborah Birx, M.D., the coordinator of the U.S. global AIDS efforts who has suddenly turned into the response coordinator for the White House coronavirus task force?

Was it on March 13, when she praised President Trump for imposing travel restrictions on China that, to quote Aaron Rupar on Vox, “did nothing to stop the spread of the coronavirus that was already happening within America’s borders in a largely undetected manner because of lack of testing”?

Was it that same day, when—with Trump standing right alongside her at the podium—she praised him because he “quickly realized that our current approach to testing was inadequate” and “asked for an entire overhaul”—basically making it sound like Trump had swooped in, superhero-like, to swiftly fix a broken public health response?

Was it on March 18, when—with Trump again standing beside her—she said she found it “exciting ... to see this administration harness the full capacity of the private sector” in ramping up testing, when the administration has been widely criticized for not onboarding adequate testing back when they could have?

Was it on March 25, when, in an interview with Christian Broadcasting Network, she said that “[Trump is] so attentive to the scientific literature and the details and the data. I think his ability to analyze and integrate data that comes out of his long history in business has really been a real benefit”?

Or was it on March 26, when, echoing Trump, she said that there was no “evidence” that hospitals were facing a severe shortage of ventilators, despite frantic reports to the contrary from multiple frontline providers?

Much as with her longtime mentor and fellow White House COVID task force “adult in the room” Anthony Fauci, M.D.—whose role in the COVID pandemic response we profiled last week—Birx, whose medical career has moved from the military to the Centers for Disease Control and Prevention to U.S. Global AIDS Coordinator, has riveted national and global attention around a key question: Just how far can a respected scientific expert go in playing along with an egotistical, science-flouting president, in the broader name of the public good, before their involvement—not to mention their own personal credibility and legacy—starts to experience diminishing returns?

It’s a question asked with particular keenness by HIV/AIDS activists both in the U.S. and Africa who have known and respected Birx for years. Many now have mixed feelings about how far the legendarily pragmatic, diplomatic doctor will go to “stay in the room” alongside a president whose pronouncements on COVID—such as saying he wanted the U.S. economy up and running again by Easter—have been widely denounced as a danger to public health (the administration conceded this point and extended the social distancing guidelines until then end of April.).

“She’s in an awkward situation with her pedigree on the line, and I feel very, very sorry for her,” says Ken Mwehonge of the HIV/AIDS advocacy group HEPS Uganda, who has met with Birx annually the past several years as they coordinate the deployment of U.S. PEPFAR (the President’s Emergency Plan for AIDS Relief, a program started under President George W. Bush) funds to combat HIV/AIDS in key countries in Africa and elsewhere.

“But at a certain point, she has to stand her ground and stick to the science,” he adds.

Has she already compromised in that regard?

For Birx, a Strong Reputation Rooted in HIV/AIDS Leadership

Almost to a one, global AIDS activists in the U.S. and Africa describe Birx as a highly effective, detail-obsessed, relentlessly data-driven program coordinator who is not afraid to rub leadership in certain countries the wrong way if she feels that scientific evidence demands an abrupt course reversal in policy and programs.

“As far as I’m concerned, she’s been the best PEPFAR director we’ve had,” says Rev. Charles King, the CEO and cofounder of the New York City HIV services organization Housing Works, who was among HIV experts globally who together urged the Trump administration, when it came into power, not to fire Birx from the position as part of a general house-cleaning. (The administration apparently listened.) “She’s the first one who took seriously social determinants of health. I don’t always agree with her, but you can push back and if you provide data, she’ll listen and change her mind, and I think that’s good.”

In Africa, activists say that Birx has been keenly, substantially attuned to the input of so-called vulnerable “key populations”—usually MSM (men who have sex with men), transgender women, prisoners, drug users, and sex workers—as crucial stakeholders in turning around HIV stats in any given place.

“She’s always waiting to hear from individual communities and civil society [non-governmental advocacy groups],” says Richard Lusimbo of Sexual Minorities Uganda (SMUG), noting that Birx has overseen within PEPFAR a $100 million investment fund in the above-mentioned key populations. According to Lusimbo, at a 2019 meeting where he and other activists complained that members of key populations were operating below capacity, she said, “We’ve been talking about that and we haven’t seen results, and I think it’s very clear that these resources need to go directly to the community groups that represent the key populations, because they know what the issues are and they can help us get the program where it needs to go.”

That directive, says Lusimbo, forced in-country governments to be more responsive to groups they might otherwise marginalize, because there was a clear call from U.S. leadership to center them in the HIV-fighting process. Likewise, he says, Birx has made in-country PEPFAR top-tier leadership, which he says previously could be inaccessible, far more transparent and responsive with community groups.

Birx has also made PEPFAR countries set—and consequently meet—far more ambitious targets on rollout of things like PrEP, the HIV prevention pill, according to Mwehonge. “She set the bar much higher,” he says. “We started with a goal of 11,000 people on PrEP and now our target is 300,000, which has made us scale up rapidly.”

HIV treatment targets were similarly boosted in Uganda under Birx’s direction, according to Margaret Happy of International Community of Women Living with HIV Eastern Africa (ICWEA), based in Uganda. Due to a push from PEPFAR leadership under Birx, Ugandans on treatment went from about 372,000 in 2012 to about 566,000 in 2013—a one-year increase “more than any other country in the world.”

That’s according to Happy, who also says that Birx has been a staunch advocate for women and girls living with HIV in PEPFAR countries. “I remember when I criticized PEPFAR and other stakeholders for institutionalizing stigma and discrimination against adolescent girls and young women through the DREAMS intervention,” Happy said in an email, noting that the DREAMS program initially excluded HIV-positive girls and young women. “Ambassador Birx made a resolution that all programs for [girls and young women] should benefit both HIV-positive and negative young women and girls. The community of people living with HIV was thrilled by that decision.”

Birx Is Now in a Really Tough Spot

Birx, like Fauci, is widely hailed for having the diplomacy and charm to finesse different presidential administrations in order to keep on doing good work. Advocates say that her obsession with yielding good data in PEPFAR countries is part of how she has convinced the Trump administration, which is not wild about foreign humanitarian aid, to go on supporting PEPFAR, which enjoys broad bipartisan support.

But her scrupulousness is precisely what makes watching Birx flirt with misinformation in her fealty to Trump so painful for activists—at least some of whom are aware that coming down harder on her than Fauci runs the risk of a sexist double standard.

Says King, who mentions that he ran into Birx while out jogging in D.C. only a few weeks ago, right after she’d returned from South Africa to be COVID coordinator, “I don’t want to fall into some sort of sexist trope of criticizing her for being obsequious while Fauci is doing the same. They’re both kissing the ring and repeatedly telling the president how great he is.”

At the same time, Birx and Fauci are playing different roles and have different statuses. Although he technically serves at the pleasure of the president, Fauci, who is nearly 80, enjoys a certain degree of autonomy as the nation’s leading epidemics expert, built up over six presidential administrations dating back to Reagan. This gives him slightly more leeway to, say, put his palm over his face behind Trump when Trump invokes “the Deep State Department,” or, more importantly, to correct or contradict Trump’s underestimation of the scale of COVID—or Trump’s overestimation of possible treatments such as chloroquine plus azithromycin, in the absence of clinical data.

Birx, who is 63, is not as well known or trusted by the general public. And while Fauci’s job is to “be the expert,” which gives him that leeway to correct the president, Birx’s job is to coordinate the White House response—to somehow be the fixer between Trump’s desires and pronouncements and the medical truth on the ground—which is arguably tougher than Fauci’s.

At the same time, if one were keeping score as of today, March 29, it would appear that Birx has backed up, or at least tried to bring medical legitimacy to, the president’s remarks far more than Fauci, leading some to believe she deserves more critique.

Meanwhile, longtime HIV activist and Yale public health professor Gregg Gonsalves, Ph.D., has been coming down harder and harder on Birx. On March 28, after Birx said in a press conference that “almost 40% of the country” had “extraordinarily low numbers” of COVID cases, factcheck.org pointed out that “only 7.2% of the population lives in those states.” Gonsalves tweeted scathingly: “Dr. Birx, what the hell are you doing? What happened to you? Your HIV colleagues are ashamed.”

He’s not the only activist who feels torn between support and frustration for Birx right now. “It’s obvious that anyone in the presence of Trump must blow smoke up his ass before you can begin speaking the truth,” says longtime HIV activist Eric Sawyer. He adds that, due to his former role as a UNAIDS official, he sympathizes with anyone who must walk the line between public health goals and politics. “But there is a line, and when Birx starts praising Trump for his attentiveness to data and science, then she’s crossed it.”

King, on the other hand, distinguishes between what he calls the “harmless” flattery of praising the president’s “attention to detail,” which exists merely to grease his wheels, “and suggesting that we don’t need more ventilators,” or other remarks that fly directly in the face of lifesaving medical truth.

In fact, what is so interesting about watching Birx’s clip with the CBN reporter is that she uses her flattery about Trump’s “attention to detail” as a way to segue seamlessly into a public health point, “calling on every American, do that social distancing, because some might not know that they’re infected and unknowingly spreading the virus,” before she wraps up by bringing it back to the heroics of Trump.

Clearly and painfully, it’s not an easy line to walk. You can almost see Birx fretting that line herself during the CBN interview in the hand-clasping that’s become almost as familiar as her scarves. She must not only be thinking about her integrity and her legacy, but about the PEPFAR work she presumably wants to get back to when the COVID crisis settles down. Both U.S. and African activists working on PEPFAR don’t seem to want to lose her in that role. So she must also be thinking about how her current, too-close-for-comfort relationship with Trump is going to affect her day job—and a program relied on by countless people overseas.