Can Deborah Birx Save Us?

Her leadership of the U.S. effort to combat AIDS across the globe has been highly successful — and sometimes controversial. Will her data-driven approach work with covid-19?
Deborah Birx, the White House’s coronavirus response coordinator. (Jonathan Ernst/Reuters)

On Dec. 20, 2019, Deborah Birx’s annual holiday party was in full swing, and Birx, in a baby-blue Christmas sweater with sequined snowflakes circling the heads of polar bears, would not stop restocking the bar. She stood at her white kitchen island, piling bottles of seltzer and cans of soda into buckets of ice, then cracking open bottles of wine. “You know, you could hire a millennial to do this,” I noted. I’d wedged myself into a corner between the flat-screen TV and Birx’s husband, former Clinton advance man Paige Reffe. The world was simpler then. The gig economy was in swing, parties were still thrown, and Birx’s current job as the White House coronavirus coordinator didn’t yet exist. She was only the United States global AIDS coordinator, in charge of the American fight to try to end HIV.

“It’s important that I do this myself,” she told me. Her D.C. house was packed with people: staffers from Birx’s office with their families; Birx’s daughters, Devynn and Danielle; Danielle’s two young children, one of whom was often in the arms of either Birx or Reffe. “We do this to show love.”

By “we,” Birx meant herself and her longtime deputy, Angeli Achrekar. Together, they’d cooked the food for the party — ham, scalloped potatoes, string beans, Brussels sprouts salad — and risen at 6 a.m. to wrap silverware in gingham napkins tied off with twine. They finish each other’s sentences and thoughts with such ease and equity that it’s easy to forget who works for whom.

On Feb. 27, they started working separately for the first time in 15 years. That’s when Birx left a marathon meeting in Johannesburg of the President’s Emergency Plan for AIDS Relief, or PEPFAR, the massive global program she’s run for the past six years. Flying economy class, as she always does to save money for PEPFAR, she returned to Washington to take on the position of coronavirus response coordinator at the White House.

After years of looming large in the relatively insular world of international AIDS work, Birx is now on the global stage in an unprecedented way — joining the White House for its daily briefings, urging millennials to take precautions, explaining what she has figured out about different respirator masks. Each time she takes the stage alongside President Trump, she’s alternately pilloried and praised on social media for hanging tough through his freewheeling, fact-flouting remarks.

But while those encountering Birx for the first time are resorting to parsing the Morse code of her eye blinks, people who’ve worked with and watched her during her career fighting AIDS need no interpretation. When she’s working on a vital public health issue, Birx will do whatever is necessary, as long as she thinks she can make a difference. In the field of international AIDS, her leadership decisions have raised eyebrows, but they’ve also garnered respect and, in some quarters, admiration.

Her title is global AIDS ambassador, but that’s not a matter of rarefied diplomatic visits and photo ops with happy babies. It isn’t a job Angelina Jolie could fill. PEPFAR is a highly successful foreign-aid program because it is scrupulous about documenting and delivering its results to Congress and the president. Chief among these results is the number of people living with HIV the program identifies and treats. This is good for individual health, but it also prevents transmission. Imagine if covid-19, the disease caused by the coronavirus, could be vanquished only with lifelong treatment that has to be taken every day, without missing a dose. Imagine if, every year, securing the funding to fight the disease depended on being able to explain how many people you started on treatment, how many of them stayed on treatment and where the new infections were.

The best way to understand what Birx brings to the fight against covid-19 is to understand how she’s fought the battle against global AIDS. The fact that she’s a physician and a trained immunologist who has run vaccine trials is key, but so is her eye for detail, her willingness to take on scutwork, and her determination to stay on the job. She’s remained with PEPFAR even when some said she was compromising herself, and has gotten results, in terms of lives saved and infections averted. If she hadn’t had that experience, she might not have been prepared for this new role. Persisting in the face of criticism — some of it personal and deeply gendered — is part of the job description for much of her résumé. This time it could be her downfall, or it could be the country’s salvation.

Birx during a press briefing at the White House on March 18. (Alex Wong/Getty Images)

Do you want a piece of toast?” Birx asked me in late January, the last time I saw her in person. Impeachment and the outbreak in Wuhan, China, were on the crawl of the muted flat-screen TV; holiday decorations were still stacked on tables, waiting to be put away. I’ve known Birx for 20 years; as an HIV/AIDS activist and science writer, I started interviewing her back in 2000. For the past three years, I’ve been writing a book about the history of PEPFAR, interviewing Birx, Achrekar and more than a hundred people who’ve worked for or with PEPFAR in Washington and across Africa.

That day I’d returned to her house to talk to her husband, who was cleaning the filters for the HVAC system of their newly remodeled home. “It’s physics,” she said, when he mused about why one side of the house was dirtier than the other. She said something technical about airflow, then asked me if I wanted jam.

When Birx was announced as the White House coronavirus coordinator, the news release said she was a “scientist, physician and mom.” “Mom” might have made it into any news release about a high-profile woman, but for Birx, 63, it’s still a present occupation. Birx splits her time between the Northwest Washington house where she hosted the Christmas party — with its open floor plan and kitchen island facing a white sofa that could seat up to 12 people, it could be the tears-inducing renovation reveal on any HGTV show — and a house in Potomac, Md., that she shares with her daughter, son-in-law and two granddaughters under 2, along with her parents, both of whom are well into their 90s. She cooks the family’s meals for the week ahead, gets up with her daughter’s youngest baby. On Christmas Eve, she hosts a 24-hour buffet.

It’s a level of domesticity that’s made it into her public profile, at least in the AIDS world. She mentions her grandchildren in briefings; nearly 100 people enjoy the Christmas party and its homemade feast. Once, I told her that I’d heard, from multiple sources, that she puts up four Christmas trees. “Oh, it’s more than that,” she said. Birx knows that women don’t get to decide which details of their lives are used to define or diminish them. She doesn’t much care, either. What she does care about is getting the details right. (“Do they know we have a theme every year?” she said of her Christmas trees, swiping through the pictures on her phone. “It’s elephants.”) It’s an imperviousness to being underestimated that makes me wonder, sometimes, if only a woman could be doing the job she’s doing right now.

Persisting in the face of criticism — some of it personal and deeply gendered — is part of the job description for much of her résumé.

Birx graduated from high school at 16, got married and graduated from college at 20, finished medical school at 23 and had her daughters shortly after. She wanted to do her residency at Johns Hopkins University in Baltimore, but the school’s rotation schedule would have meant she never saw her then-husband, whose military scholarship meant he was doing his residency at the VA. So she entered the military system along with him. “I said, well, if you can’t get out, I have to go in,” she told me during a 2018 interview. That’s how she ended up, in 1980, at the Walter Reed Army Institute of Research. She got a uniform without doing basic training, but the olive drab wasn’t enough to make her fit in. “There were hardly any women. I mean, it was all male,” she said. During her immunology fellowship at the National Institutes of Health in the early 1980s, she met Anthony Fauci, now the head of the National Institute of Allergy and Infectious Diseases and the other star physician on the podium during the White House’s briefings on the outbreak. “I was just so stunned by his compassion for patients, and his encyclopedic knowledge, and his research,” she told me.

By the mid-1980s, a mysterious new disease had captured the attention of Fauci, Birx and others. On the weekends, Birx’s older daughter would sit on the floor of the lab, playing with the colored caps of sample tubes, while Birx cultured HIV.

In 1996, lifesaving medications called antiretrovirals changed the face of HIV in the United States. At the time, ARVs were still deemed, by the United States and other wealthy nations, too expensive and too complex to deliver in low-income countries, particularly in eastern and southern Africa, areas that were and are home to the majority of the global population of people living with HIV. That changed in 2003, when George W. Bush surprised all but a handful of insiders by announcing PEPFAR, the largest disease-specific foreign-aid program in American history.

Since 2014, Birx has been running the entire program, making her one of two Obama-era appointees to retain their position, as several stories have noted in recent weeks. PEPFAR has helped put more than 14 million people with HIV on antiretrovirals in more than 32 countries, changing the face of the AIDS epidemic from one of overflowing hospital wards to clinics filled with healthy people going about their daily lives.

PEPFAR’s structure is one of the keys to its success. Instead of nesting within the U.S. Agency for International Development, which does a lot of the development work most Americans think of when they imagine foreign aid, or at the Centers for Disease Control and Prevention, which fights epidemics, it sits at the State Department. The job comes with an ambassador-level title that empowers Birx to run the program as she sees fit.

After completing her training, Birx worked as a doctor in the military and continued her HIV research. From the military, Birx went to the CDC, heading its Global AIDS Program. At the CDC, epidemiologist Irum Zaidi, who would eventually join Birx at PEPFAR headquarters as a deputy coordinator for strategic use of data — and who has a ferocious command of detail herself — used to worry before progress-review meetings with Birx. “Without coffee, she’d be bubbly,” Zaidi recalled of Birx in a 2019 interview. “I was really anxious overall. I don’t know if I know all my data. She’s going to know something and I’m not going to know it.”

Birx pairs her eagle eye with strong convictions about what to do based on the data she’s looking at, whether that’s adjusting a target, swapping one PEPFAR grantee for another or altering a budget line. This approach hasn’t always been well received. In February, a report from the State Department’s Office of the Inspector General reviewed PEPFAR’s management processes and found that the majority of field staff didn’t feel they had much of a say in their annual plans. “In the last 2 years, there has been no negotiation [by headquarters] with the country [team working on PEPFAR],” one interviewee told the inspectors, adding that the office of the global AIDS coordinator “has set the targets using ... estimates. It is ‘take it or leave it.’ ” Other employees said PEPFAR management was “dictatorial,” “directive” and “autocratic.”

In the course of reporting my book on the history of PEPFAR, I’ve heard all of the characterizations that feature in the inspector general report, and many more. Often the criticisms take aim at Birx’s domesticity, her multitasking, her wardrobe — a classic tangled takedown of a powerful woman. But the AIDS world is as rich with loyalties as it is with rivalries, and no one I’ve spoken to for the PEPFAR history wants to go on record with their cavils about Birx in the midst of her work on the novel coronavirus.

What almost everyone does acknowledge is that she takes stands and acts out of conviction and principle, not ego. And she often gets results. Another finding of the OIG report was that the quarterly data reviews Birx and her team implemented are widely viewed as beneficial to the program’s functioning. Much of how you see Birx depends on how you feel about means vs. ends. Matthew Kavanagh, an AIDS activist and Georgetown professor, first encountered Birx during the Obama administration’s ill-fated attempt to cap the number of people PEPFAR was putting onto antiretrovirals. “There were many people who realized this was a very bad idea,” he says, “but Dr. Birx was one of the few people willing to go out on a limb.”

In 2014, PEPFAR had been flat-funded for four consecutive years by the Obama administration and was facing a financial cliff, with spending outpacing the program’s budget. “We needed somebody who was wicked smart and somebody who would not be afraid to act, who wouldn’t be afraid to make hard decisions and could do it quickly, because we were heading towards the iceberg and we didn’t have time to think about turning the wheel,” says Sandy Thurman, the “AIDS czar” under President Bill Clinton, who threw her valuable endorsement to Birx when candidates for the position were being considered, then joined her as a chief strategic adviser.

To turn things around, Birx told all of the 32 PEPFAR countries that they’d have to redo their annual operating plans, and began asking for more data about what was happening in each part of each nation — down to the district and even clinic level. She did a listening tour around the United States and, for a time, used maps in her legendarily comprehensive slide decks that showed HIV prevalence (the percent of people who have it) and incidence (the rate of new infections) from Oakland, Calif., alongside maps of Kenya. The idea was to show that HIV wasn’t everywhere, but in specific locations — and that’s where the money and resources needed to go.

At a March 23 covid-19 press briefing, Birx said: “You have to focus the resources, and the intervention … has to be tailored geographically.” That’s an evidence-based strategy the AIDS field had heard many times before. Birx’s approach to HIV, and almost certainly her approach to covid-19, is to know all of the data, and what that data means: whether an increase is related to an uptick in testing or something else, where there are worrying trends, where something might be working.

Birx’s notes during a press briefing on March 19. (Jabin Botsford/The Washington Post)

To fight an epidemic, you have to think big picture and super local. This is true for covid-19 and for AIDS. You also have to be able to make multiple agencies get in line, whether they like it or not. After all, public health overseas and in America is fragmented along institutional mandates and perceived areas of expertise and authority.

To overhaul PEPFAR’s approach, Birx dispensed with testing and treatment clinics that weren’t finding or treating substantial numbers of people living with HIV. If a testing program wasn’t diagnosing anybody with HIV, she wanted America to stop paying for it. To effect this shift, known within the AIDS world as “geographic prioritization,” she had to negotiate with country governments and U.S. partners. PEPFAR turned sites with few or no HIV tests over to national systems; meanwhile, American agencies, particularly USAID and the CDC, had to adjust their plans to PEPFAR’s new specifications. Since PEPFAR’s inception, USAID and the CDC have been engaged in often-venomous battles for the program’s money and resources; any time resources move around, tempers and turf battles flare.

Many people I’ve spoken to mark Birx’s arrival as the moment when the office of the global AIDS coordinator became more hands-on and hard-driving with PEPFAR’s participating nations — removing autonomy from both the Americans working on various countries’ programs and the governments of those countries. “When you take a situation and you withdraw power from the parties that are meant to be your partners, then you are directing the show, and that means that you’ve not even doubled your job — you’ve multiplied it beyond any comprehension,” one former PEPFAR staffer told me. Birx believes in the data above all and will point to PEPFAR’s performance as justification for her hard-driving approach. (When I wrote to thank her for the Christmas party — I’d wrangled an invitation after we talked about her tree habit — she sent me a graph of PEPFAR data by way of reply.)

Birx made all of these changes with Achrekar by her side or as her emissary in the field. When they were done, the program had balanced its books and set a course for reaching more people with treatment and prevention services every year, even as the funding has remained more or less the same. She’d corralled the CDC, USAID and the Department of Defense (all collaborators on PEPFAR work) into coordination and aligned them toward her targets.

She’d also become the most polarizing global AIDS ambassador in the program’s history. Her office routinely sets targets for countries that their programs do not meet, which the countries say isn’t a sign of bad performance, but of bad target setting. These varied expectations came up in the OIG report and are among the most frequent concerns I hear from program staff in PEPFAR countries. Yet the science, and many activists, say that in the absence of an HIV vaccine, an uncompromising commitment to finding people with HIV and starting them on treatment is essential to bringing the epidemic — now in its fourth decade — to an end. (The mixed reaction started early. In her first speech as head of PEPFAR at the annual meeting, she told the crowd to get ready to abandon work-life balance. Some people thought it was about time for a sense of urgency; others cried, according to four sources at the meeting.)

As divisive as she may be, Birx has been notably successful at remaining the public face of and champion for America’s war on AIDS in Africa, even managing to stay at PEPFAR’s helm after the 2016 presidential election. The PEPFAR head plays a critical role in rallying support in Congress and the White House for the program — and the outcomes of her work on this front speak for themselves. In 2018, Congress drafted legislation reauthorizing the program for another five years — as it did in 2008 and 2013. On Dec. 11, President Trump signed it into law, 12 days after Vice President Pence declared that PEPFAR was “inarguably one of the most successful investments in health care and humanitarian aid in American history.” Like every other federal agency, the Office of the U.S. Global AIDS Coordinator has had Trump administration political appointees involved in its day-to-day work, and, through it all, Birx and Achrekar have maintained the program’s focus on data, including a signature initiative aimed at reducing HIV risk among adolescent girls and young women.

In other words, Birx has significant political chops. And so, it’s not at all surprising to see her holding a placard about a Google virus-testing service that doesn’t actually exist, clasping her wrists with a church-choir grip while the President claims that more people will die from an economic slowdown than from a viral epidemic, or stepping away from the lectern when Fauci, standing behind her in a press briefing, rattles his pages because he has information he wants to interject. “He was my mentor,” she said that day, pressing her hand to the chest of her silver Nehru jacket. “I have to let him speak.”

Birx with Anthony Fauci during a press briefing on March 4. (Manuel Balce Ceneta/AP)

After Birx left the annual PEPFAR meeting in late February to return from South Africa to Washington, the discussions continued: Employees, government officials and activists — sequestered for 10- and 12-hour days — hammered out targets for finding new people living with HIV, preventing infections in adolescent girls and young women, and treating people with antiretrovirals. The notion that the fight against HIV in Africa would be curtailed or imperiled by covid-19 was far from anyone’s mind.

For the first several weeks of the outbreak, as attention leapfrogged from China to Seattle to Italy to New York, from Tom Hanks to Idris Elba, African countries remained on the margins. But on March 17, South African President Cyril Ramaphosa declared a “state of disaster,” and within 48 hours, the number of cases of community transmission had jumped — just the way it did in Seattle, New York and every other place on the terrifying roller coaster that is the covid-19 epidemic curve. Thirty-four African countries now have reported cases; South Africa has entered total lockdown. On March 19, the head of the World Health Organization, Tedros Adhanom Ghebreyesus, told Africa to “wake up.”

In many of these countries, rates of new HIV infections have dropped in recent years among the general population. In some places, they have also dropped among adolescent girls and young women, progress that PEPFAR attributes to a program called the DREAMS Partnership, which Birx and Achrekar started designing even before they arrived at the office of the global AIDS coordinator. They talked to everyone they could about what programs and services could be used to reduce the alarmingly high rates of HIV among young African women. The initiative they created put unprecedented resources toward girls and women, even though Republicans have policed PEPFAR’s payouts for such work since its inception, convinced that anything related to women’s health is code for abortion.

Birx believes in the data above all and will point to PEPFAR’s performance as justification for her hard-driving approach.

“PEPFAR stepped into the breach,” declared the Center for Health and Gender Equity (CHANGE), the leading reproductive health and rights advocacy group acting as a watchdog for PEPFAR. CHANGE is unflinching in its analysis of conservative restrictions on global health spending but has also found, in numerous field visits, that DREAMS is meeting many of its critical goals. In addition, infections have come down as a result of other strategies supported by PEPFAR, including expanded testing and treatment programs, pre-exposure prophylaxis (known as PrEP) and provision of voluntary medical male circumcision, a simple, one-time, risk-slashing procedure.

Now all of that progress, much of it paid for by American taxpayers, is imperiled by covid-19. Everything that’s required to curtail covid-19 also causes huge problems for people living with HIV, a chronic illness that requires a regular supply of medications to preserve health and eliminate the risk of onward transmission. Transportation bans or restrictions and overcrowded health facilities will make it harder for people living with HIV to get their drugs — a situation that already arose in Wuhan. People who stop treatment see their viral load rebound in weeks or even days. They become more likely to transmit the virus and more likely to fall sick. If they take fewer pills or share drugs with friends or family members, the virus can develop resistance, and new medications will be needed.

If testing and treatment hit snags, then incidence and drug resistance will rise — and the AIDS epidemic in the post-covid world will be worse than it was before. This will be true for many other health issues too, including tuberculosis, which goes hand in hand with HIV in many settings. For the past 12 years, HIV activists have had to continually re-litigate the case for HIV’s relatively sizable budget compared with that of other global health issues. While it’s hard to picture exactly what life will look like post-covid, it’s easy to imagine a diminishing appetite for fighting a single infectious disease that affects largely black and brown people, both in the United States and worldwide.

Winnie Byanyima, executive director of UNAIDS, the United Nations program on HIV/AIDS, forecasts a rollback in foreign spending on AIDS, just like there was after the 2008 financial crisis. This time, covid-19 could prompt a surge of funding to prevent the next global outbreak — which is needed, but not at the expense of the fight against AIDS. “There could be a divestment from one struggle that isn’t over yet; that would be a real mistake,” Byanima predicts. In the immediate term, UNAIDS is urging all countries to adopt “multi-month” prescriptions that will allow people living with HIV to get medications to cover an extended period of time.

With Birx’s new temporary role, she and Achrekar are physically split up, but they check in every day, with Achrekar keeping her mentor and boss apprised of the progress in the PEPFAR planning process that was underway in Johannesburg. “We are doubling down to protect the gains in the HIV response,” Achrekar told me via email, a few days before PEPFAR released guidance for all of its countries about how to adjust for the covid-19 response. They’re focusing on maintaining continuity of care for people on treatment, minimizing spread of covid-19, including by sharing the PEPFAR-supported lab capacity for testing, and protecting the U.S. staff and partners who work on the program every day. “We’re both moving very quickly, as we normally do,” Achrekar said of her and Birx.

If Birx’s experience with PEPFAR is, or should be, reassuring to the American public, her work on covid-19 is reassuring to many in Africa. When she was appointed, “we were happy, we were excited as advocates,” says Yvette Raphael, a South African AIDS activist. Having the PEPFAR head, who’s intimately aware of the ins and outs of every country’s treatment program, in charge of the coronavirus outbreak might just make the difference — for not just one epidemic but two. If Birx has her way, it will, no matter what that requires. “When I see something wrong, I just rail against it,” she once said to me, about her work with HIV. “I don’t really expect anything from anyone else that I wouldn’t do myself. I’m very careful that way. ... But I’m willing to do anything to change the course of this pandemic. I mean anything.”

Clarification: This story has been updated to attribute to PEPFAR the assertion that a PEPFAR program called the DREAMS Partnership is responsible for recent drops in rates of new HIV infections among adolescent girls and young women.

Emily Bass’s history of America’s war on AIDS in Africa will be published by PublicAffairs in 2021.

Photo editing by Dudley M. Brooks. Design by Christian Font.

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