Inside the extraordinary effort to save Trump from COVID-19

This article is adapted from “Nightmare Scenario: Inside the Trump Administration’s Response to the Pandemic That Changed History,” which will be published June 29 by HarperCollins.

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Health and Human Services Secretary Alex Azar’s phone rang with an urgent request: Could he help someone at the White House obtain an experimental coronavirus treatment, known as a monoclonal antibody?

If Azar could get the drug, what would the White House need to do to make that happen? Azar thought for a moment. It was Oct. 1, 2020, and the drug was still in clinical trials. The Food and Drug Administration would have to make a “compassionate use” exception for its use since it was not yet available to the public. Only about 10 people so far had used it outside of those trials. Azar said of course he would help.

Azar wasn’t told who the drug was for but would later connect the dots. The patient was one of President Donald Trump’s closest advisers: Hope Hicks.

A short time later, FDA Commissioner Stephen Hahn received a request from a top White House official for a separate case, this time with even greater urgency: Could he get the FDA to sign off on a compassionate-use authorization for a monoclonal antibody right away? There is a standard process that doctors use to apply to the FDA for unapproved drugs on behalf of patients dealing with life-threatening illnesses who have exhausted all other options, and agency scientists review it. The difference was that most people don’t call the commissioner directly.

The White House wanted Hahn to say yes within hours. Hahn, who still did not know who the application was for, consulted career officials. The FDA needs to go by the book, the officials insisted. Hahn relayed the message back to the White House. They kept pressing him to effectively cut corners. No, we can’t do that, Hahn told them several times. We’re talking about someone’s life. We have to actually examine the application to make sure we’re doing it safely.

When Hahn later learned the effort was on behalf of the president, he was stunned. For God’s sake, he thought, it’s the president who’s sick, and you want us to bend the rules? Trump was in the highest-risk category for severe disease from COVID-19 - at 74, he rarely exercised and was considered medically obese. He was the type of patient with whom you would want to take every possible precaution. As it did with all compassionate-use applications, the FDA made a decision within 24 hours. Agency officials scrambled to figure out which company’s monoclonal antibody would be most appropriate given the clinical information they had, and selected the one from Regeneron, known simply as Regen-Cov.

A five-day stretch in October 2020 - from the moment White House officials began an extraordinary effort to get Trump lifesaving drugs to the day the president returned to the White House from the hospital - marked a dramatic turning point in the nation’s flailing coronavirus response. Trump’s brush with severe illness and the prospect of death caught the White House so unprepared that they had not even briefed Vice President Mike Pence’s team on a plan to swear him in if Trump became incapacitated.

For months, the president had taunted and dodged the virus, flouting safety protocols by holding big rallies and packing the White House with maskless guests. But just one month before the election, the virus that had already killed more than 200,000 Americans had sickened the most powerful person on the planet.

Trump’s medical advisers hoped his bout with the coronavirus, which was far more serious than acknowledged at the time, would inspire him to take the virus seriously. Perhaps now, they thought, he would encourage Americans to wear masks and put his health and medical officials front and center in the response. Instead, Trump emerged from the experience triumphant and ever more defiant. He urged people not to be afraid of the virus or let it dominate their lives, disregarding that he had had access to health care and treatments unavailable to other Americans.

It was, several advisers said, the last chance to turn the response around. And once the opportunity passed, it was the point of no return.

An ill president

The week leading up to Trump’s infection was frenzied, even by his standards. On Saturday, Sept. 26, he had hosted a party with scores of maskless attendees to announce Amy Coney Barrett as his pick for Supreme Court justice. The celebrations had continued indoors, where most people remained maskless. By that time, the virus was surging again, but Trump’s contempt for face coverings had turned into unofficial White House policy. He actually asked aides who wore them in his presence to take them off. If someone was going to do a news conference with him, he made clear that he or she was not to wear a mask by his side.

The day after the Supreme Court celebration, Trump had also hosted military families at the White House. At Trump’s insistence, few were wearing masks, but they were packed in a little too tight for his comfort. He wasn’t worried about others getting sick, but he did fret about his own vulnerability and complained to his staff afterward. Why were they letting people get so close to him? Meeting with the Gold Star families was sad and moving, he said, but added, “If these guys had COVID, I’m going to get it because they were all over me.” He told his staff that they needed to do a better job of protecting him.

Two days after that, he flew to Cleveland for the first presidential debate against his Democratic challenger, Joe Biden. Trump was erratic that whole evening, and he seemed to deteriorate as the night went on. The pundits’ verdicts were brutal.

Almost 48 hours later, Trump became terribly ill. Hours after his tweet announcing he and first lady Melania Trump had coronavirus infections, the president began a rapid spiral downward. His fever spiked, and his blood oxygen level fell below 94 percent, at one point dipping into the 80s. Sean Conley, the White House physician, attended the president at his bedside. Trump was given oxygen in an effort to stabilize him.

The doctors gave Trump an eight-gram dose of two monoclonal antibodies through an intravenous tube. That experimental treatment was what had required the FDA’s sign-off. He was also given a first dose of the antiviral drug remdesivir, also by IV. That drug was authorized for use but still hard to get for many patients because it was in short supply.

Typically, doctors space out treatments to measure a patient’s response. Some drugs, such as monoclonal antibodies, are most effective if they’re administered early in the course of an infection. Others, such as remdesivir, are most effective when they’re given later, after a patient has become critically ill. But Trump’s doctors threw everything they could at the virus all at once. His condition appeared to stabilize somewhat as the day wore on, but his doctors, still fearing he might need to go on a ventilator, decided to move him to the hospital. It was too risky at that point to stay at the White House.

Many White House officials and even his closest aides were kept in the dark about his condition. But after they woke up to the news - many of them were asleep when Trump tweeted at nearly 1 a.m. on Friday that he had the virus - Cabinet officials and aides lined up at the White House to get tested. A large number had met with him the previous week to brief him about various issues or had traveled with him to the debate.

It was unclear even to Trump’s closest aides just how sick he was. Was he mildly ill, as he and Conley were saying, or was he sicker than they all knew? Trump was supposed to join a call with nursing home representatives later that day as part of his official calendar. Officials had been scheduled to do it in person from the White House, but that morning they were informed the call would be done remotely. Trump’s aides insisted that he would still be on it.

As one aide waited in line for a coronavirus test, she saw Conley sprint out of his office with a panicked look. That’s strange, the aide thought. An hour or two later, officials were informed that Pence would be joining the nursing homes call. Trump couldn’t make it.

‘Like a miracle’

Trump’s condition worsened early Saturday. His blood oxygen level dropped to 93 percent, and he was given the powerful steroid dexamethasone, which is usually administered if someone is extremely ill (the normal blood oxygen level is between 95 and 100 percent). The drug was believed to improve survival in coronavirus patients receiving supplemental oxygen. The president was on a dizzying array of emergency medicines by now - all at once.

Throughout Trump’s time in the hospital, his doctors consulted with the medical experts on the White House coronavirus task force whom the president had long ago discarded. They talked to Hahn, National Institute of Allergy and Infectious Diseases Director Anthony Fauci and Centers for Disease Control and Prevention Director Robert Redfield, seeking input about his treatment.

Trump and his aides had ignored numerous warnings from the task force doctors that they were putting themselves and everyone in the West Wing at risk by their cavalier behavior. Over the past eight months, Trump had come dangerously close to the virus a number of times. Those repeated escapes had made the White House more careless, constantly tempting fate. Deborah Birx, the White House coronavirus task force coordinator, and Redfield wrote to top aides after every White House outbreak, warning them that 1600 Pennsylvania Avenue was not safe. Birx took her concerns to Pence directly. This is dangerous, she told him. If White House staff can’t or won’t wear masks, they need to be more than 10 feet away from one another. This is just too risky.

Their warnings had gone unheeded, and now some would pay a price. Trump hadn’t wanted to go to the hospital, but his aides had spelled out the choice: He could go to the hospital Friday, while he could still walk on his own, or he could wait until later, when the cameras could capture him in a wheelchair or gurney. There would be no hiding his condition then.

At least two of those who were briefed on Trump’s medical condition that weekend said he was gravely ill and feared that he wouldn’t make it out of Walter Reed. People close to Trump’s chief of staff, Mark Meadows, said he was consumed with fear that Trump might die.

It was unclear if one of the medications, or their combination, helped, but by Saturday afternoon Trump’s condition began improving. One of the people familiar with Trump’s medical information was convinced the monoclonal antibodies were responsible for the president’s quick recovery.

Throughout the day Saturday, Oct. 3, the restless Trump made a series of phone calls to gauge how his hospitalization was being received by the public. In all likelihood, the steroid he was taking had given him a burst of energy, though no one knew how long it would last. Perhaps buoyed by that, Trump continued to post on Twitter from the hospital, anxious to convey that he was upright and busy. At one point Trump even called Fauci to discuss his condition and share his personal assessment of the monoclonal antibodies he had received. He said it was miraculous how quickly they made him feel much better.

“This is like a miracle,” Trump told his campaign adviser Jason Miller in another one of his calls from the hospital. “I’m not going to lie. I wasn’t feeling that great.”

Waiting for a sign

Redfield spent the weekend Trump was sick praying. He prayed the president would recover. He prayed that he would emerge from the experience with a newfound appreciation for the seriousness of the threat. And he prayed that Trump would tell Americans they should listen to public health advisers before it was too late. The virus had begun a violent resurgence. Redfield, Fauci, Birx and others felt they had limited time to persuade people to behave differently if they were going to avoid a massive wave of death.

There were few signs that weekend that Trump would have a change of heart. It had already been a battle to get him to agree to go to Walter Reed in the first place. Now, he was badgering Conley and others to let him go home early. Redfield heard Trump was insisting on being discharged and called Conley on the phone. The president can’t go home this early, Redfield advised the doctor. He was a high-risk patient, and there were no guarantees that he wouldn’t backslide or experience some complication. (Many COVID-19 patients seemed to be on an upswing and then quickly deteriorated.) Trump needed to stay in the hospital until that risk had passed. Conley agreed but said the president had made up his mind and couldn’t be convinced otherwise.

If they couldn’t keep him in the hospital, the advisers hoped that Trump would at least emerge from Walter Reed a changed man. Some even began mentally preparing to finally speak their minds. It would surely be the inflection point, they all thought. There’s nothing like a near-death experience to serve as a wake-up call. It was, at the end of the day, a national security failure. The president had not been protected. If this fiasco wasn’t the turning point, what would be?

Just as the country had been watching a few days before, many people tuned in again as Trump took Marine One back to the White House’s South Lawn on Monday night. They saw him step out in a navy suit, white shirt and blue-striped tie, with a medical mask on his face. He walked along the grass before climbing the steps to the Truman Balcony.

But Trump didn’t go inside. It was a moment of political theater too good to pass up - as suffused with triumph as his trip Friday had been humbling. He turned from the center of the balcony and looked back toward Marine One and the television cameras. It was clear that he was breathing heavily from the long walk and the climb up the flight of stairs.

Redfield was watching on television from home. He was praying as Trump went up the steps. Praying that he would reach the Truman Balcony and show some humility. That he would remind people that anyone could be susceptible to the coronavirus - even the president, the first lady and their son. That he would tell them how they could protect themselves and their loved ones.

But Trump didn’t waver. Facing the cameras from the balcony, he used his right hand to unhook the mask loop from his right ear, then raised his left hand to pull the mask off his face. He was heavily made up, his face more orange tinted than in the photos from the hospital. The helicopter’s rotors were still spinning. He put the mask into his right pocket, as if he was discarding it once and for all, then raised both hands in a thumbs-up. He was still probably contagious, standing there for all the world to see. He made a military salute as the helicopter departed the South Lawn, and then strode into the White House, passing staffers on his way and failing to protect them from the virus particles emitted from his nose and mouth.

Right then, Redfield knew it was over. Trump showed in that moment that he hadn’t changed at all. The pandemic response wasn’t going to change, either.