The week America lost the fight against the new coronavirus, the nation’s premier health agency promised local officials it had the virus under control.
It was the third week in February. And senior leaders at the Centers for Disease Control and Prevention repeatedly brushed off calls to take COVID-19 more seriously.
They dismissed concerns from Minnesota to Hawaii that their plan to contain the outbreak by screening overseas travelers was riddled with inconsistencies.
They punted questions from state officials worried that returning travelers could spread the coronavirus when they showed no symptoms.
For days, they refused to test a California woman because she had not traveled overseas. When she tested positive, the CDC downplayed the fact that the patient – who would become known as Patient Zero – proved the virus was already spreading within the U.S.
Instead, CDC Director Dr. Robert Redfield went on national television and repeated seven times that the threat to the nation remained low.
“The American public needs to go on with their normal lives,” he said.
As the virus raced across America, state and local authorities sought help from the CDC, the $7 billion federal agency established to lead the nation through a pandemic like this.
Instead of answers, many received slow, confusing and conflicting information – or no response at all – a USA TODAY investigation has found. Reporters reviewed 42,000 pages of emails and memos obtained from local health departments and interviewed more than 100 community leaders and public health experts, including current and former CDC officials.
The agency has received widespread scrutiny for yielding to political pressure from the White House. But these interviews and records provide the most extensive look yet at how the CDC, paralyzed by bureaucracy, failed to consistently perform its most basic job: giving local public health authorities the guidance needed to save American lives during a pandemic.
Communities were left to make life-or-death decisions about testing, personal protection and reopening.
Local health officials flooded the CDC with hundreds of phone calls and emails. Many questions went unanswered. In other cases, the agency response amounted to you decide.
In Nevada, the state’s top infectious disease scientist called the CDC begging for a list of travelers coming from China. A flustered agency representative hung up on her.
In Kentucky, a CDC official recommended that visitors continue to be allowed into nursing homes because they might not get another chance to visit family members. In an email, he wrote: “Let people choose.”
Authorities in at least 13 states questioned CDC guidance that contradicted either scientific evidence or information put out by the CDC itself, records show. At times, rank-and-file CDC representatives, aware of their own leadership’s lagging response, told state health departments to consider adopting guidance from academic studies or other states.
Meanwhile, in more than two dozen press briefings, congressional hearings and other public statements between January and April, the CDC downplayed the potential harm from the virus.
In the most extreme cases, the CDC undermined local health officials advocating a more aggressive approach to control the spread.
The agency went so far as to edit a government science journal in late March to remove a Washington state epidemiologist’s call for testing throughout senior assisted-living facilities. “I would be careful promoting widespread testing,” the CDC editor noted, according to drafts obtained by USA TODAY.
The CDC declined to make senior leaders available for interviews and did not answer detailed questions about USA TODAY’s findings. In a statement emailed by CDC spokesman Tom Skinner, the agency said it has executed its mission to protect Americans and worked to support state and local health departments with accurate information.
“CDC has based decisions on known science and data available and has been clear that, as more became known about the virus, guidance and recommendations would evolve and change,” the statement said.
The pandemic has presented unprecedented challenges and many health officials told USA TODAY they were grateful for the CDC’s help. “CDC has been an incredible partner to us,” said Dr. Kathy Lofy, the health officer in Washington state.
The White House also handicapped the agency from the start. Last week, journalist Bob Woodward disclosed that President Donald Trump told him in early February that his administration knew the virus was spreading through the air and killing people at a higher rate than the flu, but Trump publicly minimized the risks.
Still, former CDC officers who held senior leadership roles under Republican and Democratic presidents told USA TODAY the agency that once commanded global respect collapsed just when local communities needed it most.
“They are incapable of responding to the emergency,” said Dr. Pierre Rollin, former deputy chief of a CDC branch on viral pathogens and one of the world’s most renowned infectious disease experts.
Nearly 200,000 have died of COVID-19 so far in the U.S., with more than 6.5 million infected. The CDC suspects 10 times more Americans have caught the virus, but official counts remain skewed by its inability to fix chronic testing issues.
Without a national plan to guide them, local authorities lost months debating whether to require face masks and when best to reopen businesses and schools.
Last month, the CDC abruptly reversed critical testing guidance for people exposed, saying those without symptoms did not need to be tested. Local health officials and even the staunchest CDC champions lambasted the move. Some states are choosing to ignore it.
The CDC’s own scientific advisors now fear the agency’s multiple failures since February have destroyed the public’s confidence, which will be crucial to successfully roll out a future vaccine.
“The leadership role of the CDC didn’t hold firm,” Dr. Brent Pawlecki, the chief health officer at Goodyear, told agency leaders in July as a panel of independent scientists reviewed the agency’s early response. “It has created a lot of confusion and unfortunately a lot of distrust.”
Cynthiana, Kentucky, a community of 6,400 residents without a four-lane road, took the CDC’s advice to continue life as normal.
No one paid much attention when the tenor with the best voice in the church choir called in sick after Sunday practice. Then, alto Julia Donohue’s migraine turned into a fever. The 28-year-old Walmart cake decorator, who liked to bake brownies for her church family, was airlifted to intensive care as her oxygen levels plunged.
Donohue’s positive test for COVID-19 was the first confirmed case in the state. Kentucky joined more than 20 states reporting their earliest brushes with coronavirus during the first week of March.
As Kentucky’s case count ballooned, so did the fallout from the CDC’s missteps.
The area’s highest elected official, Harrison County Judge Alex Barnett, spent the next two weeks on a lunch tour to support local businesses, visiting restaurants with his family. He snapped pictures posing with meals and posted them to Facebook to show people it was safe.
From the CDC’s news briefings, the new coronavirus – related to the viral family that causes the common cold – sounded like a concern mostly for America’s distant big cities.
In public statements, local leaders from Connersville, Indiana; Hudson, New York; and Winston-Salem, North Carolina, all repeated the CDC’s “low risk” talking points.
The Kentucky hospital where Donohue first went to the ER had received no urgent warnings about community spread. More than 50 hospital workers did not wear masks or other protective gear, already in short supply, when they came into close contact with her.
“I don’t think people understood,” Crystal Miller, health director for four counties in the area, told USA TODAY. “We didn’t know.”
For two weeks between when Donohue fell ill and when the governor shut down the state, Barnett, the judge, said he did not realize how much the small city of Cynthiana was at risk.
“I am no expert in health when it comes down to it. I am a farmer,” Barnett told USA TODAY. “I am an expert on growing cattle and tobacco. I rely on the CDC for guidance.”
Within weeks, the confirmed case count in the county, population 19,000, climbed to 11. An outbreak engulfed a nursing home.
Miller sent constant updates around the state about her area’s cases, tracking new information first on sticky notes and then a spreadsheet. She worked 15-hour days, responding to text messages from colleagues until 2 a.m.
In email exchanges, Kentucky officials questioned nonsensical directives from the CDC, such as to tell doctor offices when testing for coronavirus to make sure “the air does not mix with other air.”
“This is next to impossible for provider practices to accomplish,” Andrea Flinchum in Kentucky’s health department told the CDC in a March 10 email.
Later that month, Flinchum asked CDC headquarters for advice on when and how to reuse respirators. A local representative shared several studies, but more than a week went by without official word from the agency. “Waiting patiently to see this,” Flinchum wrote.
In another email exchange, Dr. Kevin Spicer, a federal CDC medical officer stationed in Kentucky, acknowledged that he had been waiting two weeks for the agency to update its guidance on when and how to release people with COVID-19 from hospitals and isolation.
Lacking anything official, Spicer shared a link to a Washington state document outlining more up-to-date practices. It was “not consistent with current CDC guidance,” he noted.
Long-term care facilities, especially vulnerable, became another point of confusion during the first wave of Kentucky’s outbreak in March. Matthew Penn, director of the CDC’s public health law program, told a lawyer in the state’s health department not to ban nursing home visitors outright.
“‘Persuasion by education’ strategy may work best,” he wrote in an email. “Let people choose.”
But two days later, Gov. Andy Beshear banned non-essential visits at nursing homes. Then, later that week, the Centers for Medicare and Medicaid Services, which regulates the facilities, advised nursing homes nationwide to do the same.
More than 2,600 nursing home residents have tested positive in Kentucky since March. At least 530 have died, according to CMS data. Across the country, more than 53,000 residents have died.
Dr. Muhammad Babar, a geriatrician at the University of Louisville advising the state on coronavirus care at long-term care facilities, told USA TODAY that following the CDC lawyer’s advice “would have resulted in a disaster.”
In its statement to USA TODAY, the CDC noted that the agency had sent approximately 1,300 public health experts to conduct more than 2,000 investigations in states to combat the pandemic. The agency said its guidance was tailored around keeping communities “informed of the evolving science and changes to guidance through routine, direct and transparent engagements.”
Kentucky’s first recognized victim, Donohue, recovered but still suffers from migraines and shortness of breath.
Another singer in her choir died after being infected with COVID-19. For that, Donohue carries guilt that she might have unwittingly spread disease.
“I thought I didn’t have to worry about a killer virus,” she told USA TODAY.
The CDC was created 75 years ago to fight malaria. Today, Americans pay billions for its protection against outbreaks of disease and chronic conditions.
Headquartered in Atlanta, removed from the direct line of politics, the federal agency employs thousands of public health experts, many embedded in local health departments. While not primarily a regulatory agency, its science guides national medical practice.
When the novel coronavirus surfaced last winter, the CDC spent weeks repeating assurances that the risk to Americans was low. Many local authorities, however, realized a crisis was coming – and that they were unprepared.
“I just can’t see how this outbreak will be contained,” the Nebraska state epidemiologist wrote on Jan. 23. “I think this is going to be a big pandemic.”
In Kansas, the health director wrote to his staff on Feb. 19: “Are we behind the power curve on planning?”
The CDC missed the early spread of the new coronavirus, blinded by its own decision to limit screening for the virus after its initial testing kit failed. That was one of the agency’s most consequential scientific errors.
In California, Solano County public health officer Dr. Bela Matyas, working alongside CDC experts, had seen how people without symptoms could spread the disease in February, at an early quarantine site at Travis Air Force Base.
He said it was clear the agency’s travel screenings focused on obvious symptoms like fever were not going to work.
“By definition, it was going to be a failure,” Matyas told USA TODAY.
The agency’s own director of global migration and quarantine knew it, too. Dr. Martin Cetron called the airport temperature screening a “poorly designed control and detection strategy” in internal emails later in the spring, resisting White House pressure to revive the program.
Local health authorities trying to protect their communities pushed the CDC to loosen its restrictions on early testing.
The CDC controlled the nation’s first tests for COVID-19. Supplies were limited, and the agency designed restrictive testing guidelines. Fever and respiratory illness were not enough. The person had to have traveled to China or had contact with someone with a confirmed case.
Public health experts, including former CDC officials, have accused the agency of creating guidelines on crucial measures like testing based on supply shortages, not science.
“We were told you don’t need to be tested unless you have symptoms. That’s stupid and it’s always been stupid,” Dr. Jim Curran, an epidemiologist at Emory University who previously led the CDC’s research into HIV for 15 years, told USA TODAY. “Policy shouldn’t be based on scarcity.”
One hospital in Seattle, the site of the first major U.S. outbreak, used paper and some spare space at the nurse’s station to track changes to the CDC testing guidance that often came unannounced and without clarifications, emergency room physician Dr. Sachita Shah told USA TODAY.
They taped paper after paper onto a computer monitor. The CDC told the hospital to test patients only if they had symptoms and had traveled to China; then Japan and South Korea; then Iran and Italy.
By the time the agency broadened the criteria to those without travel histories, the hospital had turned away several patients who needed testing.
“CDC was too slow,” Shah said. “They should have been on top of this.”
The case in Northern California, known locally as Patient Zero, ultimately exposed how wrong the CDC had been to test so narrowly.
Doctors at UC Davis Medical Center pleaded for days to test the woman on a ventilator, who was suffering from an unexplained respiratory disease yet had not recently traveled. The CDC’s testing process did not allow for the possibility that the virus was spreading in the community.
“We weren’t even able to test for it,” CEO Dr. David Lubarsky said. “It was a failed algorithm.”
The CDC said in its statement provided to USA TODAY that the early testing protocol was “based on the epidemiology of the disease at the time.” CDC senior officer Dr. Nancy Messonnier told reporters in February that the agency green-lighted testing for the patient when it became aware of the case. However, clinicians and a health official involved said they lost days pushing for access.
Patient Zero ultimately led the agency to rewrite its testing guidance. But by then, more than 200 workers at two hospitals that treated her had risked exposure.
So many staff members had to be quarantined that one of the hospitals temporarily shut down its intensive care unit.
The CDC’s leadership went on to fail Latino, Black and Native American communities and low-income neighborhoods. Experts say minority populations often were excluded from the policy-making process. They are now more than twice as likely to be infected as non-Hispanic whites – and nearly five times as likely to be hospitalized.
“We were not prepared despite everything we know about public health disparities,” K. Vish Viswanath, a health communication professor at Harvard and an independent scientist on the CDC’s advisory board, told the agency during a July review panel. “That to me is inexcusable.”
Donald Flores, a maintenance worker at the hospital that treated Patient Zero, developed symptoms in quarantine but was never tested. He still worries every workday that he is not being protected.
“Somebody,” Flores said, “doesn’t give a damn.”
The breakdown in the agency’s communication with local communities contributed to the failure of the Trump administration’s signature defense against the pandemic: restrictions on travel from hotspots in China and later around the world.
Local authorities expected the CDC to provide basic information – names, contact information and arrival time – so they could track travelers. Time and again, the CDC failed to do so.
In early February, Nevada state epidemiologist Melissa Peek-Bullock learned from the local news about an airplane carrying three people who had been traveling in China, which was about to land in Las Vegas. The travelers posed a threat to U.S. cities, based on the CDC’s criteria.
But when Peek-Bullock called the agency seeking the passengers’ names and contact information, she was met with hostility, according to interviews and documents from the health department.
At the Los Angeles airport, where the flight had been temporarily redirected, officials with the CDC’s quarantine and mitigation division told her they were unaware of the requirements drawn up by their own colleagues.
In a call to the CDC’s emergency hotline, Peek-Bullock said she spoke with a representative who refused to identify the passengers, saying they were “free to move along their way.”
Increasingly desperate, she explained her fear that they could place all of Las Vegas at risk. Then the CDC representative hung up on her, Peek-Bullock said.
“It’s hard to imagine that would happen,” she told USA TODAY. “Truly, you just want to get the information that you need to do the right thing.”
Afterward, the head of Nevada’s health department, Richard Whitley, wrote to Redfield, the CDC director, to complain: “The lack of communication in this circumstance created frustration and confusion for all those involved.”
Senior CDC official Dr. José T. Montero responded that the agency was trying to educate all of its divisions on the latest guidelines and requirements to share traveler information. He wrote: The CDC “regrets that Nevada Department of Health and Human Services had difficulty initially obtaining this information.”
The shortcomings exposed by a pandemic had been years in the making.
The agency knew it had work to do around data management, scientific readiness and domestic operations after reviewing its response to recent emergencies such as the Ebola and Zika outbreaks, according to minutes from a 2018 meeting of outside experts who advise the CDC’s Center for Preparedness and Response.
Today, the CDC acknowledges that the COVID-19 crisis also has exposed weaknesses in U.S. health preparedness.
“This pandemic has spotlighted shortcomings within our nation’s public health system, including the need for long-term and sustained funding for state and local health departments,” the agency said in its statement.
For months, the agency struggled to gather testing and reporting data from states and cities. Federal auditors at the Government Accountability Office in June faulted the agency for “making it more difficult to track and know the number of infections, mitigate their effects, and inform decisions on reopening communities.”
Dr. William Schaffner, an infectious disease specialist at Vanderbilt University and a former CDC investigator, told USA TODAY the scientists working on HIV do not even coordinate with those concentrating on preventing and treating other sexually transmitted diseases.
“The CDC is notoriously siloed. People stay in their own unit and only modest communication,” he said. “The silos go to the top.”
When states and counties asked important questions related to COVID, the CDC often either punted decisions back to them or failed to provide answers.
In early February, Vermont’s state epidemiologist, Patsy Kelso, emailed the CDC twice asking how the state would learn about travelers who fly into Canada and then drive over the border undetected. The agency did not write back.
“I don’t believe we ever got a response,” Kelso told USA TODAY.
Three days later, CDC officials acknowledged internally that they were failing to prevent the influx of potentially infected travelers.
“Hearing word of people already leaking through screening system,” Penn, the director of the CDC’s public health law program, wrote to colleagues and lawyers in several state health departments. “Knew it would not be perfect, but it has begun.”
At one point, the agency told employees at the Los Angeles airport not to screen private charter planes, which are “mainly for rich people.” Flight attendants in Dallas witnessed travelers from China entering without a second look. “The customs agent told them ‘not to worry about it,’” state officials wrote to the CDC in February.
That month, as the University of Kansas was preparing to host a basketball game that would fill its 16,000-seat arena, state health director Dr. Lee Norman learned that a student who had traveled to Wuhan, China, was showing symptoms of the new coronavirus.
While the student and his roommate quarantined in an apartment on campus, the CDC did not tell state health departments about other travelers who might have come into the state from Wuhan.
“CDC not able to let us know about travelers that have already come,” Farah Ahmed, the epidemiologist at the state’s department of health, wrote to colleagues.
Looking back, Norman told USA TODAY, “we just never had a great deal of information.”
The agency did not manage to ensure the safety of more than 2,000 travelers on a single cruise ship, the Grand Princess, after an outbreak led to quarantines at military bases in March. Many were allowed to go home without COVID-19 testing, or before results came back.
“A lot of breakdown in communication between the CDC and us,” said Teresa Johnson, a Grand Princess passenger who was quarantined in Georgia with her husband, less than 20 miles from CDC headquarters. Both had symptoms but were not tested before heading home.
Now Johnson says she has lost trust in the CDC altogether: “You get to where you don’t really know what to believe.”
State and local authorities are supposed to look to the CDC in a public health crisis. But records and interviews show the agency, under political pressure, repeatedly tried to minimize the crisis.
The CDC puts out a weekly scientific journal, the Morbidity and Mortality Weekly Report, to inform doctors and scientists about emerging evidence and critical guidance. Local leaders rely on the unvarnished scientific conclusions to make sound policy.
In March, the CDC watered down an MMWR by deleting a Washington state epidemiologist’s explicit call for widespread testing – and not just symptom screening – to prevent outbreaks in assisted-living and long-term care facilities.
“I would be careful promoting widespread testing,” the CDC editor noted in an internal document.
At the time, the U.S. was still struggling to test widely enough, despite a White House pledge to rapidly expand testing capacity. The published article merely listed a half dozen mitigation efforts that are important, including “resident and staff member testing.”
By summer, White House officials had started screening the MMWR reports, receiving full drafts ahead of publication. Former CDC leaders say that practice undermines good science.
“It’s unconscionable that that’s happening,” said Nancy Cox, former director of the CDC’s influenza division, who worked at the agency for 37 years.
The agency also tried to soften a public health officer’s early warning about the coming spread of the virus in Placer County, California.
“You mentioned community spread,” CDC press officer Scott Pauley said in an email exchange about a Placer news release in early March, a day before the county reported the state’s first death, “and that could lead people to think you currently have community spread cases.”
Dr. Aimee Sisson, who had previously worked in the state health department, pushed ahead anyway, including a strong warning in her news release: “We expect to see additional cases in coming days, including cases of community spread, not linked to travel.”
She told USA TODAY that she felt confident the virus was already “out of the bag.”
Behind the scenes, the CDC had known the same for at least a week. “We knew then that detecting any community-acquired cases meant that the virus was already circulating in the U.S.,” senior officials would later write in an internal CDC memo.
The Trump administration began to publicly sideline the agency and attempt to overrule its decisions.
The White House weakened the CDC’s early no-sail orders for cruise ships in April. It pushed for a return to the failed public health strategy of airport fever screenings over the CDC’s objections and delayed its recommendations for reopening schools and businesses as “overly prescriptive” in May. It prodded the CDC to explore blaming Latino immigrants for causing regional surges in June.
“CDC’s role always is going to be defined by an administration,” CDC scientific advisor and longtime public health expert Alonzo Plough said in an interview. “Their role as defined currently was unlike any that I had seen in my 25 years of practice.”
In a statement to USA TODAY, White House spokesman Judd Deere denied that the Trump administration has ignored science. He said that every decision made by the CDC has been driven by data.
“This dishonest narrative that the media and Democrats have created that politics is influencing approvals or decisions is not only false but is a danger to the American public,” Deere said.
Recently, following pressure from the White House, the CDC blindsided local health officials by revising its testing guidance yet again to say that people exposed to the virus but not showing symptoms do not necessarily need to be tested.
The agency said that shift still allows for testing when public health officials and doctors think “there is the need for action tied to a diagnosis – for example isolating infected individuals and quarantining close contacts.”
Dr. Sara Cody, the public health officer in Santa Clara County, California, was bewildered. Testing is critical with COVID, where symptoms alone are not a guide to who poses a risk of spreading infection, she said.
That was the type of public health tenet that Cody learned from the CDC, which she has long revered. She will keep testing, she said, despite its new guidance.
“This premier public health agency that trained me, and has produced so many public health leaders, is now really not able to implement their mission, which in part is to support state and locals,” she told USA TODAY. “It is extraordinarily sad.”
Additional reporting by Kenny Jacoby, Dan Keemahill and Curtis Tate.
Brett Murphy and Letitia Stein are reporters on the USA TODAY investigations team. Contact Brett at [email protected], @brettMmurphy by Signal at 508-523-5195 and Letitia at [email protected], @LetitiaStein, by phone or Signal at 813-524-0673.