WASHINGTON – It was the third week of August, the Republican National Convention was days away, and President Trump was impatient.
White House officials were eager to show a step forward in the fight against the coronavirus: expanding the use of blood plasma from recovered patients to treat new ones. However, for nearly two weeks, the National Institutes of Health had issued emergency approval for the treatment, citing ongoing concerns about its effectiveness.
On Wednesday August 19th, Mr. Trump called Dr. Francis S. Collins, the director of the N.I.H., with a blunt message.
"Do it by Friday," he demanded.
It didn't go through until Friday, and by Sunday Food and Drug Administration regulators hadn't completed a last-minute data review to help N.I.H. Doubt.
But on Sunday evening, the eve of the convention, the president, with the approval of the FDA, announced that plasma therapy would be available for wider use, stating that it could cut deaths by 35 percent and significantly overstate the data on that Advantages shown.
Mr. Trump's call to Dr. Collins was a focus in a White House pressure campaign to submit the country's health authorities to his desire to show progress in fighting a pandemic that killed more than 192,000 people in the United States. And it was just one of several moments when scientists and regulators across the health bureaucracy became increasingly concerned that the White House might put more pressure on a vaccine to approve before Election Day, even if there was no agreement on its effectiveness and safety has been .
On the night of the plasma announcement, Dr. Collins asked to show up at the White House, where he received a coronavirus test and then was escorted into the Roosevelt room while Mr. Trump and others spoke to journalists in the briefing room.
There Dr. Collins and Dr. Peter Marks, one of the Food and Drug Administration's top regulators and the person most directly responsible for maintaining the independence and scientific rigor of the vaccine licensing process, helplessly sold the president and other top administrators to the effectiveness of plasma and officials created a PR debacle that reverberated for days.
Dr. Collins left the White House following the announcement. But Dr. Marks, who had been pushing for plasma approval, was escorted to the Oval Office to spend a few minutes with Mr. Trump and his top aides celebrating with white icing cupcakes. In an interview on Friday, Dr. Marks said he was "in a bit of shock" when the president thanked him for his work on plasma approval.
Although he described it as "a brief interaction that really had no substance," health officials who had heard of the encounter said they feared it could create the impression that the barriers between politics and science would be further eroded at one time The public is already concerned about political pressures in assessing the safety of vaccines and treatments.
Some of those in attendance were baffled when Mr. Trump, who had tweeted the day before about a "deep condition" at the Food and Drug Administration blocking the rapid approval of treatments and vaccines to politically violate him, jokingly asked if Dr . Stephen M. Hahn, the FDA commissioner, did a good job.
With Election Day in just over seven weeks, Washington is seeing the collision of two worlds: a community of largely anonymous government scientists and doctors operating in a culture led by research, datasets, and peer review, and a president known to be the Science despises. Politically wounded by its failure to contain the coronavirus and now determined to move as quickly as possible to provide vaccines and treatments to Americans.
Government scientists and pharmaceutical companies have begun to take extraordinary steps to counter the impression that they may be sacrificing public safety for political expediency and have publicly committed to impartial scientific decisions about how to fight the coronavirus.
Dr. Hahn has made a public commitment to review every vaccine approval by an advisory committee of external experts. In an attempt to tighten the agency's decision-making process, he said this week that the Food and Drug Administration intends to issue new guidance on the standards used to justify the emergency use of a vaccine.
"We will not compromise public confidence in our science-based, independent review of these or any other vaccines," said Dr. Hahn on Friday on Twitter. "There is too much at stake."
The government has come under criticism for failing to act aggressively enough to counter the virus, including failing to cut red tape in the early stages of the pandemic to develop diagnostic tests that would work. White House officials say the president is now doing exactly what his opponents attacked him for failing: putting pressure to develop safe and effective drugs and vaccines as soon as possible because people are sick and die, not because of the timing of the elections.
The accelerated rollout of plasma approval is nowhere near the only aspect of the government's response to the virus shaped by White House pressure. The Centers for Disease Control and Prevention has repeatedly thought about how many tests are recommended and for whom. According to emails that Politico first reported on Friday, political officials from the Department of Health and Human Services have tried to persuade C.D.C. to revise or delay. Reports of the coronavirus they believed were not flattering to the president. The Food and Drug Administration initially granted emergency approval for the use of hydroxychloroquine to treat Covid-19 after Mr Trump advertised it, only to be forced to turn back.
The battle to get convalescent plasma approved is particularly illuminating, however, as many of the gamers are involved in a far more important decision about approving an emergency vaccine approval.
As the summer progressed, the debate on plasma evolved from a purely scientific discussion of its merits to a sort of political test of loyalty, exposed in the President's remarks in the days leading up to the announcement.
At a press conference on August 19, Mr. Trump complained that "the people over there" – an obvious reference to the Food and Drug Administration – wanted to restrict plasma treatment until after the election. In a Twitter post three days later, he accused the agency of "Deep State" officials of sluggish approval of Covid-19 vaccines and treatments in order to cause him political harm.
Like other approaches to dealing with the virus, convalescent plasma has been the subject of scientific debate and disagreement. The pale yellow fluid that remains after the red and white cells are removed from the blood has been used to treat infectious diseases such as flu, SARS, and Ebola since the 1890s.
The regulators of the Food and Drug Administration, which approves new treatments, were ready to screen convalescent plasma for emergency approval based on tens of thousands of case studies from a federal government-sponsored Mayo Clinic program. Dr. Collins and other N.I.H. wanted to test its benefits in randomized trials that scientists across the country struggled to recruit patients for. Although N.I.H. had no regulatory authority, the administration wanted an agreement of all health authorities on the further use of plasma.
In June, Dr. Marks Dr. Deborah L. Birx, the White House coronavirus response coordinator, said early data from the Mayo Clinic program was promising. White House chief of staff Mark Meadows was quick to campaign for emergency clearance, senior administration officials said.
Throughout the summer, the White House has been closely monitoring the Food and Drug Administration's progress on therapies and potential vaccines. The president himself, according to a senior administrator, calls Dr. Hahn on his cell phone.
Mr. Meadows is also in regular contact with Dr. Hahn, who sometimes makes unscheduled visits to Mr. Meadow's corner suite in the west wing.
Dr. John C. Fleming, a top advisor to Mr. Meadows, has a weekly meeting with Dr. Hahn, Dr. Marks, Dr. Janet Woodcock, a top F.D.A. Drugs Commissioner and Eric D. Hargan, Assistant Secretary of Health. Jared Kushner, the presidential senior adviser and son-in-law, was also closely involved in tracking advances in vaccines and treatments.
For weeks, F.D.A. Dr. Hahn-backed regulators insisted that the data from plasma research were not strong enough to warrant approval for wider use. By August 12, however, they were ready to move on, and decided that plasma had reached the comparatively low limit for emergency clearance, where the potential benefits outweighed the risks.
NIH. Officials were still advocating a clinical trial, but the scientists reached a compromise: the Food and Drug Administration would reanalyze the data with new results from the Mayo Clinic program.
Frustrated with the delay, Mr. Trump pressed his case with Alex M. Azar II, his Minister of Health.
Two of Mr. Kushner's allies have enlisted: Brad Smith, assistant to the president, and Adam Boehler, executive director of the US International Development Finance Corporation and former Trump administration health officer.
You spoke to Dr. Hahn and Mr Azar on data showing that plasma from the Mayo Clinic program only had three-quarters of hospitals available to treat Covid-19 patients, leaving 900 hospitals ineligible for therapy. While the emergency clearance was upheld, the Americans died.
The matter came to a head on August 19 after the New York Times published an article stating that the plasma approval was due to the N.I.H. Objection. F.D.A. and White House officials were furious that N.I.H. Officials had publicly voiced their objections despite negotiations to resolve the data conflict. Mr. Trump called Dr. Collins and requested approval of the plasma within two days.
Dr. Birx and other senior health officials also slapped Dr. Collins and asked him to clarify his position publicly, high-level administrative officials with knowledge of a tense meeting this week.
Officials at the Food and Drug Administration expected the new analysis for the N.I.H. and to announce the emergency approval for plasma as early as Monday, August 24th.
However, the previous Thursday they were told it was too late: the decision had to be announced on Sunday, the day before the start of the Republican National Convention, allegedly because the announcement appeared to be politically motivated during the meeting.
Another obstacle arose this weekend: The New Mayo Clinic data was missing important entries and could not be used, which thwarted re-analysis.
White House officials said they had heard from Mr. Azar and Dr. Hahn learned that they were ready to make the announcement on Sunday. The President's communications team quickly put an event together in the White House briefing room, with Mr. Trump being supported by Dr. Hahn and Mr. Azar was flanked. The F.D.A. called the approval "another achievement" in the government's fight against the pandemic.
The onslaught contributed to serious errors. Dr. Hahn misinterpreted the agency's data, claiming that plasma reduced the death rate of Covid-19 patients by 35 percent – a significant exaggeration of what the research actually showed.
Immediately after the announcement, however, the mood in the Oval Office was solemn. Cupcakes were served. Photos were taken.
In front of him on the Resolute Desk, the President had several copies of the Wall Street Journal that day. He was pleased to notice a prominent article that said he had forever changed the Republican Party.
Katie Thomas reported from Chicago and Mark Mazzetti from Washington.