Regardless of the election results, President Trump will be the one directing the government's coronavirus response as infections climb.
Regardless of the election's outcome this week, President Donald Trump will be the one steering the country through what is likely to be the darkest and potentially deadliest period of the coronavirus pandemic, and he has largely excluded the nation's leading health experts from his inner circle.
Trump will still have control of the nation's health apparatus and the bully pulpit that comes with the Oval Office until January 20, as infections approach 100,000 a day and death rates begin to rise as hospitals are strained to their breaking points.
But the president has largely shuttered the White House Coronavirus Task Force and doubled down on anti-science language, telling voters that the country is "rounding the corner" in the fight against the virus that has claimed nearly a quarter of a million lives.
He has stopped listening to Alex M. Azar II, his health secretary; Dr. Robert R. Redfield, the director of the Centers for Disease Control and Prevention; Dr. Stephen M. Hahn, the commissioner of the Food and Drug Administration; and Dr. Jerome Adams, the surgeon general. On Monday, the president lashed out at Dr. Anthony S. Fauci, the government's leading infectious disease specialist, hinting that he may fire Fauci after the election — though it would be extremely difficult for him to do so.
Dr. Deborah L. Birx, the White House coronavirus response coordinator, was reduced to issuing an urgent plea Monday for an "aggressive balanced approach that is not being implemented," in a memo that was promptly leaked to The Washington Post.
The adviser Trump does listen to is Dr. Scott Atlas, a former Stanford University neuroradiologist and late addition to the coronavirus task force who has dismissed the efficacy of mask wearing, suggested that the pandemic should be left largely to run its course — and last week parroted the president's views on RT, the Russian television network forced to register as a foreign agent.
All of this has epidemiologists and infectious disease experts extremely worried.
"Even if Biden wins, we still have several months of the Trump administration in which the epidemic is at its worst," said Dr. Carlos del Rio, an infectious disease expert at Emory University, referring to the president's Democratic opponent, Joe Biden. "Trump is not in charge. He's given up; he has basically implied, 'I don't care about this,' and he has turned it over to the governors."
Alyssa Farah, the White House communications director, defended the president's response, saying the White House had bolstered the nation's supply of personal protective equipment and purchased 150 million rapid coronavirus tests, items that "Dr. Birx references in her report."
"We also continue to work to safely rush therapeutics, pushing for FDA approval of remdesivir and two monoclonal antibody therapies" awaiting an emergency use authorization, she said.
Birx's plea for a more aggressive approach reflects a growing sense of despair among public health experts inside and outside the government that the winter months are a critical moment when the government must take drastic actions to stop the spread of the virus. Several European governments have announced such measures in the last several days.
There is deep scepticism that the president will follow suit in the coming weeks.
If he wins another four years, he will take his victory as a powerful endorsement of his approach to the virus — flouting restrictions on large gatherings, ignoring calls to wear masks, demanding that schools reopen and prioritising the economy over public health.
"We're up Schitt's Creek if Trump wins — and not as good as the TV show at all," said Dr. Jeffrey Koplan, who served as the director of the Centers for Disease Control and Prevention under Presidents Bill Clinton and George W. Bush, referring to a popular situation comedy.
Birx is among those who have fallen out of favour with Trump after months in which she was the public face of the administration's effort to slow the spread of the virus, standing loyally by the president's side as he assured the public that things were getting better.
In recent weeks, though, she and Fauci have become increasingly outspoken about the dangers of the president's approach.
It is unclear who leaked Birx's memo Monday. She declined to comment Tuesday.
Del Rio said he recently reached out to Birx on behalf of a reporter who wanted to know if she was distressed by the eroding of her position in the White House.
Her response, he said: "I'm distressed by the epidemic, not my position."
Regardless, Trump has pushed her and other public health officials aside in favor of Atlas, who has at times embraced the idea that the government should protect only the most vulnerable Americans while the virus infects much of the population, increasing the percentage of people he believes will be immune to the virus. Most public health officials say that course could lead to hundreds of thousands of additional deaths.
Longtime friends say Birx is frustrated.
"She feels totally sidelined and basically thinks Scott Atlas is dangerous and crazy and is just horrified that she's been pushed aside for somebody like that," said Peter Staley, a longtime AIDS activist who is close to Birx and Fauci. He added, "I think that has been reflected in these updates that she's been writing."
Staley and some fellow AIDS activists urged Birx and Fauci in mid-October to give the president an ultimatum about Atlas: "It's him or us." He declined to characterise their response, except to say that the two made it clear that they were not prepared to take such drastic action but would instead "try to keep pushing in their own way to cut out Atlas."
That has been more difficult in recent weeks as the White House has all but shut down the task force on which Fauci and Birx are still officially members.
Instead, the president is relying on a group of top aides — including Mark Meadows, the chief of staff; Marc Short, the vice president's chief of staff; Larry Kudlow, the director of the National Economic Council; Atlas; and others. That group will continue to be in charge throughout the winter months.
"Fauci and Birx missed their chance," Staley said, noting that the two doctors could have spoken out more forcefully sooner. "They had their one moment and they didn't use it."
Biden has said that if he is elected president, he will take a significantly different approach to the virus, moving aggressively to encourage — and possibly mandate — mask wearing and remaining open to imposing restrictions as needed to slow the spread of the virus.
Biden's policy advisers have been developing plans that would go into effect as soon as he took office, including ramping up testing, ensuring a steady supply of protective equipment, distributing a vaccine and securing money from Congress for schools and hospitals.
Under normal circumstances — not counting Trump's transition in 2016 — Biden would most likely wait to push those plans forward. Presidents-elect have generally chosen to stay out of the limelight until Inauguration Day, following the general principle that the United States should have one president at a time.
And departing presidents, even of opposite parties, often try to support the efforts of their successors, especially when the country is in the midst of a crisis.
But few people in Washington expect an orderly transition if Biden wins.
Trump is not likely to abide by established traditions, and he has made his views about the virus clear during numerous rallies in the final days of the campaign, telling crowds that a vaccine will soon arrive to end the threat.
"It's ending anyway, but we have the greatest companies in the world and we're literally weeks away," Trump told supporters in Butler, Pennsylvania, on Saturday. "We'll eradicate more quickly the virus, wipe out the China plague once and for all, and it's back to work, back to work, which is what we want. You know what we want? We want normal."
Koplan said that if Biden did prevail, he would need to move quickly to establish relationships with governors and to unveil a national strategy for the pandemic.
"Make this different from other transitions," Koplan said, "where this time the shadow government steps out of the shadows."
Written by: Michael D. Shear and Sheryl Gay Stolberg
Photographs by: Oliver Contreras, Doug Mills and Pete Kiehart
© 2020 THE NEW YORK TIMES