The Trump Mental Health Pandemic:

A blow-by-blow account of how mental health experts warned that what happened would happen — that a president was likely going to kill (hundreds of) thousands of Americans — but went unheeded

On August 9, 2020, William Saletan published a remarkable article on Slate by the title: “The Trump Pandemic: A blow-by-blow account of how the president killed thousands of Americans.” The below consists of quotes of that article, cited here with permission, and an item-by-item record of what mental health experts said would happen, based on our understanding of the president’s mind.

On July 17, President Donald Trump sat for a Fox News interview at the White House. At the time, nearly 140,000 Americans were dead from the novel coronavirus…. “Everybody thought this summer it would go away,” said Trump. “They used to say the heat, the heat was good for it and it really knocks it out, remember? So they got that one wrong.” Trump’s account was completely backward. Redfield and other U.S. public health officials … had cautioned against that assumption. The person who had held out the false promise of a warm-weather reprieve, again and again, was Trump.

Mental health experts had been warning for years that the president’s mental state, or specifically lack of mental capacity and psychological dangerousness, would place the nation, or the world, at risk. On April 20, 2017, Dr. James Gilligan stated: “I think we have more than enough evidence here that it is important to mention that everybody in America, and in fact everybody in the world, is in danger from the currently most powerful man in the world.” On May 24, 2017, I stated: “We have an obligation to speak about Donald Trump’s mental health issues because many lives and our survival as a species may be at stake.” We said so not to be alarmist, but because these are serious considerations in the office of the presidency, and the president’s mental impairment “was more dangerous than the public suspected,… would grow more dangerous with time,” and, without intervention, “would become increasingly uncontainable.”

The story the president now tells — that he “built the greatest economy in history,” that China blindsided him by unleashing the virus, and that Trump saved millions of lives by mobilizing America to defeat it — is a lie. Trump collaborated with Xi, concealed the threat, impeded the U.S. government’s response, silenced those who sought to warn the public, and pushed states to take risks that escalated the tragedy. He’s personally responsible for tens of thousands of deaths.

We did not know early in the presidency that there would be a pandemic, but we had a good sense of how he would respond if there were one. On March 8, 2017, Drs. Judith Herman and Robert Jay Lifton declared: “faced with crisis, President Trump will lack the judgment to respond rationally.” On November 30, 2017, I repeated: “his … loss of touch with reality, marked signs of volatility and unpredictable behavior, and an attraction to violence as a means of coping … place our country and the world at extreme risk.”

We did a dangerousness assessment from the start, using credible sources of investigative journalism, and a capacity evaluation when the relevant information became available — which was Special Counsel Robert Mueller’s report, replete with firsthand accounts by close associates and coworkers under sworn testimony. The president met almost all actuarial items for dangerousness and failed every criterion for mental capacity. We had plenty of evidence to claim, when we learned of the pandemic, that: “The final death toll from coronavirus will not be the result of viral disease; it will be the result of [the president’s] mental disease.” On January 22, 2020, we understood that it was only a sign for further concern when he said: “We have it totally under control.” We actively alerted since February 6, 2020, of the necessity to address a “mental health pandemic” first, if we wished effectively to control a viral pandemic.

This isn’t speculation…. This article … documents Trump’s interference or negligence in every stage of the government’s failure: preparation, mobilization, public communication, testing, mitigation, and reopening.

It was not speculation on our part, either. This derivative article documents our attempts at every stage of the pandemic to warn that Donald Trump would neglect or interfere with every attempt by the government to prepare, mobilize, communicate with the public, test, mitigate, and reopen safely. This is why, on March 13, 2020, I declared that Trump’s leadership in a pandemic would be “worse than having no leader at all.”

The coronavirus debacle isn’t, as Trump protests, an “artificial problem” that spoiled his presidency. It’s the fulfillment of everything he is.

We should be more specific: it is the fulfillment of his psychopathology. On March 1, 2020, I said: “The moment we feared has come: in a real emergency, the president’s inability to stay with reality … will now result in a tangible loss of lives.”

Trump never prepared for a pandemic. For years, he had multiple warningsbriefings, reports, simulations, intelligence assessments — that a crisis such as this one was likely and that the government wasn’t ready for it. In April, he admitted that he was informed of the risks: “I always knew that pandemics are one of the worst things that could happen”…. He often brags that he spent $2 trillion to beef up the military. But he squeezed the budget for pandemics, disbanded the federal team in charge of protecting the country from biological threats, and stripped down the Beijing office of the Centers for Disease Control and Prevention.

His inability to prepare for the future and a need to break with reality were the reasons we stated, on March 24, 2020, that a continued Trump presidency would be: “the difference between a contained outbreak and a catastrophe…. Whether it is impeachment, the 25th Amendment, or an ultimatum on resignation is for the politicians to decide, but our prescription is removal.” The next day, we issued our “Prescription for Survival,” outlining our recommendations from a medical perspective, focusing on public safety and removal of danger. Like the pandemic specialists, our emphasis was on prevention.

Trump has been asked several times to explain these decisions…. “Some of the people we cut, they haven’t been used for many, many years,” he said in February…. In March, at a Fox News town hall, Bret Baier asked Trump why he hadn’t updated the test production system. “I’m thinking about a lot of other things, too, like trade,” Trump replied. “I’m not thinking about this”…. “I have a lot of things going on.”

Trump prepared for a war, not for a virus. He wagered that if a pandemic broke out, he could pull together the resources to contain it quickly. He was wrong. But that was just the first of many mistakes.

This description only goes halfway. Trump was prepared for a war on reality, not for any real war. He did not wager that he could pull together the resources to contain a crisis quickly; he wagered that he could “continue to prey on our prosocial human expectations for trust, on our desire for stability, and on our fruitless craving for a capable leader,” as we stated on May 2, 2020.

Those without training or experience of psychopathology may still hold out hope that, once the barriers are removed or the initial realization sinks in, he would assume leadership or mind the pandemic — for that is what “normal” people do. However, our clinical experience, knowledge of human behavior, and documented evidence on the president himself tell us that he cannot. Continuing the current arrangement is little different than knowingly continuing a massacre, or a genocide and democide.

In early January, Trump was warned about a deadly new virus in China. He was also told that the Chinese government was understating the outbreak. (See this timeline)…. Trump was about to sign a lucrative trade deal with Beijing. “We have a great relationship with China right now…,” Trump told Laura Ingraham in a Fox News interview on Jan. 10…. He lauded Xi and said previous American presidents, not Xi, were at fault for past troubles between the two countries. Three days later,… health and human services … phoned him with an update on the spread of the novel coronavirus. On Jan. 21, the CDC announced the first infection in the United States. Two of the government’s top health officials … said the virus was beginning to circulate around the world.

Trump would later claim that he saw from the outset how grim the situation was. That was clear, he recalled, in the “initial numbers coming out from China.” But at the time, he told Americans everything was fine. “We’re in great shape,” he assured Maria Bartiromo in a Fox Business interview on Jan. 22. “China’s in good shape, too”…. On CNBC, Joe Kernen asked Trump whether there were any “worries about a pandemic.” “No, not at all,” the president replied. “We have it totally under control.”

This is a thought process that is irrational and disconnected from reality and rather responding to internal needs, which we have observed from the start. Mental health experts assembled around a conference on our “duty to warn” at Yale School of Medicine in April 2017 because our knowledge and training about human behavior informed us that he was not likely ever to “pivot” to become more presidential but would only “grow worse with actual power” — until the nation reached a crisis point, either internally or externally introduced. We decided, when mental compromise “goes so far as to affect an individual’s ability to perform his duty, and in some cases risks harm to the public as a result, then the health professional has a duty to sound the alarm.” If we did not, the severity of symptoms the president displayed, combined with the public’s general unfamiliarity with it, risked their being underestimated and normalized. The normalization of pathology is very dangerous, for “long-term results are inescapably catastrophic for all.”

The crisis in China grew. In late January, Trump’s medical advisers agreed with his national security team that he should suspend travel from China to the United States. But Trump resisted. He had spent months cultivating a relationship with Xi and securing the trade deal. He was counting on China to buy American goods and boost the U.S. economy, thereby helping him win reelection. He had said this to Xi explicitly, in a conversation witnessed by then-National Security Adviser John Bolton. Trump also worried that a travel ban would scare the stock market. But by the end of the month, airlines were halting flights to China anyway. On Jan. 31, Trump gave in.

In addition, that the president “cozies up to Vladimir Putin and Xi Jinping,” not to mention other strongman types, as a part of his obsequious disposition, is the reason why we condemned his labeling of “Chinese virus” as an attempt to “scapegoat the Chinese people … even as he praised their leader Xi Jinping during the early coverup.” We remarked since before the presidency Donald Trump’s deep emotional hunger to be an authoritarian, strongman-type leader, which arises from “narcissistic wounds” and causes him in turn to give his obedience and submission to brutal dictators. On July 9, 2018, before his summit with the Russian leader, Drs. John Zinner, James Merikangas, Leonard Glass, and I warned in a letter to the U.S. Congress: “the signs that he exhibits, should preclude his partaking in any more consequential decisions.” On December 27, 2019, I noted his preference for associating with “dictators … who successfully manipulate him,” over democratic leaders or other rational players.

His advisers knew the ban would only buy time. They wanted to use that time to fortify America. But Trump had no such plans. On Feb. 1, he recorded a Super Bowl interview with Sean Hannity. Hannity pointed out that the number of known infections in the United States had risen to eight, and he asked Trump whether he was worried. The president brushed him off. “We pretty much shut it down coming in from China,” said Trump. That was false: Thanks to loopholes in the ban, the coronavirus strain that would engulf Washington state arrived from China about two weeks later. But at the time of the interview, the ban hadn’t even taken effect. The important thing, to Trump, was that he had announced the ban. He was less interested in solving the problem than in looking as though he had solved it.

That he had no such plans to do what is necessary is correct. His inability to govern in any beneficial way is what Drs. Judith Herman, Nanette Gartrell, and Dee Mosbacher alerted about as far back as in December 2016 because of his “symptoms of mental instability — including grandiosity, impulsivity, hypersensitivity to slights or criticism, and an apparent inability to distinguish between fantasy and reality.”

There were three logical steps to consider after suspending travel from China. The first was suspending travel from Europe. By Jan. 21, Trump’s advisers knew the virus was in France. By Jan. 31, they knew it had reached Italy, Germany, Finland, and the United Kingdom. From conversations with European governments, they also knew that these governments, apart from Italy, weren’t going to block travel from China. And they were directly informed that the flow of passengers from Europe to the United States far exceeded the normal flow of passengers from China to the United States. Trump’s deputy national security adviser, Matthew Pottinger, pleaded for a ban on travel from Europe, but other advisers said this would hurt the economy in an election year. Trump, persuaded by Pottinger’s opponents, refused to go along.

While we estimated from the start that he would be unable to solve real problems, based on our clinical experience collectively with thousands of individuals of Donald Trump’s presentation, we were able to confirm this when definitive information became available, through the special counsel’s report.

Not until March 11 … did Trump take similar action against Europe. In a televised address, he acknowledged that travelers from Europe had brought the disease to America. Two months later, based on genetic and epidemiological analyses, the CDC would confirm that Trump’s action had come too late, because people arriving from Europe — nearly 2 million of them in February, hundreds of whom were infected — had already accelerated the spread of the virus in the United States.

In order to perform the necessary test, we formed an independent, peer-reviewed panel of top national mental health experts, which included Drs. Edwin Fisher, Leonard Glass, James Merikangas, and James Gilligan. The relevant test was a mental capacity evaluation, which determines the ability to make sound decisions — and he failed every criterion, based on plentiful, high-quality evidence. In other words, we knew on April 25, 2019, based on rigorous data and methods, that the president was “incapable of making sound, rational, reality-based decisions … with most notably an absorption in self-interest that precludes the consideration of national interest.” In other words, the possibility that he could properly handle a crisis such as the pandemic was practically nonexistent.

Unlike a diagnostic test, which is for the benefit of the individual, a functional test is for the benefit of the employer, in this case the people, and a personal interview is not necessary but can be counterproductive, as the evaluee may try to hide the very things that the evaluator is trying to investigate. This is one of the reasons why a personal physician who is an employee of the White House and a subordinate of the commander-in-chief is ineligible to perform a fitness test, because of a lack of independence. Still, given our own independence, we invited the president to meet with us if he considered himself fit. We found out through his staff that he received our invitation, but he did not respond within the timeframe we gave him, and therefore we proceeded with our recommendations on May 22, 2019, and submitted our findings to all members of the U.S. Congress as well as to the press.

The second step was to gear up production of masks, ventilators, and other medical supplies. In early February,… officials warned of impending shortages of these supplies…. everyone in the administration was pleading for more equipment. But when Azar requested $4 billion to stock up, the White House refused. Trump dismissed the outcry for masks and ridiculed Democrats for “forcing money” on him to buy supplies. “They say, ‘Oh, he should do more,’” the president scoffed in an interview on Feb. 28. “There’s nothing more you can do.”

In sum, our analysis had revealed to us that a tragedy that would cost hundreds of thousands of lives, tens of millions of jobs, and one of the greatest economies in the world was entirely avoidable, based on our rigorous analysis nine months before the pandemic in the United States even began. For us, his refusal to provide protective equipment, his reluctance to invoke the Defense Production Act, and his failure to institute necessary testing was a fully expected result. The converse would rather have been surprising.

The third and most important step was to test the population to see whether the virus was spreading domestically…. Like the United States, South Korea had identified its first case on Jan. 20. But from there, the two countries diverged. By Feb. 3 South Korea had expanded its testing program, and by Feb. 27 it was checking samples from more than 10,000 people a day. The U.S. program, hampered by malfunctions and bureaucratic conflict, was nowhere near that. By mid-February, it was testing only about 100 samples a day.

The bureaucratic malfunction and ineffectual governmental agencies, in ways that are unprecedented for those agencies, can be traced directly to his mental incapacity. We understood enough to say on April 11, 2020, without mental health intervention, “He will continue to push for the maximal number of deaths possible.” The saddest thing is that it would be no exaggeration to say, without restrictions, his psychopathology favors deaths.

From Feb. 14 to March 11, [Fauci] warned in a dozen hearings, forums, and interviews that the virus might be spreadingunder the radar.” But Trump wasn’t interested. He liked having a low infection count — he bragged about it at rallies — and he understood that the official count would stay low if people weren’t tested. Trump had been briefed on the testing situation since late January and knew test production was delayed. But he insisted that “anybody that wants a test can get a test” and that “the tests are all perfect.” Later, he brushed off the delay in test production and said it had been “quickly remedied.” He complained that additional tests, by exposing additional cases, made him “look bad.”

From April 2017 to August 2020, we warned in more than 300 pages of letters, petitions, public forums, and media interviews that “the impulsivity, recklessness, lack of empathy, verbal abuse, and cognitive impairment [were] only the tip of the iceberg.” At first, the public was very interested. But the American Psychiatric Association (APA) oddly seemed to prefer promoting a low estimation of the president’s mental disturbances. It focused not on science, ethical principles, professional standards, or the clinical reality, but on not speaking about the president — and not letting anyone else speak at all cost.

To keep the numbers low, Trump was willing to risk lives. He figured that infections didn’t count if they were offshore…. In mid-February, even as he refused to bar Europeans from entering the United States, he exploded in anger when more than a dozen infected Americans were allowed to return from Japan. “I hated to do it, statistically,” he told Hannity. In March, he opposed a decision to let passengers off a cruise ship in California. “I’d rather have the people stay” offshore, he explained, “because I like the numbers being where they are.”

To keep its federal dollars, the APA seemed willing to risk lives. Perhaps it figured that omissions of duty did not count if the mental health profession kept its profile low…. On March 16, 2017, less than two months after Donald Trump’s inauguration, the Association dug up the 47-year-old “Goldwater rule,” based on one lawsuit 56 years ago, which most considered outdated if not invalid since at least 1980. It was founded on the premise that diagnoses could not be made without a personal examination, but since 1980, diagnostic criteria have been observation-, not introspection-based. It was also established as a response to a political situation, where then-presidential candidate Barry Goldwater sued a popular magazine that did a survey of psychiatrists. While less than 10 percent of those surveyed gave irresponsible diagnoses, it was enough of a political shakeup for the APA to be pressured into entering the guideline — not rule — into its books.

With decades of science and practice evolving in the opposite direction, the APA should perhaps have abolished it; there were few scholars studying it, as it faded into obscurity, and a poll by the American College of Psychiatrists showed that an overwhelming majority of psychiatrists disagreed with it. Meanwhile, “duty to warn” and “duty to protect” laws have continually expanded since 1976, with almost 100 direct lawsuits in the U.S. alone, affirming the principle that a clinician’s responsibility to the safety of society and its members supersedes even the confidentiality of a therapeutic relationship. These laws now apply beyond the clinical context and are common throughout the world.

When the spread of the virus in the United States could no longer be denied, Trump called it the “invisible enemy.” But Trump had kept it invisible. The CDC would later acknowledge that due to woefully insufficient testing, the overwhelming majority of infections had gone undiagnosed. Models would show that by mid-February, there were hundreds of undetected infections in the United States for every known case. By the end of the month, there were thousands.

When the concerns of mental health professionals could no longer be denied, the APA reinterpreted “the Goldwater rule” in a way that would enable to call those who spoke up “unethical”. In other words, with the Trump administration, it prohibited professionals not just from diagnosing but from making any comment on objective observations of any kind. This did not make sense, since there are plenty of things we could obtain enough information to speak about responsibly, such as dangerousness or, as would later be done, incapacity. This is information vital to public health and safety, since the stated purpose of “the Goldwater rule” was for psychiatrists “to participate in activities contributing to … the betterment of public health.”

Another change it made was to turn it into not only into a literal “rule” but a fiat, by eliminating exceptions — and not even the most sacred guidelines of the core tenets of medicine are without exception. Ethical guidelines are specifically defined as “principles”, not rules, in the code’s preamble. Despite APA membership comprising only 6 percent of practicing mental health professionals, and despite the fact that “the Goldwater rule” was not even admissible to state licensing boards — and any complaints would be “dead on arrival” because of the First Amendment — the organization embarked on a campaign that gave the public the impression that its guild rule was the law and universal. It would create a chilling effect that silenced thousands.

Trump didn’t just ignore warnings. He suppressed them. When Azar briefed him about the virus in January, Trump called him an “alarmist” and told him to stop panicking. When Navarro submitted a memo about the oncoming pandemic, Trump said he shouldn’t have put his words in writing. As the stock market rose in February, Trump discouraged aides from saying anything about the virus that might scare investors.

Suppression and obstruction were our concern. When we briefed Congress members in December 2017, upon their or their intermediaries’ invitation, they charged us with “doing our part” — that is, educating the public on medical matters — so that they could “do their part” — or carry out the necessary political intervention. However, even though we followed the APA’s own guideline that we “serve society by advising and consulting with the executive, legislative, and judiciary branches of the government,” the APA again became our greatest obstacle.

For weeks after he was briefed on the situation in China, including the fact that Beijing was downplaying the crisis, Trump continued to deny that the Chinese government was hiding anything. He implied that American experts had been welcomed in China and could vouch for Beijing’s information, which — as he would acknowledge months later — wasn’t true…. “Great discipline is taking place in China, as President Xi strongly leads what will be a very successful operation,” he proclaimed…. the Chinese “have everything under control…. We’re working with them. You know, we just sent some of our best people over there.” Then Trump walked onstage and exploited the political payoff of his deal with Xi. “Last month, we signed a groundbreaking trade agreement with China that will defeat so many of our opponents,” he boasted. He told the crowd that he had spoken with Xi and that the virus situation would “work out fine.”

“By April,” he explained, “in theory, when it gets a little warmer, it miraculously goes away.” Trump … had an overnight phone call with Xi. Immediately after that call, Trump began to promote the idea. Later, he mentioned that Xi had said it. When Fauci, Messonnier, Azar, and Redfield were asked about the theory, they all said it was an unwise assumption, since the virus was new.

For weeks we tried to inform the public on the seriousness of the president’s mental state, and by January 2018, we had become the number one topic of national conversation. All major primetime programs were inviting us, although we accepted them only cautiously, hoping for a gradual and nuanced buildup. But the APA was aggressive in denouncing us, publicly accusing us of practicing “armchair psychiatry” and using psychiatry as a “political tool” for “self-aggrandizing purposes.” It did so even as we kept with all its guidelines, and without asking about our motives. Perhaps it believed the president’s impairments truly were not serious, or that they would miraculously go away. We have no way of knowing.

Trump defended China’s censorship of information about the virus. In a radio interview, Geraldo Rivera asked him, “Did the Chinese tell the truth about this?” Trump … said, “If you were running it … you wouldn’t want to run out to the world and go crazy and start saying whatever it is, ’cause you don’t want to create a panic.” Weeks later, Trump would [tell] Fox New viewers that “every country does it.”

Trump envied Xi. He wished he could control what Americans heard and thought, the way Xi could control China’s government and media. But Trump didn’t have authoritarian powers, and some of his subordinates wouldn’t shut up…. On Feb. 25, when Messonnier said Americans should prepare for school and workplace closures, the stock market plunged. Trump, in a rage, called Azar and threatened to fire Messonnier. The next day, the president seized control of the administration’s press briefings on the virus.

On Feb. 26, shortly before Trump held his first briefing, aides gave him bad news: The CDC had just confirmed the first U.S. infection that couldn’t be traced to foreign travel. That meant the virus was spreading undetected. But when Trump took the podium,… he assured the public that infections in the United States were “going down, not up” and that the case count “within a couple of days is going to be down to close to zero”…. When a reporter pointed out that the United States had tested fewer than 500 people, while South Korea had tested tens of thousands, Trump shot back, “We’re testing everybody that we need to test. And we’re finding very little problem.”

Trump’s eruption brought his subordinates into line. Shortly after the president’s angry call to Azar, Redfield told Congress that “our containment strategy has been quite successful.” At her next briefing, for the first time, Messonnier praised Trump by name. She parroted his talking points: that the United States had “acted incredibly quickly, before most other countries” and had “aggressively controlled our borders.” Azar, in testimony before the House, went further. When he was asked to explain the discord between Trump and his medical advisers, the health secretary argued that Americans, like citizens of China, needed to be soothed. The president, Azar explained, was “trying to calm” the populace because, as “we see in China, panic can be as big of an enemy as [the] virus.”

Having cowed his health officials, Trump next went after the press. He told Americans to ignore news reports about the virus. On Feb. 26 and Feb. 27, Trump denounced CNN and MSNBC for “panicking markets” by making the crisis “look as bad as possible.” He dismissed their reports as “fake” and tweeted, “USA in great shape!” At a rally in South Carolina on Feb. 28, he accused the press of “hysteria,” called criticism of his virus policies a “hoax,” and insisted that only 15 Americans were infected. Weeks later, he would tell the public not to believe U.S. media reports about Chinese propaganda, either.

The American Psychiatric Association, too, focused on the press. On January 10, 2018, it enlisted the New York Times to announce that psychiatrists “should know better” than to speak, asking, “why do we need to hear it from psychiatrists?… Anyone with access to newspapers or Mr. Trump’s Twitter feed can do the same.” But it was not the same. It was not necessarily access to special information that made our interpretation different, but our bringing to the same informationsolid scientific research and clinical experience accumulated over decades to make our assessment.”

Rather, the newspaper published its first and only full-page opinion on the president’s mental state, by Dr. Jeffrey Lieberman, a past APA president of questionable ethics himself who championed against our cause and equated us with Nazi psychiatrists for “diagnosing”, when we have not, but who himself was found to have extensively diagnosed — except only favorably to the president. He again downplayed the president’s impairments to claim, “he’s just a jerk,” on the opposite page of the above New York Times’ editorial.

Another sign that the APA’s objective was to suppress voices on the president’s impairments, not to enforce “the Goldwater rule,” is the fact that it remained silent about Dr. Allen Frances, who explicitly diagnosed from afar by stating the president does not have narcissistic personality disorder (ruling out disorders is also “diagnosing”, as per the APA itself). This contrasts the way it sanctioned since publication the authors of bestselling public-service book, The Dangerous Case of Donald Trump, who did not diagnose but alerted the public to the president’s dangerousness, in line with the purpose of “the Goldwater rule,” which is “to participate in activities contributing to the improvement of the community and the betterment of public health.” The New York Times did not fail to amplify Dr. Frances’ voice, either.

In the three weeks after his Feb. 26 crackdown on his subordinates, Trump opposed or obstructed every response to the crisis. Doctors were pleading for virus tests and other equipment. Without enough tests,… the virus was spreading invisibly. Fauci was desperate to accelerate the production and distribution of tests, but [on] a March 6 visit to the CDC, the president argued that … it was better to “find out those areas just by sitting back and waiting.” A proactive CDC testing program, lacking presidential support, never got off the ground. Nor did a separate national testing plan — organized by Trump’s son-in-law, Jared Kushner — which … was never announced.

Trump also refused to invoke the Defense Production Act, which could have accelerated the manufacture of masks, gloves, ventilators, and other emergency equipment. In January, HHS had begun to plan for use of the DPA, and in early February, some members of Congress suggested it might be needed. But Trump declined to use it until the end of March. When he was asked why, he said that governors, not the president, were responsible for emergency supplies and that telling “companies what to do” might upset the “business community.”

Within two or three weeks of the New York Times’ criticism of psychiatrists who would speak up, inquiries from all major media came to a sudden stop. Without this coverage, there was no way to open a national conversation. We proactively sought every minor media that would have us, but after the crackdown by both the APA and the New York Times, our message was pushed into hidden places where it would not upset the president, but remain only as a record of what we wished to say.

The president’s most decisive contribution to the death toll was his resistance to public health measures known as “mitigation”: social distancing, school and workplace closures, and cancellations of large gatherings. Messonnier and others had warned since early February that Americans needed to prepare for such measures. On Feb. 24, Trump’s health advisers decided it was time to act. But they couldn’t get a meeting with Trump, because he was off to India to discuss another trade deal. When he returned, he blew up at Messonnier for talking about closing schools and offices. The meeting to discuss mitigation was canceled.

The APA’s most decisive contribution was to bar expert voices from public discourse, and abundant financial rewards from the federal government followed. As with a serious pandemic, it is difficult to imagine that a condition as severe as the president’s could be dealt with effectively without specialists of mental health, and it wasn’t, as with the pandemic. Even if standard mental health interventions were never possible, mitigation would have been effective, preventing what we call a “malignant normality” from taking hold, where “factual reporting and rational discourse are no longer possible.”

Mitigation required leadership. The president needed to tell Americans that the crisis was urgent and that life had to change. Instead, he told them everything was fine. On March 2, he held another rally, this time in North Carolina. Before the rally, a TV interviewer asked him whether he was taking more precautions because of the virus. “Probably not so much,” Trump replied. “I just shook hands with a whole lot of people back there.” The next day, he said it was safe to travel across the country, since “there’s only one hot spot.” On March 5, at a Fox News town hall, he repeated, “I shake anybody’s hand now. I’m proud of it.” On March 6, visiting the CDC, he was asked about the risks of packing people together at rallies. “It doesn’t bother me at all,” he said.

Protection of the public required leadership. That is why thousands of mental health professionals from around the country, and then the world, came together to form the World Mental Health Coalition. As the first professional organization to form specifically to speak up about the president’s psychological dangers, we did so “in opposition to the American Psychiatric Association, which, with the Trump presidency, not only failed to meet the psychiatric profession’s societal responsibility but inhibited individual professionals from doing so.” It intended to fulfill our stated purpose, as of January 25, 2018: “helping the public to understand behaviors that are unusual and alarming, but which can all too easily be rationalized and normalized.”

As schools and businesses began to close, Trump pushed back. On March 4, he dismissed a question about further closures, insisting that only “a very small number” of Americans were infected. On March 9, he tweeted that the virus had hardly killed anyone and that even in bad flu seasons, “nothing is shut down, life & the economy go on.” Italy locked down its population, the NBA suspended its season, and states began to postpone elections. But through the middle of March, as advisers urged the president to endorse mitigation, he stood his ground. Finally, as the stock market continued to fall, Trump’s business friends agreed that it was time to yield. On March 16, he announced mitigation guidelines.

However, the public and hence lawmakers had begun to close off to expert input. “We already know he’s dangerous” or “We know he’s nuts” became a typical refrain, if not “We don’t need to be a doctor to know it’s serious,” when from our perspective critical understanding was lacking or absent. People continued to tell themselves they “hit bottom” with him when they were at the tip of the iceberg, and without a good grasp of human behavior, hope sprung eternal that he would change someday to become more reasonable.

By then, the number of confirmed infections in the United States had surged past 4,000. But that was a fraction of the real number. The CDC would later calculate that in the three weeks from “late February to early March, the number of U.S. COVID-19 cases increased more than 1,000-fold.” And researchers at Columbia University would find that the final two-week delay in mitigation, from March 1 to March 15, had multiplied the U.S. death toll by a factor of six. By May 3, the price of that delay was more than 50,000 lives.

On March 23, a week after he announced the mitigation guidelines, Trump began pushing to rescind them. “We have to open our country,” he demanded. He batted away questions about the opinions of his medical advisers…. The next day, the stock market soared, and Trump took credit. Investors “see that we want to get our country open as soon as possible,” he crowed…. In more than a dozen tweets, briefings, and interviews, he explicitly connected his chances of reelection to the speed at which schools and businesses reopened. (Trump focused on schools only after he was told that they were crucial to resuming commerce.) The longer it took, he warned, the better Democrats would do in the election. In April, he applauded states that opened early and hectored states that kept businesses closed. In June, he told workers in Maine, “You’re missing a lot of money.” “Why isn’t your governor opening up your state?” he asked them.

Trump pushed states to reopen businesses even where, under criteria laid out by his health officials, it wasn’t safe to do so. He called for “pressure” and endorsed lawsuits against governors who resisted. He issued an executive order to keep meat-processing plants open, despite thousands of infections among plant employees. He ordered the CDC to publish rules allowing churches to reopen, and he vowed to “override any governor” who kept them closed. In April, he made the CDC withdraw an indefinite ban on cruises, which had spread the virus. In July, he pressed the agency to loosen its guidelines for reopening schools.

But then people began to die. Denying, minimizing, and normalizing his dangerous mental pathologies in order to maintain polite coexistence could no longer hold. It became a stark division between those who remained grounded in facts and those who bought into his “alternative reality,” or the choice of fantasy as a substitute for the actual solving of problems. As he created more crises, his desire to hold onto power grew more fierce, and so did his distortions. Above all, he needed to redirect and to use the growing fury as a weapon against his opponents, and he did, just as we warned he would since the beginning of the pandemic. He turned the frustration of lockdowns and economic hardship, which he himself made necessary, into reasons for attacks against elected officials attempting to institute public health measures. Acting as his tool, against their own safety, to threaten Democratic governors came to be declared as personal “liberation”, and even mask wearing and standard measures to protect oneself were political statements inviting a fight. Hence, the initial, natural sense of cohesion and readiness to unite against a common threat gave way to an antagonism of partisans, the battle of reality and fantasy, or a level of chaos seldom seen elsewhere in the world. He claimed, “large portions of our country [are] corona-free,” even as federal officials issued a report finding that 21 states had outbreaks so severe that they were in the “red zone.” As a result, “unscientific” lockdowns, not Donald Trump, would be blamed for devastating the economy and for exacerbating domestic abuse, depression, suicides, and drug overdoses, among other problems, which were projected to produce 75,000 additional deaths to those from Covid-19.

He continued to suppress warnings. In April, he claimed that doctors who reported shortages of supplies were faking it. When an acting inspector general released a report that showed supplies were inadequate, Trump dismissed the report and replaced her. When a Navy captain wrote a letter seeking help for his infected crew, Trump endorsed the captain’s demotion. The letter “shows weakness,” he said.

Meanwhile, the APA’s suppression of warnings worked: from January 2018 through August 2019, there were only a handful of mental health professional appearances on major programs and then none at all for almost a year, whereas before, we were interviewing nearly every day.

Having argued in March against testing, Trump now complained that doctors were testing too many people. He said tests, by revealing infections, made him “look bad.” When Fauci and Deborah Birx, the response coordinator for the White House Coronavirus Task Force, said more tests were needed, Trump openly contradicted them. In July, he claimed that 99 percent of coronavirus infections were “totally harmless” — which wasn’t true — and that the testing system, by detecting these infections, was “working too well.”

Fauci, Birx, Redfield, and other health officials … argued against premature resumption of in-person social activities…. Trump publicly overruled them, tried to discredit them, and pressured them to disavow their words. To block Fauci from disputing Trump’s assurances that the virus was “going away,” the White House barred him from doing most TV interviews. In June, when Fauci said resuming professional football would be risky, Trump rebuked him. “Informed Dr. Fauci this morning that he has nothing to do with NFL Football,” the president tweeted.

Trump interfered with every part of the government’s response. He told governors that testing for the virus was their job, not his. When they asked for help in getting supplies, he told them to “get ’em yourself.” He refused, out of pique, to speak to House Speaker Nancy Pelosi or to some governors whose states were overrun by the virus. He told Vice President Mike Pence not to speak to them, either. He refused to consult former presidents, calling them failures and saying he had nothing to learn from them.

Without mental health experts to provide grounding in reality and to explain why things were happening as they were, we came to live in a world where anything goes. Far before the pandemic even began, Donald Trump’s pathological envy of Barack Obama led to his dismantling of a global pandemic response system that was lauded throughout the world. And when the pandemic hit, he made it multifold worse, as we predicted: what we learned from his capacity evaluation was that he is simply incapable of doing what is necessary, for that would mean facing reality, including his own emptiness and incapacity.

Trump didn’t just get in the way. He made things worse. He demanded that Wisconsin hold elections in early April, which coincided with dozens of infections among voters and poll workers. (Some researchers later found correlations between infections and voting in that election; others didn’t.) He forced West Point to summon cadets, 15 of whom were infected, back to campus to attend his commencement speech in June. He suggested that the virus could be killed by injecting disinfectants. He persistently urged Americans to take hydroxychloroquine, a malaria drug, despite research that found it was ineffective against the coronavirus and in some cases could be dangerous. Trump dismissed the research as “phony.”

His psychology could not help but make things worse. Going further back, his lack of interest in prevention and public good led to the depletion of funding and withdrawal of support for great public health institutions such as the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). These acts alone probably hampered worldwide containment of the pandemic — perhaps even its emergence into a pandemic in the first place — as well as worldwide response. While he might have outdone the authoritarian Chinese government in denial, reprimand of medical experts, and incapacitation of scientific teams working on pandemics, he did not hesitate to call the novel coronavirus “Chinese virus,” in order to deflect blame while creating new targets for attack. He similarly blamed the WHO for his own failures, halting funding and withdrawing membership at a critical time when the world depended especially on the WHO to fill in where the weakened CDC was no longer available. Finally, his preoccupation with his self-image and reelection prospects compelled him to dominate daily press briefings and to place the public in harm’s way by touting unproven treatments, spreading misinformation, and modeling disease-spreading behavior.

Trump ridiculed masks. He said they could cause infections, and he applauded people who spurned them. Polls taken in late May … indicated that Trump’s scorn was suppressing mask use. A Morning Consult survey found that the top predictor of non-use of masks, among dozens of factors tested, was support for Trump. An NBC News/Wall Street Journal survey found that people who seldom or never wore masks were 12 times more likely to support Trump than to support his opponent, former Vice President Joe Biden. Some scientific models imply that Trump’s suppression of mask use may have contributed to hundreds, if not thousands, of deaths.

In this manner, Donald Trump succeeded in making the U.S. the pandemic epicenter of the world, despite having all the medical, financial, and military resources the rest of the world could only envy. It is now responsible for a third of the world’s confirmed coronavirus cases and a quarter of its deaths, while only 1/24 of its population. Nevertheless, as expected and as we said repeatedly, his behavior would not change but only worsen:

On June 10, Trump announced that he would resume holding political rallies. He targeted four states: Florida, Texas, Arizona, and Oklahoma. The point of the rallies, he explained, wasn’t just to boost his campaign but to signal that it was time to “open up our country” and “get back to business.” When reporters raised the possibility that he might spread the virus by drawing crowds indoors, he accused them of “trying to Covid Shame us on our big Rallies.”

Despite being warned that infections in Oklahoma were surging, Trump proceeded with a rally at a Tulsa arena on June 20. To encourage social distance, the arena’s managers put “Do Not Sit Here” stickers on alternate seats. The Trump campaign removed the stickers. Trump also refused to wear a mask at the rally — few people in the crowd did, either — and in his speech, he bragged about continuing to shake children’s hands. Two weeks later, Tulsa broke its record for daily infections, and the city’s health director said the rally was partly to blame. Former presidential candidate Herman Cain attended the rally, tested positive for the virus days afterward, and died at the end of July.

At the rally, Trump complained that health care workers were finding too many infections by testing people for the virus. He said he had told “my people” to “slow the testing down, please.” [In] an interview with the Christian Broadcasting Network, he said he was only half-joking. He affirmed, this time seriously, that he had told “my people” that testing was largely frivolous and bad for America’s image. Weeks later, officials … disclosed that the administration, against the wishes of Senate Republicans, was trying to block funding for virus tests.

Two days after the Tulsa rally, an interviewer asked Trump whether he was putting lives at risk “by continuing to hold these indoor events.” Trump brushed off the question: “I’m not worried about it. No, not at all.” The next day, June 23, the president staged another largely mask-free rally, this time in a church in Arizona, where a statewide outbreak was underway. Days later, Secret Service agents and a speaker at the Arizona rally tested positive for the virus. On June 28, Trump urged people to attend another rally, this time featuring Pence, at a Dallas church where five choir and orchestra members had tested positive.

[Since] his interview with Wallace, Trump has attacked and belittled his medical advisers. He lashed out at Birx for acknowledging the ongoing spread of the virus. He retweeted a false claim that Fauci was suppressing hydroxychloroquine “to perpetuate Covid deaths to hurt Trump.” When Fauci told Congress that infections had increased due to insufficient mitigation, Trump rebuked him and blamed the surge on increased testing. And when Dave Portnoy, a wealthy Trump supporter, complained that his stocks tanked every time Fauci called for mitigation, Trump assured Portnoy that the doctor’s pleas would go nowhere. “He’d like to see [the economy] closed up for a couple of years,” Trump said of Fauci. “But that’s OK, because I’m president.”

His psychological need for “total authority” and intolerance for dissenting or even differing opinion makes democracy incompatible with this presidency. He has difficulty tolerating protesters especially, and since the rise of perhaps the largest people’s movement in Black Lives Matter, he has been quick to portray them as “professional anarchists, violent mobs, arsonists, looters, criminals, rioters, Antifa, and others.” Even as there has been no proof of “Antifa’s” involvement in violence, but rather of his supporters, he has used the minimal violence as a reason for his crackdown with federal forces — even as local authorities implore Congress to make it illegal to send federal agents to cities where they are unwelcome. Even the police force has been a shocking instigator of violence, responsible for 125 documented violent acts against protesters throughout the country over an 11-day period, as if acting on the president’s cue. And as the president called journalists “truly bad people with a sick agenda,” the U.S. Press Freedom Tracker also documented over 400 direct police harassment and attacks of reporters at protests, many of whom have suffered permanent injuries, over the span of two weeks. All this is consistent with the multiple ways in which Donald Trump has directly inspired, incited, stoked, and laid down a culture of violence, as we had warned he would since the beginning.

It’s hard to believe a president could be this callous and corrupt. It’s hard to believe one person could get so many things wrong or do so much damage. But that’s what happened. Trump knew we weren’t ready for a pandemic, but he didn’t prepare. He knew China was hiding the extent of the crisis, but he joined in the cover-up. He knew the virus was spreading in the United States, but he said it was vanishing. He knew we wouldn’t find it without more tests, but he said we didn’t need them. He delayed mitigation. He derided masks. He tried to silence anyone who told the truth. And in the face of multiple warnings, he pushed the country back open, reigniting the spread of the disease.

We must go further to be accurate: it’s hard to believe that a president “genuinely cares for no one but himself, [that he] lacks the capacity to feel regret or to avoid the harm he can cause to others, [and that he] can derive a sadistic pleasure for the hurt he may create.” But this is his psychological disposition. If not for the criticism and potential economic effects that would cause problems for his re-election bid, he would only be too delighted to have people suffer and die.

Our nation is in peril, which is why we issued our “Prescription for Survival,” on March 25, 2020, recommending that sidelining or removing the president, however it is done, remained necessary for preventing the worst effects of the pandemic. We also do not believe the public should continue to be deprived of expertise, or the best available knowledge, just as it should not be deprived of facts. Knowledge saves lives and is the key to a functioning democracy, or a rule by the people for the people. In line with the above, we are urgently issuing the documents of the World Mental Health Coalition, or a collection of our letters, petitions, and conference transcripts, in order to share the knowledge we believe will be critical to the public’s ability to protect itself and to make informed decisions. We must address the primary problem that is the source of all that the excellent Slate article outlines: the president’s mental impairments. It is the key to our naming the problem and solving it.

Now Trump asks us to reelect him. “We had the greatest economy in the history of the world,” he told Fox News on Wednesday. “Then we got hit with the plague from China.” But now, he promised, “We’re building it again.” In Trump’s story, the virus is a foreign intrusion, an unpleasant interlude, a stroke of bad luck. But when you stand back and look at the full extent of his role in the catastrophe, it’s amazing how lucky we were. For three years, we survived the most ruthless, reckless, dishonest president in American history. Then our luck ran out.

It should not run out more, for it could still get a lot worse.

Written by

Forensic psychiatrist, violence expert, president of the World Mental Health Coalition (worldmhc.org), and editor of "The Dangerous Case of Donald Trump.”

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