In late September 2014, Texas looked like it might become the epicenter of a devastating viral outbreak in the United States. A Liberian man named Thomas Eric Duncan had traveled to Dallas to visit family, checked into the emergency room at the Texas Health Presbyterian Hospital Dallas with a mild fever, abdominal pain, dizziness, nausea, and a headache. After several days of missed diagnoses, Duncan tested positive for the Ebola virus, which was ravaging portions of West Africa at the time. Duncan eventually died of the disease, and it infected two nurses, both of whom recovered.

As it became clear that Texas Health Presbyterian and the entire state health care system had been caught off guard, Governor Rick Perry created the Texas Task Force on Infectious Disease Preparedness and Response to investigate what went wrong and make recommendations for future instances of epidemic illness.

On February 4 of this year, weeks before the first known cases of community spread of the coronavirus in the U.S., the task force held a public meeting to go over the current trajectory of the disease. Toward the end of the discussion, Dr. William Tierney, chair of the Department of Population Health at Dell Medical School, delivered what amounted to a warning: In the past, when big public health efforts ramped up early and were successful, the medical community got accused of “crying wolf.” On the other extreme, an insufficient mobilization to counter a serious epidemiological crisis could lead to disaster and cries of negligence. Tierney urged the task force to think carefully about how to sell policy makers and the public on a much-needed response.

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On Thursday, Texas Monthly spoke with Tierney about what has happened since, what should be done now, and the best and worst case outcomes for the state and the nation.

[This interview has been edited for length and clarity.]

Texas Monthly: When I heard the comment you made at the last public meeting of the infectious disease task force, I wondered if policy makers in the U.S. had reacted slowly to the pandemic because they were worried about “crying wolf.” Do you think leaders were wary of looking like they were overreacting?

William Tierney: Well, let me tell you why I said that. During the 2009 H1N1 pandemic, I was the chairman of the Department of Internal Medicine of the fourth largest safety-net health system in the country, in Indianapolis. [Safety-net health systems provide care to patients whether or not they have health insurance or can pay.] We were gearing up for it. Much of what we’re doing now, we did back then. We were bumping elbows [instead of shaking hands] and everybody got a flu shot. The center for bioethics for the university was in my department, and [the center was] working with the state to decide, if there weren’t enough ventilators, who would get them. So we were having all those conversations.

But then it wasn’t as contagious as we had feared. The explosion never happened. And we got a bunch of blowback that our response was a tempest in a teapot, that it just wasted a lot of money. So I mentioned that at the February meeting of the task force and said, “You can’t win. If you get people real excited at mitigation efforts, the mitigation efforts are successful and it’ll look like a tempest in a teapot. And if they’re not successful, you get blasted for not doing enough.” So I said you have to stay ahead of it in the messaging, saying that if we are successful, it’ll look like a tempest in a teapot. Sadly, I don’t think we’re going to have that problem.

TM: No. There is no one in the world who’s going to say this was a tempest in the teapot at this point.

WT: Not anymore. Look at New York City. I have friends in New York City on the front lines, and it is worse than you’re seeing on the news. That’s starting to happen to Detroit and Chicago and New Orleans. It’s marching in this direction. We’re going to see it here. You’ve seen the national projections. I think the [recent White House] projection of 100,000 to 240,000 person mortalities is woefully underestimated. I hope I’m wrong about that, but we’d have to have so few people infected to hit that rate and we haven’t seen it yet.

TM: That’s really bleak. Is there any reason to believe it might not get that bad?

WT: At Dell Medical School I’m trying to find out what’s happening around the country and around the world, so that we can stay ahead of it and we can put those data into our models. So I’ve got friends I’ve been pinging in Seattle and New York and New Orleans. Pretty soon I’ve got friends in Detroit I’m going to be bugging. My contact in Seattle has said that the city did not see the spike that they anticipated. The mitigation efforts there actually seemed to have worked. They’re busier than hell, but it hasn’t overwhelmed their system.

EB: How are we doing in Austin?

WT: I am encouraged that Austin actually acted early, knowing all the economic flack that that was going to cause, and the flack they were going to get, and just said, “No South by Southwest. Isolate. Not quite shelter in place, but certainly isolate and only go out if you really need to, and only the central businesses stay open.” I think that’s why you’re seeing only around three hundred cases in Austin so far [as of noon Thursday there were 351 confirmed cases in the city]. It really hasn’t hit Austin yet, but it’s going to get much bigger. We’re still in the shallow part of that particular curve. So most of what we’ve been doing is setting up testing and then getting people ready for the surge.

EB:  Is that surge inevitable?

WT: Unless we clamp down so remarkably that essentially no one interacts with anybody, we’re still going to reach the capacity of our health system. It’s just going to be later and much broader. Instead of just a one month period of hell, it’s going to be three months of purgatory—if we’re lucky. If we’re not lucky, we’re going to overwhelm our resources and have a quarter of the ventilators we need. The other three-quarters of the people will die.

EB: Going back to that early February meeting, do you think there are things we could have done as a country or a state to make COVID-19 into a tempest in the teapot?

WT: No, because this is so contagious. Our model shows that we would have to have 90 percent success of mitigation, which means you get rid of 90 percent of the potential interactions between you and me, and throughout the entire community, to be able to blunt this to be like a bad flu season. We would have had to start that weeks ago. I think that you can argue that not all states and not all people in our federal government took it seriously early on. Although you have to give the federal government credit for stopping transportation from China and Europe early on, but even then, how prepared are we? The ventilators are not distributed. There’s not enough protective equipment. You look at New York City, they’re scrambling to open beds in tents in Central Park. That shouldn’t happen when your ICUs are full. It should happen when they’re empty.

EB: I think the argument with New York and the nation is that they could have been looking at what was happening in Wuhan and Milan and started building hospitals, or more hospital capacity in February.

WT: Yeah. I can’t disagree with that. I think it certainly would have helped New York to get the heads-up, especially if they could have gotten an additional 20,000 ventilators and brought in ventilator techs from other places and trained nurses to be ventilator techs and things like that. Yes, that would have helped. It probably would have saved thousands of lives, but this all happened in a month. If we wanted to plan for this, it should have been years ago.

EB: So at this point, we’re nearly all under stay-at-home orders. What would you like to see happen that’s not happening now? Do you think there are other things that we could be doing, both in Texas and the nation, to blunt this?

WT:  Yeah. The first thing I would do is I would have the National Guard delivering groceries. Close the grocery stores. I don’t care how much they wipe down stuff with people wearing masks, we’re exposed if we go there. That’s where people are getting infected now, in the grocery stores. The delivery companies are overwhelmed. Right now, if you sign up for grocery delivery, it’s a month away. I’m not criticizing anybody. What I’m saying is that the existing infrastructure can’t handle demand and they can’t ramp up fast enough, because we need it today.

So, where is there manpower? Well, there’s manpower in things like the National Guard and the military, but there’s also manpower in the people who’ve been laid off. But there’s no central organizing force to make it happen.