The Premonition: A Pandemic Story

by Michael Lewis

In February 2021, The Lancet published a long critique of the U.S. pandemic performance. By then 450,000 Americans had died. The Lancet pointed out that if the COVID death rate in the United States had simply tracked the average of the other six G7 nations, 180,000 of those people would still be alive. “Missing Americans,” they called them.

If this story speaks to that management in any way, I hope it is to say: There are actually some things to be proud of. Our players aren’t our problem. But we are what our record says we are.

But Santa Barbara County was both bigger and more complicated than it seemed. It had the highest rate of child poverty in the state. It sheltered maybe fifty thousand illegal immigrants in abject squalor. Plus all hell could break loose at any time: wildfires and mudslides and oil spills and mass shootings. Scratch the surface of paradise and you were plunged into the Book of Job.

To minimize horrific death, and to chase disease, the state of California had bestowed upon local public-health officers extraordinary legal powers.

Steve Hosea burned into my mind that the most important part of the medical history isn’t the medical history. It’s the social history.”

The simplest explanation is usually the best.

If there is the faintest possibility of a catastrophic disease, you should treat it as being a lot more likely than it seems. If your differential diagnosis leads to a list of ten possibilities, for instance, and the tenth and least likely thing on the list is Ebola, you should treat the patient as if she has Ebola, because the consequences of not doing so can be calamitous.

When something doesn’t quite seem right about your diagnosis, respect the feeling, even if you can’t quite put your finger on why the diagnosis might be wrong. A lot of people had died because doctors had allowed their minds to come to rest before they should.

“They said, ‘You need to do these things one at a time and gather evidence.’ They wanted to learn from this meningitis outbreak, and I wanted to stop it. My goal was to stop it, and that was not their goal. They wanted to observe it as if it were a science experiment on how meningitis moves through a college campus. And I was like, ‘Are you kidding me: a kid just lost his feet.’

In theory, the CDC sat atop the system of infectious-disease management in the United States. In practice, the system had configured itself to foist the political risk onto a character who had no social power. It required a local health officer to take the risk and responsibility, as no one else wanted to. Charity could see that the CDC’s strategy was politically shrewd. People were far less likely to blame a health officer for what she didn’t do than what she did. Sins of commission got you fired. Sins of omission you could get away with, but they left people dead. The health officer’s job was to choose, all by herself, the direction in which to err: do too much, or too little? “I did not sign up to be that kind of brave,” said Charity. “That wasn’t my plan. I was always saying to the CDC, ‘This is your job! Do your job!’ But after the UCSB outbreak, my motto was, ‘Stop waiting for someone to come and save you. Because no one is coming to save you.’ ”

“What scares me most and what I think about most,” said Charity, “is our ability to respond to a new pathogen, maybe one we’ve never seen before, or an old pathogen, like influenza that’s just mutated. The H1N1 pandemic of 1918 was over 100 years ago now. The world is overdue for a pandemic like that, whether it’s influenza or something else. And in public health, we know that we have to be prepared for that.”

The words mattered less for what they said than for what they could be made to say. Like the words in the Holy Bible or the U.S. Constitution, they invited the problem of how they might be interpreted, and by whom, and for what purposes.

People who complained about “government waste” usually fixated on the ways taxpayer money got spent. But here was the real waste. One box might contain the solution to a problem in another box, or the person who might find that solution, and that second box would never know about it.

Until that moment, no one had really seen what was unusual about schools, at least from the point of view of the pandemic strategist. It had taken the Glasses’ model to point it out. Why? Carter wondered. Why hadn’t they seen it? Then it struck him. They saw it all with adult eyes. They forgot the world that their kids live in, and that they once lived in.

“Imagine if we had the capability to reduce a category 5 storm to a category 2 or a 1 . . . Now although the Federal Government is not at the threshold of significantly reducing the potency of a hurricane, it is at the threshold of doing just this to another natural disaster—pandemic influenza.”

He’d coined a phrase for their strategy: Targeted Layered Containment. TLC.

“There was the CDC way of doing things,” she said. “It was vaccinate and isolate. And this wasn’t that.” No one in the CDC was thinking about how, in the event of a deadly pandemic, the government might move people apart from each other in this way or that.

Carter wondered why this had been so hard to see. A big part of the answer, he decided, was in the nature of pandemics. They were exponential processes. If you took a penny and doubled it every day for thirty days, you’d have more than five million dollars: people couldn’t imagine disease spread any better than they could imagine a penny growing like that.

The same mental glitch that leads people to not realize the power of compound interest blinds them to the importance of intervening before a pathogen explodes.

By then science perhaps didn’t need her as much: the insights at the heart of her project had become the official policy of the United States government, and were spreading rapidly from the CDC to the rest of the world.

Carter and I argued as hard as we could for a ‘tactical pause’; CDC felt we “didn’t have enough data.” It was an argument about the precautionary principle v. the scientist’s desire not to make a mistake, coupled with risk aversion that was all too characteristic of public health bureaucrats. It was literally driving Carter nuts.

[CDC acting director] Rich [Besser] has leaned over and unclipped the leash without knowing whether he was setting free a puppy dog or a tiger. The recklessness of the decision, given the uncertainties, was astonishing, a deep failure, to my mind, of the institution to perform its primary duty, which is to protect the public health.

Richard’s other takeaway from his second tour of duty in the White House was just how little government was able to do quickly. “You only have whatever buttons to push that you had going into the crisis,” he said. “You don’t get any new buttons. You could see by September how little we had in fact gotten into place that was different from when the pandemic started.”

The United States government might not have closed the schools and used other social distancing measures, as Mexico had, but these things were now real options. The country had a new button to press, and new experts who might press it.

His mind unspooled a different scenario that left him with a conviction that nuclear fallout shelters were probably a dumb idea.

“Experience is making the same mistake over and over again, only with greater confidence,”

“A peacetime institution in a wartime environment,” Carter called it. Its people were good at figuring out precisely what had happened, but by the time they’d done it, the fighting was over. They had no interest in or aptitude for the sort of clairvoyance that was needed at the start of a pandemic. Yet the CDC was now the home for the strategy he and Richard had created. “So the CDC is the authority, and everyone is going to be waiting for the CDC to make a decision,” said Carter. “And who is going to go against the CDC—some local health official?” *

American society had no ability to deal with what she felt was coming.

“The United States doesn’t really have a public-health system,” she said. “It has five thousand dots, and each one of those dots serves at the will of an elected official.”

Science was just curiosity’s tool. Progress often began when someone saw something they hadn’t expected to see and said, “Huh, that’s weird.”

“The little game of finding the reservoir species has been easy for coronaviruses,” said Joe. “No one has ever figured it out for Ebola. People took whole zoos out of Africa and they never found the animal.”

There was a second kind of call, more urgent than the first. The voice on the other end of the line would say: This person is dying and we don’t know why.

The postdocs subjected Balamuthia to the 2,177 drugs known to have done no harm to humans. Each day, they’d remove the amoeba from its place on the rack in the world’s most dangerous refrigerator and see if any of the drugs might kill it. “It’s scary to work with,” one of the postdocs confessed, but then suddenly it wasn’t. Because one of the approved drugs indeed killed the amoeba. Nitroxoline, it was called. Joe and his postdocs wrote up their findings and published the result in mBio, a microbiology journal, in October 2018.

There were several points to this story. One was how screwed up the incentives were inside the medical-industrial complex. It was possible to spend $1,000,100 on drugs to prevent you from dying without anyone’s having any idea if any of them would work; at the same time, inside of a few weeks but too late to save you, some ill-paid postdoc was able to find a cheap cure. Another was that even when you might have thought that problem was solved, it wasn’t. Two years after Joe and his postdocs published their findings on Balamuthia, the FDA had yet to approve Nitroxoline, long since cleared by European regulators, as a treatment. The CDC website continued to recommend an old treatment (another one of the 2,177 drugs) that the DeRisi Lab had demonstrated did nothing but create unpleasant side effects. Which is to say that American citizens could and would die of Balamuthia without ever knowing what they had, or that there was a cure. Unless, somehow, they’d heard about the Red Phone.

That was Joe’s big takeaway from the story: what he called the last mile problem in medical science. Corporations were interested only in stuff that made money. Academics were interested in anything worthy of publication, but once they had their paper done, they tended to lose interest. The government was meant to fill in the blanks, but the United States government by now mystified Joe. He’d visited the CDC to explain the new genomic technology, only to be met with boredom and blank stares. In the Food and Drug Administration there was one woman—a single human being—trying to curate the academic literature so that doctors and patients could easily access new knowledge. She’d taken it upon herself; no one had asked her to do it. “It’s often individuals who pick up the baton, and they’re not even doing it as part of their day job description,” said Joe. “Scattered throughout those organizations there are these peo...

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Matt Hepburn, for instance, had spent much of the previous decade inside DARPA, the Department of Defense’s elite research unit, working on rapid vaccine development.