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What happens when the people in charge of managing these risks, along with the experts who understand them, have no interest in them?
But as I got into it, and found these wonderful characters to tell the story through, it became clear that Trump’s approach to government management was only a part of the story, and maybe not even the bigger part. As one of my characters put it, “Trump was a comorbidity.”
A group called the Nuclear Threat Initiative partnered with Johns Hopkins and The Economist Intelligence Unit to create what amounted to a preseason college football ranking for one hundred ninety-five countries. The Global Health Security Index, it was called. It was a massive undertaking involving millions of dollars and hundreds of researchers. They created stats and polled the experts. They ranked the United States first. Number 1. (The United Kingdom was Number 2.)
I think this particular story is about the curious talents of a society, and how those talents are wasted if not led. It’s also about how gaps open between a society’s reputation and its performance.
As she watched her father’s computer screen, she thought, It’s almost like the red dots are infecting the green dots. In history class she’d been reading about the Black Death. “I was fascinated by it,” she said. “I had no idea. It wiped out a third of Europe.” She asked her father: Could you use this model to study how a disease spreads? He hadn’t considered using his model to study disease.
The model he’d built with his daughter showed that there was no difference between giving a person a vaccine and removing him or her from the social network: in each case, a person lost the ability to infect others.
“I don’t really care about obesity or diabetes,” she said. “I actually don’t give a shit about chronic disease. What I like is a crisis.” What she more than liked was the kind of crisis that might be created by a communicable disease.
She knew it sounded odd, but she’d been consumed by this interest since she was a small child. Disease had shaped history; disease had crippled societies—but that’s not why, at the age of seven, she’d become obsessed with it. “It was gruesome death,” she said. “It was the human powerlessness over it. I was interested in horrific disease that swept across huge swaths of the population, who were powerless to stop it, and died these awful deaths.”
Most of the citizens of Santa Barbara, including nearly all of the public officials by whose pleasure she served, didn’t even really understand what a public-health officer was supposed to do.
“Men like that always underestimate me,” she said. “They think my spirit animal is a bunny. And it’s a fucking dragon.”
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.”
If there is the faintest possibility of a catastrophic disease, you should treat it as being a lot more likely than it seems.
Her patient was Santa Barbara County. To keep it healthy, she needed to think about it the way Stephen Hosea thought about his patients. She needed to keep her hands on it. To be its detective.
The business card that described him as a “specialist in orthopedic medicine.” That’s what doctors called themselves when they weren’t actually trained as orthopedists.
Charity then asked Dr. Thomashefsky if she could observe him while he treated a patient. He’d be on his best behavior, she knew, but she also thought doctors, especially older doctors, had trouble hiding who they were. “Doctors get into habits in the way they flick their wrists. How they turn, how they spread things out on a table.”
She watched Dr. Dean tell this important doctor, on the spot, that she was issuing a health order to shut him down. What struck her was the total absence of apology or hesitation in Dr. Dean’s voice. “You know how some people kind of look away when there’s conflict,” she said. “She doesn’t do that. It’s straight eye contact, and very direct. ‘Effective today, you’re closed. Here’s what we need to do.’ ”
“The CDC was aghast,” she said. “They were aghast that I hadn’t asked their opinion. They said no local health officer in the history of local health officers has ever issued an order to close down a doctor’s office based on a suspicion.”
But because people who had health insurance thought it had nothing to do with them—that it was just government—the society had starved the system of resources. “People don’t realize what it is until something bad happens,” said Charity. “It’s protecting the entire society, the whole economy.”
She’d grown used to the lack of material support. But in her investigation of the Thomashefsky clinic, the total absence of moral and practical support from the state and federal governments mystified her. “I kept waiting for the feds—the CDC, maybe the FDA—to say, ‘Dr. Dean, we got this.’ And no one ever said that.”
I know what it means for me to ignore the lab report and assume it is meningitis B, he said. And it’s very different from what it means for you. In other words, a misdiagnosis carried no professional risk for him. For her, the risk was massive.
If one kid had the disease, others surely did, too. If six kids had it today, twelve kids might be infected the following week. And if twelve had it next week, twenty-four might have it the week after. And if . . . well, it wasn’t long before she’d have an epidemic on her hands.
The root of the CDC’s behavior was simple: fear. They didn’t want to take any action for which they might later be blamed.
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.’
The mudslide forecast proved incredibly prescient: the mountain moved exactly as the experts had predicted.
The federal and state governments were now helping with the response, and the director of the California Department of Public Health, Dr. Karen Smith, suggested that Charity try to figure out what was in the mud on her own. “So I said, ‘Okay, I’m gonna make a list. I’m going to guess what’s out there.”
She tracked rashes. When first responders came off their shifts, she’d pull up the legs of their pants and inspect their skin. “That’s the only way to know what diseases they might be coming back with,” she said. “We had no surveillance system. I was the surveillance system—seeing what disease emerged from the muck.”
The story of how the United States more or less invented pandemic planning began when George W. Bush, in the summer of 2005, read a book. Written the year before, it was the same volume that had dropped Bob Glass’s jaw: John Barry’s The Great Influenza: The Story of the Deadliest Pandemic in History.
Bush was the modern president perhaps most frequently reminded that freakishly terrible events can and do happen. He presided over the deadliest ever attack on American soil and the deadliest American natural disaster in a century. Hurricane Katrina was still in his thoughts, and on his daily schedule, when he picked up Barry’s account of the 1918 Spanish flu.
Yet in national security policy circles the threats posed by nature remained someone else’s problem. Then Bush read John Barry’s book, and asked, What’s our strategy? “We didn’t have a strategy,” said Rajeev.
It was new and a bit odd for the White House to put itself in charge of creating a new strategy for disease control, especially as there was an entire federal agency down in Atlanta called the Centers for Disease Control.
The federal government had a well-earned reputation for moving slowly. Rajeev marveled at just how fast it could move—when the president was pissed.
Eleven days after Rajeev sat down in his parents’ basement, Bush asked the U.S. Congress for $7.1 billion to spend on his three-part pandemic strategy, and Congress gave it to him.
To staffers on the U.S. House Appropriations Committee, John Barry’s The Great Influenza became known as “the seven-billion-dollar book.”
The possibility that Saddam Hussein had preserved the smallpox virus preoccupied the Bush administration.
Like Rajeev, Richard thought that the United States government was paying too much attention to the threats posed by people and too little to those posed by nature.
One way to reduce medical error, he thought, was to redesign the environment to make it more difficult for bad things to happen.
She looked at the White House request. “They wanted someone who could think ‘outside the box,’ ” she said. “There was only one name that came to mind, and that was Carter Mecher.”
The others kept referring to “the NRP,” until finally Carter leaned over and asked Richard, “What the hell’s ‘NRP’?” The National Response Plan, said Richard. It lays out how the federal government organizes itself during an emergency. That sounded important to Carter, and so he went and found a copy and read all four hundred pages of it, and felt no wiser for the experience. “It’s all government language,” he said. “They’re just saying the same thing over and over.”
There was, most importantly, a passage that suggested what the federal government might do, at the start of a pandemic, before a vaccine was available. It would, they’d written, “provide guidance, including decision criteria and tools, to all levels of government on the range of options for infection control and containment, including those circumstances where social distancing measures, limitations on gatherings or quarantine authority may be an appropriate public health intervention.”
As read by Richard Hatchett and Carter Mecher, those words gave them cover to answer the most important medical question they’d ever faced: How do you save lives in a pandemic before you have the drugs and vaccines to do it?
One day some historian will look back and say how remarkable it was that these strange folk who called themselves “Americans” ever governed themselves at all, given how they went about it.
Bob Glass had now read enough about epidemiology to know that his daughter’s project was an original contribution to the field. “I asked myself, Why didn’t these epidemiologists figure it out? They didn’t figure it out because they didn’t have tools that were focused on the problem. They had tools to understand the movement of infectious disease without the purpose of trying to stop it.” With the help of the computer programming genius at Sandia Labs, he and Laura had built a tool that might stop a disease.
Richard was nearly alone in his interest in models. The National Institutes of Health had funded three academics to build models of disease, but it was unclear how useful they would be. The new models were complicated and slow and expensive to run. If you asked a simple question—for instance, “What happens to the spread of a certain disease if you insist that people work from home?”—it could take days to get an answer.
And so it was strange indeed that, as he sat there in the White House compiling this extremely boring spreadsheet about these possibly useless models, he was overcome by feeling. “It hit me like a lightning bolt,” he said. “This is it; solving this problem is why I’m here. I’m the only person in the White House who cares about this stuff, and if I don’t pursue this, it won’t happen. And I mean it really hit me like a thunderclap.
A powerful conventional wisdom held that there was only one effective strategy: isolate the ill, and hustle to create and distribute vaccines and antiviral drugs; that other ideas, including social interventions to keep people physically farther apart from each other, had been tried back in 1918 and hadn’t worked.
Richard believed that if the country was suddenly overwhelmed by some strain of flu for which there was no vaccine, there nonetheless existed strategies to prevent illness and death. He also wanted to believe that the benefits of these strategies could exceed their costs. He even thought it might be possible to eradicate a new virus without a vaccine.
One intervention was not like the others, however: when you closed schools and put social distance between kids, the flu-like disease fell off a cliff.
“I said, ‘Holy shit!’ ” said Carter. “Nothing big happens until you close the schools. It’s not like anything else. It’s like a phase change. It’s nonlinear. It’s like when water temperature goes from thirty-three to thirty-two.
Richard viewed models as a check on human judgment and as an aid to the human imagination. Carter viewed them more as flashlights. They allowed him to see what was inside a room that, until now, had been pitch-black.
A few days after Richard first called him, Bob Glass installed a bed on stilts beside his computer in a shed in the backyard. Each night in Albuquerque, he ran computer simulations of various pandemics, and various responses to them, so these guys he’d never met could have answers when they arrived at work in the morning.
