The Premonition: A Pandemic Story

by Michael Lewis

It has started. Charity was a doctor and thought herself, if not a scientist, at least scientifically minded.

A picture formed in her mind: a giant wave. A tsunami. “It’s a foreboding,” she said. “A knowing that something is looming around the corner. Like how when the seasons change you can smell fall in the air right before the leaves change and the wind turns cold. I know things before they happen sometimes, although I can’t put my finger on the details.”

When Duane Caneva got back in touch with her, she didn’t think of him as an ally. “I saw him as a storm trooper for Trump,” she said. She surely was not prepared for what he had to say.

This Duane who was telling her that he belonged to this small, informal, almost secret group of doctors who had once worked in the White House under Bush or Obama and were now scattered to the four winds but not without influence. This Duane was now working, without the White House’s permission, to coordinate some kind of national pandemic response.

He needed her help, he explained, in getting what this secret group of doctors had to say to the governor of the nation’s most populous state so that it might take the lead for the country, as the White House clearly was not going to. “I was like, Wait a second,” said Charity, “there’s a group of people—a break glass group—who meet during pandemics?”

“The perfect pathogen has a very long infectious period and a very long incubation period—because the longer it takes for the pathogen to declare itself, the harder it is to track,” she said. One reason measles was so wildly transmissible was that a person with it was infectious for four days before he knew he had it. This new thing felt to her a bit like that, just watching how the Chinese were reacting to it. “China was behaving like this was the perfect pathogen,” she said.

fact, there is no fire alarm in this country.” By the third week of January, Charity Dean, like Carter Mecher, did not believe that the risk to the American people was low. She thought that the virus was already spreading exponentially inside the United States.* It was as if she, and she alone, had spotted the fire in Mann Gulch, and no one else was willing to turn and run.

She looked into the capacity of the morgues. “Everyone forgets about the morgues,” she said. “It’s the part of the health care system that’s never included in disaster response preparations.” She went to bed at night thinking about the need to establish sites for mass graves. “A switch flipped in me mid-January,” she said. “My whole being came alive.”

“They really should just change the name,” she said. “It shouldn’t be the Centers for Disease Control. It should be the Centers for Disease Observation and Reporting. That’s what they do well.”

On January 20, the virus made the television news.

A history Charity had started for pleasure had become something else. She didn’t so much read it as investigate it, the way she might an outbreak of tuberculosis. By late January she’d underscored half the lines on the pages leading up to Great Britain’s declaration of war, and scribbled comments in every margin. “Chamberlain publicly accused Churchill of lacking JUDGEMENT!” she wrote. “The leaders with the worse judgement smugly claim they have the best.” A bit farther on: “Don’t prepare a white paper when you need to be bombing the shit out of Germany!”

“The emails were intriguing,” said Charity, “but as soon as Carter started talking, I knew I had found my person.”

Carter proposed using the patients with flu-like symptoms who turned up in emergency rooms across the United States as a quick and dirty tool to figure out where the virus was. Take those numbers and compare them to the seasonal averages and they might lead you to outbreaks, where you could test for the virus.

As she explained the critical role of the local public-health office, and the need for the state and the federal government to stand behind health officers in their dealings with their communities, her audience on the phone call pushed back against her. “They didn’t want to accept it,” she said. “Anyone at the federal level is so removed from the shitstorm that is the CDC that they have no clue. They wanted to believe that the CDC, or the state, could just make local health officers do what they wanted to do. You know why I think they didn’t want to accept it? It’s too terrifying. Too chaotic. Too WTF. Too much of a shake to federal officials’ foundation to digest the truth that local nobodies are really in charge.”

Just then the CDC was supervising the return of Americans from China, and that offered her a case in point. Many of the returning Americans had passed through airports in California, and Charity had seen the ineptitude with which they’d been handled. The CDC hadn’t bothered to test them—not even the people returning from Wuhan.

When local health officers, her friends and former colleagues, set out to find these possibly infected Americans, and make sure that they were following orders to quarantine, they discovered that the CDC officials who had met them upon arrival had not bothered to take down their home addresses. When local health officers called the CDC to say how hard it was to track down John Smith when the CDC had listed his residence as “Los Angeles International Airport,” the CDC said, “Just don’t follow up on them.” What was the point of having these travel restrictions from Wuhan if the federal government was going to just let people loose upon their return?

Charity’s boss tried to block her from speaking with the CDC, but she had gotten herself onto the first of these calls. She’d posed a rude question to the senior CDC official on the call: How can you keep saying that Americans are at low risk from the virus if you aren’t even testing for the virus? She’d been answered with silence, and then the official moved on to the next topic. “The single most important question is how many undetected cases are out there in our community,” said Charity, “and we don’t know.”

There was, in effect, no leadership, either from the state or the federal government.

The names at the top of the Red Dawn emails grew in both number and importance. Charity thought of it as “the Carter show” and noticed that, even though Carter Mecher supplied almost all of the interesting material, he demanded none of the attention. It was never “look at me!” but always “look at this!”

He pulled the ship’s itinerary and reconstructed what had happened on board, day by day. The Diamond Princess had left Yokohama on January 20. Five days later it docked in Hong Kong, where an eighty-year-old passenger disembarked. On February 1, the passenger, still in Hong Kong, tested positive for the new coronavirus. The ports for which the cruise ship was headed canceled its certificates of landing. On February 3, the Diamond Princess chugged back into Tokyo Bay and its port of origin. Two days later the first passenger tested positive; two days after that the number of confirmed positives reached sixty-one people.

At that moment there was essentially no COVID-19 testing inside the United States. The Food and Drug Administration was still insisting that state and local health officers wait for the test kits supplied by the CDC. And the CDC was still saying that the risk to Americans from the virus was very low. The entire country was dismissing what the redneck epidemiologist had glimpsed in Wuhan. The Japanese weren’t dismissing it, though. The Japanese were alert. They had their own labs and planned to use them to test everyone on board the cruise ship.

Over the next three days, the case count on board the ship rose from 61 to 135. The numbers shocked even Carter. “This is unbelievable,” he wrote. “We are so far behind the curve.” He laid out side by side the first ten days of the 2009 swine flu outbreak against what had already happened on the cruise ship. Swine flu had been so frightening because it spread so fast; this new virus was spreading much faster. Over the next ten days, the numbers grew exponentially. On February 16, when Lawler and Callahan evacuated 329 Americans from the ship, the count reached 355. By February 19, when the first two passengers died, 621 people were infected. Two days after that, Carter found, on the website of Japan’s National Institute of Infectious Diseases, a field report filled with data from the cruise ship. “I can’t understand why no one is paying attention to this,” he said. “It’s a gold mine.”

The cruise ship was dramatizing just how stealthy the virus might be, and also helping to explain what appeared, in Wuhan, to be a truly fantastic rate of transmission.

The infection fatality rate on the ship, Carter reckoned, fell somewhere between 1 and a half and 2 percent. Its population skewed older than the American population, but you could, and he did, take those numbers and adjust them, by assigning different mortality rates to different age groups in the United States. Once he’d finished, he had an infection fatality rate of between half of 1 percent and 1 percent.

“I think this data is close enough to convince people that this is going to be bad and we will need to pull the full array of NPIs [social interventions],” wrote Carter on February 28. “All that is left is when (timing).” Back in 1918, St. Louis had introduced social interventions one week after the first local cases, he pointed out. Philadelphia had waited three weeks. Already there were cities in the United States behind St. Louis, and maybe even behind Philadelphia.

He had the right mental model for the virus. The glitch was in his mental model of his own country, and its leadership.

On February 26, President Trump announced at a press conference that only fifteen Americans had been infected with the virus, and that “when you have fifteen people, and the fifteen within a couple of days is going to be down close to zero, that’s a pretty good job we’ve done.” The next evening, taking questions after a White House meeting with African American leaders, Trump had simply declared, “It’s going to disappear. One day—it’s like a miracle—it will disappear.”

The CDC, for its part, lagged about five steps behind where it should be. On March 1, it announced that the United States would screen people arriving from other countries for symptoms of the virus. “I wouldn’t waste a moment of time on travel restrictions or travel screening,” Carter wrote. “We have nearly as much disease here in the US as the countries in Europe.” Every passing moment could be measured in lives lost; and yet, a week after Carter had all the confirmation he needed for his mental model of the threat, nothing had changed. “I sense confusion among very smart people,” he wrote in early March. “[They] hear that more than...

To “help people get their head around what is perceived to be a mild outbreak,” he ran some numbers. Using the most conservative assumptions suggested by the cruise ship—an attack rate of 20 percent and a fatality rate of...

He liked to imagine himself two weeks into the future, looking back on the moment and asking himself: Knowing what I know now, what do I wish I had done back then?

Italy was just then illustrating the point. Back on February 20, a grand total of three COVID-19 cases had been discovered in the whole of the country. None of the infected was seriously ill. By March 13, the Italian case count had gone to 17,660, with 1,328 people in intensive care and 1,266 dead.

On March 15, after the CDC suggested both that gatherings of more than fifty people should be avoided for the next eight weeks and that schools should remain open, Carter went off. “That CDC would not want 50 people being together for even an hour while hundreds of thousands of kids could be together for 8 hours defies common sense,” he wrote. “Imagine CDC getting on TV and trying to explain. Good luck with that.”

He’d now awakened to the possibility that at least one of his mental models badly distorted reality: his model of American government. People who might be led to prepare for what was coming were being led not to.

Charity wrote an email to her boss suggesting that the western states—California, Oregon, and Washington—seize the moment to form a coalition. They would stop waiting for the CDC to create a test for COVID-19 that actually worked and create their own test, using their own laboratories. The three states together would have a credibility that no state on its own could generate. “She called me at nine at night and started screaming at me about having put it in an email,” recalled Charity.

She was now going back and forth privately with maybe twenty of the fifty-eight local California health officers. She knew them all, in one way or another, and thought of herself more as one of them than anything else. They supplied her with a steady flow of on-the-ground intelligence, and she, in return, told them what she thought they might do to compensate for the lack of action by the federal and state governments.

A number of countries had set out to contain the new virus. Charity admired them for that. She thought that the United States should have had the good sense to emulate them.

Singapore was using law enforcement to escort people to their place of quarantine and ensure that they remain there for fourteen days; those requiring isolation included every new arrival to the country. “That’s what you do in TB control,” Charity said. “The nurses take them to a hotel room and the sheriff watches them. If you think you have a shot at containing it, that’s what you do. You have to do it by health officer authority. People say you can’t do it, but we do it every day for TB.”

Donald Trump had said that it was every state for itself.

On a Red Dawn phone call in early March, she was laying out her ideas about what California and every state in the country should do when a new voice came on the line. “This is Ken,” it said. Ken Cuccinelli, the acting deputy secretary of homeland security and a member of Trump’s coronavirus task force. “He said, ‘Charity, you need to push these things through. You’re the only one who can do this.’ ” She was taken aback by his insistence. “He wasn’t pleading with me to do the right thing. He was yelling at me. He was basically implying that the White House is not going to do the right thing. The White House is not going to protect the country. So California needs to take the lead.” That was the moment she learned that the White House was listening in on the calls—and also the moment when she realized just how lost and desperate the people at the top were. “He’s the deputy director of homeland security. He can just go talk to the president. And he’s relying on some random blond girl to save the country. Really?”

In Oakland she found herself in a room inside a FEMA tent, with a whiteboard and a gaggle of Newsom’s most important advisers. She offered to show them the math of epidemics, and they accepted. She proceeded to lay out the deceptions of any disease that is spreading exponentially, especially when large numbers of people with it have no symptoms and you have no ability to test. The only clear signal you get from the virus is death.

But whatever people did, Charity explained, the story ended only with a vaccine or herd immunity. There was no vaccine in sight; and the number of infections required to achieve herd immunity could be calculated, as it was a simple function of the reproductive rate. (The formula was 1 − 1/R0, where R0 was the reproduction number.) The simple truth that the formula captured: the more transmissible the disease, the more people needed to be infected before the herd was theoretically safe.

“No one cares about data when everything is going well,” said Josh Wills, the former chief data engineer at Slack, who agreed to help. “People only care about data when the shit hits the fan. ‘Oh my God, what’s going on??? We need data!’ ”

At some point Park turned to Patil and said, “She’s the L6.”

The L6. The person buried under six layers of organization whose muzzled voice suddenly, urgently needed to be heard. “I got the feeling that she hadn’t been at the table,” said Park of Charity. “It was clear that this was the moment that she had been preparing for her entire life, and that she was finding it incredibly frustrating that she wasn’t being allowed to help.”

She watched Park and Patil bring a team together to rewrite the code of a disease forecasting model created at Johns Hopkins so that it ran much faster and incorporated lots of data about California—and how they did this she had not the faintest clue. She was strangely relieved to see that once you plugged in what she (and Carter) knew, or thought they knew, about the virus, the new computer model regurgitated the coming disaster they imagined. That view happened to be radically different from the official position of the CDC, the White House, and, for that matter, the state of California.

Before Park had traveled to Sacramento, Governor Newsom’s advisers had sent him an Excel spreadsheet with some calculations made by someone inside their public-health department. These showed the virus never generating so much illness that the state’s seventy-five thousand hospital beds couldn’t handle. “I don’t know who did it,” said Park. “But it was all wrong.” The new model suggested that, if no action were taken to minimize the virus’s spread, the state would need seven hundred thousand hospital beds by the middle of May.

Slavitt renamed the plan “Victory over COVID-19” and presented it to Kushner as his own.

“I said number one was testing,” recalled Joe. “Because if there is no testing, there isn’t even the possibility of a solution.” Testing was the only way to find the virus and to predict its movements. Testing was so important, Joe told Newsom, that there wasn’t much point in worrying about the other items on either list.

Joe could see that the CDC wasn’t going to solve the problem. But there was a solution: the United States was by far the world’s leader in microbiology research.

“How much is it going to cost?” asked the woman at Zuckerberg General, after the team at Chan Zuckerberg had explained their new COVID-19 testing lab. “It’s free,” said the Chan Zuckerberg person. “There was this super-long pause,” said Joe, who was on the line. “We don’t know how to do no-cost,” said Zuckerberg. “What do you mean?” asked Chan Zuckerberg. “It shows up as an error in the hospital computer if we put zero cost,” said Zuckerberg. “It won’t accept zero.” “Can’t you put like one-tenth of a cent?” asked Joe. They couldn’t. The system wouldn’t allow it.