The Premonition: A Pandemic Story

by Michael Lewis

“All science is modeling. In all science you are abstracting from nature. The question is: is it a useful abstraction.” Useful, to Bob Glass, meant: Does it help solve a problem?

The Utility of Abstraction in Science

Medicine had always felt to her a man’s world. Especially in the places, like here, where it touched government. It was then Charity Dean realized: the real problem is that this man is frightened. The douchebag is scared. She’d been around terrifying diseases most of her adult life and had made a pact with herself not to fear them. “If you’re a truck driver, you know you’re going to get into an accident sooner or later, so you just learn what to do if you are in an accident,” she said. “That’s how you get over the fear. You just accept that you’ll get the disease one day.” Men weren’t so accepting, she’d noticed, especially the big and supposedly brave ones. As a medical student she’d seen the fear—in the eyes of the New Orleans cops in the trauma center. “They’d haul in some guy with a gunshot wound, but when they found out he had hep C or HIV, they’d squeal and go take a shower in Clorox from head to toe.” Over and again she’d seen mesomorphs with crew cuts who would happily run into a burning building to save a dog turn uncertain and uneasy in the presence of disease. Airborne diseases in particular seemed to spook them. “That was the number one reason I could not get TB patients arrested,” she said. “The police would turn into these squeamish little girls. They’d sit in the car and let a nurse go get them.”

Fear, Gender, and Courage in the Face of Disease

There is no shortcut to courage. Courage is a muscle memory. The tallest oak in the forest was once just a little nut that held its ground.

Courage as Muscle Memory

In her first year of residency at Santa Barbara Cottage Hospital, Charity had worked under a doctor named Stephen Hosea. Dr. Hosea was a poor boy from Kentucky who had trained at Harvard in the 1960s and then spent a decade researching disease at the National Institutes of Health (alongside a young researcher named Tony Fauci) before coming to California to treat infectious disease. He was tall and easygoing and wore his learning lightly, but he had a genius for figuring out what was wrong with patients, and for training young doctors. Each morning, he’d take the new doctors with him to visit patients whose illnesses remained undiagnosed. “The Dr. Hosea Show,” the young doctors called it. “He said you should always put your hands on the patient,” said Charity. “He’d get right in close into the patient’s space. You know there are people who stand a little too close. He’d be like that.” Soon the patients would be babbling on about their travels, their love lives, their workplaces, their extended families. It could seem like a natural conversation, but it never was. “The patients were all like, ‘Oh, he wants to know all about me,’ ” said Charity. “But not really. He was digging into the parts that helped to inform his differential diagnosis.” The differential diagnosis was Dr. Hosea’s mental list of the infectious diseases that might have caused the symptoms, along with his best guess of the odds of each being right. Over and over again, Charity watched the older doctor tease...

The Art of Diagnosis: Lessons from Dr. Hosea

This wasn’t how she’d been taught in medical school. As a medical student, she’d been shown how to follow a checklist to get the life history of a new patient. She’d spend forty-five minutes asking questions and yet scarcely touch on the patient’s social relationships. Communicable disease required a different approach. “It’s one person spreading it to another person,” said Charity. “It’s not what you ate or smoked or something you did with yourself. It’s something you have to get from another person. It’s ‘Who lives with you in your home?’ It’s ‘What kind of sex do you have and how often?’ It’s ‘Have you ever lived in a homeless shelter?’ 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 Power of Social History in Medicine

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. “The message they send is, We’re better than you and smarter than you, but we’re letting you stick your neck out to take the risk,” said Charity. “They would argue with me about how kids behave in fraternities and sororities. And I had been president of Kappa Delta!” In the middle of the crisis, Charity figured out what it would take to appease the nation’s highest authority on infectious disease. “It was when they said, ‘If any of this works, you won’t know which one worked,’ ” she recalled. “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.’ ” Charity never would know which of the measures she took had controlled the disease; she knew only that all of them together had. To her, all that really mattered was that the disease had been contained. The job of the public-health officer—or at least her job as the public-health officer—was a series of intense firefights. There was no standard operating procedure for many of the situations in which she found herself: usually, they were sufficiently different from anything that had ever ...

Action Over Analysis: Fighting Disease Amid Bureaucratic Fear

The New England Journal of Medicine had just published a study of medical mistakes. It showed that for every thousand people admitted to a hospital in the United States, three would die from error. The Veterans Health Administration treated a quarter of a million Americans a day: it was the second-largest provider of medical care in the world, behind the UK’s National Health Service. The entire scandal could have been a statistical artifact: in such a vast system, there were bound to be, as a matter of pure chance, clusters of error.

When Scale Turns Error Into Scandal

“When you go into the details of the cases, you see it’s not bad people,” he said. “It’s bad systems. When the systems depend on human vigilance, they will fail.”

Bad Systems, Not Bad People

He also set out to learn everything he could about the inner workings of the human mind, and where and why it was prone to err. He found a book called Human Error, by a British psychologist aptly named James Reason. “It was like reading the owner’s manual of the human mind,” he later recalled. “Not the usual owner’s manual, but an owner’s manual that pointed out all the peculiarities and idiosyncrasies of how we operate—especially under conditions of stress.” The ICU was a stressful and complicated place; Carter had experienced what Reason described. He was struck especially by Reason’s argument that the best way to guard against error is to design systems with layered and overlapping defenses. There was an image of Reason’s that Carter loved, of slices of Swiss cheese being layered on top of one another, until there were no holes you could see through. All of which was to say that when he was handed his new job in Atlanta, his mind behaved a bit the way it did when he was a kid, sitting in the classroom, and the teacher said something that caused him to think of something else. He was always less interested in answering the question he’d been asked than in finding a more interesting question to answer. So, while running a bunch of hospitals, he was also now making himself expert in all sorts of seemingly irrelevant subjects. Aviation safety, for instance. Whenever two planes almost collided, the Federal Aviation Administration knew about it and investigated. But when a nu...

Learning from Near Misses: Building Systems That Prevent Error

people don’t learn what is imposed upon them but rather what they freely seek, out of desire or need. For people to learn, they need to want to learn.

The Freedom to Learn: Desire as the Engine of Knowledge

Everyone could see that kids played a role in disease transmission. No one imagined they would have the effect that they had in the Glasses’ model. That didn’t mean the model was right; but it might be. “It showed me where to dig,” said Carter. “I said, ‘I’m going to dig deep right here. Is there something about kids and schools that I don’t know enough about and haven’t thought about?’ ” To Carter, digging meant gathering data, and no place on earth collected as much of it as the United States government. In federal databases, he discovered that the majority of Americans employed by state and local government were employed in education, and he thought, No wonder those unions are so powerful. He learned that there were more than one hundred thousand K–12 schools in the country, with fifty million children in them. Twenty-five million rode a bus to school. “I thought, Holy crap, half the kids in the U.S. hop on a school bus.” There were seventy thousand buses in the entire U.S. public transportation system, but five hundred thousand school buses. On an average day, school buses carried twice as many people as the entire U.S. public transportation system. A lot of the talk in the White House pandemic planning room had been about grown-ups: how they worked and traveled. “We’d been talking about the New York subway and the DC Metro,” said Carter, “but for every person hopping on public transportation in one day, there are two kids taking the school bus.” How kids got to school...

The Forgotten Density of Childhood: How Schools Became Perfect Engines for Disease Spread

It took just a few months for them to piece together what had actually happened in 1918. Their paper appeared in the May 2007 issue of the Proceedings of the National Academy of Sciences. A coauthor and friend, the Harvard epidemiologist Marc Lipsitch, did the statistical work and the other stuff that made it seem as if it were written by proper scholars.§ Titled “Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic,” the piece revealed, for the first time, the life-or-death importance of timing in the outcomes of 1918.

The 1918 Pandemic Revisited: The Crucial Role of Timing

people have a very hard time getting their minds around pandemics. Why was it still possible, in 2006, to say something original and important about the events of 1918? Why had it taken nearly a century to see a simple truth about the single most deadly pandemic in human history? Only after three amateur historians studied the various interventions, and the various death tolls in individual American cities, did the importance of timing become obvious. 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. “I think it’s because of the way our brains are wired,” said Carter. “Take a piece of paper and fold it in half, then fold it in half again, for a total of 50 times folding it in half. If a piece of paper is 0.004 inches thick to begin with, by the time you fold it 50 times, it is more than 70 million miles thick.” Again, it feels impossible. 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.

The Mental Glitch: Why Humans Struggle to Grasp Exponential Threats

The CDC seemed intent on preserving their privileged view of the outbreak. Several times Richard caught the CDC slow-walking data about the illness and deaths caused by this new flu. They had to strain to see what was going on. I see New York City as the chief battleground right now. There’s now potentially as many as 300 chains of infection in the city and it is conceivable that the virus could explode there. On May 17, the week after Richard wrote those words, Mitchell Wiener, a fifty-five-year-old assistant principal in New York City, died of the new swine flu. But it was impossible to actually say what that meant: it was one death. The secretary of education, Arne Duncan, had said he would do what the public-health people told him to do. But one set of experts, inside the White House, thought they should close schools; and the other, at the CDC in Atlanta, thought they shouldn’t. When Obama had asked Carter what he should do, Carter had told him that he ought to close schools until they knew what they were dealing with. Obama had instead listened to the CDC. A few months later, the fog would have lifted and the war would be over. The new flu would turn out to be less lethal than it might have been. The CDC would report that somewhere between forty and eighty million Americans had been infected but only 12,469 had died. Their judgment had been vindicated, and President Obama’s decision had worked out, and everyone would soon move on and forget about the pandemic that wa...

The Illusion of Success: When Luck Masquerades as Good Judgment

There Carter and his family remained for three days. The researchers stepped around them, taking notes. “They wanted to watch how people would behave,” said Carter. “So I got to watch, too.” What he realized, as he watched, was that there was no way a nuclear war would be anything like that. “My mom would be at home, and we’d be at school, and my dad would be at work,” he said. “We’d all be separated. We wouldn’t know how to get to the shelter, and that’s not where we’d go anyway.” His mind unspooled a different scenario that left him with a conviction that nuclear fallout shelters were probably a dumb idea. “Going through that experience forever changed my vision of these events.” He had a similar feeling at the end of the faux pandemic of 2009. Things went down differently than he’d ever imagined. If he had to do it all over again, he’d still have told Obama to close the schools. The lesson many had taken away from the event was how smart it was not to have closed the schools, or taken the kind of aggressive action that was necessary at the start of a deadly outbreak, to prevent its explosion. “It’s like someone who looked down at their phone while driving and drifted onto the shoulder but didn’t hit anything,” he said. “The lessons aren’t as strong and defined. Had that person hit a mailbox or ended up in a ditch and wrecked his car, he would have learned a hard lesson. Had they hit and killed a pedestrian, they probably wouldn’t want to get into the driver’s seat again...

The Downside of Experience: Mistakes Repeated with Greater Confidence

Early on, they’d been discussing the pandemic plan, and he had shared with her his thoughts about maps. They were also his thoughts about plans, as a plan is a kind of map: a map of what you plan to do. He told her a story about some troops who’d gotten lost in the Alps. “They’re in a blizzard,” said Carter. “A guy finds a map in his backpack. The map leads them to safety.” What was cool about the story, Carter thought, was that once the soldiers were safe and able to study the map more closely, they saw that it was a map not of the Alps but of the Pyrenees. “A map has value when you are lost,” he said. “It gives you a starting point.” There was an analogy with his earlier life as a doctor in an intensive care unit. “The patient is fading right there in front of your eyes,” he said. “You cannot run out of options. Because what do you do when you run out of options? You panic. Having something in front of you, a map, a plan, a list of treatments, even if it isn’t completely right, is better than nothing.

The Wrong Map That Saves You: Finding Direction Amid Uncertainty

Managing a pandemic was like driving a weird car that only accelerated, or braked, fifteen seconds after you hit the pedal. “Or think of looking at a star,” he said. “It’s the same thing. The light you see is from years ago. When you are looking at a disease, the disease you are seeing is from last week.” The CDC had lots of great people, but it was at heart a massive university. “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.

Peacetime Minds in Wartime Crises: The CDC’s Struggle with Foresight

A lot of her lists were mental. One of them detailed the roughly twenty things that had tried to come between her and her life purpose.

The Obstacles Between Purpose and Persistence

“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.”

A Nation of Dots: The Fragmented State of U.S. Public Health

Joe loved science. He also thought that science was in some ways misunderstood, at least as it was often taught to children. After the fact, scientific progress was often described as a cool, antiseptic affair. A lone scientist or team of scientists had formed some hypothesis, created a way to test it, and discovered some new truth, or not. Joe thought that scientists should be encouraged to look at stuff without having any idea of what they were looking for. “There’s a time and a place for a hypothesis,” said Joe, “and there’s a time and a place to let it go.” He also thought that people who looked at stuff without any preconception of what they might find were the ones who saw the things that no one had seen before. “It’s science’s dark secret,” he said. “If you actually look at the great discoveries—okay, maybe not in astrophysics, but in medicine and biology—you don’t have to go back more than a couple of steps to find a chance observation.” 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.”

Curiosity’s Tool: The Power of Seeing Without Expectation

There’s a widely agreed-upon standard of proof in virology, collectively called Koch’s postulates, for the German doctor who first developed the criteria, in the late nineteenth century. “The only way to prove that a virus causes a disease is to isolate the virus and inject it into a healthy animal,” Joe explained. “If the injection causes the disease, everyone agrees that you’ve proved your case.” To prove that the virus they’d isolated was killing boas and pythons, they’d first need to grow this ancient ancestor of Ebola in the lab, find some healthy boas and pythons, and then infect them with the virus. To inject a virus into an African python took some trouble. Snakes don’t have injectable veins. They do, perhaps surprisingly, have hearts, and that’s where the virus must be injected. Snake hearts don’t stay put, like human hearts, but travel up and down the snake’s body. To inject a snake’s heart with a virus requires two postdocs and one full professor: one to hold the snake in a death grip, one to use a Doppler radar to find the snake’s heart, and a third to plunge the needle into it.

Proving Causation: Science, Snakes, and the Challenge of Koch’s Postulates

The story, in Joe’s telling, began in July 2014, when the seventy-four-year-old woman, who spoke no English, walked into San Francisco’s Chinese Hospital. She had a fever and felt shaky. The doctors suspected a urinary tract infection, gave her antibiotics, and sent her home. Three weeks later, on August 1, the woman appeared in St. Mary’s Medical Center with fever and a cough and loss of vision. This time the doctors did an MRI. The picture of her brain suggested that she’d suffered many tiny strokes. They gave her anticoagulants, to reduce the risk of stroke, and sent her home. Two days later, her relatives wheeled her into one of UCSF’s hospitals, comatose. The doctors ran her through the MRI machine again: suddenly her scans showed massive cell death in her brain. There was very little brain left to save. Still, UCSF’s doctors did everything they could think of to save it. They gave her expensive drugs that killed fungal infections and more expensive drugs that killed parasites. In just one morning they gave her $150,000 worth of medications. None of it had the slightest effect. On August 15 they removed a piece of her brain and found nothing unusual. A week later, on August 22, they did another biopsy and this time found that the blood vessels in the woman’s brain were all dead. No one knew why. And yet it wasn’t until two days later, on August 24, forty-five days after the woman walked into a hospital and three weeks since she’d arrived at UCSF, that anyone thought t...

The Last Mile Problem: How Science Finds Cures That Systems Fail to Deliver

His was the most interesting story, at least to Carter. At 5:55 p.m., with the fire just a minute away and rushing toward him at ever greater speed, he’d lit a second fire, up the hill he needed to climb. As his fire burned the grass in front of him, he walked into it and threw himself onto the hot ashes. He’d called for his men first to abandon their packs and Pulaskis, and then to follow him into the fire he’d set. Either they didn’t hear him or thought he’d lost his mind; at any rate, they didn’t really know Wag Dodge or have any reason to trust him. Dodge alone heard and felt the main fire passing by on either side of him, leaving him unscathed. Until that moment there was no history of a firefighter having done such a thing, but it became an accepted strategy in the fighting of grass fires. “Escape fire,” was what they’d call it. The event so captivated the writer Norman Maclean, best known for his only other book, A River Runs Through It, that he wrote a book about it, called Young Men and Fire. It so interested a doctor named Don Berwick, maybe best known for running Medicaid and Medicare during part of the Obama administration, that he’d given a talk about it. Carter had heard the talk and thought: the Mann Gulch fire isn’t about fire, or at least not only about fire. It’s also about pandemics. In fire you could see lessons for fighting a raging disease. He jotted them down: You cannot wait for the smoke to clear: once you can see things clearly it is already too l...

The Escape Fire: Lessons from Disaster on Acting Before It’s Too Late

Carter already had a view about these kinds of decisions. He thought that they should be approached the way an ICU doctor treated a patient clinging to life. Play forward whatever you are thinking about doing, or not doing, and ask yourself: Which decision, if you are wrong, will cause you the greatest regret? Richard agreed, and never looked back.

The Regret Test: Decision-Making in Life-and-Death Moments

this distinction, in leaders, between Churchills and Chamberlains. The people who presided in times of peace tended to have a gift for avoiding or at least disguising conflict. People made for battlefield command did not find their way into positions of authority, at least not until the general public sensed existential risk. By then—by the time people knew enough about a communicable disease to be terrified—the war’s most critical phase was over.

Churchills and Chamberlains: The Wrong Leaders for the Right Crises

Everyone has a story they tell themselves about themselves. Even if they don’t explicitly acknowledge it, their minds are at work retelling or editing or updating a narrative that explains or excuses why they have spent their time on earth as they have.

The Stories We Tell Ourselves: How Narrative Shapes Identity

In effect, she was telling them what she had figured out when she was herself a local public-health officer. There was no system of public health in the United States, just a patchwork of state and local health officers, beholden to a greater or lesser degree to local elected officials. Three thousand five hundred separate entities that had been starved of resources for the past forty years. Yes, these local nobodies might allow themselves to be led by a health officer they respected—say, somebody from the Centers for Disease Control, or a state health officer who knew what she was doing.

A Patchwork Defense: The Fragmented Reality of American Public Health

“Here is the frightening aspect of the global supply chain,” said Joe. “When there is a surge in demand, inventory goes to zero. Just-in-time manufacturing. Great concept! Horrible in a pandemic.”

Just-in-Time Disaster: How Efficiency Fails in a Crisis

One measure of poverty is how little you have. Another is how difficult you find it to take advantage of what others try to give you.

The Hidden Measure of Poverty: Inability to Benefit from Help

Back when she was twenty-four and newly divorced, Charity had rented a small apartment. The place was on the ground floor of a building in a dicey New Orleans neighborhood that got away with describing its units as “luxury” only because they were new. For the first time, she had her own porch. It was protected by an iron fence but visible to anyone who walked by. She felt a need to make it not just presentable but charming. “I was trying to be my mother,” said Charity. “I wanted to show I could be a homemaker.” She bought wind chimes and flowerpots and flower boxes and dirt and fertilizer and some huge number of brightly colored flowers and turned her front porch into the Luxembourg Gardens. The young professionals and graduate students who lived in the building and passed her porch on the way to their units showered her with compliments. Neighbors came over just to sit on her porch. Even strangers on the street paid her compliments. For a short stretch Charity Dean was the young woman with the porch bursting with flowers. Then her flowers began to die—though not all at once. The first few deaths left only a bald spot in one of the pots. Charity happened to have a bouquet of plastic flowers. “That’s how it started,” she recalled, “just to fill in the blank spot in the pot where the flowers had died.” From a distance the fake flowers could pass for real; the combover was a success. Then more real flowers keeled over. Charity was studying for two graduate degrees at once and...

The Plastic Flowers of Public Health: When Optics Replace Action

“I have found that there is an order of magnitude difference between bearing the ultimate responsibility for decision-making and being either an advisor or student of the process,” he wrote. “It’s one thing to experience an orgasm or an arrow between your ribs and it’s another thing to read about it.” Sencer had experienced an arrow between his ribs. Neustadt had only read about orgasms—and yet used his vicarious experience to swan about as an authority on the subject. “As an administrator, one is regularly obliged to make decisions based on incomplete evidence,”

The Weight of Command: The Difference Between Advice and Responsibility

The Reagan administration must have noticed the possibility. After Foege resigned, the White House converted the position of CDC director from career civil servant to presidential appointee. Since the agency’s inception back in 1946, no one had paid much attention to the party politics of the CDC director. (“No one ever asked me,” said Foege.) Henceforth the CDC director would not bubble up from inside the CDC, lifted by the approval of his peers, but would be plucked from the supporters of whichever politician happened to occupy the White House. Foege’s replacement, James O. Mason, was an ideological soulmate and good friend of Republican senator Orrin Hatch. If somehow he still managed to displease the White House, the president could fire him on a whim, as he could not have fired David Sencer.* Henceforth the CDC director would not serve across administrations, as past directors had done, but would be replaced when the president was replaced, or usually sooner. The entire United States government had been drifting that way for some time—management jobs once done by career civil servants being turned into roles performed by people appointed by the president. One of the problems this created was management inexperience: the average tenure of the appointees fluctuated between eighteen months and two years, depending on the administration. Another was the kind of person the job now selected for. There would be exceptions, of course, but the odds favored the pleaser. The per...

From Scientists to Servants: How Politics Captured the CDC

“Government—and the value government provides—isn’t just the whim of whoever happens to be elected at the moment,”

The Enduring Value of Government Beyond Politics