The Premonition: A Pandemic Story

by Michael Lewis

The Thomashefsky clinic wasn’t going to cripple society. The situation was entirely ignorable: a doctor to the rich and famous and a single case of hep C. If she were wrong, they’d have to fire her.

On her subsequent trips to the clinic, she discovered that Thomashefsky was prescribing Versed—one of the drugs that killed Michael Jackson—and that he was making house calls to inject it into rich old ladies in the hills. She found a great many more multidose vials of medicine than the doctor claimed to have used. She figured out that when the doctor used one of his multidose vials of painkiller on different patients, he changed the needle but not the syringe—and to prevent the spread of disease you needed to change both.

It took a few months for the test results to arrive. When they finally did, four more of Thomashefsky’s patients were found to have been infected with hepatitis C. All had been treated by the doctor on a single day, September 4, 2014.

their new virus shared the same genome, which proved they’d all been infected by the same source.

The culprit turned out to be a single syringe the doctor had used...

She was also growing to adore Santa Barbara’s chief counsel, who kept handing her enough rope to hang herself, by confirming that, yes, the law allowed her to do whatever the hell she thought needed doing to protect the public.

But some of her fellow local health officers, like Charity herself, were so deeply committed to the job that they experienced it more as a mission. These people she loved best. But their needs and issues were too diverse for them to function as a single, powerful unit. And they weren’t in a position to have her back in a crisis.

At the end of 2013, for instance, as she was promoted to chief health officer, she had a call from a local hospital saying that a nineteen-year-old student-athlete at the University of California–Santa Barbara had just been brought in by friends with symptoms of meningitis B.

“It’s one of the most feared diseases for student health doctors,” said Mary Ferris, UCSB’s medical director. “We knew right then people’s lives were at risk.”

No one knew exactly all the ways the disease might spread, though one known path was through saliva. There was no agreement on what actions to take on a college campus in the event of an outbreak. “We spoke with the CDC and asked them what to do,” said Dr. Ferris. “But the CDC initially wasn’t too impressed. We rely on them for advice on what to do. And their advice was to do nothing.”

The initial problem was that there was no c...

The young man’s legs, Dr. Hosea told her, were purple. But the lab test of the young man’s blood and spinal fluid had come back negative for meningitis B, and essentially eliminated the possibility that he was carrying a dangerous communicable disease.

The Gram stain—the test that came back negative for meningitis—was the first clue: it told you in which of two big buckets the bacteria you were dealing with

“It’s very reliable,” said Charity. “And it’s har...

To stop the infection from moving farther up his body, he could already see, they’d need to amputate both legs.

I think the Gram stain is wrong, she said. As it happened, he’d already asked the lab how often the Gram stain had been wrong, and they had said never. But the Gram stain was to him mainly of academic interest. He was already treating the young man for meningitis B, just in case.

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. What do you think? she asked again. I think the Gram stain is wrong, too, he said.

The Gram stain was indeed wrong—but that would take a day and a half to figure out. They didn’t have ...

ninety percent of the battle is in the first few days. But in the beginning it’s always quiet, and you are quietly making decisions, and you’re a nut job.”

They were an invisible mob inside an ivory tower.

at the end of these sessions I had to make a decision.”

The first decision was to scour the student population for cases that had gone undetected. Charity instructed the Santa Barbara medical community to test any young person who turned up with a low-grade fever.

As the CDC dithered, three more UCSB students tested positive for meningococcal disease. Each case presented differently. One student, with only a rash, had been diagnosed initially with chicken pox; the other two had slight fevers and had been initially misdiagnosed as having nothing special. “None of them lived together,” recalled Dr. Ferris, UCSB’s medical director.

she had charted the social relationships of the infected UCSB students. At the top of the board she had written “Cross-Pollination,” a term of art she’d picked up from Dr. Hosea. “It’s when you don’t want to say ‘he had sex with her’ and what kind of sex they had,” she said. “But I was basically trying to figure out who had shared saliva with whom, and where they’d shared it.” All signs pointed to the Greek system. She decided to shut down the college sororities and fraternities and give the twelve hundred students in them a prophylactic drug. “With meningitis B you have a very narrow window to give the prophylaxis,” she explained, “and it was a weekend. You had to do it fast and all at once, or else the pathogen just keeps circulating.”

She got on the phone with the main guy at the CDC and his silent crowd. The guy strongly disagreed with her doing anything. “What he actually said,” recalled Charity, “was, ‘That decision is not supported by the data.’ I said, ‘Oh, really—there is no data.’ ”

She outlined a plan she’d created: thin out the dorms by moving some of the students into hotel rooms; shut down the intramural sports teams; and administer a vaccine that had been approved in Europe but that the FDA had not yet signed off on. “T...

that, we’re going to put it in writing that it was your decision and we disagreed wit...

in the end the campus ignored the CDC and did everything Dr. Dean recommended.

as Dr. Ferris put it, “the CDC wasn’t pleased with her. The CDC kept saying, ‘There is no evidence to back it up.’ They didn’t have any evidence, because there is only one case every four years.”

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 ...

“They would argue with me about how kids behave in fraternities and sororities. And I had bee...

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 experi...

The job of the public-health officer—or at least her job as the public-health officer—was a series of intense firefights.

If she waited until she had enough evidence to publish in a scientific journal, the battle would be over, and she’d have lost. Kids would lose limbs, or die.

The decisions she was forced to make were less like, say, those made by a card counter at a blackjack table, and more like the ones made by a platoon leader in combat. She never had all the data she wanted or needed when making her decisions—enough so that afterward she could defend them by saying, “I just did what the numbers told me to do.”

The moment an infectious disease appeared, decisions cried out to be made.

Two years after the UCSB meningitis outbreak, the CDC finally published a report on how to deal with a meningitis outbreak on a college campus. On its list of best practices were most of the things Charity had done at UCSB. After that, from time to time, someone would call her from the CDC and ask her if she’d please get on the phone with some college health officer somewhere in the United States and describe how she handled the UCSB outbreak. But by then Charity had washed her hands of the CDC. “I banned their officers from my investigations,” she said. The CDC did many things. It published learned papers on health crises, after the fact. It managed, very carefully, public perception of itself. But when the shooting started, it leapt into the nearest hole, while others took fire. “In the end I was like, ‘Fuck you,’ ” said Charity. “I was mad they were such pansies. I was mad that the man behind the curtain ended up being so disappointing.”

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.

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...

On December 7, 2017, a fire swept down from Ventura County. It grew big enough to earn its own name: the Thomas fire. Then it grew even bigger, into the largest wildfire in the recorded history of California. In the dead of winter, in a county of less than half a million people, more than a hundred thousand people had to be evacuated. The ash that fell in downtown Santa Barbara was not the light dusting they usually got. It rose above the street curbs. It became dangerous to breathe, and impossible to tell what colors the cars had been. When the county’s emergency response team went looking for a precedent for how to deal with the volume of ash, the only one they could find was the eruption of the Mount St. Helens volcano back in 1980.

But the Thomas fire was just the opening act. It burned the vegetation in the Santa Ynez Mountains, above the town of Montecito, so there was nothing to grip the soil and rock. The National Weather Service forecast for January 8, 2018, was for heavy rain. A team from the federal government created a forecast for a possible landslide. The county issued a mandatory evacuation of the hills around Highway 192,

Matt Pontes saw right away how hard it was to persuade people that the mountain in the distance might more or less collapse on them.

People had never seen a mudslide, and in truth the event was hard to imagine. “It’s blue skies,” said Pontes. “It’s something that’s never happened before, at least not in memory. It was, ‘Hey, something’s coming. It’s not a fire. We got to get you out of here.’ And they said no.”

Around three in the morning of January 9, the mountain that looms over Montecito in effect melted and rushed down upon the town. The water and mud moved at such speed that boulders the size of automobiles skipped along their surface. Cars parked up in the hills were caught and dragged down for miles until finally deposited in the ocean. Over the next week or so, first responders dug out twenty-three bodies from the mud. Two were never found. Some of the dead were never honestly counted, including the bodies of old people found weeks later, still in their armchairs, depleted oxygen tanks beside them.

The mudslide forecast proved incredibly prescient: the mountain moved exactly as the experts had predicted.

figure out what was in the mud.

she’d declared a public-health emergency, to enable crews to go onto the private property of the absent rich and clear the debris from the fire. “There is this hazardous pile of toxic goop. You have just set all the chemicals in your garage on fire. Now you are about to put a hose on it and spread it into the waterways.” The cleanup crews made only a dent in the mess before the rains, and now the mess was everywhere. “I needed to know what microbial pathogens are there—to know which vaccines do you give the first responders and utility workers.” No one seemed to have any idea. She tried to educate herself.

I’m going to guess what’s out there.” She started with the likely bacteria (E. coli, Clostridium tetani—the cause of tetanus), before moving on to viruses, like hepatitis B, and, finally, other single-cell organisms. “The one that really scared me was Vibrio cholerae,” she said. “This was a ripe setting for cholera.”

She tracked rashes.