The Premonition: A Pandemic Story

by Michael Lewis

Then she figured it out: the oil from poison oak had mixed with liquid and blended into the mud. They ended up giving it its own name: the Montecito rash.

Casa Dorinda was a rich person’s old-age home. Julia Child famously had ended her days there. Now it was the sort of place to which billionaires sent their mothers. A second big storm was about to hit. The same forecasters who had predicted with such fantastic accuracy where mud would flow the first time around thought the most likely path of the next mudslide was right through Casa Dorinda. And no one was doing anything about it.

The mud was the most incredible thing: what would turn out to be 4.5 million wheelbarrows of toxic debris wasn’t simply going to be returned to the mountain. She realized that she’d need to help them figure out the safest place to put it, and that people wouldn’t like the answer. “The public-health officer is like the garbage disposal,” she said. “Whatever issue can’t be filed into someone else’s box or slot winds up in the health officer’s.”

Casa Dorinda itself sat in the middle of the devastation.

The mud from the first slide had missed the fancy old-age home.

Then the sun went down. She watched as Casa Dorinda went dark. It had no power.

The forecasters put the chance of another mudslide wiping out the place, and the hundred or so people inside, at 20 percent. The medical director estimated that there was a 100 percent chance that five of the residents would die if forced to evacuate.

“I told them, ‘We can do this the easy way or the hard way,’ ” said Charity. “They were very upset, but they decided to do it voluntarily. Sure enough, there were seven deaths. Their medical director sent me a scathing email saying, ‘Their deaths are on you.’ He was right.” The second mudslide never came.

“There are two ways to be a health officer,” he said. “One is to pretend it’s not happening. She didn’t do that.”

Something was coming: she felt it. She’d obsessed about it since childhood and had learned not to talk about it, because other people thought she was kooky when she did. But as she drove into Sacramento, one subject was at the front of her mind. And not long after she arrived, toward the end of 2018, a journalist asked her about it. “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.”

As it happened, the United States of America had a plan to fight a pandemic. The first draft had been written back in October 2005, by a man named Rajeev Venkayya, in the basement of his parents’ house in Xenia, Ohio. He’d given himself just a weekend to write it, but even that felt to him like too much. The president was waiting, and not patiently.

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.

the 1918 Spanish flu. Inside of eighteen months, a virus had killed somewhere between forty and sixty million people around the world, but Barry focused on the American carnage. At least half a million Americans, most of them young, had died. A similar culling of the far larger population in 2005 would kill a million and a half Americans. If anything like Barry described were to occur again, it would distort American life in the most fantastic ways, and leave it forever changed.

Bush returned to the White House from his summer vacation with a new interest in pandemics. His concern led to a meeting in the Oval Office, on October 14, 2005, to which Rajeev Venkayya was invited.

then worked his way into an obscure unit of the Homeland Security Council that dealt with biological threats to the American people. The Biodefense Directorate, it was weirdly called. In the summer of 2005 he’d been named the unit’s head.

“The hard-core biodefense types didn’t like to talk about it because it isn’t interesting to them,” said Rajeev. “H5N1 [a flu strain] appears in poultry in Hong Kong. Who the fuck wants to talk about chickens?”

In 2003, a new strain of flu found in geese and other migratory birds had jumped into 120 humans and killed half of them. Migratory birds migrated. That same year, a new coronavirus had moved, probably from an animal called a masked palm civet, into humans, infecting eight thousand people and killing eight hundred. A mutation here or a mutation there, and either one of these viruses could have wreaked havoc on American life. 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.

they had an unsatisfying document. Recently generated by the Department of Health and Human Services, it laid out plans, in the event of a pandemic, to speed up the production of vaccines and stockpile antiviral drugs. That was the reason for the Oval Office meeting: Bush had read it and hated it. “The president said, ‘This is bullshit,’ ” Rajeev recalled. “ ‘It’s just health. We need a whole-of-society plan. What are you going to do about foreign borders? And travel? And commerce?’ ” And how were you going to stop hundreds of thousands of Americans from dying while they waited for even a speeded-up vaccine?

“We wasted the first week,” said Rajeev. “It was smart people trying to create the thing by consensus. You can’t write a strategy by committee.” He decided he’d just take the notes he’d made in the White House meetings with him back to his parents’ house in Ohio and write it himself.

“I wrote the whole thing in six hours on Friday night,” he said.

on November 1, Bush gave a speech at the National Institutes of Health, announcing the new strategy. It had three parts to it: to detect outbreaks overseas so they might remain there; to stockpile vaccines and antiviral drugs; and, finally, to “be ready to respond at the federal, state and local levels in the event that a pandemic reaches our shores.”

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 plan gives you cover to do all sorts of things,” said Rajeev. “It gave us license to go and figure things out.”

“The United States took this on as a national priority before anyone in the world,” said Rajeev. “We want to use all instruments of national power to confront this threat. We were going to invent pandemic planning.”

He asked for and was given permission to hire seven people, from relevant federal agencies, to help. His first pick was Richard Hatchett, another doctor who had stopped treating patients and moved into government service. Richard belonged to a dying species: the romantic southern man of letters who travels north and there makes an uneasy home for himself. He’d grown up in Daphne, Alabama, and in 1985 had gone off to Vanderbilt University, where his poetry caught the eye of the eminent poets in residence Donald Davie and Mark Jarman. They’d picked him to represent Vanderbilt at a national collegiate poetry competition, in which he finished second. A judge, the future Pulitzer Prize–winning Irish poet Paul Muldoon, singled out one of his poems as the work of a young poet of promise. When asked why, instead of pursuing a career as a poet, he had gone to medical school, Richard would say simply, “Writing is too hard.”

In September 2001, he was working in the emergency room at Memorial Sloan Kettering Cancer Center, in New York City, and preparing to start a fellowship in oncology. On September 11, he moved to a field hospital that arose spontaneously in Stuyvesant High School, where he ran triage for the rescue workers at Ground Zero. Years later he wrote a letter to his newborn son describing the feelings of that moment. What positive I remember about that day and the weeks that followed was the profound social cohesion and solidarity of communities and the desire of individuals to serve and contribute. That sounds, superficially, like patriotism and in a sense it is patriotism of the best sort but in fact, at least for me, it was more complex than that. What we experienced had more to do with communities coming together than it did with a sense of national identity. It had more in common with the social cohesion that occurs after a tornado or hurricane, at least for the first few days, than it did with the nationalism of people at war.

A pair of recent events had pushed the threat of bioterrorism to the front of the minds of the people who worked in and around national security. One was the series of anthrax attacks on Capitol Hill in October 2001; the other was an exercise conducted a few months before those attacks, called Dark Winter. In the summer of 2001, a bunch of smart people in and around the U.S. government gathered at Andrews Air Force Base and thought through a bioterrorist attack on the U.S. population. In the imaginary attack, on shopping malls in Atlanta, Philadelphia, and Oklahoma City, three thousand Americans are infected with smallpox. The disease had been eradicated in the 1970s, vaccine was scarce, and so the U.S. population was vulnerable to any new introduction of the virus. The imaginary exercise did not end well. Just a few months after the hypothetical attack, three million Americans were infected. A million were dead.

By January 2003, Richard found himself giving a talk at the Pentagon on how the country might minimize illness and death if terrorists seeded it with smallpox.

The problem, as he framed it for the Pentagon, was how to slow the spread of a communicable disease until you can produce a vaccine. As communicable disease spreads through social networks, Richard reasoned, you had to find ways to disrupt those networks. And the easiest way to do that was to move people physically farther apart from each other. “Increasing Effective Social Distance as a Strategy,” he called it.

What he also didn’t realize was that he was giving new life to a dead idea: that apart from isolating people who were ill, you needed to do anything you could to slow the spread of a disease before you had drugs to help. “I was this emergency room doctor,” he said. “I didn’t know that people said all this stuff had been tried in 1918 and it hadn’t worked. I wasn’t rejecting anything. I just didn’t know any better.”

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. Like Rajeev, he believed that some new strain of flu, or some similar respiratory virus, was an accident waiting to happen. And so when he heard Rajeev’s offer to create a pandemic plan for the country, he was all in. His employer, on the other hand, was not. The National Institutes of Health didn’t want to let him go. “It caused some bitterness when I asked for him,” recalls Rajeev. “We had to ask Tony Fauci for permission.”

Soon he had a team. The State Department sent him someone to think through how to coordinate with foreign governments—to find and contain new viruses before they even got to the United States. The Justice Department sent him someone to create a strategy for safeguarding law enforcement and the courts. And so on. All these people were of a certain Washington type. Smart. Schooled in the inner workings of the federal government. Experienced in the crafting of national policy. They were all insiders. Even, by then, Richard Hatchett.

The guy sent by the Department of Veterans Affairs was the glaring exception. Rajeev had figured that he needed someone from the VA, as it ran the nation’s largest hospital system and, during a pandemic, might be tapped both for hospital beds and for data about what was going on around the country. The VA sent not a policy person, not a Washington person, not a person who knew anything about pandemics, not a person who looked all that happy wearing a suit and tie, but a doctor from Atlanta named Carter Mecher. As it turned out, he would make all the difference.

Carter Mecher had only ever wanted to be a doctor, but the world kept find...

Working with his hands, Carter became perfectly focused; otherwise, his mind refused to sit still. “I think I have ADD,” he’d say. “I have something like that. I wander all over the fucking place.” By the time he reached college, he’d grown so used to not paying attention in class, and instead thinking about whatever he wanted to think about, that he would just make note of whatever book the professor was talking about so that he could go read it on his own later. There were exceptions, though. Times when Carter’s mind would lock into a problem, in the same way it did when he was fixing a car engine. That was when he was at his best, and most himself. An inability to pay attention to anything except that which you find totally riveting might not sound like the most promising trait in a medical student. But almost by process of elimination, it led Carter to his calling: critical care.

From the moment he walked into an ICU, Carter sensed it was where he was meant to be. The ICU rewarded his handiness: he could intubate anyone. “There are two skills you have to have in an ICU,” he said. “You need to be able to put an IV into anybody, and you got to be able to stick a tracheal tube into anybody. You can’t do that, and you are going to lose a patient.”

When Carter first started teaching medical students, in the early 1990s, he was working in a VA hospital. Most of the patients were blue-collar guys who had fought in the Second World War. All you saw as a doctor, or medical student, were these dying old men. But if you got them talking, you’d hear the most amazing stories—how they once flew their fighter plane under the Golden Gate Bridge, how they had taken Iwo Jima. “All of us are like a story,” he’d tell students. “You’re seeing the last two pages of the book. You know so little about him. He was once a little kid. He was your age once.”

Carter would never forget one crusty old World War II vet with incurable lung disease, and a tube down his throat. He’d been able to communicate only by writing on a whiteboard. I want to die, he’d written one day. The nurses brought Carter over. I want you to take me off this goddam machine and let me die, he wrote to Carter. Carter told him that if he really wanted to die, he could die, but maybe they should sleep on it, as death wasn’t one of those procedures that was easy to reverse. The old vet wrote, If you don’t pull this tube out, I’m going to yank it out. “He was in a rage,” said Carter. “They brought in the chaplain and the family.” Carter decided to change the subject. “What can we do to make you more comfortable?” he asked. The old vet studied him a beat and then wrote on the board, “Beer.” “What kind of beer?” asked Carter. A few minutes later Carter was at a gas station buying a six-pack. He gave it to the ICU nurse along with a formal prescription: one can of beer a night. “I hand him the beer and he has a smile on his face,” said Carter. “And he went to sleep.” The old World War II vet decided he preferred to live, and he lasted a surprisingly long time.

Mistakes inside a VA hospital had to be reported to Congress, where members of whichever party did not control the White House would set about blaming the president for mistreating veterans.

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. He also knew that the VA surgeons were doing their best; and all of them could have made more money in private practice.

The dean pressed Carter until he agreed, but only after his mind made a little leap. “My strength is taking care of really sick patients,” he said. “We’ve got an entire medical center that is a really sick patient. It’s a dying hospital. That’s how I approached it: How do I stabilize it?”

Once you had the data, you could see weaknesses more quickly and fix them.

How exactly they did what they did is relevant here mainly because of where it led Carter Mecher. It led him to take an interest in medical error, and that interest soon became an obsession.

“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.”

He now had a rule: if you visit a hospital to investigate some problem, visit more than once, as on the first visit the locals assume that you have come merely to find fault and assign blame rather than to enlist them as partners in the hunt for the flaw in the system. He’d learned that from some field anthropologists whom he had sought out. “They taught me how important it was to have a second visit when they visited villages,” said Carter. “The second visit made a statement to the villagers, and it usually wasn’t until the second visit that trust emerged.”

The Charleston hospital, like other hospitals, mailed out these test kits with little cards on which patients were meant to capture a stool sample. To ensure that the test kits made their way back to the hospital, the hospital enclosed pre-addressed envelopes. Carter had asked if they could go see where the test-kit envelopes arrived. They took him to the mailroom, where someone dumped the sack with that day’s mail onto a table. A bunch of test kits were in the pile, but each envelope bore the same red notice: Insufficient Postage: Return to Sender. (“Thank God the post office delivered them anyway.”) One of the nurses said: I wonder how many of them were returned to the sender? “Bulbs went off in everyone’s head,” said Carter. It had occurred to no one that the colon-cancer test kits might require two postage stamps. “Who the hell would know that you need more than one stamp to send it back to the medical center? I would have done the same thing.” People were dying, for a stamp. The Charleston VA began to send out pre-addressed envelopes with two stamps, and within a year had leapt to the front of the pack in its detection of colon cancer. “I loved that moment,” said Carter. “It was so commonsense.”

Human Error, by a British psychologist aptly named James Reason.

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.

why did so much of what he learned in life come from doing some job, and so little from school? And why . . . well, from there his mind became totally engrossed, but not with the problem his superiors had asked him to solve. “I did pull a group together,” said Carter, “but the task I gave the group was to figure out why the idea of a Lessons Learned website didn’t work.”