The Premonition: A Pandemic Story

by Michael Lewis

As one of my characters put it, “Trump was a comorbidity.”

Back in October 2019—nearly three years into the Trump administration, and before anyone involved was aware of the novel coronavirus—a collection of very smart people had gathered to rank all the countries in the world, in order of their readiness for a pandemic. 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.)

For years the University of Texas football team, with its vast resources and sway with voters, always seemed ranked more highly at the start of the season than at the end. The United States was the Longhorns of pandemic preparedness. It was rich. It had special access to talent. It enjoyed special relationships with the experts whose votes determined the rankings.

He picked up The Great Influenza, a book by the historian John Barry about the 1918 flu pandemic. “My God, fifty million people died!” said Bob. “I had no idea. I started thinking, God, this is an important problem.”

Not enough people know this

Health officers in California, like health officers across the United States and the rest of the free world, had a long list of responsibilities. Registering births and deaths. Inspecting restaurants. Counting bacteria in ocean water and swimming pools. Managing chronic diseases. None of that really interested her. Then she saw the phrase “Communicable Disease Controller.” It was an official state role. Played by local health officers. Her mind lit up. “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.”

She knew that her obsession with pandemic disease was unusual, even off-putting. “I learned not to talk about it,” she said, “because when I talked about it, people thought I was crazy.” But the fact remained that, from a very young age, when she was feeling low, she had cheered herself up by reading books on bubonic plague.

The public-health officer had somehow come to be a recessive character. The other officials, and the public, expected her to lie low, like a carrot in a school play, or the wife of a rich surgeon, until called upon, usually to make some brief ceremonial appearance.

Carrot in a school play 😂

To the men she left behind, the entire scene would remain a vivid memory; to her it was almost just another day in her life as the local health officer. They had no idea of the things she had done, or what she was capable of. The coroner obviously hadn’t even considered the possibility that she was a trained surgeon. “Men like that always underestimate me,” she said. “They think my spirit animal is a bunny. And it’s a fucking dragon.”

By 2016, hep C was killing more Americans than all the other infectious diseases put together, according to the Centers for Disease Control and Prevention, but it never made the list of diseases that required a swift response from the local health officer. It was blood-borne, which made it harder to contract, and easier to ignore.

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 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.

That threat actually wasn’t all that original. As Kat DeBurgh, head of the Health Officers Association of California, put it, “To do the job of local public-health officer, you basically always need to be willing to lose your job.” To be a public-health officer—to really own the role—you needed to be prepared for your only appearance on the front page of the local newspaper to be in a story about a call you got wrong. That might be the only time anyone ever looked up and noticed who you were: the moment they chopped off your head.

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 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.

“Increasing Effective Social Distance as a Strategy,” he called it. “Social distance” had been used by anthropologists to describe kinship, but he didn’t know that at the time, and so he thought he was giving birth to a phrase. (“But I don’t think I turned it into a gerund,” he’d later say.)

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.

Though his father hadn’t finished the ninth grade, he had a highly successful career as a tool and die maker, and as a parent. He encouraged his children to tackle problems with the same confidence that he shaped steel. “If some other dumb fuck can do it, so can you,” he liked to say. He’d said exactly that when Carter asked him if he thought he could become a doctor.

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.”

What the fuck

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.

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.”

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.

“You’d see Richard on the phone late at night explaining to his wife when he might be coming home,” recalls one White House colleague. “He was like cheating on his family for pandemic preparedness.”

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.

“I couldn’t design a system better for transmitting disease than our school system,” he said after his visit.

Arriving a few days later at the White House gates, she was so nervous that she called Carter from outside and said, “I’ve never been here! You’ve got to meet me on the street and walk me in!”

Me at my friend’s parents’ house

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.

He felt a little bad dumping all of this on Obama, as the president was just then dealing with a global financial crisis, two foreign wars, and a domestic fight to the death over his proposed health care plan. As he was speaking, Rahm Emanuel, Obama’s chief of staff, looked up and said, “What’s next, locusts?”

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 wasn’t. To Richard’s way of thinking, the fact that the decision happened to have worked out did not mean it was the right decision; in a funny way, it was alarming that it had worked out, as it created a false sense of confidence in the process that had rendered it.

“Experience is making the same mistake over and over again, only with greater confidence,”

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.”

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.”

“They got to decision branch number twelve and—I shit you not—it was, ‘What happens if you inject the snake with live Ebola virus, and you come back later and there is a hole in the snake’s cage and the snake is gone?’ ” To which Joe’s first response had been: “You fucking run!”

At some point during his residency, Wilson realized that if he were to become a neurologist who specialized in infectious disease, he’d spend a lot of time giving up hope. “There was a fascination with these patients,” he said, “but there was also a certain nihilism.”

Four days later, she was dead. Her hospital bill came to $1,000,100, and why they didn’t just round it to the nearest million was an open question.

Asked to explain what he’d found, Joe would only say, “Balamuthia is an amoeba and it eats your brain, and there is no cure.”

Joe asked his team to test every drug that had been approved by either the U.S. Food and Drug Administration or the European regulators. “No weird Russian shit,” as Joe put it.

Nine days into Carter’s silence, on January 18, the world was still paying little attention to what appeared to be a small local outbreak. The World Health Organization was saying that there was “no sustained human-to-human transmission” of the virus, and the Chinese government was allowing forty thousand families in Wuhan to gather for an annual celebration, complete with a buffet.

Jesus Christ

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?

“She was looking for the CDC to pull the fire alarm,” said Charity. “The CDC does not know how to pull the fire alarm. In fact, there is no fire alarm in this country.”

“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.”

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!”

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.

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.”

“The only way I make sense of things is through stories that I tell myself,”

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?

One evening in March, Joe looked down, saw an unfamiliar number, and very nearly didn’t answer it. The area code was Sacramento, his hometown, and so he gave the caller the benefit of the doubt. “I thought it was a telemarketer, but I picked it up and it was Gavin Newsom.”

Gavin Newsom had no plan to create a lot of testing in California: Why would he? Like everyone else, the governor had assumed the federal government would make sure that the country had enough testing to track any new virus.

As a pathogen threatened to overrun the United States and shut down its economy, he detected an odor he distinctly did not like coming off the private sector. One company was the biggest supplier of an enzyme they needed to run tests. “We called and told them what we were doing and that we wanted to buy a million dollars’ worth of the stuff,” said Joe. “When you buy that quantity you always get a discount. But they said nope, you’re paying full price.” He was so pissed off that he looked around and found a smaller company, New England Biolabs, that sold the same enzyme. “Completely different spirit,” said Joe. “They said, ‘This is amazing! Forty percent discount right now!’ That’s how companies should behave.” It went that way with much of what they needed to buy: some companies sought to exploit the moment; others sought to help. “We quickly figured out that some companies actually have a moral compass and some of them don’t,” said Joe.

“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. It was Balamuthia all over again. The cure meant nothing if the patient never received it. Standing between the cure and the patient, in this case, was a U.S. medical-industrial complex that lurched between lethargy and avarice.