The Premonition: A Pandemic Story

by Michael Lewis

At last count the United States, with a bit more than 4 percent of the world’s population, had a bit more than 20 percent of its COVID-19 deaths. In February 2021, The Lancet published a long critique of the U.S. pandemic performance. By then 450,000 Americans had died. The Lancet pointed out that if the COVID death rate in the United States had simply tracked the average of the other six G7 nations, 180,000 of those people would still be alive. “Missing Americans,” they called 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.

“When a doctor stops treating patients, they slowly start to forget. Seeing patients is how you develop a sixth sense.” She wasn’t simply doing good works, in other words. She was gathering intelligence.

If there is the faintest possibility of a catastrophic disease, you should treat it as being a lot more likely than it seems. If your differential diagnosis leads to a list of ten possibilities, for instance, and the tenth and least likely thing on the list is Ebola, you should treat the patient as if she has Ebola, because the consequences of not doing so can be calamitous.

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.

It was like that famous problem taught to college freshmen in ethics classes across the country. You, college freshman, are driving a train. Ahead on the tracks you spot five people. Do nothing and the train will run them over and kill them. But you have an option! You can flip a switch and send the train onto a siding, on which, unfortunately, there stands a man named Carl. Do nothing and you kill five people; flip the switch and you kill Carl. Most college freshmen elect to kill Carl and then, wham, the professor hits them with the follow-up. Carl has five healthy organs that can be harvested and used to save the lives of five people in need of them. All you need to do is shoot Carl in the back of the head. Would you do that, too? If not, explain the contradiction

“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.

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.”

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.

I love this.

‘You’re going to make a mistake,’ ” said Carter. “The sin is making the same mistake twice. The best is to learn from other people’s mistakes.”

Learning from other people's mistakes is the most valuable part of mentor relationships, in my opinion.

Carter was fielding calls from various people to let him know that the system he oversaw had boiled someone alive. The nurses were devastated, but to Carter’s way of thinking they were victims, too. The environment in which they worked, and which they had been encouraged to trust, had failed them. “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.”

Carter visited the hospital to poke around. 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.”

“You can keep mistakes from happening if you can identify the almost mistakes. This kind of changes how I view everything.”

“People in an organization learn,” said Carter. “They’re learning all kinds of things. But they aren’t learning what you are teaching them. You go to a formal meeting. The important conversation is not in the meeting. It’s in the halls during the breaks. And usually what’s important is taboo. And you can’t say it in the formal meeting.”

Once Carter saw how government reports got written, he understood why no one ever really wanted to read them. Richard was a natural writer, but there was no place in the process for a natural writer. “There were all these stupid rules,” said Carter, whose first job was making sure that whatever Richard wrote conformed to the U.S. government’s style manual. “Like you need to put countries and states in alphabetical order, so no one is offended. You can’t say ‘over’ three hundred bucks—you have to say ‘more than.’ ” The bigger obstacle to clear prose was the sheer number of people invited to complain about whatever Richard wrote. Anything that implicated any federal agency had to be sent to that agency for approval. “So we’d send it to, like, the EPA,” said Carter. “And it wasn’t one person at the EPA. It was ten. There were times I had five different comments on the same sentence all wanting me to change the sentence a different way.”

Inside the United States government were all these little boxes. The boxes had been created to address specific problems as they arose. “How to ensure our food is safe to eat,” for instance, or “how to avoid a run on the banks,” or “how to prevent another terrorist attack.” Each box was given to people with knowledge and talent and expertise useful to its assigned problem, and, over time, those people created a culture around the problem, distinct from the cultures in the other little boxes. Each box became its own small, frozen world, with little ability to adapt and little interest in whatever might be going on inside the other boxes. People who complained about “government waste” usually fixated on the ways taxpayer money got spent. But here was the real waste. One box might contain the solution to a problem in another box, or the person who might find that solution, and that second box would never know about it.

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.”

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

In the end he plotted both the deaths and the restrictions imposed to prevent them, and saw that the earlier the restrictions imposed in any given outbreak, the fewer the deaths. In the case of Philadelphia, he wrote, “the closing of schools and churches, banning of public meetings, and banning of large public gatherings occurred relatively late into the epidemic”—nearly one month after the outbreak began and just a week before its peak.

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. Cities that intervened immediately after the arrival of the virus experienced far less disease and death. The first reported flu cases in Philadelphia had been on September 17. The first case wasn’t spotted in St. Louis until October 5—which also happened to be the day the United States surgeon general, Rupert Blue, finally acknowledged the severity of the disease and recommended that local leaders take action. The death rate in St. Louis was half that of Philadelphia because St. Louis’s leaders used the cover provided by the federal government to distance its citizens from one another.

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 Mexicans, interestingly, had taken the new pandemic strategy of the United States and run with it. They’d closed schools, and socially distanced the population in other ways that, studies would later show, shut down disease transmission. The CDC, by contrast, sent the message that each American school should make its own decision, which was a bit like telling a bunch of sixth graders that the homework was optional. A few schools closed, but the vast majority did not. The local public-health officials with the power to close the schools had no political cover to do what needed doing.

There was, Carter thought, a downside to experience. “Experience is making the same mistake over and over again, only with greater confidence,” he said. The line wasn’t his, but he liked it.

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.”

Investigators would wind up grabbing animals across China until they found the SARS virus inside one of them, reproducing without sickening the animal. To the surprise of all, the new virus’s old home turned out to be the horseshoe bat. “No one had ever seen bat coronaviruses,” said Joe. “They didn’t exist.”

About 1% of Americans travel outside the US each month for comparison. Maybe disease outbreaks need a warning like the one on your car mirror—things are much larger than they appear.”

One fire in particular had captivated his and Richard’s imagination when they’d read of it years earlier. It was known as the Mann Gulch fire, after the area in Montana that had burned back in 1949. A decade earlier the U.S. Forest Service had created an elite team of smokejumpers who parachuted into fires. One August afternoon, fifteen young men, most between the ages of seventeen and twenty-three, parachuted into what they thought was a small and simple fire. They landed by 4:10 p.m. and began to hike down into Mann Gulch, with their heavy packs and Pulaski axes on their backs. They didn’t know each other and, as they hiked, split into smaller groups. To their right was a steep ridge, to their left a creek. The fire they’d been sent to fight burned safely on the other side of that creek, or so they imagined. There weren’t many trees, just tall grass, but they were unable to see much ahead of them. A mile or so down the gulch, the creek drained into the Missouri River. Their plan was to walk to the river, cross over the creek, and fight the fire with the river at their backs. The river at their backs was their escape route. But as they neared the river, there came a shocking sight: fire. It had jumped across the creek and now blocked them from the river. Worse, it was moving across the grass toward them. One moment the fire had been invisible, the next a terrifying wall of flames thirty feet high. It was now 5:45. They turned to flee, but the only escape route was up and ...

The problem with implementing (the social interventions) too late is you get all the downsides and little benefit, so speed is critical.

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.”

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?

For the better part of two months, they’d repeated the same mantra: the risk to Americans is low, and there is no evidence of transmission inside the country. That fiction ended on February 25, when the CDC’s lab in Atlanta identified as positive for COVID-19 the patient inside the UC Davis Medical Center with no history of foreign travel. That day, the CDC’s Nancy Messonnier held a press conference to say that the spread of the disease was inevitable. “It’s not so much a question of if this will happen anymore,” she said, “but rather more a question of exactly when this will happen and how many people in this country will have severe illness.” The stock market dropped 1,100 points, and Trump ranted and raved, thus frightening everyone else in the CDC into silence and turning Messonnier into a martyr. An order came from Vice President Mike Pence’s office saying that henceforth no one in the Department of Health and Human Services was allowed to say anything that might alarm the public.

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. Measles’ reproductive rate of 18, on the high end, implies that ninety-five percent of the population needs to be immune to measles before measles stops spreading. That’s why we have as our goal to vaccinate 95 percent of the population against measles. Before COVID-19 stopped spreading, two-thirds of Californians would need to become infected.

“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.”

What he didn’t say, because he was too embarrassed to say it, was that inside the truck they’d discovered not medical swabs but Q-tips. So far as he could tell, there had never been any swabs in the Strategic National Stockpile.

“It’s the one thing if I could go back in time and change I would,” he said. “I wish I had bought one hundred thousand swabs. It was not on my radar. It was not a thing I thought would be the limiting factor in life.”

In the end, roughly three thousand of the 4,087 official residents showed up to be tested over four days in late April 2020. A bit more than 6 percent of the Latino residents turned out to be infected by COVID, most with high loads of the virus, though many had no symptoms. There were patterns in the test results—for example, the richer the person, the less likely he was to be infected. Latinos were only 44 percent of the study but 95 percent of the positives. Of the 981 white people tested, zero were positive. The big takeaways seemed to be what everyone was just then figuring out: the virus was disproportionately attacking poor people of color unable to work from home; and lots of infectious people were walking around without a clue about their condition.

On September 23, 2020, a former director of the CDC, Bill Foege, sat down to write a letter to the current director, Robert Redfield. Foege was eighty-four years old and a legend in disease control—to many “the man who eradicated smallpox.” He wore his principles lightly but he had some, and had lived by them. He’d been the last CDC director to rise from within the ranks, propelled by the admiration of fellow experts, rather than through connections to a politician. Later, Jimmy Carter would introduce him as the man he’d handpicked to run the agency, but Jimmy Carter hadn’t picked him at all: Foege’s peers in disease control had. “Dear Bob,” he now wrote, as a disease swept through the American population. “I start each day thinking about the terrible burden you bear. I don’t know what I would actually do, if in your position, but I do know what I wish I would do. The first thing would be to face the truth. You and I both know that: 1) Despite the White House spin attempts, this will go down as a colossal failure of the public health system of this country. The biggest challenge in a century and we let the country down. The public health texts of the future will use this as a lesson on how not to handle an infectious disease pandemic.” Points 2 and 3 followed Point 1. The gist of all three was that the CDC, under Robert Redfield, had been disgraced. It had let itself be used by the Trump administration to lead the United States in a direction opposite to the direction the ...

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 person who did not present risks to the White House’s political operation. The person who deferred, rather than made, hard decisions. A Chamberlain, rather than a Churchill.

“Richard and I used to talk about this all the time,” recalled Carter. “What if we do all these things and we close the schools and the result is that we have a very mild epidemic? And people look around and say, ‘Why did we do all this?’ ” They decided that their hides would be saved by the countries that had bungled their pandemic response. They’d be able to point to them and say, “Look! That’s what would have happened to us!” They never imagined that other countries would use the United States to demonstrate their own counterfactual. “We are the bad example for the rest of the world,” said Carter. “That’s what is so embarrassing.”

He was like the surgeon, famously described by a writer, who had inside himself a small cemetery where he buried his failures and, from time to time, went to pray.

The pandemic had given America’s enemies a clear view of the country’s weakness: its inability to respond to a COVID-like threat.