The Plague Year: America in the Time of Covid

by Lawrence Wright

A legend was concocted in the party press about how far and how quickly the old man swam that day—more than nine miles in sixty-five minutes, according to the state newspaper, which would have been a world record. Video of the event shows him doing a leisurely side stroke, surrounded by bodyguards and thousands of enthusiastic supporters who plunged in after him. The swim was a turning point in Mao’s chaotic rule, amplifying a personality cult among young people who now saw him as their champion. They became the Red Guards, the vanguard of the reign of terror that lasted until Mao’s death ten years later.

At about the same time, healthcare workers were falling ill with similar symptoms, indicating human-to-human transmissions of the new pathogen was taking place. That fact was not acknowledged by government officials until nearly a month later; instead, authorities instructed the medical staff not to wear masks or gowns because they might give rise to panic.

There was good reason for Dr. Ai’s concern. Severe acute respiratory syndrome, or SARS, a coronavirus that erupted in China in November 2002, had thrown the country into its worst political crisis since the 1989 Tiananmen Square uprising. The initial response of the Chinese government and the ruling Communist Party had been to hide the outbreak, even from its own public health officers. Under the cloak of the news blackout, SARS spread through the country, reaching Beijing the following March. Doctors in charge of the treatment had no idea what was going on, so closely held was the information, but frightened rumors spread by text messages. Pharmacies sold out of antibiotics and flu medicines. The new disease killed nearly 10 percent of the people it infected, becoming the first epidemic since HIV/AIDS dangerous enough to threaten the entire world. SARS is thought to have passed from horseshoe bats into masked palm civets and presumably into its first human hosts in the wet markets of Guangdong.

There were reasons for the cover-up of SARS, including the fear, typical of repressive systems, of passing bad news up the ranks; a tangled bureaucracy; and the singular priority of economic growth over all other considerations; but the naked fact stood that the Chinese government was willing to sacrifice its own people and place the entire world in jeopardy, risking millions of lives, simply to avoid accountability for the outbreak.

Left to draw their own conclusions, the Taiwanese began early screening and quarantines, which would result in a strikingly low rate of infection on the island.

On January 11, an ER nurse at Dr. Ai’s hospital became infected with the virus, but hospital authorities again denied that human-to-human transmission was occurring.

American intelligence would later surmise that the central government had been caught by surprise because of the duplicity of local officials, but it is also true that Chinese authorities continued to downplay the threat once they knew about it. They demanded that researchers stop publishing about the virus without government authorization and cease warning about the danger of the outbreak. They continued to deny that there was evidence of human transmission. The government refused to share virus samples with the U.S., which set back the production of the tests needed to detect the disease by a couple of weeks.

The coronavirus revealed China as a country struggling in the grip of one-party control, at once fearful and defiant, ambitious and proud of its rise in the world but also seething with popular resentment at the political calculations that valued the party’s image over human life. The reluctance to disclose the scope of the outbreak and to share the science that was necessary to stop its spread displayed an indifference to life that is the enduring legacy of Maoism.

Chinese New Year, the most important holiday on the calendar, when people return to their hometowns, visit relatives and friends, and travel for vacation. Chinese authorities estimated nearly three billion trips would be taken during the forty-day festival. An immense portion of the travelers would pass through Wuhan along their way. International students went home for the holidays. It is the world’s largest annual migration. Covid-19 was on the move.

Redfield offered to send a team of CDC disease detectives from the U.S to investigate, but Gao said he was not authorized to invite them. He told Redfield to make a formal request to the Chinese government. Redfield did so, and immediately assembled a team of two dozen epidemiologists and disease specialists, but no invitation ever arrived.

When Redfield first spoke to Gao, the “unknown pneumonia” was presumed to be confined to China, not yet posing an imminent threat to the rest of the world. In fact, the virus was already present in California, Oregon, and Washington State, and within the next two weeks would be spreading in Massachusetts, Wisconsin, Iowa, Connecticut, Michigan, and Rhode Island—well before America’s first official case was detected. In another conversation that first week of the new year, Dr. Gao started to cry. “I think we’re too late,” he told Redfield. “We’re too late.”

On January 20, the coronavirus officially arrived in America. “This is a thirty-five-year-old young man who works here in the United States, who visited Wuhan,” Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), said on a Voice of America broadcast. “There was no doubt that sooner or later we were going to see a case. And we have.” President Trump took note of the event at the World Economic Forum in Davos. “It’s one person coming in from China, and we have it under control,” he remarked. “It’s going to be just fine.”

The only thing that kept democracy from winding up in a suicidal brawl of self-interest was a sense of common purpose, but the pandemic exposed that the United States no longer had one.

In January 2017, days before Donald Trump was inaugurated, Dr. Fauci had warned there was “no doubt” that the incoming president would be dealing with an infectious disease outbreak. “We will definitely get surprised in the next few years,” he predicted.

During the transition to the Trump administration, the Obama White House handed off a sixty-nine-page document called the “Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents.” A meticulous, step-by-step guide for combatting a “pathogen of pandemic potential,” the playbook contains a directory of the government’s resources in time of need and is meant to be pulled off the shelf the moment things start to go haywire.

At the top of the list of dangerous pathogens are the respiratory viruses, including novel influenzas, orthopoxviruses (such as smallpox), and coronaviruses. The playbook outlines the conditions under which various government agencies should be enlisted.

The Trump administration jettisoned the Obama playbook. In 2019, HHS, headed by Alex M. Azar Jr., conducted an exercise called Crimson Contagion.

One could say that the Trump administration was in an enviable spot at the beginning of the pandemic. It had a step-by-step playbook that could serve as a guide through bureaucratic snares that accompany such a disaster. It had been alerted to its own failings by the Crimson Contagion exercise. And it was blessed with institutions that were envied and admired throughout the world. Beyond the matchless government medical and research institutions such as the CDC, National Institutes of Health, Walter Reed National Military Medical Center, the U.S. Army Medical Research Institute of Infectious Diseases, and the Biomedical Advanced Research and Development Authority, America also commands the world’s top medical schools and many of the largest pharmaceutical companies. When the Trump administration came into office, it was handed the keys to the greatest medical-research establishment in the history of science. Robert Kadlec, the assistant secretary of HHS in charge of preparedness and response, had led the Crimson Contagion exercise. He would later admit, “We knew before the movie started it was going to have a bad ending.”

At first, SARS-CoV-2 presented itself as a typical coronavirus, like the common cold, spreading rapidly and symptomatically. In fact, this new virus was more like polio, in which most infections are asymptomatic or very mild, with fever and headaches. The cases that doctors actually see are about one in every two hundred infections. Stealth transmission is why polio has been so hard to eradicate.

Armstrong realized that, unlike SARS or MERS, there were probably a lot of asymptomatic or mild infections with the SARS-CoV-2 virus. That spelled trouble. Contact tracing, isolation, and quarantine were probably not going to be enough. These telling details were buried in Table 1.

“There are three things this virus is doing that blow me away,” said Brooks, marveling at the resourcefulness and agility of his adversary. “The first is that it directly infects the endothelial cells that line our blood vessels. I’m not aware of any other respiratory viruses that do this. This causes a lot of havoc.” Endothelial cells provide a protective coating inside the blood vessels, sealing off the cell like a Ziploc bag. They modulate blood pressure and serve as traffic cops, using sticky proteins to nab passing immune cells and direct them where they are needed when a threatening virus is present. With coronaviruses, the vulnerable spot for infection in humans is the ACE2 receptor. If the virus is the key, the receptor is the lock it’s looking for. ACE2 receptors are enzymes found in the lungs and kidneys as well as in the gut and the brain, accounting for the many manifestations of the disease in humans. They are also abundantly present in the endothelial cells. The virus binds to these receptors, hijacking the cell’s machinery to make copies of itself, thereby killing the cell and scouring the thin cell wall, which generates turbulent blood flow. Powerful chemical contents get dumped into the bloodstream, stirring up inflammation elsewhere in the body. Brooks had never seen that condition before. The second surprise was hypercoagulability—a pronounced tendency to develop blood clots. Brooks was reminded of Michael Crichton’s 1969 best-selling thriller, The Andro...

Some patients require kidney dialysis or suffer liver damage. The disease can affect the brain and other parts of the nervous system, causing delirium and lasting nerve damage. Covid can also do strange things to the heart. Hospitals began admitting patients with typical symptoms of heart attack, including chest pains and trouble breathing. “They do the EKG, and the EKG says this person is having a heart attack,” said Brooks, “but their coronary vessels are clean. There’s no blockage.” Instead, an immune reaction has inflamed the entire heart muscle, a condition called myocarditis. “And there’s not a lot you can do but hope they get through it.” A German study of 100 recovered Covid patients with the average age of 49, found that 22 of them had lasting cardiac problems.

In 1998, there was a paper published in The Lancet, one of the world’s oldest and most respected medical journals, by Andrew Wakefield, a British doctor, that purported to show a link between the Measles Mumps Rubella (MMR) vaccine and the development of autism. Numerous other studies have contradicted the findings, and The Lancet withdrew the paper in 2010, after investigations showed the original study was fraudulent and that Wakefield had been bankrolled by a lawyer trying to raise a class-action suit against vaccine manufacturers.

in the middle of the road, they came upon a shivering pig. It had apparently tumbled out of the bed of a pickup into the snow. Peg estimated that it weighed at least two hundred pounds. David nudged it with the car to see if it would move out of the way. Finally, he got out and grabbed the pig by the ears and tugged it aside. In that fateful moment, did the pig cough in his face? Peg and I retraced their steps, stopping at farmhouses along the way. We finally found the owner of the pig, who was not happy to hear my theory that his pig may have been the source of a disease that could potentially kill millions. I told him I just needed a little blood from his pig, which was actually a house pet, to send to the CDC. The owner turned to this still grieving young woman sitting on his couch and said, “I know you. I know where you live. You fuck with my pig and I’ll burn your house down.” Wow, welcome to epidemiology.

I finally negotiated a deal in which his veterinarian would draw the blood and send it to Gary Noble at the CDC. I was pretty sure that the blood would show antibodies to swine influenza, and that the vaccination program would be put on ice until other infections surfaced, if they ever did. The pig had never been sick a day in its life. The vaccination program went ahead, “whole hog.”

Building 40 of the main campus of the National Institutes of Health, in Bethesda, Maryland, houses the National Institute of Allergy and Infectious Diseases. On the second floor is the laboratory of Dr. Barney Graham, deputy director of the Vaccine Research Center and chief of the Viral Pathogenesis Laboratory and Translational Science Core. He studies how viruses cause disease and designs vaccines to defeat them. The first thing you notice about Barney Graham is that there’s a lot of him. He’s six-foot-five, with a gray goatee and a laconic manner. Graham’s boss at NIAID, Dr. Anthony Fauci, said, “He understands vaccinology better than anybody I know.”

Graham are essentially puzzle solvers. When the actual pandemic struck, he solved one of the most consequential puzzles in modern science: He is the chief architect of the first Covid vaccines to be authorized for emergency use. Manufactured by Moderna and Pfizer, they differ only slightly in their delivery systems.

First, he and Cynthia had to complete residencies. They wanted to be in the same town, a problem many professional couples face, but additionally complicated in their case because Cynthia is Black. She suggested Nashville: he could apply to Vanderbilt Medical School and she to Meharry Medical College, a historically Black institution. Tennessee had only just repealed its ban on interracial marriages, more than a decade after the Supreme Court struck down miscegenation laws, but attitudes were slow to change. Driving back to Kansas on Christmas Eve, Graham stopped in at Vanderbilt. He asked for an application form and was surprised to find that the director of the residency program, Dr. Thomas Brittingham, was at his desk and willing to interview him right then. Afterwards, as Graham was leaving, he said to Brittingham, “I know this is the South. I’m going to marry a Black woman, and if that makes a difference, I can’t come here.” “Close the door,” said Brittingham. He turned out to be a closet integrationist and an ardent proponent of interracial marriage. He welcomed Graham on the spot. Cynthia was accepted at Meharry, and so they made a home in Nashville.

In 2000, NIH recruited Graham to evaluate vaccine candidates. He insisted on keeping a research lab. With space for two dozen scientists, his lab focused on creating vaccines for three categories of respiratory viruses: influenza, coronaviruses, and a highly contagious pathogen called respiratory syncytial virus (RSV), which ended up playing a key role in the development of a Covid vaccine.

Classically, vaccines are made from real viruses. One way is to weaken them to the point that they no longer cause illness but can still stir up an antibody response; that is how Louis Pasteur, one of the founding figures of microbiology, created a vaccine for cholera in chickens. Chemically inactivated viruses can fool the body into believing it is being infected; such vaccines have been used for encephalitis and rabies.

Fortunately, around 2013, what McLellan called a “resolution revolution” in cryogenic electron microscopy allowed scientists to visualize microbes down to angstrom level, one ten-billionth of a meter. Finally, vaccinologists could truly see what they were doing.

About two dozen virus families are known to infect humans, and the modified protein that Graham’s lab had developed to deal with RSV might be transferable to many of them. Then there was the question of how to deliver the vaccine. Graham knew that Moderna, a biotech startup in Cambridge, Massachusetts, had encoded a modified protein on strips of genetic material known as messenger RNA.

Graham had already proved the effectiveness of structure-based vaccine for RSV, and had applied similar approaches to MERS. He had arranged a demonstration project for Nipah, a particularly fatal virus that has no cure, using Moderna’s mRNA platform. He was about to prepare enough protein to take the Nipah vaccine through the first phase of human trials when he heard the news from Wuhan. Graham called McLellan, who was in a Park City, Utah, resort shop getting snowboard boots heat-molded to his feet. By then, Jason McLellan was a recognized star in the field of structural biology and had been recruited to the University of Texas at Austin and given a lab of his own, along with access to the latest cryogenic electron microscopes. It took someone who knew Graham well to detect the urgency in his voice. Graham said he suspected that China’s cases of atypical pneumonia were caused by a new coronavirus, and he was trying to obtain the genetic sequence. It was a chance to test their concept in a real-world situation. Would McLellan and his team like to get “back in the saddle” and create a vaccine? “Of course,” McLellan said. “We got the sequences Friday night, the tenth of January,” Graham recalled. “We woke up on the eleventh and started designing proteins.” Nine days later, the coronavirus officially arrived in America.

Graham and McLellan designed the modified proteins within a day after downloading the sequence for SARS-CoV-2. The key accelerating factor was that they already knew how to alter the spike proteins of other coronaviruses. On January 13, they turned their modified spike protein over to Moderna, for manufacturing. Six weeks later, Moderna began shipping vials of vaccine for clinical trials. Typically it takes months to years, if not decades, to go from formulating the vaccine to making a product ready to be tested, a process that privileges safety and cost over speed. The FDA required another twenty-four days to approve the product for trials, for a total of sixty-five days from inception to trials, “an all-time record,” said Graham. Graham had to make several crucial decisions while designing the vaccine, including where to start encoding the spike-protein sequence on the mRNA. Making bad choices could render the vaccine less effective—or worthless. He solicited the advice of his colleagues. They all said the final decisions were up to him—nobody had more experience in designing vaccines. Graham made his choices. Then, after Moderna had already begun the manufacturing process, the company sent back some preliminary data that made him fear he had botched the job. Graham had a panic attack. Cynthia was alarmed by his mood. “It was a crisis of conscience that I just never see in him,” she said. “He was beside himself.” His expertise and judgment had been called into question. ...

On January 27, Bowen wrote, “Rick, I think we’re in deep shit. The world.” There was an op-ed in USA Today that morning. “I remember how Trump sought to stoke fear and stigma during the 2014 Ebola epidemic,” Joe Biden wrote. “Trump’s demonstrated failures of judgment and his repeated rejection of science make him the worst possible person to lead our country through a global health challenge.” The former vice president cited Trump’s proposed cuts to NIH, CDC, and the Agency for International Development—“the very agencies we need to fight this outbreak and prevent future ones.” Trump had dismantled the White House team in charge of global health security. “And he has treated with utmost contempt institutions that facilitate international cooperation, thus undermining the global efforts that keep us safe from pandemics and biological attacks. “To be blunt, I am concerned that the Trump administration’s shortsighted policies have left us unprepared for a dangerous epidemic that will come sooner or later.”

Moreover, at least 14,000 passengers from China were arriving in the U.S. every day;

Transmission was so widespread that contact tracing was no longer possible, the doctor told him. People were getting sick and there was no way to know how and where the infection happened—a stage of contagion called community spread.

Pottinger asked, “Is this going to be as bad as SARS?” “Don’t think SARS, 2003. Think flu, 1918,” the doctor said. “SARS had 9,600 cases. Only one was ever shown to be asymptomatic. In China, 50 percent of the cases of this new disease are asymptomatic. And they spread.”

“Mr. President, I actually covered that,” he said, recounting his experience with SARS and what he was learning now from his sources—most shockingly, that more than half of the spread of the disease was by asymptomatic carriers. China had already curbed travel within the country, but every day thousands of people were traveling from China to the U.S.—half a million in January alone. “Should we shut down travel?” the president asked. “Yes,” Pottinger said unequivocally.

A two-week quarantine was imposed on travelers coming from the Wuhan region, but the U.S. did little to make sure incoming passengers actually isolated themselves—unlike Taiwan, Hong Kong, Australia, and New Zealand, which rigidly enforced quarantines. In each of those countries, the travel ban plus the mandatory quarantine helped get the contagion under control.

“Nonpharmaceutical Interventions Implemented by US Cities During the 1918–1919 Influenza Pandemic” was published in JAMA: The Journal of the American Medical Association in August 2007. “The Influenza pandemic of 1918–19 was the most deadly contagious calamity in human history,” the paper begins. “We found no example of a city that had a second peak of influenza while the first set of nonpharmaceutical interventions were still in effect.” When the measures were withdrawn, “death rates increased.” October 1918 remains the most mortal month in American history.

In 1918, scientists had a poor understanding of viruses, which were murderous phantoms too small to see. Although the curtain that concealed the viral world has been pulled open, the tools for curbing a novel pandemic haven’t changed. Nonpharmaceutical interventions—traditional public health measures—are still the only reliable way of slowing contagion until effective treatments or vaccines can be put into play. The only real difference in a hundred years is that face masks are more effective.

Whenever Markel was in Atlanta, he and Cetron would go to a Thai restaurant for dinner and talk over their study. One night they were working late at the hotel and ordered out. Finally, when dinner arrived, Markel opened his Styrofoam container. Inside, was a mass of noodles, which instead of a fluffy mound was a level, gelatinous mass. “Oh, look,” said Markel. “They’ve flattened the curve, just like we’re trying to do.” A slogan was born.

Matt Pottinger handed out a study of the 1918 flu pandemic to his colleagues in the White House, indicating the differing outcomes between the experiences of Philadelphia and St. Louis—a clear example of the importance of leadership, transparency, and following the best scientific counsel.

America would have three distinct opportunities to curb the Covid contagion before it got out of hand. The first was lost when the Chinese rejected U.S. offers to send a team of disease detectives to investigate the outbreak in Wuhan. Had CDC specialists been allowed to visit China in early January, Redfield believes, they would have learned exactly what the world was facing. The new disease was a coronavirus, and as such it was thought to be only modestly contagious, like its cousin the SARS virus. This assumption was wrong. The virus in Wuhan was far more infectious, and it spread in large part by asymptomatic transmission. “That whole idea that you were going to diagnose cases based on symptoms, isolate them, and contact-trace around them was not going to work,” Redfield told me. “You’re going to be missing 50 percent of the cases. We didn’t appreciate that until late February.” The testing fiasco marked the second failed opportunity America had to control the Covid contagion. At a Coronavirus Task Force meeting, Redfield announced that the CDC would send a limited number of test kits to five “sentinel cities.” Pottinger was stunned: five cities? Why not send them everywhere? He learned that the CDC makes tests, but not at scale. For that, you have to go to a company like Roche or Abbott—molecular-testing powerhouses which have the experience and capacity to manufacture millions of tests a month. The CDC, Matt realized, was “like a microbrewery—they’re not Anheuser-Busch.”

CDC scientists began working sixteen-hour days, trying to make the test kits as quickly as possible. For a diagnostic test to be properly validated, virus samples from an actual patient are required, but the Chinese refused to provide them. A human sample wasn’t available until the first reported case in Washington State, on January 21, and then it had to be isolated and propagated in a special lab, which took until February 12. By then, the German test had been distributed to seventy laboratories around the world.

On February 12, CDC officials estimated that it would take another week to remanufacture the third component, but six days later, Redfield told Secretary Azar that it might take until mid-March. By February 21, the test was failing in nearly every lab and the CDC admitted that it had no idea when the new test kits might be ready. More than a month had passed since the first known patient arrived in the U.S., and in that time the CDC had conducted fewer than 500 tests. South Korea, which had its first case one day before the U.S., had already tested 65,000 people. China was reportedly testing 1.6 million per week. The United States remained blind to the spread of the contagion, unable to fight what it couldn’t see.

Without the test kits, contact tracing was stymied; without contact tracing, there was no obstacle in the contagion’s path. America never had enough reliable tests, with results available within two days, distributed across the nation. By contrast, South Korea, thanks to universal health insurance and lessons learned from a 2015 outbreak of MERS, provided free, rapid testing and invested heavily in contact tracing, which was instrumental in shutting down chains of infection. By the end of 2020, the country would record some 50,000 cases in total; the U.S. was reporting more than four times that number every day. The first two chances to curb the spread had already been lost. The third would presently appear.

“It’s going to disappear,” President Trump promised. “One day, it’s like a miracle, it will disappear.”

Of the 175 attendees, about 100 would eventually test positive.