The Premonition by Michael Lewis is one of the most interesting books I have read in awhile. It is provides a focussed look at the Covid pandemic as it was evaluated and studied by people who took the threat seriously and whom had a variety of relevant talents and skills. Being a doctor, I enjoyed the perspectives I read and of course, some medical points of view came to mind.
I attended UCLA’s School of Medicine between 1974 and 1978. In my Sophomore year, we had courses presented, methodically working through infectious diseases and the topic of the 1918 worldwide influenza pandemic was presented. It stood out, next to smallpox (which would be eradicated from the world’s environment shortly after I graduated) and was, with the last two centuries in mind, the most damaging infectious event in modern history as measured by death rates and economic dislocation. The lecturer looked at us seriously, “You will live to see a pandemic like this in your lifetimes.” That message was received; a few years ago, I read the book The Great Influenza by John M Barry. It reinforced what that distant lecturer had said.
George W Bush, to his credit, read the same book after 9/11; he asked that a plan be established for this eventual event. The plan that was developed and read in effect, “suck it up until we can make a vaccine and vaccinate our way out of it.” He did not regard that response as adequate, and asked that a better plan be developed. One was—-but the elements were never put together at the federal level for action—as the book details, not only was the Covid experience one for the States to manage, but within each state, by each public health officer, county by county. It has been anarchy as seen through the lens of a national view.
One conclusion of the book is that the Public Health learnings from the generation of my grandparents and great grandparents were regarded by most as irrelevant in our modern time. There was nothing to learn there. There was no tech to rely on; there was nothing elegant about those lessons. Those lessons were important when they were all you had to protect your family from a pretty lethal disease, but here, that stark choice seemed just a bit overplayed. These measures seemed as clumsy as a stone knife for performing circumcisions……The practical information to be gleaned after all that death was lost but to a few people tasked to use it in developing a plan that was never rolled out. The “why” is not about President Trump—-though anyone planning to fight a public health epidemic never took into consideration sabotage from the leader of the country—and this happened in other countries as well—-but rather it is about all of us individually as well as how our thinking and behavior rolls up into business and government.
As I read the book, the words, “Failed State” kept coming into my mind; Lewis uses the expression about two thirds into the reading. A Polish contributor makes the point that as the communist state in Poland collapsed, he saw dysfunction that was very reminiscent of this country’s response to Covid. Lewis’introduction sets this up: In the Fall of 2019, there was an international conference working on the general theme of planning for epidemics and they rated countries, sort of a powerhouse ratings system before the football season, and the USA was ranked #1 in preparedness with Great Britain in second place. By the time the book was written a year and a half later, the USA, with only 4% of the world’s population, would have 20 % of the world’s covid deaths attributed to it. Even if that is off by 50%, it is an astounding problem to confront.
Points brought out along the line of “Failed State.”
The CDC (Centers for Disease Control). I have historically been a great fan; my introduction to the CDC was as a young doctor in the early 1980’s worrying about AIDS. The CDC was invaluable presenting updates and advice regarding AIDS. One of the smartest of my UCLA classmates worked there. The fumbles observed during Covid were easily attributed to president Trump’s management style. This book sends a clear message: the CDC is incredibly dysfunctional and has been for awhile. Gay advocates in the time of the early AIDS epidemic made the same point. Here are some examples from our current setting:
He introduces Charity Dean, the Public Health Officer for Santa Barbara County prior to Covid. She requests advice from the CDC twice for public health outbreaks in her county. One involved a well connected (with business and local political leaders) elderly doctor who was not using sterile technique in his practice and who likely was the cause for a woman acquiring hepatitis C. After examining his office and practices within it, she closed his practice. The CDC phone consultant was astounded: “You shut him down on just the suspicion?” The consultants tied to the phone disagreed that she had the authority to do this (they were wrong) and they would not close a doctor’s office down until they had proof that they could publish in a peer reviewed article in the appropriate journal. Her conclusion? They were more interested in the science than in saving people from actually acquiring illness. The second case related to an outbreak of meningitis in a UCSB student. This is a disease than can spread rapidly through a college environment and does significant damage. She did her homework testing for it in the community and sorted out that the majority of positive tests were found in those who lived in the “Greek system.” She got them to agree to some social isolation while taking prophylactic antibiotics and no further cases were seen. The CDC consultants thought that again, she overstepped as she had no proof this would work. They were clear that they disagreed with her steps and would not support her if she were confronted on the measures she took. They had no alternative plan and as the years passed, she learned that the CDC did refer other public health officers with similar outbreaks to her directly ie they did not advise…….
She would be included in a group trying to develop plans and consult with the CDC, this time trying to prepare a California State response, and the bureaucracy of the CDC led to her no longer collaborating with or depending on them at all. Her stance was after the CDC guidelines strictly forbade the testing for Covid in people without symptoms and who had not been connected in some fashion to travel from China early in the epidemic. People repatriated from cruise ships that had had outbreaks were quarantined but not tested and no follow-up was possible because no one recorded addresses! When asked why testing could not be done, the CDC answer was that in quarantine, they were essentially prisoners and one cannot do testing like that—-even though those quarantined often wanted to be tested. In addition, a Cruise liner docked in Japan with a shipload of quarantined people (2/3 of whom fit the demographics of elderly residential home patients and 1/3 young healthy crew) were tested extensively and preliminary results showed the disease was very infectious, that people were infectious when without symptoms, and a mortality rate of roughly 1%. She with others would expand on those numbers as cases showed up in the USA (so one person with no travel connection to China in the ICU with Covid in Davis in March 2020 meant at least 100-200 other people in the community were likely infected and not identified). As with her previous practical cases, the CDC was interested in studying the disease and not taking even basic definitive steps to understand or control Covid as it expanded exponentially. Her (and others’) frustration was the reluctance to test broadly to seek out the extent of the spread prior to hospitals being overrun.
The CDC would give confounding bits of advice that whatever your stance on risk or importance, were easy to point out. Adults should not gather in groups larger than 50 for over an hour? What about kids mixing in school for eight hours? What about transportation systems where on a given day, the largest group in the nation were school kids in school buses—without social distancing or masks?
And of course, the testing kit fiasco brought out once more, the concept of “failed state.” Other countries were vigorously seeking out information on where the virus was and how fast it spread, not to mention evolving strains, and our country remained stubbornly blind and acted collectively like a dinosaur whose forebrain was gone but whose second brain (in the tail ) allowed for thrashing of the giant tail, this way and that. We did not have test kits. When we had them, we used them conservatively.
2) Following the presidential lead on epidemics is fascinating. Poor Gerald Ford! He led the way with a very supportable action and a very dismal outcome. Soldiers died of a form of influenza at Fort Dix; the virologist suggested this strain had the same lethality potentially, as the 1918 strain. Only a few people had been infected but the source was unclear. Ford faced a decision none of us would like: spend millions on a vaccination program and sell it to citizens or assume this problem would take care of itself. If the plague came, and the no action had been taken, he would be blamed. If it did not come, he would be blamed for being an alarmist who wasted our tax money. He made the difficult decision with the support of the CDC lead. The money was spent. People got vaccinated. The flu epidemic did not come. Some of people got Guillain Barre, a neurological condition from the vaccine. Government attempts to protect the population caused harm to a few citizens and the trust in the government, already evaporating, took a big hit.
Ronald Reagan was famous in infectious disease circles for both his not being, “a science major” as well as being callous as his administration looked upon the AIDS epidemic with seeming indifference. More importantly, under his administration, the head of the CDC stopped being a Civil Servant who worked through the ranks and was promoted, in part, for merit, and became a presidential appointee.
President Bush as I noted, decided to develop a plan for possible large epidemics.The focus was in part related to fears of bioterrorism post 9/11 but natural disease was clearly on the table for a response. Subsequent administrations would lose that focus.
President Obama was also confronted with a serious epidemic threat. A new influenza virus in Mexico with what initially looked like a 10% mortality caught the attention of his administration’s CDC. Only a few cases were found in the US. He had a plan laid before him that outlined social distancing measures as a vaccine program ramped up. He decided not to pull that trigger. The Mexican government did ie they closed schools in the affected communities and socially distanced —-and the epidemic disappeared. Obama dodged a bullet.
3) For a historical romantic like myself, there are critical people. Charity Dean is featured in this book over and over —as my kind of doctor, actually seeing patients while holding an administrative position and making logical hard decisions even without an overwhelming case given that lives were at risk. She worked within a system that failed all of us over and over and persisted—-at significant personal/professional risk. We are all better for the Charity Deans in our lives. Google her! You will see how she managed the next steps in her career.
Bob Glass — he with others drafted the original “Bush” epidemic response which included much of what has been so controversial with Covid: closing schools, limiting social and business contacts, and so on. Critical to that working well, is an early intervention, ie lots of resources on a process—like a forest fire—before it expands exponentially.
Joe DiRiss— a biochemist and not a virologist— worked at UCSF and used new technologies to identify microbial causes of disease. In 2003, he read of the WHO concern regarding new flu-like illness in China that had a mortality rate much higher than flu. The lead doctor investigating the outbreak from the WHO had died of the disease. He wrote the CDC which was trying to discover the nature of the illness and was sent tissue. Within twenty-four hours, he had identified the causative agent as a Coronavirus. This was the first time coronaviruses had been shown to cause serious illness in humans. This illness would eventually be labeled SARS (Severe acute respiratory syndrome). His technology was a game changer. He would eventually become lead of an NGO group dedicated to eliminating disease on earth—and worked with money donated by the founder of Facebook and a Pediatrician: the Chan Zuckerberg Biohub and as the Federal Government and WHO were not interested, joined by the Gates Foundation. Their goal was to have sensing stations for infections. As the Chinese would not participate, there was a plan to ring China with these stations.. He was traveling to Cambodia through China in January of 2020 and found himself in an airport in Guangdong which was transformed—there were security people wearing masks. Passengers were being screened for fever. As he was screened, he knew: “These people know something we don’t…….”
Richard Hatchett and Carter Mecher: these two collaborated with others behind the scenes as civil servants within the Trump Administration tried to understand the spreading disease in opposition to the stated plans of the CDC. Meetings at the White House made it clear that there was a fundamental lack of knowledge about what was happening and what likely would happen with a spreading respiratory virus. This group would eventually include Charity Dean. Many of their predictions came true; they held out hope that with their guidance, China could be the Philadelphia of the 1918 Flu epidemic, and the USA could be the St Louis (which instituted earlier interventions and decreased the death rate by 50% in 1918) but that did not happen despite the development of a vaccine in record time. And the reason? Before a vaccine is in play, the only tools were those learned in 1918 which no one wanted to contemplate—not the Federal Government, not State Governments, and in fact, not by local governments, no matter what case was presented. In talking to Public Health Officers in California, Dean would make it clear: “Don’t wait for help. Help is not coming. Use your best judgement and your authority.”
Failed State!
The book shares a metaphor for this group identifying a William Manchester’s biography of Winston Churchill: Alone. It details his life in the 1930’s when he railed against his government’s policy and his fellow citizen’s attitudes toward fascists regimes on the continent. He predicted the war and war came finding Great Britain unprepared and paying a high cost for that lack of preparation.
Another metaphor was the Mann Gulch fire in Montana. This story was used in my experience, at executive training talks to identify the need to train well, make good plans, and innovate when disaster hits. The other part of this metaphor is the exponential rate of spread a forest fire has in the early phase—in this case, killing all but one fast-thinking fire fighter caught within it. A forest fire on a dry summer day is exactly what our targeted maps of Covid cases in the US reflect even now, when everyone eligible in the US has had access to a life saving vaccine.
It is easy to point the finger at President Trump regarding the Covid epidemic’s course in the United States. I do think we citizens have to accept our role in this as well. Collectively, we could not agree and we elected people who could not prioritize even when the problem was clear to people who study and understand disease. I do not refer to the CDC in this case. My personal experience finds my metaphor for the difficulty this disease conferred on us. I had many patients with diabetes or vascular disease who had gangrene of a leg and were going to die (slowly and painfully ) if they did not consent to an amputation. It was beyond most people to make that decision until they were nearly dead or until a relative over-rode their inability to decide. I have come to think of this as natural and very human. It takes a functional, thoughtful, informed, and determined person to hear the information in this setting and not equivocate. If there is a reason to live on, one can do it without a leg. As a society, we do not have these qualities.
Lastly: an alternative history—President Trump hears the problem and has the necessary consultants giving him the advice of the scientists and doctors in this book. He goes on TV:
“ My first priority has always been business. If the economy does well, we all do well—I—We—have been successful with my administration’s pro-business outlook and the economy is successful—it’s beautiful. Am I right? My consultants have reviewed the potential harm this virus can do to our society—people will die and businesses will be set back—potentially for years. As a businessman, I understand the power of exponential growth and this virus will grow exponentially if we don’t stop it and stop it now. As your president, I think that to succeed we have to accept some loss up front, but if we stick with it until Warp Speed delivers on its promise, we can minimize the loss ie take something horrible and convert it to something bad —but manageable. Please follow guidelines to change your way of doing business. I will be signing executive orders to help control this epidemic. We are going to shut down schools and ask people to minimize face to face contact. In six months to a year, we will be much better off than if we keep putting off the measures we need prior to achieving a 90% vaccination rate.”
I believe that if President Trump had said something to this effect, and if he had actually acted on it, he would still be president. Think about that!
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