Michael Lewis, one of the best writers of creative non-fiction since John McPhee invented the genre has followed his eye-opening The Fifth Risk with the eyeball-popping The PremonitionThe Fifth Risk, by excavating Trump’s malignant hollowing out of government institutions, showed the hidden, vital ways in which government departments and their many dedicated public servants, protect our health and safety. The Premonition is a look at how federal and state public health departments failed us, colossally, during the Covid pandemic.  This time, the heroes were similarly dedicated, experienced public servants, but not, at first with a portfolio in government.  The book relates their initial experience together in the George W. Bush White House, their dissolution in the Obama administration and how, as the Covid pandemic grew during Trump’s third year, they were able to coalesce, share knowledge, and invent and advocate for the response that eventually took hold. 

What The Premonition is about, Lewis says in the preface, is the unfortunate answer to the question which The Fifth Risk had asked about the Trump administration:

“What happens when the people in charge of managing [the] risk, along with the experts who understand them, have no interest in them?

The Trump administration’s response wasn’t, however,  the only problem. As the Covid virus made its way into the consciousness  and the bodies of people around the world Lewis discovered that Trump was, as one source said, “only a comorbidity.”  Below the inept, and even malicious, response were deep structural flaws in the U.S. public health system; chiefly, that there was no such thing.  Despite the enormous wealth of the United States, the high degree of medical research and professional expertise, the high regard of medical people around the world for the CDC (Centers for Disease Control), the public health system was more virtual than real.  What passed for one, was in fact, as Charity Dean pointed out, 5,000 dots on a map representing state or local health officials, all beholden for their jobs to elected (pressure vulnerable) officials, looking to the CDC for authoritative guidance. 

Though the CDC  had once been able to offer best available knowledge and recommendations, it had been hollowed from the time of President Jimmy Carter, and especially under President Ronald Reagan.  The leadership, instead of being the top talent, as determined by peer consensus, was now an entirely political creature – serving at the President’s pleasure. As with local officials, this made the CDC risk-averse. As one of Lewis’ informants said, it should be the Center for Observation and Study of diseases, not for Disease Control. 

“The CDC did many things,” writes Lewis. “It published learned papers on health crises, after the fact. It managed, very carefully, public perception of itself. But when the shooting started, it leaps into the nearest hole, while others took fire.”

“…we have allowed that institution, to drift over the course of a couple of generations from a really well run, proud institution filled with public servants and run by public servants to one that’s managed at the top by political appointees who are there for very short periods of time and are on a very short leash from the political process.

As Lewis puts it in his always handy sports analogies, the U.S. had long been been rated like the Texas Longhorn football team, at the top of everyone’s rankings. It was thought to be ideally situated to knock back any possible pandemic, to “win.”  By the time the book was published, the U.S. was not even in the top ten.  Even with some excellent players, whom he describes at length in the book, without leadership and solid organization, the team lost big-time: hundreds of thousands of human lives. 

Instead of collecting the best data, following best practices and issuing timely recommendations, the CDC, and the President, explicitly, left it to the states to figure out. The states in turn, not much more set up for command and control than the CDC,  left much in the hands of county health officials – most of whom, as Dean found out, were unaware of their own legal powers.  The results of such a “let the markets decide” approach were, as predicted, chaotic.  Remember the bidding wars for masks, swabs and even ventilators?

Ω

Lewis tells his story, as he always does, through relevant biographical bits of the characters lives, how certain experiences, or studies, or interests unexpectedly prepared them for major roles in unanticipated ways; not only what each one knows, but how they have come to know — how have they learned to assemble new knowledge as it arrives, especially under conditions of urgency. 

The group that constituted itself via e-mail and phone in January 2020 as puzzling events in China began to be noticed, were a re-constitution of several who had been pulled together in the White House during the Bush administration.  Alert to national calamities after September 11, 2001 and Hurricane Katrina, Bush was further motivated by reading read John Barry’s The Greatest Influenza : The Story of the Deadliest Pandemic in History.  In 2005 he appointed Rajeev Venkayya, a doctor at Homeland Security to set up a task-force. Carter Mecher from the Department of Veterans Affairs and Richard Hatchett from Health and Human Services were brought in and then Lisa Koonin, a registered nurse at the CDC in Atlanta.  Bob Glass from Sandia National labs also came on board. He had been trying to get attention at the White House for computer models he had developed predicting the speed and direction of contagious spread, under varieties of circumstances.  It was work that had begun by helping his eighth grade daughter, Laura, who had posited the idea of contagion spread by social networks, not simply random one-to-one transmission, for a school science fair. The group was given the moniker of The Wolverines, which stuck with them as they reassembled in late 2019. 

Their work initially was to figure out, when the silver bullet of a vaccine was not yet available, and a contagion event was fast and deadly, what can be done? From reading accounts of the 1918 Flue pandemic they  came up with the idea of “social distancing.”  It was to be, however, only one layer of a  “Swiss cheese” model of correcting for human error, an idea which Carter had picked up from James Reason in his book Human Error. Since human reasoning has gaps, or holes, like a slice of Swiss cheese, the way to compensate is to put various slices on top on one another so that eventually, all the holes are covered.  Social distancing was one of several “layers” to slow the spread of disease, hand washing another, wearing masks another, working from home, closing the schools.  Another name Melcher came up with was TLC – Targeted Layered Containment. 

By 2006, the team had convinced CDC staffers and public health officials from around the country that TLC was the best option in case of a deadly, fast-spreading pandemic, even if it meant keeping millions of schoolchildren at home. A Pandemic Plan was drafted and was part of the Homeland Security portfolio.  When, in the Obama administration, a worrisome strain of Swine flue, fell far short of its feared growth, the plan was relegated to another cubicle in another department.  Carter Melcher was the only team member who stayed; the rest returned to their old, or began new, lives.

When news of a unknown, virulent strain of flu began to surface in December of 2019, e-mails and phones began beeping and ringing at all hours.  The Bush/Venkayya team found each other and began reaching out across the country.

One of their most remarkable finds was Charity Dean. She had come from an extremely poor rural Oregon family and had moved into a position as the lead public health official for Santa Barbara County.  When she became the Deputy Director at the California Department of Public Health in 2018, she was already alert to the dangers of contagion and lack of preparedness.  In December of 2019, scanning Chinese web-sites and blogs, as were, unknown to her, Mecher and Hatchett on the East Coast, she sounded one of the earliest warnings of the coming pandemic.  It was she who persuaded Governor Gavin Newsom to issue the first state Covid lockdown. 

Though Newsome’s order, and government prescience look good in hindsight, what was really going on is an interesting, and sobering, story in itself.  Dean was not the Director of California Public Health, she was the Deputy Director.  At one point, her boss Sonia Angell banned her from using the word ‘pandemic’ and from sharing her whiteboarded data narratives of the pandemic’s trajectory.

“She told me I was scaring people,” said Dean. “I said ‘Shit, they should be scared.’”

She was excluded from email conversations and meetings related to California’s response. She was concerned enough, however,  that she kept her findings, data she had collected, mathematical projections, e-mails, and her own analysis,  along with other supporting documents and appeared at meetings uninvited.  Her large binder of data made an impressively loud thud when she dropped it on the conference table.  By the time the Wolverine network  reached out to her, she was ready.  And they reached, it turned out, with intention.  While the Trump administration was actively torpedoing efforts to deal with the growing pandemic, the Wolverines knew that a big example of the Swiss Cheese defense was necessary.  Her knowledge, articulateness, fearlessness and energy, and her position in the health department of the biggest state made her indispensable.

Joe DiRisi, a gene expression expert at UCSF (University of California at San Francisco), and a MacArthur “Genius” with multiple other hats, was another addition.  He came in to build, in a matter of weeks, a fast turn-around Covid detection system, lessening the time from test to results, from days to hours.

Ω

What Lewis saw in these people were two things, their “premonition,” and their courage.   

“I came to appreciate the power of intuition. And it isn’t just random intuition, it’s trained intuition. You have to be able to look around the corner. You have to be able to see a little further that it’s, than is really visible.”

But not only to see. The courage to act on what is seen, to follow the data, in the face of disinterest or outright opposition, is also necessary.

In an email to the Wolverines, Mecher vented his frustrations about the Department of Veterans Affairs and CDC:

“I am still having issues in VA with leaders avoiding the use of the term pandemic and then not wanting to implement key portions of the VA pandemic plan because this is not a pandemic,” he wrote. “They will not say or use that word … They expect to see the term pandemic used by CDC and WHO. CDC continues to say this is not a pandemic. … I know this is not CDC’s intent but it is creating problems for bureaucrats who suffer from malignant obedience.”

As Lewis tells it, 

“A system was groping toward a solution, but the solution required someone to be brave, and the system didn’t reward bravery. It was stuck in an infinite loop of first realizing that it was in need of courage and then remembering that courage didn’t pay. Charity (Dean) didn’t think of it this way, but it was striking how often the system returned to her and very nearly sought her leadership, without ever formally acknowledging its need.

“In the pandemic, you saw this. Charity would tell you — and I think it’s true — that the pandemic has created a kind of selective pressure on our public health officers,” Lewis says. “And it’s removed the brave ones. The brave ones have all got their heads chopped off. So it’s sort of institutionalized a cowardice that we’re going to need to face up to so that this business of punishing people who are doing their damnedest to try to save us from ourselves has got to stop.”

 

My take aways :

  • These people should all receive the Presidential Medal of Freedom.
  • Congress should take away Presidential Appointment power for the CDC, and likely a host of other heath, safety and emergency responders of the government; let experts choose their best to lead
  • Public health is a matter of national, even international concern. Decisions cannot be left to the voluntary actions of the uninformed. 
  • Pandemic plans, like hurricane and tornado plans, should be part of all local responders tool-kits, practiced and brought to community notice on a regular basis.  Given globalization and the near instantaneous transmission of microbial dangers, pandemic days at school may replace snow days.
  • We must re-educate ourselves about Courage.  It is not just the quick Courage of extremity that should be celebrated, but the slow Courage of using analysis, experience and data and then standing, if we must, against the purveyors of received wisdom threatening to expel us from their company.