The Premonition: Book Review

The Premonition: A Pandemic Story (2021), Michael Lewis; another key book from a unique perspective by a fantastic writer. The book tells the pandemic story from the perspective of California public health official Charity Dean, Joe DeRisi, Richard Hatchett, Carter Mecher and others; a complicated story that’s takes the individual stories and then goes back and forward in time. It’s a fun read (especially if you like to get into some of the weeds of science), but difficult to see relationships develop. They do, but a scorecard is useful. The history of why the CDC does not function effectively has to wait to the end, for example. The CDC is response central and, apparently, doomed to fail.

The importance to MVG is the relationship to government, which proved to be a failure much of the time. Big problem is lack of funding of important government programs that remain obscure until something bad happens—plus politics. Funding deficiencies result in poor performance. The public has little of idea of what governments do; therefore, they lack interest and their opinions often based on media that has difficulty with complex stories, in part based on ideological biases. This helps the Republican cause (post-Reagan) that government is inept and the problem rather than the solution. There are also systemic problems with leadership, mainly related to politics. The case of the CDC is significant. The CDC head (an expert) took the fall for a rapid vaccine program that proved to be unnecessary. The CDC head was made a political appointee, not civil service. The result was decisions were dominated by politics, not science. Also, the CDC refused to lead crisis efforts—that was politically risky and therefore not done. The CDC became authoritative—after the fact.

In his last book, Lewis noted that the major role of the federal government was to deal with risk, with the 5th risk unknown. Trump abused the experts with the knowledge and skills to respond. Trump was lucky until the pandemic hit at the start of 2020. The planning and tools that were prepared before Trump were effectively gone, although experts were around (but doing other things). This was going to be bad, just how bad and why is the story told here. The US should have been in position to respond best in the world; the talent, labs and potential logistics were available—assuming competent leadership. Instead, they were badly handled or wasted entirely. The US did not even perform average. The bureaucracies were something of a black hole: why did the vital information and sometimes decisions get lost? Lewis attempts to answer part of this mystery, at least for California. “Our players aren’t the problem. But we are what our record says we are” (p. xv).

Part I.

Prologue. Laura Glass as a student developed a pandemic tracking program as a science fair project based on social networks. This tells how the disease moves through the community. “The model … showed that there was no difference between giving a person a vaccine and removing him or from the social network; in each case, a person lost the ability to infect others” (p. 9). It was an original contribution to the field, developed with her dad, Bob Glass. Why didn’t the epidemiologists figure it out? Apparent answer: they didn’t have to tools.

Chapter 1. Dragon. Charity Dean, MD, MPH, started as the chief health officer for Santa Barbara County. Here she became interested in infectious disease, beginning with tuberculosis and super-spreaders. There were other major issues, for which the health dept. was underfunded.

Chapter 2: The Making of a Public-Health Officer. “The illness you prevented, and the lives you saved, went unnoticed by the people sitting on top of society. That’s why her role was, every year, less well funded than the year before. … If I wanted to send a letter, I needed to fill out a form, and the form had to be approved.” (p. 32). Generally, most communicable disease came through public health clinics (people with no health insurance) and the public was not much interested. “The total absence of moral and practical support from the state and federal governments mystified her” (p. 33).

She noted that the CDC flees when conflict arose: “The CDC wasn’t pleased with her. The CDC kept saying ‘there is no evidence to back it up’” Bad stuff had to happen for evidence to accumulate. “They wanted to learn from this meningitis outbreak, and I wanted to stop it. … They wanted to observe it as if it were a scientific experiment. … The moment an infectious disease appeared, decisions cried out to be made. … When the shooting started, it leapt into the nearest hole, while others took fire” (p. 40-2). “The CDC strategy was politically shrewd. People were far less likely to blame a health officer for what she didn’t do than what she did. Sins of commission got you fired. Sins of omission you could get away with” (p. 42).

Chapter 3: The Pandemic Thinker. “The United States of America had a plan to fight a pandemic. The first draft had been written back in October 2005” (p. 50). Bush had read Barry’s The Great Influenza about the 1918 flu. A Biodefense Directorate was part of Homeland Security. HHS plans called for rapid vaccine development and stockpiling antiviral drugs. A new strategy called for early detecting of outbreaks, have vaccines ready, and prepare all levels of government.

Richard Hatchett, an emergency room doctor, turned into the emergency response guy. “The problem … was how to slow the spread of a communicable disease until you can produce a vaccine” (p. 58). This included social distancing. The policy guy from the VA was Carter Mecher, a critical care specialist. “The sin is making the same mistake twice. The best is to learn from other people’s mistakes” (p. 63). VA mistakes were reported to Congress: “where members of whichever party did not control the White House would set about blaming the president for mistreating veterans” (p. 64). About three patients die in hospitals for medical mistakes for every thousand admitted. The VA saw about 250,000 a day. Mecher tried to measure everything that might be measured on quality of care; he called it “Prime health.” In other words, his focus became systems. Problems mean bad systems. His solution was to make it difficult for bad things to happen, like using bar codes on medications. “The best way to guard against error is to design systems with layered and overlapping defenses” (p. 70). Also focus on “almost mistakes,” near misses, including incident reports.

“Richard [Hatchett] was a natural writer, but there was no place in the process for a natural writer” (p. 76). There was a government style manual and a multitude of critiques. Step one was provide guidance on options for infection control and containment.

Chapter 4: Stopping the Unstoppable. Carter and Richard worked on using models, including the Linda Glass model. The Glass model idea of preventing the disease from spreading within the populous was new. The Glass model showed the impact of different scenarios (“isolating the ill, quarantining entire households when they had a sick person in them; socially distancing adults; giving people antiviral drugs” p. 86). Closing schools and social distancing kids stopped flu-like disease. Bob Glass moonlighted “at the White House with her science fair project” (p. 89).

It turns out that the majority of state and local government employees were in education, with more than 100,000 K-12 schools and 50 million kids. About half rode the bus to school. Lisa Koonin worked for the CDC. Richard Hatchett called her up and she basically moonlighted with the White House. Carter reanalyzed the 1918 flu. Barry’s book suggested that restrictions on social life didn’t work. His more detailed analysis showed they did; earlier restrictions meant fewer deaths. A key point: the pandemic was an exponential process. “It had taken Lisa, Richard, and Carter some time to see that they were in a war of competing narratives. … Carter ceased his appeal to reason and began to appeal to emotion … he stopped making an argument and began to tell a story” (p. 105). “So it’s only poor kids who need school lunch who should risk illness and death to go to school. Why don’t we just find another way to feed them so they can stay home too? (p. 107).

Chapter 5: Clairvoyance. There was a swine flu epidemic that was not handled well, but not catastrophic: “The entire epidemic has been characterized by nothing so much as ambiguity. … The CDC sent the message that each American school should make its own decision. … CDC felt we ‘didn’t have enough data.’ It was an argument about the precautionary principle v, the scientist’s desire not to make a mistake, coupled with risk aversion. … Richard and Carter had trouble getting good information from the CDC. … The CDC seemed intent on preserving their privileged view of the outbreaks” (p. 118-9). Government seemed unable to do things quickly.

The CDC’s “people were good at figuring out precisely what had happened, but by the time they’d done it, the fighting was over. They had no interest in or aptitude for the sort of clairvoyance that was needed at the start of a pandemic” (p. 126).

In California, new governor Gavin Newson hired Sonia Angell to the state’s health agency, after Charity Dean had basically run the office for four months. According to Dean: “The US doesn’t really have a public-health system. It has 5,000 dots, and each one of those dots serves at the will of an elected official” (p. 131). Once again, common in government.

Part II

Chapter 6: The Red Phone. On Joe DeRisi: “It’s a mind that is interested in everything and afraid of nothing. It’s a bandwidth that is hard for most people to fathom” (p. 137). DeRisi’s UCSF lab quickly identified a coronavirus in 2003 causing an epidemic in China, later to be called SARS by the WHO. Those infected were isolated and the epidemic stopped.

“You need a lot of virus before you can see it … Virus extracted from some infected human is seldom sufficient, and so virologists usually need to take whatever they find and then grow more. … Only after you have it can you form a hypothesis about what the virus might be. Your hypothesis needs to be tested” (p. 140). DeRisi’s lab created a new chip (Virochip) to remove the prediction part. Genetic sequences were stored in Gen Bank, part of NIH. In DeRisi’s lab “genetic matter from any unidentified virus would bind to any identical genetic matter belonging to a known virus” (p. 141). New viruses were similar to existing viruses (all evolved from a common ancestor and are genetically related) and required further analysis, to be evaluated by genetic material. (Additional information on DeRisi’s new process is explained in the book.)

Over time: “the virus hunter’s arsenal had expanded. Big, fast genomic sequencing machines had come onto the market to do what the Virochip had done” (p. 147). The machine figured it out. DeRisi studies starting with snakes discovered the ancestor of the Ebola virus, which also had been in dinosaurs. Koch’s postulates: “The only way to prove that a virus causes a disease is to isolate the virus and inject into a healthy animal” (148). “Soon [Michael] Wilson realized that the DeRisi Lab was to science what Willy Wonka’s Chocolate Factory was to candy” (p. 152). “If you happened to be dying of an unknown brain disease, your chances of survival rose if you had no more than two degrees of separation from either Michael Wilson or Joe DeRisi. ‘Joe called it Michael Wilson’s Friends and Family Plan” (p. 153).

Later, DeRisi also ran the Chan Zuckerberg Biohub, dedicated: “to eliminate all disease on earth by the end of the 21st century” (p. 157). Biohub partnered with the Gates Foundation for infectious-disease information. China did not participate.

The Bush White House set up a program called Predict to test animals for viruses that could jump to people; of course, eliminated by Trump, plus most other pandemic prevention.

Chapter 7: The Redneck Epidemiologist. Carter went back to work for the VA, first trying to answer complaints of long wait lines: doctor shortage or inefficient practices? Key point is how government agency allocates resources. A 100 billion annually for VA. It was more of a systemic problem on increasing funding. Carter’s informal calculations: “academically laughable and fantastically insightful” (p. 166). Carter considered the Covid pandemic closely related to SARS. Cases appeared in the US in January 2020.

Chapter 8. In Mann Gulch. Charity Dean became the number two public health officer for California in 2018. She was tasked with helping to stop a health crisis due to border crossings. She had problems with other officials.

Chapter 9: The L6. “The CDC reminded Charity of a person who allows a false but flattering story about himself to circulate. What he cared about, suddenly, was this rogue group of patriots who were working behind the scenes to save the country. ‘When I met Carter, it was a game changer. I was no longer a crazy person’” (p. 218-9). Papers by Carter and Richard on the 1918 flu and Bob Glass’ model, evidence was available on social intervention. Dean worked with the 58 local health officers. Because of CDC problems, she tried to get them to create their own Covid tests: “I was basically encouraging them to go rogue, because the state’s chief health officer is team CDC” (p. 220). She believed in containment (banning mass gatherings, school closings), not mitigation—that was months away. “By then, Zimbabwe could test but California could not, because of the CDC” (p. 223).

Trump said every state was on its own; ditto Newsom on California counties. This included equipment like ventilators and respirators: the states were on their own. Trump then blasted governors that complained about his lack of leadership. Trump would say supplies were on the way, then they didn’t arrive. “The absence of federal leadership had triggered a wild free-for-all in the market for pandemic supplies. In this market, Americans vied with Americans for stuff made mainly by the Chinese” (p. 252).

Part III

Chapter 10: The Bug in the System. “The absence of federal leadership, combined with the fragmented nature of the American health care system, meant that tests for the virus either weren’t available or were being processed too slowly to be of any use. … Without fast tests, you could not isolate the people who needed to be isolated, or liberate the people who didn’t” (p. 242-3). Newsom allowed non-certified labs to test; that included Biohub, which was soon assisted by hundreds of volunteers, mostly from UCSF. They would do it quick and for free. The commercial labs were slow and charged up to $160 a test. Getting supplies was problematic. Large company suppliers focused on profit, although many small companies (e.g., New England Biolabs) gave discounts to help actually save people. Lack of test kits proved to be a problem. Biohub opened testing, despite the problems, in eight days (on March 18).

The amazing part is lack of response for testing. Private hospitals wanted to make money and set up their own labs or contracted with for-profit labs. “Standing between the cure and the patient, in this case, was a US medical-industrial complex that lurched between lethargy and avarice” (p. 248). The public health centers also did not use them much for various unusual reasons. Some did not know how to do “no-cost” in their systems. “Many local health offices were so understaffed and underequipped that they had trouble using the test kits. Most were unable to receive the results electronically; they needed the results faxed to them. … Biohub got into the business of buying and delivering fax machines along with test kits” (p. 253). “Only a tiny handful of local public-health offices had the interest in or the ability to exploit the most powerful tool the Chan Zuckerberg Biohub was trying to give them for free. …They didn’t know how to ask for things” (p. 261). One member of the public-health volunteers was from Poland, and the situation reminded him “of the total breakdown of the government’s ability to be useful to its citizens. … These are the symptoms of a failed state” (p. 255).

When Biohub did testing in a limited geographic area, they discovered the richer the people, the lower the infection rate; especially true for white people.

Chapter 11: Plastic Flowers. As a student, Charity planted flowers on her balcony and was praised for them. She didn’t have time to care for them and they slowly died. She replaced them with artificial flowers and maintained the lie of great flowers. She used that as a metaphor for losing quality and lying to maintain a reputation.

“Inside California state government, inside even the Trump administration, there was some logic to everything that happened. … An innocent outsider who turned up and looked at what they had done could be utterly baffled” (p. 270). Paul Markovich, CEO of Blue Shield of California noted that the state ranked last in the rate of testing. Of course, Charity was supposed to solve the problem. Testing went up, relying on local testing labs and a private sector that stepped up. The state’s computer systems were so out of date, Markovich offered to replace them for free (an offer they didn’t take him up on). He did pay for buy some supplies, noting the bizarre personnel management system. He also wondered where the head health officer (Sonia Angell) was: “This is the biggest public-health crisis ever, and she’s nowhere to be found” (p. 272).

“You can’t fire the state health officer in the middle of a pandemic one high-level state official explained to Charity” (p. 274). It meant Charity had no legal authority. She developed a system through Biohub to provide the information on transmissions across the state free. “[Charity’s planned system] went into the bureaucracy and never came out” (p. 277). The state bureaucracy did not intervene. “There was something deeply dysfunctional about how the government worked that I never fully grasped. … The CDC—well, the CDC was its own mystery” (p. 278). Why doesn’t the United States have the institutions it needs to save itself?” (p. 279).

Charity: “The greatest trick the CDC ever pulled was convincing the world containment wasn’t possible. Our dignity was lost in not even trying to contain it” (p. 274). Add the falsehoods, story-telling and optics. “It sucked in data from others and seldom shared its own, except in the form of academic papers that brought glory to its authors” (p. 278).

Former CDC Director Bill Foege wrote to the incumbent director Robert Redfield: This will go down as a colossal failure of the public health system of this country. … The public health texts of the future will use this as a lesson on how not to handle in infectious disease pandemic” (p. 280). Problem included lies posted on the CDC website, public guidance that ignored science, silence. Foege suggested Redfield apologize for the failures and correct them.

Lewis tells the CDC story. In 1976 swine flu hit and the CDC decision was made to quickly produce a vaccine to vaccinate most Americans (mask wearing and social distancing were not considered effective). The vaccine program had problems but 43 million people were vaccinated. Some54 people got Guillain-Barre syndrome, blamed on the vaccine. Then the pandemic never came. After the fact, it seemed an inept decision. The CDC administrator took responsibility and was fired. So much for the respect for the CDC. The position was made a political appointment by Reagan—the new CDC director was an ideological “soulmate” to Reagan and his agenda. The White House meddled in the science and the structure changed to politics. The lesson was not to take chances, react after the fact and issue reports. Defer to the White House. Leading public health responses was done. Just about all agencies were run by political appointees of the president.

“The need to make hard decisions in public health didn’t just go away. It got pushed down in the system, onto local health officers. They had little social status and were highly vulnerable” (p. 291). Also underfunded. Early on was the absence of a strategy to fight the virus, except vaccinations. The US became one of the “bad examples” for the rest of the world.

Epilogue. Charity created a private company, the Public Health Company: “I’m going to create a data-based tool for disease prevention that companies can use to secure their supply chains” (p. 299). Money is available for private firms, plus she had a great reputation and backing by Biohub, DeRisi, and Carter among others.

Quotes I liked: “All science is modeling. In all science you are abstracting from nature. The question is: is it a useful abstraction. Useful, to Bob Glass, meant does it help solve a problem? (p. 5).

“Inside the US government were all these little boxes. The boxes had been created to address specific problems as they arose. … 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 … with little ability to adapt and little interest in whatever might be going on inside the other boxes” (p. 78).

“Experience is making the same mistake over and over again, only with greater confidence” (p. 124).

“After the fact, scientific progress was often described as a cool, antiseptic affair. … People who looked at stuff without any preconception of what they might find were the ones who saw the things that no one had seen before. … Science was just curiosity’s tool. Progress often began when someone saw something they hadn’t expected to see” (p. 146).

DeRisi’s: “Last mile problem in medical science. Corporations were interested only in stuff that made money. Academics were interested in anything worthy of publication, but once they had their paper done, they tended to lose interest” (156). [As a former academic, I agree. When we discovered something important to the profession, we published. There was no incentive or good mechanism to get the word out to the professionals.]

“Some companies sought to exploit the moment; others sought to help. … Some companies actually have a moral compass and some of them don’t” (p. 246).

“Government—and the value government provides—isn’t just the whim of whoever happens to be elected at the moment. That government provides continuity across administrations and should be the repository of accumulated institutional experience and wisdom” (p. 293).