Michael Lewis The Premonition: A Pandemic Story is another cracker to add to his other books such as ‘Liar's Poker’, ‘The Big Short’ and ‘The Undoing Project’.
In October 2019 a report which cost millions of dollars ranked the US first (and Britain second) on the Global Health Security Index. Months later the Covid virus hit. The race is still on but among the affluent countries the US has the highest Covid mortality rate, with Belgium, Italy and Britain close behind. The New Zealand rate is 0.4 percent of the US rate. (By affluent I mean the top of the OECD by per capita income; their data is more reliable and they have better medical services.)
So much promise but appalling execution. It is easy to blame it all on President Trump, but Lewis dismisses him as a ‘co-morbidity’ – an additional complication in an already sick patient. The fundamental condition is a malfunctioning public health system. This may be surprising, given the reputation of the federal government’s Centre for Disease Control and Prevention but Lewis reports that it would be better called the ‘Centre for Disease Observation and Research’ for it has little commitment to its stated objectives.
In the critical early weeks of the pandemic, CDC officials repeatedly downplayed Covid. They wanted more data, not wanting to act until the danger was clear, which is a no-no in fighting a pandemic. Because of its exponential growth, the earlier the easier. When a CDC official defied Trump and announced that the spread of the disease was inevitable, ‘people were soon saying how brave [Nancy] Messonnier had been to say that the virus could not be stopped’. The reality, Lewis argues, is that the CDC did not even try.
Their source of the CDC problem is nicely illustrated at the state level when California appointed someone from Washington’s CDC to head its Department of Public Health, ignoring the merits of the well-qualified, experienced and able, local public-health doctor Charity Dean, who is the heroine of the book. As the virus began to take over the state, Dean was told by her boss not to use the term ‘pandemic’. The appointment was very much politically correct – a Latino woman. Dean met the gender criterion but not the ethnicity one, although one could argue her background – ‘poor white trash’ (as she described it in her application to medical school) – meant she was just as politically correct if one was not racist. Leadership was critical. The appointee resigned after a major mistake, but not before she almost blocked Dean’s access to the Californian Governor.
The CDC was similarly timid towards Covid. Its story goes back to the 1970s when its advice on a flu threat did not work out, embarrassing the President. After that US presidents have made political appointments to run the agency rather than professionals; they saw their main role was to defer to the head of state. This is not quite the public impression because it saw the sterling work of Dr Tony Fauci, director of the National Institute of Allergy and Infectious Disease, standing beside Trump providing informed public common sense in a time of confusion. In a pregnant footnote, Lewis notes Fauci was a career professional public servant, who could not be easily sacked; presidential appointments can be, by Twitter.
Some presidents come out well in Lewis’s account. George W. Bush read an account of the 1918 influenza epidemic and asked for advice. The resulting working party presented to Barrack Obama, who was initially sceptical but quickly grasped the danger of a major pandemic and formed the Directorate of Global Health Security and Biodefense. However, Trump’s National Security Advisor, John Bolton, closed it down; apparently the only threats to national security were foreign countries (a mind set which might explain Trump’s obsession with the Chinese origin of the virus).
However, the extraordinary resilience of the United States made it possible for an informal group called the ‘Wolverines’ (named after the scrappy American teenagers fighting off a Soviet invasion in the 1980s movie Red Dawn). Because the federal government was failing they asked Dean (a ‘wolverette’) to approach the Californian Governor who both took up the initiative and encouraged other state governors to as well. California has one of the lowest mortality rates, an impressive achievement given is it a major point of international entry. The state initiatives probably saved 25,000 and more lives.
The story of the Wolverines makes fascinating reading. They were led by Dr Carter Mecher whose analytic abilities were only outweighed by his modesty. Lewis is sceptical of complex mathematical models, but Mecher could get to the guts of the mathematics without carrying the overload which bedevils most users.
The first chapter of the book opens with a subplot involving a Bob Glass and his daughter Laura. Glass worked at Sandia National Security which was so secret he had difficulties publishing their work on the completely independent issue of modelling of pandemics. Laura watching her father’s abstract modelling on a screen – he was working in the finance and energy sectors – thought the red dots eating the green dots was like a disease spreading. (She had been studying the Black Death in history at school; do you like the imaginative crossover?) So they transferred the model to disease transmission and bingo! There were a number of lessons. One is the exponential growth of an epidemic; lesson, get it early. Another was the crucial role of the transmission rate (we call it R0); lesson, get it down. (Both lessons have been at the heart of New Zealand’s strategy.) A third was that children were critical in the transmission process (which is why schools get closed).
Underlying the book is the problem of the public-private interface of the US health system. One memorable vignette was about a charity hospital turned down the free tests it was offered:
‘How much is it going to cost?’
‘It’s free.’
‘We don’t know how to do no-cost.’
‘What do you mean?’
‘It shows up as an error if we put zero-cost. It wont accept zero.’
Trump went for public funding the development of vaccines – very much a private-sector thing. (Thankyou, Donald.) But behaviour change – like masks and social distancing – which can be a very effective and cheap means of improving public health were downgraded. Lewis wryly points out that we can spend a fortune on preventing a single death using an unproven treatment, but we are less likely to spend smaller amounts on public health policies which effectively prevent death.
There is much to be learned from this book, often of the form of how not to do it. Once more the US shows itself with a dysfunctional public sector, a private sector which is not good at doing public sector things (like public health) and an appalling interface between the two – with some redemption from the charitable and voluntary sectors. But we know this.
I came away with the message that despite these failings, the flexibility and initiative of the US is impressive, while the quality of their very best is extraordinary. However, the US is sixty times larger than New Zealand; we cannot have the same depths of quality. As Rutherford almost said, ‘We haven't the resources so we’ve got to think.’