The Premonition: A Pandemic Story

“All communicable diseases were infectious, but some infectious diseases were not communicable. Communicable meant a person could give it to another person. You could get Lyme disease, for example, but you couldn’t give it to somebody else. Communicable diseases were the diseases that created crises.”

Charity Dean refers to the importance of defining terms that everyone can agree on and follow. The difference between communicable and infectious is significant, but many figures—particularly decision makers—in the book couldn’t have described the difference. Infectious sounds worse than communicable but is less worrisome.

“The root of the CDC’s behavior was simple: fear. They didn’t want to take any action for which they might later be blamed.”

Charity Dean experiences resistance from the CDC on her prophylaxis ideas. The CDC wishes to be seen as the ultimate authority on matters of disease prevention, yet they’re unwilling to take risks that could damage their reputation. The choices in the book that have the greatest results require bold, often unpopular decisions. Charity Dean, Carter Mecher, and Richard Hatchett never worry about their reputations, only their effectiveness.

“What scares me most, and what I think about most […] is our ability to respond to a new pathogen, maybe one we’ve never seen before, or an old pathogen, like influenza that’s just mutated. The H1N1 pandemic of 1918 was over 100 years ago now. The world is overdue for a pandemic like that, whether it’s influenza or something else. And in public health, we know that we have to be prepared for that.”

Charity Dean is referring to how the interval between pandemics is long enough that people forget the urgency. Until COVID, few US citizens had any experience with a pandemic. Each pandemic is an opportunity to prepare for the next one, because the odds are always in favor of another pandemic. That the next pandemic is always some expert’s greatest fear doesn’t mean that it’s true for anyone else. However, preparation requires buy-in on a large scale.

“When the systems depend on human vigilance, they will fail.”

Carter Mecher evaluates a veteran’s death of and realizes that the nurses are also victims. Humans will always be fallible. Unless we have infallible systems to work within, we’ll always make human errors. The vigilance necessary for a pandemic is among the hardest because it must start—and sustain—long before a virus begins to spread.

“One way to reduce medical error […] was to redesign the environment to make it more difficult for bad things to happen.”

Carter Mecher is good at thinking of solutions that others would not. Rather than fighting against certain conditions, he’s often more interested in arranging the circumstances such that the conditions cannot arise. For instance, social distancing helps prevent germs from spreading. In addition, through his process of elimination, Carter can focus on solving the most urgent problems, which often result from smaller systemic problems.

“You can keep mistakes from happening if you can identify the almost mistakes. This kind of changes how I view everything.”

Many of Carter Mecher’s successes stem from an ability to spot the near misses. His approach to the pandemic is similar. The most obvious solutions to Carter are those that prevent further mistakes—including rapid spread of a virus. However, others interpret what he views as near misses as proof that they never had never anything to worry about.

“I couldn’t design a system better for transmitting disease than our school system.”

After visiting a school, Carter Mecher realizes that he’s forgotten how close the students always are to one another. Kids have a different sense of space and are more likely to be close to each other. He realizes that schools have almost no organic space—at least, not to the extent that social distancing requires. His insight makes the government’s resistance to school closures more frustrating.

“No single intervention would stop a flu-like disease in its tracks, just as no single safety measure would prevent a doctor from replacing the right hip when it was the left hip that hurt. The trick was to mix and match strategies in response to the nature of the disease and the behavior of the population. Each strategy was like another slice of Swiss cheese; enough slices, properly aligned, would hide the holes.”

Carter Mecher explains his Swiss cheese approach to problem solving. He doesn’t think that one solution can prevent a pandemic. Rather, he’s interested in finding as many ways to succeed as possible and then overlaying them. Prevention is a multifaceted approach even if some layers have less benefit than others. Carter’s theories don’t produce instant, flashy results or supply a miracle solution.

“The specific thing that blew my mind was using multiple semi-effective strategies together. There was no silver bullet.”

Carter Mecher’s approach to prevention impresses Charity Dean. A vaccine is closer to the customary silver bullet analogy. However, the more she learns, the more that Dean understands that the only responsible approach to a pandemic is to use as many strategies as possible that each produce a positive result. None was a miracle cure. However, it was hard to get buy-in for the less glamorous method of layering many strategies.

“The paper’s more subtle message appeared between its lines: people have a very hard time getting their minds around pandemics. Why was it still possible, in 2006, to say something original and important about the events of 1918? Why had it taken nearly a century to see a simple truth about the single most deadly pandemic in human history?”

In 2006, it was difficult to get people to think about the 1918 pandemic with any urgency. Indeed, it was difficult to persuade people that the 2006 the SARS outbreak deserved much thought. Pandemics are rare enough that their lessons do not stick in the minds of all but the most observant—or obsessed—people.

“There was, Carter thought, a downside to experience. ‘Experience is making the same mistake over and over again, only with greater confidence,’ he said.”

Carter Mecher sees people learning the wrong lessons from their near mistakes. He gives the example of someone who looks at a phone while texting but doesn’t hit anyone or anything. That person can learn that reading a phone while driving is safe. In an analogy to the pandemic, the authorities’ resemblance to the distracted driver frustrates Carter; they’ve failed to learn from past pandemics because they were either not as bad as predicted or because they’re so far in the past.

“Managing a pandemic was like driving a weird car that only accelerated, or braked, fifteen seconds after you hit the pedal. ‘Or think of looking at a star,’ he said. ‘It’s the same thing. The light you see is from years ago. When you are looking at a disease, the disease you are seeing is from last week.’”

The cost of delayed response is a theme throughout the book. Getting the CDC to buy into preventative health measures, particularly if they’ll be unpopular, is difficult. However, reactions to obvious symptoms of the pandemic are already too late. Managing a pandemic takes foresight and courage, and authority figures are unwilling to act on models and projections.

“That was Joe’s big takeaway from the story: what he called the last mile problem in medical science. Corporations were only interested 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. The government was meant to fill in the blanks.”

Everyone who should be helping curb, prevent, or stop a pandemic has their own agenda. If solutions that involve corporations also require a cut to the bottom line, corporations are less likely to help. The expediencies of academic publishing fade once it satisfies a requirement. Government decision makers are key public office figures and—in trying to manage perceptions and image—tend to avoid making decisions unpopular to their constituents.

Everyone who should be helping curb, prevent, or stop a pandemic has their own agenda. If solutions that involve corporations also require a cut to the bottom line, corporations are less likely to help. The expediencies of academic publishing fade once it satisfies a requirement. Government decision makers are key public office figures and—in trying to manage perceptions and image—tend to avoid making decisions unpopular to their constituents.

Carter Mecher draws an analogy from the Mann Gulch fire and the associated escape fire. The Mann Gulch fire was comparable to the aggressive spread of a disease. This passage distills Carter’s philosophy for handling—and preventing—pandemics: Time is critical, and any time and effort spent on things that don’t help with the problem is a waste.

“Play forward whatever you are thinking about doing, or not doing, and ask yourself: Which decision, if you are wrong, will cause you the greatest regret?”

To make decisions, the researchers in the book follow this code. Closing schools earlier than people think is prudent can damage an official’s political standing. However, not closing schools and suffering catastrophic losses as a result is worse. The barometer of potential regret gives Carter Mecher, Charity Dean, and the others courage and direction.

“The CDC does not know how to pull the fire alarm. In fact, there is no fire alarm in this country.”

A fire alarm is an agreed-upon, recognizable signal of danger. The natural, accepted response is to evacuate. The CDC doesn’t have an equivalent of a fire alarm that applies to the threat of a pandemic. No system exists for warning people, and the decision makers agree little about what constitutes cause for alarm.

“The people who presided in times of peace tended to have a gift for avoiding or at least disguising conflict. People made for battlefield command did not find their way into positions of authority, at least not until the general public sensed existential risk.”

During wars—or crises like the pandemic—peacetime leaders are less effective. A real crisis reveals that they’re more concerned with their reputations than with results, and they’re often indecisive to the point of paralysis. By the time the public perceives existential risk, it’s too late for preventative decisions.

“Everyone has a story they tell themselves about themselves. Even if they don’t explicitly acknowledge it, their minds are at work retelling or editing or updating a narrative that explains or excuses why they have spent their time on earth as they have.”

Lewis reflects on the ways that people can recast their roles in their own lives. The mind is a pattern-making machine, and it tends to find patterns that justify its owner’s behavior. Many people in the book cast themselves in roles in which the pandemic is someone else’s responsibility.

“History will long remember what we do and what we don’t do at this critical moment. It is time to act and it is past the time to remain silent. This outbreak isn’t going to magically disappear on its own.”

Many people—including government officials—ignored the pandemic as if it would go away. This is still happening. Pandemics don’t resolve themselves without a combination of luck, foresight, and proper action. However, acting out of a desire to be on the right side of history requires the long view, over a long timeline. Officials often make decisions that focus more on their short-term public image than on the long-term public good.

“People were soon saying how brave Messonnier had been to say that the virus could not be stopped. To Charity, her words sounded like the CDC letting itself off the hook for failing even to try.”

After Nancy Messonnier says at a press conference that the disease is inevitable, the Trump administration blacklists her. No one is henceforth allowed to say anything alarming during press conferences. Charity Dean is unimpressed. The CDC is constantly maneuvering so that in hindsight it won’t look like it was part of the problem. The Trump administration punishes people—even people whose job is to fight the pandemic—for criticizing the government or implying that its response has been lacking.

“‘He wasn’t pleading with me to do the right thing. He was yelling at me. He was basically implying that the White House is not going to do the right thing. The White House is not going to protect the country. So California needs to take the lead.’ That was the moment she learned that the White House was listening in on the calls—and also the moment when she realized just how lost and desperate the people at the top were. ‘He’s the deputy director of homeland security. He can just go talk to the president. And he’s relying on some random blond girl to save the country. Really?”’

Ken Cuccinelli, the acting deputy of homeland security, tells Charity Dean that she needs to act on her own, since the White House won’t act. Dean realizes the extent of the problems in the Trump administration. People who believe her can’t get buy-in from their superiors. They must circumvent the presidency and encourage smaller leaders like Dean to go rogue and fix things on their own so that they can lead by example.

“It went that way with much of what they needed to buy: some companies sought to exploit the moment; others sought to help. ‘We quickly figured out that some companies actually have a moral compass and some of them don’t.’”

Unscrupulous capitalists find ways to exploit the pandemic for financial gain. Many companies that usually offered a discount when selling in bulk insisted on charging full price for the enzymes necessary for COVID testing. In addition, new underground markets arose, charging exorbitant prices for items like nasal swabs. The pandemic clarified which companies act according to their mission statements and which value profit first.

“The pattern continued right through the pandemic: the Trump administration would claim with fanfare that supplies were on their way to the states and leave it to the career civil servants whose job was to interact with state officials to reap the humiliation when those supplies failed to arrive. It would happen again with ventilators, with the drug Remdesivir, and, finally, with vaccines.”

The federal government didn’t lead by example in the COVID pandemic. While the administration was willing to take credit for any progress and success, it left local officials like Charity Dean on their own. Local leaders often took the reputational hit when the federal government didn’t deliver on its promises.