Last week I finished reading Michael Lewis’ The Premonition. The following parts of the book (with page numbers) stood out to me.

The U.S. Centers for Disease Control (CDC) is portrayed as a risk-averse bureaucracy that wants to study disease and not take strong measures to control disease. Sometimes this interest conflicts with local health officials who want to save lives and see strong measures as necessary even if not all the evidence is available yet. Health officials are always firefighting and can’t wait for more data. Lewis compared them to platoon leaders during battle. (page 40)

Deadly mistakes are often result from the combination of systemic and human failures. Lewis tells the story of a Veterans Affairs (VA) patient who was accidentally boiled alive in an Atlanta VA hospital. The hospital heated water to a specific temperature hot enough to kill certain bacteria but not hot enough to scald people. Bathtub faucets had a special valve that prevented water that was too hot from emerging. The water heating mechanism was broken, however. So the nurses compensated by adjusting the valve to a hotter temperature. Then one day, plumbers fixed the heating mechanism without telling the nurses. Normally a patient would tell the nurses when the water was too hot. But the nurses happened to be bathing one patient who was an older man with mental health problems. He always screamed no matter what. The nurses didn’t think anything was wrong when he screamed this time. “An hour later, the man’s skin was peeling away, and he was dying of thermal burns.” (67) This is a powerful story. Unfortunately, I’m unable to find corroborating news articles, and Lewis doesn’t have references or footnotes.

Why and how people learn.

…people don’t learn what is imposed upon them but rather what they frely seek, out of desire or
need. For people to learn, they need to want to learn… “People in an organization learn,” said
Carter. “They’re learning all kinds of things. But they aren’t learning what you are teaching them.
You go to a formal meeting. The important conversation is not in the meeting. It’s in the halls
during the breaks. And usually what’s important is taboo. And you can’t say it in the formal
meeting.”

Is Lewis’ account of the CDC’s aversion to computer models accurate? Premonition says the CDC had models that were just in people’s heads. “They, too, used models. They, too, depended on abstractions to inform their judgments. Those abstractions just happened to be inside their heads.” (85)

One of the two main protagonists of the book is an American physician named Carter Mecher. From 1996 to 2005, Mecher served as the Chief Medical Officer for the Southeast Veterans Administration Network. Mecher wanted to figure out how government should allocate resources.

Each year, Congress would hand more than a hundred billion dollars to Veterans Affairs, and various
people inside the VA would bay for more than they’d gotten the year before. The top brass had no way
to figure out who was actually busting their ass and needed more help and who was loafing…He hated
in particular the way some people were able to use their own inefficiency to create a seeming need
for more funding; and other people, people with a gift for making do with less, were, as a result,
given even less. “It drove out the entrepreneurial spirit,” said Carter.

ICE under the Trump administration was bussing and flying undocumented immigrants into cities in California to manufacture a humanitarian crisis according to the other protagonist of the book, a public health official named Charity Dean. (187, 190) This seemed insane to me, but I was able to find news articles about this. The actual story seems a bit more nuanced as one can read from this AP article “Far from border, US cities feel effect of migrant releases.”

Charity Dean explained to the CDC at the beginning of 2020 that there is no “system of public health in the United States, just a patchwork of state and local health officers, beholden to a greater or lesser degree to local elected officials. Three thousand five hundred separate entities that had been starved of resources for the past forty years.” This explains why the U.S. had no coordinated and science-based approach to Covid. (205-6)

A major antagonist of the book is Sonia Angell. She was the director of California’s Public Health Department and supervisor to Charity Dean who was the deputy director at the time. Lewis describes how she actively prevented any measures to acknowledge the severity of the virus or to try to contain it. Did Lewis try to interview and incorporate Sonia Angell’s side of the story?

A particularly egregious story of CDC incompetence is when they didn’t bother recording the addresses of Americans returning from China.

When local health officers called the CDC to say how hard it was to track down John Smith when the
CDC had listed his residence as “Los Angeles International Airport,” the CDC said, “Just don’t
follow up on them.” What was the point of having these travel restrictions from Wuhan if the federal
government was going to just let people loose upon their return?

There’s a particularly enraging and scary part of the book on CDC inaction. Mecher learns about Covid transmission, hospitalization, and death reates among passengers on the Diamond Princess cruise ship. This is a perfect and scary real life simulation of how Covid will behave in the general population. Mecher compares the situation of the world at the time to the Mann Gulch fire. This was a wildfire that initially looked containable. 13 smokejumpers parachuted in to fight it. But then “unexpected high winds caused the fire to suddenly expand, cutting off the men’s route and forcing them back uphill. During the next few minutes, a “blow-up” of the fire covered 3,000 acres (1,200 ha) in ten minutes, claiming the lives of 13 firefighters, including 12 of the smokejumpers. Only three of the smokejumpers survived.“ Mecher tries desparately to convince the CDC to take strong enough actions.

“I sense confusion among very smart people,” he wrote in early March. “[They] hear that more than
80% of those who are infected have mild disease and that overall case fatality rates are on the
order of .5%. And then they equate these states to a mild outbreak.” … Using the most conservative
assumptions suggested by the cruise ship—an attack rate of 20 percent and a fatality rate of
half of 1 percent—you wound up with 330,000 dead Americans… “You have all been quiet for
most of the discussion over the past several weeks. I would urge you to read the article I just sent
out and upbrief your boss… 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.”

It’s obvious that people at the top of government agencies at all levels are lost. No one’s coming to save us. Here’s another enraging anecdote about Angell.

On March 6, Gavin Newsome convened a hundred of the state’s top officials to discuss the new
coronavirus. Sonia Angell had told Charity that she, Angell, would give the briefing to the
governor, and that it was better if Charity did not attend the meeting. *You have no role*, Angell
explained, *so you should not be there*. Charity didn’t believe Angell had the ability to get up in
front of the audience and explain what was going on. “I just had a feeling that something would
happen and she wouldn’t be able to make it,” she recalled. Sure enough, the morning of the event,
the phone call came. Angell couldn’t make the meeting. Might Charity step in at the last minute to
replace her?

Media changes now force technical people to consider the cynical perception of their actions instead of strictly whether their decision in and of itself is the best. (287)

Lewis introduces the interesting concept of L6.

In any large organization, the solution to any crisis was usually found not in the officially
important people at the top but in some obscure employee far down the organization’s chart. A case
in point was the day the software used by the State Department to process visa applications stopped
working. That day the U.S. government simply lost its ability to issue visas… “Six layers down
from the people in charge we found two contractors who actually understand what is broken.” The L6.

The private sector is inefficient at generating knowledge because profit motive prevents collaboration and openness. (246)

Another story about how the federal government’s laissez-faire attitude towards helping state and local governments secure personal protective equipment led to a market free-for-all that drove prices way up. (253)

Local health offices are understaffed and behind the times. Joseph DeRisi is an American biochemist who heads the Chan Zuckerberg Biohub, a nonprofit research organization. In April 2020, Biohub had developed a Covid test kit and offered it free to any local public health officials who needed it.

Once his team began to deliver free test kits to them, he understood why they’d been slow to take up
the Biohub’s offer of free testing. Many local health officers were so understaffed and
underequipped they had trouble using the test kits. Most were unable to receive the results
electronically; they needed the results faxed to them. Some had fax machines so old that they
couldn’t receive more than six pages at a time. A few didn’t even have functioning fax machines, and
so the Biohub got into the business of buying and delivering fax machines along with test kits.

This story is corroborated by this NYT article “Bottleneck for U.S. Coronavirus Response: The Fax Machine.”

One reason why the CDC is dysfunctional is because Reagan changed its director from being a civil servant to a presidential appointee. (289-90)

Local health officials who were courageous lost their jobs and feared for their safety because there was a lack of leadership from CDC and federal and state leaders. (291)

further reading

• Barry’s The Great Influenza
• Rajeeev’s 12 page document written in 2005
• interviews with Carter Mecher or Charity Dean
• former CDC director Bill Foege’s letter to Robert Redfield who was CDC director at the time