Monday, October 11, 2021

The Premonition: A Pandemic Story


 Book: The Premonition: A Pandemic Story
Basic Information : Synopsis : Characters : Expectations : Thoughts : Evaluation : Book Group : New Words : Book References : Good Quotes : Table of Contents : References

Basic Information:

Author: Michael Lewis

Edition: ePub on Libby from the San Francisco Public Library

Publisher: W. W. Norton Company

ISBN: 0393881555 (ISBN13: 9780393881554)

Start Date: September 27, 2021

Read Date: October 11, 2021

304 pages

Genre: History, Biography, Science, Osher, COVID

Language Warning: Medium

Rated Overall: 4½ out of 5


History: 4½ out of 5


Synopsis:

Works through the biographies of several people who would later become instrumental in the behind the scenes fight against COVID.


Cast of Characters:
  • Laura Glass-13 year old who entered a simulation model of what happens when a virus enters into a population into a science fair in 2003. You can find her papers on PubMed
  • Bob Glass-father of Laura Glass who was a scientist at Sandia. He was an expert in figuring out and modeling what happens within a chain reaction, such as the financial impact of one segment of the economy or a failure of part of the power grid. You can find his papers on PubMed
  • Walt Beyeler-Computer programmer at Sandia
  • Charity Dean-Public Health Officer for Santa Barbara County, assistant director of the California Department of Public Health, and started the company The Public Health Company. See also her biography at the USC site.
  • Stephen Hosea-minor character, but major influencer. Taught Dean how to think about diseases and how to deduce issues.
  • Rajeev Venkayya-original author of how to fight a pandemic, Oct 2005. Formed the team which became the stealth COVID group fighting the pandemic.
  • Richard Hatchett-a main character in the pandemic planning and fight.
  • Carter Mecher-Mecher was made for the ICU, where he could work on figuring out problems. Has a mind adapt at figuring out connections
  • Lisa Koonin-Masters in nursing. Worked as a low level in the CDC, but understood how to respond in a pandemic
  • Joe DeRisi-As a postgrad student in biochemistry, he was given his own laboratory. He had created a means to identify viruses quickly.
  • Duane Caneva-U.S. Navy. Was part of the immigration settlements. Recruited Charity Dean to the Wolverines. Worked behind the scenes trying to coordinate a response to the COVID pandemic
  • James Lawler- U.S. Navy
  • Matt Hepburn-U.S. Army, was put in charge of Operation Warp Speed
  • Dave Marcozzi-U.S. Army
  • Todd Park-entrepreneur, started three health companies, Obama’s Chief Technology Officer. Told Governor Newsome to call him if he needed anything.
  • DJ Patil-data specialist
  • David Sencer-the man in 1976 who sounded the alert about the swine flu
  • John Ioannidis-From Stanford. Medical doctor who said that the COVID scare was not as serious as we think it would be. He predicted that less than 10,000 people would die.

Expectations:
  • Recommendation: OSHER Book Club Read
  • When: May 2021
  • Date Became Aware of Book: May 2021
  • How come do I want to read this book: OSHER Book Club read
  • What do I think I will get out of it? Do not know

Thoughts:



Introduction: The missing Americans

Lewis looks at this book as an extension of his previous book, The Fifth Risk. The Fifth Risk was about what happens when you staff government departments with political people who have no interest in how those departments function. Then the COVID-19 pandemic hit.



Prologue: The looking glass

Talks about the modeling which Laura and Bob Glass did for Laura’s science fair. Laura asks if Bob Glass’ models could answer “how does a disease spread?” She asked students in her school questions which would answer how connected the students were and developed the equations to understand the interactions. They brought in a programmer by the name of Walt Beyeler to create the computer program for Laura’s model



Dragon

Talks about Dr. Charity Dean-newly appointed chief health officer for Santa Barbara County. She felt her role was to stop the spread of disease and sickness in her county. She is the communicable disease controller for her county. The chapter starts with a story about a woman who died of TB. Also talks about her background.

When Dean had the corner remove a lung tissue, she was forced to do it. She realized: the real problem is that this man is frightened. Diseases like TB are something to be frightened about. Dean gets her sample.

Disease had shaped history; disease had crippled societies.



The making of a public-health officer

More description of Dean, but now as a public health official. It was remarked that when Dean was around, weird things happened. But it was more because Dean saw the weirdness and took action.


Dean had trained with Stephen Hosea. Dr. Hosea was a poor boy from Kentucky who had trained at Harvard in the 1960s and then spent a decade researching disease at the National Institutes of Health (alongside a young researcher named Tony Fauci). His specialty was to diagnose and figure out what was wrong. He looked and asked questions which led him to where the problem was. He did not just go by a book and see what else happened. This was the training Dean got. This was not a checklist training. Dean would spend forty-five minutes asking questions and yet scarcely touch on the patient’s social relationships. Communicable disease required a different approach. The approach which Hosea taught was that the most important part of the medical history isn’t the medical history. It’s the social history.


Hosea taught to look for the simplest issue. Also look at what is common between symptoms, not treating each symptom separately. Finally, if there is a list of possibilities, treat what may be the worst case until you can eliminate that one. A lot of people had died because doctors had allowed their minds to come to rest before they should.


Through experience, Dean figured out she was on her own when it came to figuring out if there were issues and what she should do. She discovered the CDC was not of practical use in her day-to-day activities. It seemed like the CDC did not want to be put into a position where it would be blamed. To her, all that really mattered was that the disease had been contained. … Sins of commission got you fired. Sins of omission you could get away with, but they left people dead.


She learned that to contain an infectious disease, the quicker you contain it, the less harm will occur. The problem is that usually you do not have a clear and clean diagnosis. The longer you waited, the more likely it was that people would die waiting for you to decide—or waiting for you to gather the data you needed to cover your ass if your decisions proved wrong.


When the Montecito mudslide happened after the Thomas Fire, many people died because of the mudslide. But many of the first responders got a strange rash. Then she figured it out: the oil from poison oak had mixed with liquid and blended into the mud


Because Dean made decisions, she was asked to become the deputy State Health Officer.



The pandemic thinker

Rajeev Venkayya wrote the original pandemic report on how to fight it in his parent’s basement in Oct 2005. Bush had read a book about the 1918 pandemic and wanted to know how the United States was prepared to fight something like this.Venkayya’s report was twelve pages and had three parts:

  • monitor and identify outbreaks on foreign lands
  • Speed up production of vaccines and antiviral drugs
  • coordinate a federal, state and local response to an outbreak in America

Bush asked for $7.1 billion to obtain this goal


Venkayya needed more of a plan which would actually put flesh on his original plan’s bones. He put together a panel to write this. The first one was Richard Hatchett. Hatchett had said that until a vaccine is developed, the spread of a virus needs to be slowed. One means to do it was Social Distancing-a term anthropologists used to describe cultures. Also it had been tried in 1918 and did not work. Hatchett said I was this emergency room doctor,” he said. “I didn’t know that people said all this stuff had been tried in 1918 and it hadn’t worked. I wasn’t rejecting anything. I just didn’t know any better.”


Asked other relevant agencies to send a person who could “think outside of the box”. The agencies sent people who were government wonks, except for the Veterans Administration who sent Carter Mecher.


Talks about Mecher’s role in ICU. People have this strong will,” said Carter. “You feel it. You see it. It really was spiritual being in the ICU.” He was the one who got turned to figure out why people were dying so frequently at the Chicago VA. He did it by measuring everything he could. He became an expert on preventing medical error.


Mecher learned a good rule-the first visit to a place he was not known at, people think he is there to assign blame. It is the second visit where trust starts to be built. Mecher said: “I was allowing them to open the curtain and take a look. You see so much. If people would just spend their time and observe. You don’t need any advanced degrees.” Ways to avoid medical error is to redesign the environment to make it more difficult for bad things to happen. He gives as an example: a 120V plug cannot be plugged into a 240V outlet.


He read Human Error by James Reason and was struck by the argument that the best way to guard against error is to design systems with layered and overlapping defenses.


The gist of it was that people don’t learn what is imposed upon them but rather what they freely seek, out of desire or need.


Mecher was invited to join the group planning for a pandemic-because he could think outside of the box. To most people, it was another exercise in “government speak”. To Mecher, he brought other ideas to the table. In the process of trying to get consensus, everybody had a chance to edit what was written. So anything bold was watered down.



Stopping the unstoppable

Just from what I underlined, this has got to be one of the more important, at least noteworthy chapters.


People who complained about “government waste” usually fixated on the ways taxpayer money got spent. But here was the real waste. He goes on and notes the real waste is how compartmentalized the bureaucracy is. Solutions to problems are not generally shared.


To go with this inefficiency, There’s a natural inclination towards certain narratives. I would guess it is something to do with our own experience and concept with how the world is shaped. This is talking about Bob Glass’ daughter model and how he could not get anybody interested in it. Glass eventually goes around the bureaucracy and gets Hachett’s attention and gets invited to the White House meetings.


The infectious disease establishment felt that there was no useful information which could be obtained from modeling. This was probably true until the early 2000’s, when the art and speed of computers caught up with the requirements to get the job done. Glass’ model gave a good enough answer quickly to the problems of a theoretical pandemic.


The question was, if there was a pandemic, was there anything else which could be done to respond to the virus? Glass’ model showed that The trick there would be to lower the disease’s reproductive rate: the number of people each infected person in turn infected. Most solutions did not yield large results. But one intervention was not like the others, however: when you closed schools and put social distance between kids, the flu-like disease fell off a cliff.


I do not like this statement at all-this seems like Lewis is saying that we should base policy and lives on things which has a possibility of being right. No one imagined they would have the effect that they had in the Glasses’ model. That didn’t mean the model was right; but it might be. I think I would want to have something more substantial. Or even if the author had said that the model was not completely accurate, but was a close approximation, that would seem reasonable to use. Fortunately Lewis did talk about how the Glass’ had substantiated it. By the way, the “they” in that statement was schoolchildren.


This causes Mecher to dig deeper about the magnitude of the effect schools would have on a pandemic. It is large, maybe the largest of all sectors. Mecher said couldn’t design a system better for transmitting disease than our school system.


Mecher approached containing a pandemic as multiple layers, not one single silver bullet.


CDC is top of the medical decisions in the United States. But they tend to be more conservative in their ideas. Reactive rather than proactive. One person who reviewed Mecher’s work made sense: Lisa Koonin of the CDC. But it was hard reaching her. She ended up writing the final chapter of the report. Why? Because Carter[Mecher] also had real humility about him.


... what struck Carter[Mecher] now was how slow Philadelphia’s leaders had been to respond[in 1918], even after they knew a deadly virus was racing out of control in their city. But then he started looking at how other cities attacked the pandemic. In the case of Philadelphia, he wrote, “the closing of schools and churches, banning of public meetings, and banning of large public gatherings occurred relatively late into the epidemic”—nearly one month after the outbreak began and just a week before its peak. He wondered if other cities had reacted more quickly, and if their specific reactions might explain the huge variation in the death rates from city to city.


In other words, timing is everything in combating a pandemic. If you throw the kitchen sink at it early, you stand a good chance of combating it. Later in the game, you have already lost. Cities that intervened immediately after the arrival of the virus experienced far less disease and death. Mecher and Hatchett wrote a scholarly paper and got it published. The paper analyzed the effects of that inability, and showed that American cities that caved to pressure from business interests to relax their social distancing rules experienced big second waves of disease.


people have a very hard time getting their minds around pandemics


The big theme of her [Lisa Koonin] book would be the power of storytelling. As far as Goodreads knows, she has only been a contributor to one book, Preparing for Pandemics in the Modern World.


Mecher, Hatchett and Koonin faced so much push back on the part of kids in a pandemic-mostly from people who did not know. To refute knee-jerk arguments about the costs of social distancing, Carter had marshaled so much data from so many corners of the U.S. government that a senior public-health official who passed through the White House called him Rain Main.


Mecher’s main way to attack a huge problem was to think about the problem, shrink it into something manageable. They changed tactics-appealing to people’s hearts, not minds initially. They formed things into a story.



Clairvoyance

Change of administration from Bush to Obama. Mecher is kept on; Hatchett leaves.


A new virus turns up in Mexico, killing young people there. People catch it in the United States. Carter hung up and called Heidi Avery. He told his new boss that a pandemic had begun and should be viewed as an imminent threat to national security.


After leaving the White House, Hatchett kept a personal diary. Within seven months of him leaving, the swine flu came through. His diary became a journal of response to this flu. A premonition. A warning. Richard emerged having absorbed dozens of small lessons and two big ones—the first being just how different a real pandemic was from an imagined one. “The entire epidemic has been characterized by nothing so much as ambiguity—and in particular about the number of people infected,” he wrote on May 9, nearly three weeks after he’d moved back into the White House. Interesting how Hatchett felt that the message of the swine flu had been dispersed. Not enough concrete information about what it was, what the possible effects could be and what would be an appropriate response. Is this a weakness of our democracy? Every four years-at most eight years-each administration has to relearn what was learnt before.


Hatchett and Mecher argued the United States should have a tactical pause. But the CDC said there was not enough data to support that-sounds familiar. Once there is enough data, then it is too late in a fast moving pandemic. The Mexicans, interestingly, had taken the new pandemic strategy of the United States and run with it. They’d closed schools, and socially distanced the population in other ways that, studies would later show, shut down disease transmission.


Two modelers from London showed what was not known as well as why we did not know it. They also showed the ranges of stats for the swine flu-somewhere between 20-30% of the Mexican population caught it with a fatality rate of 0.1 to 1.8%. To put a human toll on this, if this was in the United States, it would be slightly above a normal flu season to two million people would have died. The question then becomes, how do you make policy on this? How does a population accept that policy? A case fatality rate of 1 percent implied a terrifying pandemic. At the start of the COVID-19 pandemic, it was thought we had between 1 to 1.5% fatality rate. Lately, it is between 0.5 to 0.8%


It would take extraordinary leadership to look at that situation and say, “Shut it all down.”


During the swine flu epidemic there was conflicting advice from the CDC and the White House team. The CDC showed itself to be very tight with information, possessive. To Hatchett, even though things worked out by not closing down, it was alarming that it had worked out, as it created a false sense of confidence in the process that had rendered.


Mecher was asked to stay on at the White House. He realized that it was his thought process that made them think he was useful. His thoughts were also his thoughts about plans, as a plan is a kind of map: a map of what you plan to do. …. Having something in front of you, a map, a plan, a list of treatments, even if it isn’t completely right, is better than nothing. His White House boss realized that Mecher saw things other people did not see.


Policy makers have no interest in or aptitude for the sort of clairvoyance that was needed at the start of a pandemic.


Talks about Charity Dean’s background. Sonia Angell became her boss-Angell did not have any background in public health or how infectious diseases worked. Dean was a list maker. She was cut out of decision making processes. She’d spent the previous few months asking herself why she’d ever come here, but now she felt this premonition



The red phone

Chapter highlights Joe DeRisi and his “new” machine which could isolate viruses. He was a post grad person with his own laboratory at UCSF. UCSF faculty felt he had a mind without boundaries,” He was the first to identify the SARS virus. He was an unknown at the time, a biochemist without credentials. Then he started to get noticed and got busy. He was invited to an unknown group of scientists which advised the US government called the Jasons. In his talk to the Jasons, he explained that he saw that the SARS virus had an affinity for humans, cows and birds. To the surprise of all, the new virus’s old home turned out to be the horseshoe bat.


After identifying the SARS virus, DeRisi’s phone got very busy from people asking him to identify things. The phone got a name, the Red Phone. To DeRisi, science was cool. Science was just curiosity’s tool. Progress often began when someone saw something they hadn’t expected to see and said, “Huh, that’s weird. Yep, that is so true. When pythons started getting sick, DeRisi created a genome sequence for them and then extracted the blood from a sick one. From this he found out what the added pieces were. The whole game is to separate everything that is snake from everything that is not snake, then see what is not snake.


DeRisi’s lab was being asked to identify everything. It started getting serious when a teenager had an unidentified brain disease. It was Leptospirai-something he caught while swimming in a lake. Through some creative means, he was able to circumvent a law about reporting to physicians and save the boy’s life. 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.


when you might have thought that problem was solved, it wasn’t. DeRisi would not only identify the issue, but if they also would see if there was a cure to the issue, if there was none identified.


In January 2020, he went to Cambodia to instruct doctors there on screening for diseases. On the way home, he realized something big was happening.



The redneck epidemiologist

What happened in the ten years between the team disbanding and 2020? Hatchett went on to head a Europe based group called Coalition for Pandemic Innovations (CEPI). This was the group which funded the AstraZeneca vaccine’s development.


Mecher went back to Atlanta and the Veterans Administration, basically got lost in the bureaucracy. He tackled the question about why veterans were not getting timely care. Turns out he never was idle, just did not always have a project which was authorized. 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.


John Bolton comes in and fires anybody working on pandemic response.


Mecher and Hachett had never stopped working together, just unofficially. They had gathered around them other people: Duane Caneva and James Lawler had come from the U.S. Navy, Matt Hepburn and Dave Marcozzi from the U.S. Army. And all had a role to play in the event of any pandemic. Lawler ran the Global Center for Health Security at the University of Nebraska. Turns out that they were quiet influences during each of the epidemic scares: SARS, Ebola, Zika, MERS,... A Bush White House staffer had given them a nickname, the Wolverines-from the movie Red Dawn.


Mecher went to his son's remote wedding at the beginning of the COVID-19 pandemic. Lawler did an imitation Mecher and did some Redneck epidemiology. The number Lawler came up with, while trying to work backwards was ballpark. He got to A place where you could say to yourself that you were more or less right, even if you were a little bit wrong. But a place that you had gotten to fast, so that you might act. Mecher comes back and things start to rip. Much was guesses. Looking for patterns-that is what analogies provide, a shortcut to understanding a problem.


While the SARS epidemic was close, COVID-19 started to show a new, steeper path. The Chinese response was getting urgent; the United States was not.


Mecher liked fire as an analogy. The Mann Gulch fire captured the difficulty people had imagining exponential growth, even when their lives depended on it.


The chapter goes through their calculations and understandings and how they did not see all that they needed to see. But they were quickly realizing how quickly COVID was spreading. On the other hand, the CDC seemed like it did not want to discover cases in the United States. Mecher realized that his estimates showed an enormous loss of American lives if this was not checked. After his back-of-the-envelope calculation, Carter concluded that, if the society failed to intervene, the virus would kill between 900,000 and 1.8 million Americans. “The projected size of the outbreak is hard to believe,” he wrote.


CEPI had identified a Boston-area outfit called Moderna, an oddly named British-Swedish one called AstraZeneca, and several others as promising candidates that might develop a vaccine.


By the end of January, President Trump shut down travel with China. By then, thought Carter[Mecher], the virus was likely already so widespread inside the United States that the focus on foreign travelers was a pointless distraction.


The Wolverines were searching for ways to find a state or states to take the lead since the White House was not. The White House wanted the CDC to take the lead. They were calling the shots, and we needed someone else to call the shots. In their search, Duane Caneva had a conversation with Charity Dean. He knew they had found their person.



In Mann Gulch

Dean’s first task with the State of California was to come up with how to provide healthcare to immigrants, those which the administration was dumping into California. She put together a network of people and organizations she knew to provide health support for these people.


Duane Caneva had an adversarial relationship with the immigrants. But behind the scenes he was coordinating a pandemic response which was not authorized, or probably wanted. Dean loved it when people were brave; bravery always had her at hello. Dean did not feel particularly useful in the Health area of the State of California. She felt sidelined with her new boss, Sonia Angell. But on her own, she was monitoring and questing in her mind what was going on in China. Now she saw very clearly that the enemy was attacking, and no one but she herself felt the urgency of the situation. (She did not know about the Wolverines until later) One of the things Dean did when she told her own story to herself was not to portray herself as a victim, rather as someone who had responsibility in her story. Her escape fire was a story


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. Something to remember when dealing with someone else. How you see them is not how they see themselves.


When Dean got on a conference call with the Wolverines, she told them her perception of health care in the United States. The authority belonged to each county’s health officer, not with the CDC, not with a state office. She felt the counties were waiting until someone said this is urgent. Dean’s attempts to sound an alarm in California had gotten her banned by her new boss from participating in discussions about it. But the Wolverines were on the same page as her.



The L6

The list of people grew who were on the calls. It turns out some of them were highly influential, such as Anthony Fauci, others without a name. Dean wondered, “James[Lawler],” she asked, “who exactly is in charge of this pandemic?” “Nobody,” he replied. “But if you want to know who is sort of in charge, it’s sort of us.”


Mecher talks about the cruise ship, Diamond Princess, as being the first place where they could get accurate data. The CDC was still trying to figure things out. What was reported out of the ship confirmed Mecher’s model. This was going to be a big place of panic. But there was no change in how the United States was attacking this virus.


Mecher thought to himself, imagine himself two weeks into the future, looking back on the moment and asking himself: Knowing what I know now, what do I wish I had done back then? This is a good way to look at things in general, who do I want to remember myself acting in a particular situation.


Mecher and his wife went shopping. Mecher thought that supplies would run out, so he was stocking up. He remarked about how carefree everybody was. His wife she said, ‘Maybe that’s a good thing—not to know what’s about to happen.’


Dean was getting nowhere in California, so she started acting as a renege. She was in contact with about a third of the county health officers in which she got information and gave advice. Dean wanted to find ways to contain the virus, that included quartening people and monitoring new arrivals. Of course, how do you monitor everybody coming on I5, I880 and all the rest of the highways, let alone the airports. She also wanted to get the governor involved with daily briefings-which he did. “I thought that people could handle the bad news so long as you’re straight with them. She felt people just wanted to know what was going on.


Angell would not share information with the counties.This breed distrust of Sacramento.


Japan was looking for the people who were spreading it. CDC finally turned around from not a problem, to the problem is overwhelming. A system was groping toward a solution, but the solution required someone in it to be brave, and the system didn’t reward bravery. Dean ended up briefing the governor in place of Angell. From here, she rapidly got known as the person who knew what to do in a pandemic. She explained why herd immunity would be very painful : Before COVID-19 stopped spreading, two-thirds of Californians would need to become infected. She now reported directly to Mark Ghaly, secretary of California’s Health and Human Services Agency.


No one cares about data when everything is going well,” said Josh Wills, the former chief data engineer at Slack, who agreed to help. “People only care about data when the shit hits the fan. ‘Oh my God, what’s going on??? We need data.”


When the data people were looking for who can tell them what data is useful and how to think about the data. Todd Park said to talk with Den. The data people then said, She’s the L6. That stands for somebody at level six who understands the nuts and bolts of things. The data model showed that the assumptions by the CDC, White House and the official state advisors was low-balling the problem.


The next day, Governor Newsom issued the country’s first statewide stay-at-home order. At his press conference, he said that the decision was “based upon some new information.” It should be noted that the Bay Area counties a few days before had issued lock down orders. And then some other counties followed.


She was asked to write a pandemic plan for California, but said that would not work, it needed to be for the whole nation. She got to color coding the various levels of intensity the virus was having on the various areas. As more was known about the virus new criteria could be added. The problem with that is that once presented people think this is set in stone rather than changale with new data. So people lose confidence in how the pandemic is being tackled.


Her most curious idea, given how she had gone about her job as a local public-health officer, was how she hoped for the plan to be enforced.. She felt the plan should be locally enforced rather than overarching..


The one shot America had at behaving well, and thus saving itself, was to remove the feeling that “the government” was imposing restrictions on people and re-instill the idea that people were imposing order on themselves, to fight a common enemy. Interesting. I wonder if her idea would have worked? I suspect that it would not have.



The bug in the system

Governor Newson calls DeRisi and asks that he make a list of three good things and three bad things the Governor could do. DeRisi said there was only one thing to do --increase and quicken the amount of testing. Without testing you ended up not knowing where the virus was and where it was not.


The testing manufacturer had set up machines which could do one sort of testing. But there was also a problem. When there is a surge in demand, inventory goes to zero. Just-in-time manufacturing. Great concept! Horrible in a pandemic. Another problem was money-not that he was short on it, but there was so much money being thrown at the problem, people realized they could make serious money by being the knowledge person. So over and over again he saw the wild inefficiency of the private sector as a creator of knowledge.. Some companies wanted to make a profit, others wanted to help more than the money they would receive. This was both true of machines and supplies. DeRisi converted his BioLab to test for COVID-19. They were able to process 2,666 results a day, vs the testing companies which took days to do a test.


One issue was the access to nasal swabs. There was a complete disconnect between what could be provided and what was actually being done.


Chapter now goes to Dean in Santa Barbara tracking done TB patients. I had thought that as a health officer, my reputation was supposed to be as the good cop,” said Charity. “Not after that. After that I was all about never, never letting that happen again. She realized the connections of social relationships with viruses.



Plastic Flowers

Dean gets involved with the CEO of Blue Cross to move the State from being last in testing to first. Once again, she impresses people while the official State health officer is not to be seen.


The chapter heading comes from when Dean was a post-grad student she tried to have her porch being classy with fresh flowers. But they died and she replaced them with plastic flowers. It hid the problem of not knowing how to garden. That is until one day a friend walked onto the porch and found out they were plastic. That is how Dean feels about the health services in the United States. All looks good, until you look close.


Dean was doing the work of running the pandemic response, but the government could not have her be the face of it. But she kept running into roadblocks. So she resigned.


According to a former CDC director, at least part of the problem with the CDC is the lack of independence from the political arena. This amounted to the voice of God, or at least of a different age. Bill Foege knew that The problems inside the CDC had reached some kind of climax with Donald Trump, but they hadn’t started with Trump. Lewis tracks the problem back to 1976 when soldiers were infected with the swine flu. The United States had the power to produce vaccines but you needed to figure out what you were against-the wait and see. The CDC felt the only real option was to vaccinate all Americans. Things fell apart when people died after taking the vaccine. When President Carter came in, his HEW secretary instructed the firing of the person who pushed for the vaccination program. This started the downward spiral of the CDC being cautious and it becoming more political. You were always going to be tempted to wait until you were certain of the threat. This was my failing as a manager-I wanted to be certain.


It was pointed out that in any battlefield, whether military or medical, uncertainty is always there. If you wait to be certain, you will lose. Changes in the media and in society had led to changes in the way technical decisions were perceived, and so people with mere technical expertise could no longer make decisions. This may be the most important single statement in the whole book.


Lewis points out that Deciding on a swine flu program is like placing a bet without knowing the odds,” the authors [of a report on the swine flu response]concluded, without acknowledging that not deciding on a swine flu program was also placing a bet, also without knowing the odds. We are always going to have uncertainty in our decision making process.


From Carter onward, accelerating during Reagan’s time, the CDC became more political as the science was not accepted. Starting with Reagan, the CDC job was appointed by the President rather than promoted within the CDC. To fire a competent civil servant is a pain in the ass. To fire a competent presidential appointee is as easy as tweeting


We are the bad example for the rest of the world,” said Carter [Mecher]. “That’s what is so embarrassing.”


There were medical doctors saying the COVID virus was fake.


Mecher’s parents got COVID. His mother died.



Epilogue: The sin of omission.

Dean quits her job. She feels that the country didn’t have the institutions that it needed to survive. In particular, it did not have what it needed to battle a pathogen. Is this what we need to learn after the dust settles, who will tackle the next public health crisis. From the point of view of American culture, the trouble with disease prevention was that there was no money in it. That is Dean’s mission in a company she founded, Public Health Company. Many of its advisors are names from this book. Todd Park helps Dean found this company. His idea was to find the person who was the very best in the world at a given task and, effectively, turn them into software.



Evaluation:

Let's start by saying this is not a book about COVID-19, our response to it or the politics of pandemic life. This is a story concerning a section, an important section, of the people who had both the knowledge and intuition to understand the early signs of where the COVID-19 pandemic would lead us to. Lewis takes us through the back stories of Carter Mecher, Charity Dean, Joe DeRisi, and Richard Hatchett and how they became the background leaders in our current fight. Note: the story essentially ends around April 2020.


This was my first Michael Lewis book and it will not be my last. He writes in a compelling style, bringing together disparate stories and shows how they start intersecting each other. In chapter eleven, Plastic Flowers, he brings them all together. Some points brought out are: the CDC has become so defensive, they are not useful in any fast moving situation; there is a need to make decisions fast in certain situations even if you do not have enough information to make a decision; and that our current culture has devalued scientists and technologists as being increasingly irrelevant to public policy.


The one thing which Lewis does not do is propose solutions. He lets you ponder these people’s stories and draw conclusions about where we should go as a nation. It is a good book to understand what a good response could look like, but it will not be the last book. Read It!



 Notes from my book group:

OSHER Book Club, November 2021


Lewis notes that the doctor Charity Dean studied with, felt that A lot of people had died because doctors had allowed their minds to come to rest before they should. What does he mean by this statement? When is it OK to stop thinking about an issue?


The Center for Disease Control is not presented in a good light. What failings does Lewis cite? How did the CDC get this way? If you were President, how would you work about going and correcting this situation?


Throughout the book there is a tension between taking quick action, but that which may not be supported by facts and data and waiting for the data to back up a decision. Describe this tension. What are the benefits and hazards of acting quickly or waiting for data? How do you decide when is an appropriate time to decide? What should be done with the person who has to make the quick decision and decides wrong?


Lewis talks about government waste. It usually is talked about in terms of money misspent or spent on things which did not work out. Lewis also cites opportunities missed. Describe this kind of waste. Have you observed this?


When fighting a pandemic, the trick is to lower the disease’s reproductive rate: the number of people each infected person in turn infected. How have we tried to do that with the COVID-19 pandemic? What has worked and what has not? Why?


When the swine flu came to Mexico in 2009. There was a feeling that the United States had dodged a bullet. According to the book, what measures were instituted afterwards? What were the general feelings at the time? Was the United States response appropriate? During the 2020-2021 COVID pandemian, the American response has been compared to the Chinese. Compare the two? What are things which the Chinese can do which are not part of American culture? Should it be? Is this a weakness in a democracy? When should we take efficiency over freedom? Freedom over efficiency?


What kind of leadership needs to be in place to respond to a pandemic?


Lewis calls his book The Premonition. Can policy be made on the basis of premonition? How do you put that kind of thinking into the mix of creating policy?


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. What story do you tell about yourself? How does it affect your thinking about yourself? Others? Your actions?


Carter Mecher would imagine himself two weeks into the future, looking back on the moment and asking himself: Knowing what I know now, what do I wish I had done back then? This seems like it would be applicable to more than just a crisis. Where can you apply this type of evaluation?


Charity Dean advocated that Governor Newsom provide daily briefings on the status of the pandemic. If you watched or listened to them, were they effective? Informative? Confusing? Do you think Californias were able to handle the changing dynamics of the pandemic?


Changes in the media and in society had led to changes in the way technical decisions were perceived, and so people with mere technical expertise could no longer make decisions. In a free society, who should make decisions which affect the society as a whole?


After the COVID pandemic recedes, will the United States have a plan to tackle the next pandemic? What do you think it should look like?


Todd Parks idea was to find the person who was the very best in the world at a given task and, effectively, turn them into software. How does that statement strike you? Are you in favor of doing this? What are the benefits? The drawbacks?



How do you want your life to change because you read this book?



Many of these questions are either from or adapted from LitLovers.

Why the title of The Premonition? Where does it comes from?

Does this story work as a history?

Did the ending seem fitting? Satisfying? Predictable?

Which person was the most convincing? Least?

Which person did you identify with?

Which one did you dislike?

Every story has a world view. Were you able to identify this story’s world view? What was it? How did it affect the story?

In what context was religion talked about in this book?

Why do you think the author wrote this book?

What would you ask the author if you had a chance?

What “takeaways” did you have from this book?

What central ideas does the author present?

Are they personal, sociological, global, political, economic, spiritual, medical, or scientific

What evidence does the author use to support the book's ideas?

Is the evidence convincing...definitive or...speculative?

Does the author depend on personal opinion, observation, and assessment? Or is the evidence factual—based on science, statistics, historical documents, or quotations from (credible) experts?

What implications for you, our nation or the world do these ideas have?

Are these idea’s controversial?

To whom and why?

Are there solutions which the author presents?

Do they seem workable? Practicable?

How would you implement them?

Talk about specific passages that struck you as significant—or interesting, profound, amusing, illuminating, disturbing, sad...?

What was memorable?


OSHER Book Club Questions:

Who are the heroes from this book and why? Who was your favorite hero and why?

What are some of the similar traits of the heroes in the book - tenacity, passion, problem solvers……………………

Who or what disappointed you the most after reading the book?

Do you think the United States has learned from this pandemic and will be better prepared for the next one? Do you think there will be a next one?

Richard stated he thought he had a special destiny in life (pg. 83). Charity felt the same way. Do you think we all have a special destiny? What is your special destiny?

How one chance encounter can become a turning point (pg. 81)

Politics in every part of our lives – where do you see it in your everyday life?

Do you agree with the statement that politicians are looking for mistakes to politicize for political gain? Is this new over the past decade or has it always been in society?

What happened in our country that we don’t trust the scientist and the medical professionals? Did that happen during the polio, smallpox, measles epidemics. Why or why not?

Why and how have we experienced the resistance to taking care of our society as a collective nation for the good of all people?

Do you agree with the statement you have to change hearts first to change minds? Should we appeal to emotions rather than facts?

The transitioning from one presidential administration to the next is dysfunctional at best. What safeguards should be put into place to ensure a smoother transition and the continuation of important policies and programs regardless of who is president?

The focus of the Trump administration when Bolton was brought on to the team of fighting bad people rather than bad events.

Where we would be if our country got out ahead of the virus and as a nation, we applied Targeted Layers of Containment………

Letting egos get in the way of doing the right thing. Did we see this often during the pandemic at all levels of government and non-government?

Will the United States every be able to answer a call for Americans to rise collectively in the spirit of patriotism in any circumstances and not just a pandemic?

Lessons from the Mann Gulch fire and using these lesson to fight a raging disease as stated by Carter Mecher:

-You cannot wait for the smoke to clear once you can seer things clearly it is already too late.
-You can’t outrun an epidemic: by the time you start to run it is already upon you.
-Identify what is important and drop everything that is not.
-Figure out the equivalent of an escape fire.

It seems simple – test, quarantine, mask and vaccinated. Why is it so difficult?

Were you aware of the Chan Zuckerberg Biohub and the Gates Foundation work on the pandemic?

Joe DeRisis and the Virochip………….who even thinks this way. (pg. 141)

The politicization of the CDC during Ford and Reagan’s terms in office and the impact of changing the director of the CDC from career civil servant to a presidential appointment

Main people in the book:

Bob Glass, Laura Glass, Rajeev Venkayya, Richard Hatchett, Carter Mecher, Lisa Koonin, Joe DeRisi, Charity Dean


New Words:

  • phylogenetic-relating to the evolutionary development and diversification of a species or group of organisms, or of a particular feature of an organism

Book References:
  • The Fifth Risk by Michael Lewis
  • The Great Influenza: The Story of the Deadliest Pandemic in History by John Barry
  • Human Error by James Reason
  • Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic by
  • Richard J Hatchett, Carter E Mecher, Marc Lipsitch
  • A River Runs Through It by Norman Maclean
  • Young Men and Fire by Norman Maclean
  • The Swine Flu Affair by Richard Neustadt

Good Quotes:

  • First Line: This book began with an unholy mix of obligation and opportunism.
  • Last Line: Then she made an incision in the ground, buried a piece of herself, and moved on.
  • A lot of people had died because doctors had allowed their minds to come to rest before they should. Chp The making of a public-health officer.
  • People don’t learn what is imposed upon them but rather what they freely seek, out of desire or need. Chp The pandemic thinker
  • people have a very hard time getting their minds around pandemics. Chp Stopping the unstoppable
  • a plan is a kind of map: a map of what you plan to do. Chp Clairvoyance
  • Having something in front of you, a map, a plan, a list of treatments, even if it isn’t completely right, is better than nothing.Chp Clairvoyance
  • The leaders with the worse judgement smugly claim they have the best. Chp In Mann Gulch, quote Charity Dean’s journal
  • 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. Chp In Mann Gulch
  • No one cares about data when everything is going well, people only care about data when the shit hits the fan” Josh Wills in Chp The L6


Table of Contents:
  • Introduction: The missing Americans
  • Prologue: The looking glass
  • Dragon
  • The making of a public-health officer
  • The pandemic thinker
  • Stopping the unstoppable
  • Clairvoyance
  • The red phone
  • The redneck epidemiologist
  • In Mann Gulch
  • The L6
  • The bug in the system
  • Plastic Flowers
  • Epilogue: The sin of omission.

References:
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