Thoughts about The Premonition by Michael Lewis

Ernest Davis , August 2021.

On the recommendation of Scott Aaronson in his blog, Shtetl-Optimized, I read Michael Lewis' new book, The Premonition. I can't improve on Scott's summary, so I'll just quote some key excerpts, with a few of my own edits in square brackets (Scott's whole blog is very much worth reading.)

Lewis tells the stories of a few individuals scattered across US health and government bureaucracies who figured out over the past 20 years that the US was breathtakingly unprepared for a pandemic, and who struggled against official indifference, mostly unsuccessfully, to try to fix that. As covid hit the US in early 2020, these same individuals frantically tried to pull the fire alarms, even as the Trump White House, the CDC, and state bureaucrats all did everything in their power to block and sideline them.     ...

The most compelling character in The Premonition is Charity Dean, who escaped from the Christian fundamentalist sect in which she was raised to put herself through medical school and become a crusading public-health officer for Santa Barbara County. Lewis relates with relish how, again and again, Dean startled the bureaucrats around her by taking matters into her own hands in her war against pathogens—e.g., slicing into a cadaver herself [with garden shears] to take samples when the people whose job it was wouldn’t do it.

In 2019, Dean moved to Sacramento to become California’s next chief public health officer, [she was hired as deputy, and her boss was about to retire] but then Governor Gavin Newsom blocked her expected promotion, instead [for political reasons] recruiting someone from the outside named Sonia Angell, who had no infectious disease experience but to whom Dean would have to report.     ...

After it became obvious that the White House and the CDC were both asleep at the wheel, the competent experts’ Plan B was to get California to set a national standard, one that would shame all the other states into acting, by telling the truth about covid and by aggressively testing, tracing, and isolating. And here comes the tragedy: Charity Dean spent from mid-January till mid-March trying to do exactly that, and Sonia Angell blocked her. Angell — who comes across as a real-life Dolores Umbridge — banned Dean from using the word “pandemic,” screamed at her for her insubordination, and systematically shut her out of meetings. Angell’s stated view was that, until and unless the CDC said that there was a pandemic, there was no pandemic — regardless of what hospitals across California might be reporting to the contrary.

In March 2020, the fundamental question I [Scott] had was: where are the supercompetent rule-breaking American heroes from the disaster movies? What’s taking them so long? The Premonition satisfyingly answers that question. It turns out that the heroes did exist, scattered across the American health bureaucracy. They were screaming at the top of their lungs. But they were outvoted by the critical mass of blankfaces [Scott's coinage for malevolent bureaucrats] that’s become one of my country’s defining features.

Michael Lewis, previously the author of The Big Short, Moneyball, etc. is an extremely accomplished writer. He has a gift for finding remarkable people and for portraying them vividly. He also has a gift (which, for my taste, he doesn't use often enough in this book) for crystal clear explanations of technical issues that cut directly to the heart of the matter. For instance, here is his explanation of how genomic analysis of the virus makes it possible to track the sequence of transmission between people.

Viruses mutate, which is to say that they make errors in their genetic code when they replicate. Different viruses make errors at different rates. A perfectly stable virus — that is, a virus that does not mutate — would be impossible to track. The virus in every infected person would have exactly the same genetic code. Just by inspecting those codes, you would not be able to say who gave the virus to whom. For instance, herpes mutates so slowly it's hard to divine how it has traveled from the genetic code alone. At the other extreme, when a virus mutates too quickly, its movements are equally hard to follow. The viruses that cause the common cold, for instance. They mutate so rapidly that, inside of a single human being, they replace their entire genome and escape the defenses created by any vaccine. A fast mutating virus is as untraceable as a burglar who leave behind billions of different fingerprints.

From the point of view of a virus hunter, COVID-19 sits in a sweet spot. It mutates, very reliably, every one or two times it transmits from person to person. If I catch the bug from you, the genomes of our viruses will either be exactly the same or they will differ by a single mutation. Just by watching these changes, you can track the virus' journey through a community.

Lewis' description of the dysfunction in the American health system is staggering. As Scott discusses in his blog, the Trump administration did everything it could to trash the country's preparedness for a pandemic before the outbreak and, other than pushing hard to get the vacccines, did everything wrong after the outbreak. The CDC was a hidebound, stupid, obstructive nuisance.

But the systemic dysfunction was much more pervasive than that. In March 2020, Joe DeRisi of U.C. San Francisco, one of the heroes of the book, one of the country's top biochemists, in eight days set up a lab, staffed with a small army of volunteers, which would do Covid testing for free with a few hours turn around. (The CDC's first attempts at Covid test kits were failures, and the commercial labs at that time had a turn around of two weeks and were uninterested in trying to speed it up.) He worried that the demand might far exceed the capacity of his lab. Quite the contrary: he had to beat the bushes to get anyone to send him tests, for every lousy and infuriating reason under the sun. Some public health offices had a contract with a commercial lab, or, even without a contract, were unwilling to jeopardize their relation with the lab. Some were wary because the funding for DeRisi's lab came from Mark Zuckerberg and Priscilla Chan. One hospital couldn't use them because their computer would not allow them to process a free test, or even a low-cost test. There were public health offices in California that could only communicate by fax machines. There were public health offices in California that could only communicate by ancient fax machines that could only handle six pages at a time.

And then there was a shortage of nasal swabs. Outside of China, there were two factories that made nasal swabs, one in Maine and one in Italy, and they were sold out. A sponsor of Joe's told him, excitedly, that he had managed to buy a shipment of 5000 nasal swabs, but it turned out, on inspection, that the shyster had sold him reconstituted eyelash brushes. They got in touch with the Strategic National Stockpile, maintained by HHS. Hurrah, the Stockpile had lots of nasal swabs, and could send over a truckload. But though the truck set out, it never arrived because, umm, it turned out, umm, that what they had thought were nasal swabs were actually just Q-tips.

All in all, The Premonition is an excellent book, which I highly recommend.

But I have two reservations. The first reservation can be phrased politely or unkindly. The polite way to phrase it is that I would have preferred less biography and more pandemic. It's a fairly short book (259 pages), and a large fraction of it is spent telling anecdotes, like Charity Dean cutting up the cadaver, that are entertaining and help paint portraits of the people involved but are entirely peripheral to the main story.

The unkind way to phrase it is that the book often reads suspiciously like a movie script. The heroes are exactly the odd collection of mavericks bucking The System that are a Central Casting cliché in this kind of film. (Though Central Casting would try to make them more diverse ethnically — they run strongly to white Christians from Smalltown USA.) Scott Aaronson's phrase, "the supercompetent rule-breaking American heroes from the disaster movies" seems all too apt. One can easily imagine an Oscar-winning performance by Amy Adams as Charity Dean. (I am told that the movie rights have in fact been sold.)

I don't at all want to minimize, let alone mock, Lewis' heroes. I don't doubt that they are remarkably capable and dedicated and that Dean deserves all the plaudits (60 Minutes, NPR, and so on) that she has gotten. But the degree to which they collectively fit the popular myth does raise the suspicion that there has been some selection bias in Lewis' choice of characters and of narration. It doesn't ring quite true to me.

In some ways it is a rather Trumpian view of government. (In fact, White Houses in general have a tendency this way.) The established departments and agencies are at best hindrances, at worst the deep state. What you need to do is to find the half-dozen superheroes hidden here and there and put them together into a White House task force. There is, of course, the important difference that in this view you want to get competent, dedicated people, while Trump reliably preferred incompetent, corrupt people.

Alternatively, you get a lot of funding from venture capitalists, and you put together a do-gooder, for-profit company staffed with the competent people, which is what Dean ended up doing a few months ago. Lewis reports this final development in an epilogue. Personally, I found this disheartening; it's not clear how enthusiatic Lewis is about it. But overall, The Premonition ends up being a huge advertisement for her new company, The Public Health Company.

My second reservation is that there are some odd gaps in the narrative. I'll point out two small ones, and one large one. Lewis' prologue is about a eighth-grade science project on modeling flu epidemics carried out in 2004 by Laura Glass with the mentorship of her father, Robert Glass, a scientist at Sandia National Labs. A version of the model ended up being used by the White House task force on pandemics (heroes) that George W. Bush established. (Glass's 2006 technical paper on the model, Targeted Social Distancing Designs for Pandemic Influenza is online.) Lewis writes,

Bob Glass had now read enough about epidemiology to now that his daughter's project was an original contribution to the field. "I asked myself, Why didn't these epidemiologists figure it out? They didn't figure it out because they didn't have tools that were focused on the problem. They had tools to understand the movement of infectious disease without the purpose to stop it."
Since Glass and Lewis say so, I have to believe it, but it seems strange, and I would like more explanation. Models, and even computational models, of pandemics were not new in 2004, and at the time, network models were very hot, what with the Internet and Google's PageRank and so on. There had been scientific studies of quarantining as a strategy against epidemics. A search in Google Scholar for "population simulation infectious diseases" between 1990 and 2000 gives plenty of results, some of which seem to be comparable. What specifically was revolutionary about Glass' system? What kinds of models were epidemiologists working on at the time?

A second gap: In early 2020, the former White House task force, now disbanded, started meeting regularly online to discuss what was happening, what should be done, and how to get the government to do it. They soon found Charity Dean and brought her into their discussion. Suddenly, at the start of chapter 9

The names at the top of the Red Dawn emails grew in both number and importance. ... The audience for Carter [Mecher]'s analysis would come to include the health officials of a bunch of states and a pack of current and former Trump administration officials, including Tom Bossert [former Homeland Security Advisor, until Trump fired him]; the surgeon general, Jerome Adams; and Trump's White House doctor turned presidential advisor Ronny Jackson, ... On the line at various times ... were Tony Fauci, White House staffers, and members of the president's coronavirus task force.
So how did that happen? How did Carter Mecher's informal group, which he was leading from his couch in Atlanta, break through to the powers that be? And what effect did they have? It certainly suggests that the blankfaces had some actual interest in listening to the superheroes.

The large gap is that obscure place known as The Rest of the World. In a book about a global pandemic, that is a conspicuous omission. Actually, even the rest of the country, outside California, Atlanta (CDC), and Washington DC, gets short shrift. To what extent did Lewis' heroes interact with their counterparts abroad or at the WHO (mentioned only a handful of times in this book), or elsewhere in the US? They certainly must have tracked developments abroad much more closely than Lewis' narrative indicates. Granted that the US government made a complete hash of this (again, other than the vaccine): to what extent were other governments wiser? And to what extent did that reliably get them better outcomes? A few places which immediately responded with strong social controls (New Zealand, Singapore, Taiwan) have had striking success; others that seemed to be doing particularly well at an early stage (South Korea, Japan) lost a lot of ground later. Looking at the horrible, familiar curves of illness and death, it is very hard to see a close connection between policy and outcome. "The wise dies like the fool" (Ecclesiastes 2:16).

At the beginning of his book Awakenings, Oliver Sacks remarked on the surprisingly small place that the 1918-20 influenza pandemic held in our collective memory. Well, that pandemic looms a lot larger now,* and it seems altogether unlikely that the 2020-? covid pandemic will be soon forgotten. Many histories of the pandemic will be written; no doubt many are already in progress. For a historian, Lewis' The Premonition will shed a sharp light on one particular corner, but it may give a rather slanted view of the larger picture.

* The 1918 pandemic has a large presence in The Premonition. Charity Dean and some of Lewis' other heroes studied it carefully, but were unable to persuade the blankfaces that our wonderful modern selves had anything to learn from that ancient history. More surprisingly, George W. Bush created a White House task force on pandemic preparedness in 2005, because, on the recommendation of one of his staff, he read John Barry's book, The Great Influenza: The Story of the Deadliest Pandemic in History.