Medicine / Book Review

Vol. 6, NO. 2 / September 2021

Expertise Unheeded

George Scialabba

Letters to the Editors

In response to “Expertise Unheeded

The Premonition: A Pandemic Story
by Michael Lewis
W. W. Norton, 304 pp., $30.00.

The latest book by Michael Lewis, The Premonition: A Pandemic Story, along with its predecessor from 2018, The Fifth Risk: Undoing Democracy, offer much useful material for reflecting on COVID and other recent crises. They also, unfortunately, offer reason to doubt that much reflection goes on in the upper reaches of the American government. Both books offer a view from the middle and upper-middle levels of that government, where members are trying, usually futilely, to get the political appointees above them to do the right thing, or merely to pay attention. 

The Premonition’s story begins with the first and mightiest of the modern pandemics. In 1918, an avian flu mutated and killed 50 million people worldwide, including 675,000 in the United States.1 Since then, the specter of influenza has haunted the world’s public health agencies. Much smaller pandemics in 1957, 1968, and 2009 kept the danger to the fore. But the first national pandemic preparedness plan was only created in 2005, after President George W. Bush read John Barry’s The Great Influenza, the classic study of the 1918 pandemic, and concluded that “[i]f anything like the 1918 flu occurred, the basic functions of the society would come to a halt, and no one in the federal government seemed to have worried about it.”2 Rajeev Venkayya, the youthful head of the Biodefense directorate of the Homeland Security Council, was tapped to draft a pandemic strategy embracing not just the production and stockpiling of vaccines, but also immigration, commerce, tourism, and whatever else would affect the course of a pandemic. He put together a team of brilliant and dedicated oddballs whose accomplishments and frustrations are the storyline of The Premonition.

To begin with, Venkayya’s team concentrated on modeling. They were led by an oncologist, Richard Hatchett, who had once been a gifted undergraduate poet—he had chosen medical school because “[w]riting is too hard.”3 But however elegant their models, the verdict of the Centers for Disease Control (CDC) and other health experts was always, “Not enough data.” Then Carter Mecher, an intensive-care physician from Veterans Affairs studying the pandemic of 1918, noticed that, even though the two cities took similar preventive measures, St. Louis had half the death rate of Philadelphia. There was a crucial difference: the measures were only instituted in Philadelphia several weeks after the first reported case in the city, while St. Louis had acted almost immediately. As a result, the exponential spread of the disease exacted a heavy toll on Philadelphia; much less so in St. Louis. And there was a further lesson. Philadelphia was reluctant to act without federal guidance, which did not come until three weeks after the city’s first reported case. Fortunately for St. Louis, the US surgeon general spoke out recommending school closure and social distancing on the same day as the first case was reported there, giving the city authorities political cover to take unpopular measures. Clearly, federal leadership would be crucial to any future pandemic response.

Though Mecher, Hatchett, and their colleagues would never be taken seriously by the CDC, the National Institutes of Health, and other public health organizations, it must be some comfort to them that the paper in which they reported the above results, “Public Health Interventions and Epidemic Intensity During the 1918 Pandemic,” became phenomenally popular.4 As of October 2020, it ranked as the eighth most cited paper out of 86,622 published in the Proceedings of the National Academy of Sciences.5

The administration’s pandemic plan was completed and the Mecher–Hatchett team dispersed by the end of Bush’s final term. Despite reaching this milestone, a number of political problems had not been overcome. The new strategy called for closing schools as soon as the infection rate reached 0.1. That sounds small, but only because exponential growth is hard to grasp intuitively, especially when, as with politicians and school boards, one has angry constituents demanding to know how so few apparent infections could justify so much inconvenience. Of course, by the time the number of infections has grown, controlling the pandemic will be many times more difficult.

A political test for the new strategy soon arrived in the form of a swine flu epidemic in early 2009, just a few months after the inauguration of Barack Obama. The new president asked for advice. Mecher was asked to provide a briefing and advised closing the schools; the CDC counseled against it. Obama declined to close the schools. The swine flu infected 40–80 million Americans, but luckily only 12,500 died.6 The right decision was made, it turned out, but for the wrong reasons—the numbers could easily have been much worse. Did the failure to take action this time make it even harder to do so the next time, in 2020?

The Premonition is a bicoastal story. Its three hubs are Washington, DC; Atlanta, where the CDC is headquartered; and California, where the state’s medical bureaucracy clashed repeatedly with Charity Dean, a public health officer with a background in communicable disease and a maverick temperament. Lewis shows Dean as Santa Barbara County chief health officer, facing down outbreaks of tuberculosis and meningitis, shutting down a clinic with many wealthy patients but dangerously poor hygiene, and closing an upmarket nursing home that was at risk of disappearing in a predicted mudslide. Her willingness to make hard decisions and accept the resulting flak got her promoted to deputy public health officer of California. That was as far as it would get her, though.

Jerry Brown had appointed Dean; in 2019 a new governor, Gavin Newsom, passed over her for chief health officer in favor of an unqualified affirmative action hire, Sonia Angell.7 With the first signs of a possible pandemic in December 2019, Dean pushed for full-throttle preparedness. Her boss, Angell, in response, forbade her even to use the word “pandemic.”8 An acquaintance of Dean’s in Washington, the chief medical officer of Homeland Security, put her in touch with the reconstituted Mecher–Hatchett group, still working out of the White House but without formal sponsorship. As late as February 2020, they were, as far as they could tell, the only people in government with a sense of urgency about the virus. One of Dean’s contacts in California was a brilliant, unorthodox molecular biologist, Joe DeRisi, at the University of California, San Francisco. Having imbibed Dean’s fervor about the all-importance of a fast and multipronged response, and learning from her that even simple testing, much less genomic sequencing, was lagging badly everywhere, he offered his state-of-the-art lab. For a long time, there were no takers. The CDC had its own facilities, which were free but very slow, partly because the CDC was preoccupied elsewhere with a succession of unsuccessful attempts to devise a COVID-19 test. California hospitals could not be persuaded to switch from getting expensive results after a five-day wait from giant companies Labcorp and Quest Diagnostics to getting free results the next day from DeRisi. One hospital explained apologetically that its accounting software could not handle getting something free.9 As a result,

nearly a year into the pandemic, in February 2021, the number of genomes being sequenced in the United States was trivial—less than a third of 1 percent of the virus in people who tested positive. (The UK was by then sequencing 10 percent of its positives; Denmark had set a goal of sequencing all of them.)10

The main theme of The Premonition—the major-key theme, so to speak—is the slightly offbeat heroism of Mecher, Dean, and company. Anyone who doubts the cynical maxim that for one’s career it is better to be wrong when everyone else is wrong than to be right when everyone else is wrong will find it amply confirmed here. But the protagonists do not become cynical, any more than the protagonists of The Fifth Risk, who had equally abundant justification for doing so.

The Fifth Risk and The Premonition are a departure for Lewis. His bestsellers have generally featured larger-than-life protagonists—John Gutfreund in Liar’s Poker, Steve Eisman in The Big Short, Billy Beane in Moneyball, Jim Clark in The New New Thing—doing glamorous but not particularly useful things—getting very rich in the bond market, getting very rich in the stock market, building winning baseball teams, founding billion-dollar software companies. The Fifth Risk is about ordinary, life-sized people with an extraordinary devotion to their useful but unglamorous jobs. One of them, from the Department of Energy, oversaw the design of safety devices. In 1961, one of his devices prevented a 4-megaton bomb that fell off a B-52 from destroying half of North Carolina. The Air Force, of course, insisted that the accident not be publicized, so the designer received no credit. Another tried to keep the Agriculture Department’s $220 billion Rural Development Bank from being handed over to Wall Street, which would, among other devastating consequences, triple or quadruple the price farmers pay for water. The book’s title comes from a list by one of Lewis’s interlocutors of present dangers to America’s well-being. The fifth risk is mismanagement. Every other page of The Fifth Risk details some instance of mismanagement by the Trump administration. One hopes the quiet, competent types Lewis portrays in his two most recent books will outlast them.

The Premonition has a secondary, minor-key theme, and a surprising one: the uselessness of the CDC. The CDC is the most prestigious public health organization in the world, but none of Lewis’s dedicated healthcare professionals has a good word to say for it. The problem with the CDC was precisely its prestige: it was determined to say or do nothing that might endanger its reputation. This meant never being wrong in public, which translated into never being ahead of the data. Time and again Mecher or Dean would urge some action from the CDC—testing returnees from Wuhan in January 2020, routing viral samples to DeRisi’s lab for genomic sequencing, endorsing school closings—only to be rebuffed with “sorry, insufficient data.” The problem with pathogens that spread exponentially is that in the few weeks it may take to gather sufficient data, the infection may have spread out of control. It is admittedly difficult to know precisely when decisively to favor containment. But if an organization’s overriding priorities are to produce excellent research papers a year hence and avoid being blamed for unnecessarily inconveniencing the public, as happened in 2009, it will sometimes err on the side of inaction, at a heavy cost in lives.

The CDC’s oft-reiterated public position through the end of February 2020 was that “the risk to the American people is very low.”11 That ought to have some reputational consequences. In September 2020 William Foege, a former head of the CDC, wrote to its current head, Robert Redfield:

[T]his will go down as a colossal failure of the public health system of this country. The biggest challenge in a century and we let the country down. The public health texts of the future will use this as a lesson in how not to handle an infectious disease pandemic.12

He was talking about the CDC’s acquiescence to the Donald Trump administration, of which the agency’s reluctance to champion protective measures was one expression.

The CDC’s passivity may have had something to do with a traumatic episode in its not-too-distant past. In the spring of 1976, several hundred American soldiers came down with a new variety of swine flu. The flu was expected to be dormant in the summer, as usual with flu, and to return in strength in the fall. How severe it would be was unknowable. Should the government wait or vaccinate?

The CDC convened a public-health summit. The sentiment was near unanimous: vaccinate. The CDC director, David Sencer, made the case for vaccination to the White House. A large-scale program was launched, and tens of millions were vaccinated. In the months that followed, an outbreak of Guillain-Barré syndrome was linked to the vaccine. The vaccination program was halted and “the pandemic never came. The new strain of swine flu simply vanished. No one knew why.”13

The vaccinations had been unpopular and, now that they were known to have been unnecessary, someone’s head had to roll. It was Sencer’s. It didn’t matter that the entire public health community had agreed with him. It didn’t matter that the vaccinations were unnecessary only in the sense that, say, a backup generator and extra food and water proved unnecessary because the hurricane swerved at the last minute. Someone, anyone, outside the White House had to take the blame.

Years later, his career destroyed, Sencer returned to Washington for a conference on the events of 1976. Even then he seems to have manifested signs of Stockholm syndrome. His main advice, Lewis reports, was that “to preserve the president’s credibility, you needed to keep him as loosely linked to the public side of the decision-making as possible.”14 After all, viruses mutate, which “might well necessitate big changes of strategy.” The public might see these changes not as intelligent adaptations but as “signs of ineptitude,” which must on no account be associated with the president.15

The Premonition does not end happily. Unlike the protagonists of The Fifth Risk, who mostly stayed in government and looked back on their careers with a mix of satisfaction and exasperation, for many of the later book’s leading figures, exasperation was paramount. Dean was offered the post of chief health officer of California but left instead to found a public health startup, in which Mecher, DeRisi, and other colleagues joined her. On her way out of the office for the last time, Lewis tells us, she asked herself: “Why doesn’t the United States have the institutions it needs to save itself?”16

No one in the book answers that question, including the author. Lewis is a journalist, not a social critic. But he’s a very good journalist, and he dramatizes that question in The Premonition with painful vividness.


  1. 1918 Pandemic (H1N1 Virus),” Centers for Disease Control (2019). 
  2. These are Lewis’s words to summarize Bush’s conclusions. Michael Lewis, The Premonition: A Pandemic Story (New York: W. W. Norton and Company, 2021), 52. 
  3. Lewis, The Premonition, 55. 
  4. Richard Hatchett, Carter Mecher, and Marc Lipsitch, “Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic,” Proceedings of the National Academy of Sciences 104, no. 18 (2007): 7,582–87, doi:10.1073/pnas.0610941104. 
  5. Lewis, The Premonition, 103. 
  6. See “2009 H1N1 Pandemic (H1N1pdm09 Virus),” Centers for Disease Control (2019). 
  7. As Lewis points out, Angell had “experience in neither California nor communicable disease.” Instead, she had been recruited, in part, for “her work in righting facial injustice in health care.” Lewis, The Premonition, 192. 
  8. Lewis, The Premonition, 197. 
  9. Lewis, The Premonition, 248. 
  10. Lewis, The Premonition, 268. 
  11. Lewis, The Premonition, 196. 
  12. Lewis, The Premonition, 280. 
  13. Lewis, The Premonition, 284. 
  14. Lewis, The Premonition, 294. 
  15. Lewis, The Premonition, 294. 
  16. Lewis, The Premonition, 279. 

George Scialabba is a contributing editor of the online art and literary magazine The Baffler.

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