Michael Lewis on the Mirage That Is America's Public Health System

; Michael Lewis, MS


June 04, 2021

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol for Medscape. It's my incredible privilege today to speak one-on-one with Michael Lewis, the storyteller of our era, about his new book, The Premonition: A Pandemic Story. Michael, welcome.

Michael Lewis, MS: Thanks, Eric. Good to be back.

Topol: You've taken us to another level with this book. It's quite extraordinary. What I found especially fascinating is the pre-pandemic warmup that went on for almost 15 years here in the United States. It includes a 13-year-old girl, Laura Glass, and her father, Bob, in Albuquerque, in 2004; the incredible public health physician in Santa Barbara, Charity Dean; the "Wolverine Group" of seven doctors; and Joe DeRisi, from UCSF. How did you find these people?

Lewis: I was looking for people through whose eyes I wanted to see this event, people who could teach me things I didn't know. They landed in my lap in various ways.

Joe DeRisi was the easiest find. Five years ago I published a book called Flash Boys and ended up at dinner with a San Francisco money manager who wanted to talk to me about the book. And he said, "I have a character for your next book. His name is Joe DeRisi and he's opening this institution called the Chan Zuckerberg Biohub. When you meet him, you'll be smitten."

People do this to me a lot and I nod politely and take their business cards. And then I go hide. But he was so insistent that I went and had a sandwich with DeRisi. He is a virus hunter — a sort of freelance rogue virus hunter attached to UCSF. He's a really interesting man and a nut. When I met him, he'd already hunted down pandemics in snakes and in exotic birds. He invented a genomic sequencing technology to identify unidentified encephalitis. You know, it was one thing after another.

Topol: He cracked the case for SARS in 2003 and he sequenced the genome.

Lewis: He made the sequence quickly, like in hours. When I met him I thought, I don't deserve this character. My characters have earned rights. But what right do I have to write about this? I got a D in biology my sophomore year in high school and placed out of my science requirement in college by taking something called Physics for Poets. It felt almost inappropriate, almost obscene for me to use him as a character, even though he was so interesting. I thought, Some good science writer will pick up on him. But I made a folder about him and put it in my desk.

And when the pandemic was in early stages in March 2020, I called him up. No one had found him. He was still kind of virgin territory. I said, "What are you doing?" And he said, "Well, the Centers for Disease Control and Prevention (CDC) has a test that doesn't work. And so we've turned the Biohub into a COVID testing lab and we're going hunting for the virus." So that was case number one.

For each of characters, there's a story a bit like that of someone saying to me, "You've got to talk to this person." In the case of Charity Dean, five different people said it. In the case of the Wolverines, it was people who had helped me indirectly with The Fifth Risk, the book I wrote about the federal government as a manager of existential risk. Anyone near the pandemic space knew these guys because two of them had created the country's pandemic strategy and all seven had spent time working in the White House. They were an odd collection.

The whole notion of doctors in public policy was odd. When you go to Washington and start talking to people about public policy, you inevitably will be talking to some lawyer. And even if they're talking about science, they are quick studies and not subject matter specialists. But these were real, hands-on doctors who had wandered into the creation of a public policy and found in each other companionship, inspiration, teammates. They had been together for the better part of 15 years and whenever there was an outbreak anywhere in the world — MERS or SARS or Ebola — they were close to it either in the federal government or in prominent positions where they could have some effect on disease management. I thought that was riveting.

It was clear to me when I started this thing that we weren't going to get to the pandemic until halfway through the book, because what happened before told you so much about what was going to happen during.

Topol: Each of these four people or groups are protagonists and had their own premonition path. On the cover of the book, you have dots. Are the dots the Laura Glass model, or are they the 5000 public health people who respond to nobody?

A Science Fair Project Goes to the White House

Lewis: If you look at the cover, one dot becomes two and then creeping around the edge are other dots. It's exponential growth. It's the way a virus replicates.

The Laura Glass story is an example of the quality of the material I was working with. Bob Glass was kind of an all-purpose scientist at Sandia Labs. He's a very smart man who was working with a computer model he had created, an agent-based model, and his daughter Laura was watching him play with his model. On the screen were all these green dots and one red dot, and they moved, he explained, according to rules that he wrote for them. He was trying to show the way gossip spread or the way an angry person became a mob, or how a panicked person in the financial markets became a financial crash — the way information kind of cascades through a society.

Laura was looking at it and thinking, oh crap, another year rolling around and Dad's going to require me to enter the science fair again. She actually loved doing it, I think. But Bob Glass was like a Little League dad, but instead of baseball, it was science fair. Laura looked at the model and she said, "That could be the science fair project because that reminds me of the way disease spreads." She had been learning about bubonic plague. So she set about modeling disease spread.

It started out as a sweet little project, and then it spun completely out of control. It went on for several years. Bob Glass roped in the smartest programmer he knew at Sandia. (It was like hiring LeBron James and Steph Curry to play in your pick-up basketball game.) The model they created is very stylized but quite interesting because Laura does all this research about how people interact in their communities: how many face-to-face interactions, how close are they, how many people do they see in a day, where do they see them. And they built rules for the citizens in the community to move around.

Then they started to predict where people would be infected, how they would be infected, and how fast they would be infected. They move from plague to flu as the disease. And they start to see that you can do things in this community to jam up disease transmission. In particular, given the rules, closing schools has a huge effect. Bob Glass is looking at the epidemiologic literature in 2006 and the playbook says wait for a vaccine. The so-called nonpharmaceutical interventions were supposedly discredited back in 1918.

At the same time, two doctors in the White House, Richard Hatchett and Carter Mecher, are trying to answer the question, what do you do when a pathogen is loose in society? Before you get a vaccine, how do you slow it; how do you prevent illness and death? They had very fancy people turning up with early disease models, like Neil Ferguson from Imperial College in London, people who end up being giants in their fields. But Carter Mecher said these models were so complicated, they couldn't really use them to experiment with, they couldn't ask questions like what happens if you ban large gatherings?

So Carter Mecher knows somebody who used to date Bob Glass's sister, who knows about this kid's science project and sends him the model in the mail. Bob Glass had spent the better part of a year banging on the doors of epidemiologists saying, "Please, can you look at this," and no one is answering the door. Now the White House calls and says, "This model seems really cool. Can you get on a plane and come to the White House?" This model is one of the tools they used to design the pandemic strategy that ends up saving a lot of lives in other countries, because the plan is exported. And the punch line to it all is, Laura Glass doesn't win the science fair.

Two Cities, One Paper, and Social Distancing

Topol: I was surprised that it was the Bush administration that wanted a pandemic preparatory plan and Bush brings in Rajeev Venkayya. Then Venkayya brings in the two doctors you just mentioned, Richard Hatchett and Carter Mecher. Carter is known as Rain Man because he's all about the data. Rajeev writes the pandemic plan; he ghostwrites it for the CDC in 6 hours. And Carter ghostwrites the CDC social distancing plan.

In the book, you get into their 2007 PNAS (Proceedings of the National Academy of Sciences) paper that compares outcomes in the 1918 pandemic in St. Louis vs Philly. Up until this time, that is one of the most cited papers during the pandemic because of masks and social distancing.

Lewis: It's an amazing story of people pursuing a solution to the ends of the earth. They are involved with a very skeptical public health community. They've got this toy model that is part of some girl's science fair project, and the public health community is not totally persuaded by the model. The models are not in vogue at that time. Carter and Richard are looking at the evidence the other side is offering, which is that people did this in 1918 and nothing happened. It didn't work.

Carter says what happened next was accidental. Rajeev says to Carter, I was supposed to be on a panel with John Barry, the guy who wrote the book The Great Influenza, about the 1918 pandemic. I can't make it. Could you do it? And Carter thinks, Oh God, I have to read his book. So he reads the book and it's a story of carnage. People just died as the wave of disease spread across the country.

There's no sense in the book that anybody did anything that worked or helped, but Carter notices that, in the book, you can see the outcomes are not the same in St. Louis as in Philadelphia, for example. So Carter and Richard go back and reinvestigate this incredibly important historical event, and they discover something new. There was a reason St. Louis had a fraction of the deaths of Philadelphia. It involved the measures they introduced — closing saloons or whatever. Carter and Richard went back to the newspapers of the time to find out what they did in St. Louis. Their interventions were earlier in relation to the arrival of the virus in the city and this stuff did work. The people just did not see it at the time.

So these two doctors are not academics. As Richard said, "We were just a couple of buffoons, and Carter and I wouldn't know a regression analysis if it bit us in the ass." So they've got to find someone to write this with. They end up working with Marc Lipsitch, at Harvard, who thinks these guys are incredibly interesting. Of course you'd work with them. And Lipsitch does know how to do a regression analysis. He's a giant in his field. And they start to change opinion about this idea. This is the story of the idea that these nonpharmaceutical interventions will have some effect. And it is breathtaking. We'll never know how history would have played out without these two men. I think you can make the case that they saved hundreds of thousands of lives.

Topol: They published this in 2007. They challenged the dogma that was widely accepted that distancing doesn't really make a difference, maybe masks help a little, but you just have to accept the fate of the pandemic. That was a landmark paper.

Lewis: Carter's this working-class guy whose dad is a tool and die maker. He's by nature kind of an engineer type who became a doctor. He says he has ADHD or "one of those damn things" so he had focusing problems and he still does. When you ask him a question, he gives you a 20-minute answer to some other question that was a better question you should have asked. That's not the kind of person who usually goes into medicine. But this person manages to have the brain power to basically teach himself. Classrooms weren't his thing. His mind would wander. But then he gets into an ICU and finds his calling because, as he said, it was like Ritalin. "I get into an ICU and my decisions are going to determine whether this person lives or dies," he says. "All of a sudden I was engaged." Then he manages to bottle that feeling and move it with him; instead of saving the life of a patient, he's saving the life of a hospital. Then he's saving the lives of nine hospitals, managing hospitals in the Veterans Administration. And then he thinks, I have to save society. This need for urgency made for a really interesting character.

A Clinician Gem in the Bureaucracy

Topol: I want to turn to the character who I thought was the most colorful of all, Dr Charity Dean. She's a physician in Santa Barbara. You tell the story about how she cracked the case of a hepatitis C outbreak through this so-called orthopedic medicine doctor who is obviously a scam artist. Then she cracks the UC Santa Barbara meningococcemia outbreak. She's a phenomenal public health physician. She moves to Sacramento to be California's kind of number-two physician. But a distant number two, or as you called it — L6.

Lewis: She is fascinating. She had a pretty traumatic upbringing. She grew up in a very religious community that frowned upon women getting an education, and she had a lot of reasons to have a lot of fear. Bad things happened to her, and for her own sake and for the job she had to do, she decided to will herself to be brave. She decided that no matter how much fear she had, she would be brave, and this quality became necessary over and over again in her life.

She was told by her boss early in mid-January and into February 2020, "Don't use the word 'pandemic.' You're scaring people. Don't do your math on your whiteboard showing how, if we don't do anything, 20 million people in California are going to be infected." Don't do this. Don't do that. She was shut out of meetings and marginalized. Another person would have been cowed.

So, what happens? We enter her story at the top, when she is thinking that she's been sidelined for an event she's prepared for her whole life. She is, I believe without question, the most qualified person in the state of California's government to be running pandemic response. But she's not allowed to even talk to anybody about it. Into the Newsom administration roll some Silicon Valley software programmers and entrepreneurs. The one who's chiefly responsible for what ensues is a fellow named Todd Park. He had founded three separate billion-dollar healthcare companies. But he's very receptive, very modest, and he has a reputation for fixing other people's problems without taking credit for it. Among the problems he helped fix was the healthcare.gov problem in the Obama administration. Obama brought him in to become the chief technology officer for the United States.

Todd Park writes a note to a friend who is Newsom's chief aide and says, "I'm praying for you. If you need anything, call me." The guy calls him right away and says, "Get here as fast as you can because we need to figure out what this thing is going to do to California." This is in late March 2020. Todd Park has a very interesting attitude toward big institutions — not just government institutions but also big private companies. His attitude is, if there's a crisis, there's usually someone in the institution who knows the answer to the crisis, but they're usually not where they need to be. The organizational chart is not designed for the crisis that happens. So when you get to a place, you root around and ask, "Who knows about this?" So Todd asked, "Who here knows about communicable diseases?" Everyone knew it was Charity Dean who could talk about the pandemic. They had seen her in action many times.

So Todd Park asks her questions about how she thinks about this thing: "What do you think is coming? Why do you think it's coming?" He picks her brain. After a couple of hours, he says, "You're why I'm here. I'm not here to build an abstract model for Gavin Newsom to analyze disease spread. My job is to get everything in your mind onto Gavin Newsom's desk." So they build a model. But the model is simply to get everything Charity Dean knows into the assumptions in the model, to scare the hell out of Gavin Newsom so he will shut down the state. And that's what happens. What Todd Park says is, "I've seen Charity Dean over and over and over again in various forums, and she's always six levels down from the top in the organization."

That why I call Charity the L6.

States Take the Lead

Topol: We both live in California, and on March 19th we got a government order from Newsom that said stay at home. The first in the country. Little did we know that Dr Charity Dean was the person making the call and that Ken Cuccinelli from the White House [deputy secretary of homeland security] was getting advice from Dr Dean.

Lewis: After that, Todd Park and the group of people who come in to help Newsom say she's the person who knows what to do, who could write a plan for the state of California. And she says, "At this point, I can write a plan for the state of California, but it's got to be a plan for the country." She said, "I could have given you a plan for the state of California in late January that would have involved checkpoints on highways and testing people inside airports and reverse-cordoning ourselves, but it's too late already for that. The virus is all over the country. We need a national response to mitigate it."

So she writes this plan and it's instantly in the hands of a man named Andy Slavitt, who this year has been helping run the Biden administration's response, and who in 2020 was in conversations with Jared Kushner, who was looking for a plan. Charity's plan is forwarded to Jared Kushner but not as her own; she can't put her name on it because she works for Gavin Newsom. She can't be writing plans for the Trump White House. But what comes back is that Trump is all on board with this thing. And she thinks that the next day at a press conference, he's going to announce the plan, but instead something else happened; she still doesn't know what happened in the intervening time. I think the problem is that it demanded some sacrifice and accountability from everyone and he wasn't willing to ask for that.

This is when my characters come together. Early on, by January 20, 2020, the Wolverines are diagnosing what's going on in Wuhan. They have a bead on the transmissibility and the lethality, enough of a bead that they know it's coming here and it's going to be bad. They are shocked that the CDC and the Trump administration are saying it's no real threat to Americans. And that goes on for more than a month.

Seeing that there's no coordinated federal response, they start looking for governors they know and they can talk to. And if you map the US response onto the social relationships of the Wolverines, they have Ohio and Maryland, and California through Charity Dean. They have a way to speak to the governors of those states, and those are the three states that closed early.

So you have the Wolverines trying to manage this thing in a third-best-solution way. They rope in Charity as the person they can talk to in California. So she finds herself on these conference calls and she never knows who else is on. There are people lurking; she gets the sense that people from the Trump White House are lurking. One time she's speaking up about what needs to happen right after she's written her plan, and Ken Cuccinelli says, "Yes, do that, do that, you need to do that." And she says, "No, you need to do that. I'm just a nobody in the middle of it."

It's a remarkable, remarkable moment.

Plastic Flowers: A Metaphor for Response

Topol: When the Wolverines contacted Charity Dean, they thought she had to be the one in power. And here she was, as you say, marginalized. But somehow or other, they helped get her into that power position. I broke out in laughter in the chapter called "Plastic Flowers." Tell that story.

Lewis: When Charity Dean told me that story, I thought, This belongs in the book because it's a metaphor for the whole US response. She was a newly divorced medical student at Tulane School of Medicine in New Orleans. She was divorced because the church elders had told her to come home because her husband said he's being neglected. She had to make a choice between her marriage and her education, and she chose her education. She got her own apartment and it has this wonderful balcony. Everybody who's in the apartment complex walks by it to get to their apartments. Many of them are medical students and young professionals and people she wants to get to know. She kind of channels her mother, she says, and she plants all these flowers. She has the most beautiful porch full of flowers. But she herself has absolutely no ability to keep a flower alive. She's also studying her butt off in medical school and getting her master's in public health, so the flowers start to die. They don't die all at once; first a little bald patch appears in one of the flower beds.

By this time, she has the reputation of being the woman with the beautiful flowers — everybody is praising her flowers. She's invested in this new identity and the kind of person who has this beautiful porch but realizes that she isn't able to keep these things alive. She happens to have some plastic flowers in her house, so she just takes the plastic flowers to fill in the bald spots. But then more flowers start to die. So she goes to a Michael's arts-and-crafts store and she realizes that it's the beginning of the descent, when she's looking at these fake flowers in the arts-and-crafts store and trying to pick them based on the ones that look most like the real flowers on her porch. She buys bundles and bundles of these things, and before long, all the flowers are fake and they depend for their effect on keeping some distance between the people and the flowers. So now she's keeping everyone at a distance. People had been coming to her porch to have drinks with her and smell the flowers. But now she can't let them on the porch because if they get on the porch, they're going to find out. She engages in this incredibly energetic charade of being a person who actually has beautiful flower beds until one day some guy knocks on her door and she doesn't grab him in time. He runs out onto the porch, leans over, and recoils in horror when he realizes that these things are plastic.

Charity told that story to make a point. She said she feels like that was the CDC. The CDC, once upon a time, a long time ago, had these beautiful flower beds; the flowers were the power to control disease. Slowly but surely, the flowers died and they were replaced with plastic flowers. And their effect, the effect of the institution on people, depended on a certain distance. What happened in this pandemic was that we were all brought with our noses right up to the plastic flowers. And we realized this place is not what we thought it was.

Topol: You undress the CDC through these various characters and stories so much so that readers could get the impression that maybe the CDC was trying to kill us all.

Lewis: That's an interesting observation because — obviously the people at the CDC are not that way — but if you were a Russian spy who was appointed to run the CDC and you had to do things in the beginning of the pandemic to maximize the devastation of this disease, what would you do? First, you would say that nobody else is allowed to test. You'd get the FDA in on it and say nobody's allowed to use any test but our test. So you stop all those people in those thousands of microbiology labs from developing a test. You're not allowed to do that.

Second, you'd say the test is on the way and it's great. Then when it arrives and doesn't work, you'd say, oh, well, we'll fix it. And you add a delay, you stall a few more weeks. By this time, the virus is all over the country. You would pretend to check people who are returning from China for COVID and track them. But instead, you'd only pretend; you wouldn't take their home addresses. Next to their names, in the space for their address, you'd write Los Angeles Airport or O'Hare Airport, where they entered, so no one could find them ever again.

When you get a call from a Wolverine named James Lawler, who ran a federal medical facility in Omaha, Nebraska, that is designed to take in people who've got terrifying new diseases and treat them and prevent them from infecting others... When James Lawler calls you and says, "I've got 84 people who've just been repatriated from Wuhan and I want to test them for COVID," you'd find an excuse not to let him. In this case, Robert Redfield, the CDC director, said they were not allowed to be tested even though they wanted to be tested because to do so would be performing experiments on imprisoned persons.

And on and on. It's hard to think of a trick they missed in maximizing the damage that this virus caused, especially early on, in the first 3 or 4 months.

This is not the story I set out to write. Trust me on this. I wasn't looking for the CDC to be the villain. In fact, that message seemingly conflicts with the whole point of The Fifth Risk, the previous book I wrote, about how important these government institutions are and how the people inside them are sometimes treasures. I believe that's still true of the CDC, even in spite of all this.

But it is not the institution I thought it was, and every single one of my characters led me to this conclusion. Years before Donald Trump is president, it's Charity Dean trying to fight disease outbreaks in Santa Barbara County and dealing with terrifying events on the UCSB campus, with outbreaks of multidrug-resistant tuberculosis, and over and over again finding that the CDC, an institution that is meant to have her back, instead is saying to her that all the risk of containing this is yours. If you screw up and cause a controversy unnecessarily, it's your neck that's on the chopping block. We're not going to endorse anything you do until we have perfect data.

They were so obstructive that she actually bans them from her investigations now. Charity Dean is the canary in the coal mine. She could have told you back in 2014 that this institution is not battle-ready. It's more an academic institution, and when the battles are fought, they come in afterwards and they collect data. They are like military historians.

Shifting Priorities

Topol: You had a good acronym, the CDOR: the Center for Disease Observation and Report. I thought the CDC's problems came along with Robert Redfield and the Trump administration, but it's so deep. When you told the story about the swine flu epidemic, that was illuminating.

Lewis: The question is, when were the flowers ever real? At what point did they smell like flowers? The reputation was there for a reason; it wasn't always this way, right? The CDC was created after World War II. Its original mission, if I'm not wrong, was to eliminate malaria from the American South, which is one of the reasons it is in Atlanta. They plan to eliminate malaria but find it's not there. The problem is already solved, for whatever reason. But they eliminate smallpox. That's one of the great triumphs. The World Health Organization is involved, but it's really an American-led thing. They do great stuff. When you read the memoirs of Bill Foege, who was the CDC director in the late '70s and early '80s, you're reading the work of a great man. You think, This guy may have total integrity. He's modest. He's a man of principle. And he really did fight disease with his bare hands.

But Foege also tells another story, which is how this institution started to shift right before he took control of it and how it shifted even further during the Reagan administration when he was in charge of it.

The story goes back to the swine flu nonpandemic of 1976, when there was an outbreak of a new strain of swine flu at Fort Dix in New Jersey. Some soldiers got it; it's highly transmissible. A soldier dies. It's treated as a warning shot for what's going to happen when flu season comes in the fall. Experts gather at the CDC, which at the time is a totally civil service–run operation; it has not been politicized. The experts concur that the thing to do is to get a vaccine as fast as possible and to store it — not in refrigerators, but in people's arms. And that decision is made, because if they wait until they find out there's actually a swine flu epidemic or pandemic, a lot of people are going to die before they can get the vaccine into their arms. Getting vaccine into the arms of 200 million people is not a trivial matter.

David Sencer is the director of the CDC then. Foege is a young man at the CDC and he's watching, set to run this meeting where everybody basically agrees with what they need to do. They also understand there's some risk. You don't stick needles into 200 million arms without something bad happening. So Sencer doesn't take a vote; he just writes a memo to his boss, the president, saying, "This is what we recommend." And he says to Foege, "I have to do it this way because if it goes wrong, someone needs to take the fall, and I don't want this whole group to take the fall. It's going to be me." Foege thought, If ever I'm in that position, I hope I have the courage to do what he did. Fast-forward to the fall. There is no swine flu pandemic. No one knows why. There's still no answer to that question. It was the first time in history that they knew of a new pathogen that was that transmissible, that didn't find its way through the population. The second thing that happens is that some people died because of the vaccine.

Topol: Because of Guillain-Barré.

Lewis: Sencer becomes the fall guy. He falls on his sword, he's banished from his tribe, the public health tribe in Atlanta. He never goes back to Atlanta. His son tells a heartbreaking story about this and how he descended into alcoholism. He bounces back eventually. But he did the right thing and we punished him for it. As his last act, he said, "I'll fall on my sword, but please appoint Bill Foege as my successor."

It was the last true civil service appointment in that job, because what happens is that the Reagan administration rolls in and Foege all of a sudden finds that the White House is paying a lot more attention to what's going on at the CDC. When CDC researchers publish findings that young children who are given aspirin sometimes develop Reye syndrome, the aspirin manufacturers come down hard through the White House. They're donors to the Reagan administration, and the research is shut down or they are made to do it all over again. Foege is so upset by this — that they will put young children's lives at risk for the sake of some aspirin manufacturer's profits — that he quits. He told me that he wishes he hadn't quit because "If I made them fire me, it would have been a messy thing, because I wasn't there at the grace of the Reagan administration. I was a permanent civil servant. I had protection. They would have to show malfeasance on my part."

The Reagan administration must have been aware of this because right away they turned that job into a politically appointed job, and that's a drift our government has been on for a while. These jobs that were permanent civil-service jobs became presidentially appointed, political jobs. And that has a big effect on the incentives in the institution. Suddenly, the person chosen for the job is picked out of a smaller pool of people who are politically pleasing to whoever is in the White House. They're not picking from the big pool so they're not likely to get as good a person. Moreover, appointees are on a short leash; the president can fire them on a whim and they're going to be paying a lot more attention to what the president wants rather than what the institution needs. Finally, these presidential appointees last in office about 18 months to 2 years. Certainly, they don't last beyond the term of the president. So they're dealing with short-term problems possibly at the expense of the long-term interests of the institution. That's a big deal. I think an institution that's managed by someone who's only going to be there a couple of years, or assumes they're only going to be there a couple of years, is different from an institution that is managed by someone who plans to be there for 15 years.

Topol: It wasn't the intent of the book, but what you went through from all these different characters is the failure of the public health system. These are the characteristics of our CDC even now. We're starting to see conflicts about masking, trying to do the right thing, trying to be bold but then having this confusion engendered. More and more, CDC is lacking boldness and is fearful.

Lewis: You create a bias toward inaction in that institution because the sins of commission that get punished, like vaccinating people before a pandemic, that doesn't happen. You get the death penalty for that. Whereas if you wait, like they did with this pandemic, it's too late. It's already all over the place and they say nothing could have been done anyway. That narrative is easier to tell. The sin of omission is easier to cover than the sin of commission. Dealing with the disease is easier than insisting on prevention. I'm not the official historian of the CDC, but that seemed to be an important moment and an important change at the top.

Discerning a Problem Inside vs One Coming In From Outside

Topol: I want to get to one other topic before we wrap up, and that's the genomics of the virus. So now the CDC has $1.2 billion to look at the genomics of the virus and nothing's happened yet. As you pointed out in the book, at one point not even 1% of the samples were getting sequenced. With genomic sequencing, you're basically making a movie and following the virus spatiotemporally. It's an incredibly powerful tool. You could tell now, if someone has a breakthrough infection like with the Yankees, you could say, "You know what, it was this guy who came in and he infected the other eight people." You could do that all through sequencing. Yet there's no plan, there's no system in place.

Lewis: That gets back to the question of how I found or chose these characters. One of the traits that's essential in any character of mine is that they be an unbelievable teacher, because they have, as their student, a total ignoramus — me. Joe DeRisi was an unbelievable teacher about the importance of this technology. It was his lifelong obsession and he can explain clearly the way we were blowing it.

This particular virus is perfectly trackable, because it mutates once every one or two transmissions. If it didn't mutate at all, you couldn't track it. There'd be no change from one person to another. You couldn't show that your infection was a downstream mutation from my infection. If there was one error in the code, then quite likely you either got it from me or, at most, there was one person between us. The common cold virus, in contrast, makes errors in itself so fast, that inside a single human body it mutates around any potential vaccine. So that's just a mess. There are too many fingerprints at the crime scene to figure out who committed the crime.

But in the case of COVID, this virus makes errors in itself in almost the perfect way to use this technology to track it. The power of that is, if there's a variant that escapes the vaccine, it sure would be nice to know. And the only way you can know that is to sequence the virus. As I was reporting the book, I was watching various enterprises trying to control the disease — nursing homes, local health offices in rural counties, factories trying to reopen, and schools. In every case, it seemed to me that they had the same problem in that they were designing their environment to be safe in the presence of this virus. Make sure the tables are spaced 6 feet apart, practicing hygiene inside the environment. And at the same time, they were trying to guard against the thing coming into the environment. Transmission within the environment and transmission from outside are different things, and if you could distinguish between them, it's very powerful.

For example, Joe DeRisi got two positive COVID tests from a single factory, a plant in rural California. I think it's a fish-packing plant. The plant was about to close down because they thought they had an outbreak. They assumed one of these people gave it to the other one and that they had to figure out how to redo the assembly line. But, no, the two viruses were genetically dissimilar. The two people had been infected separately from outside. So the problem was border control for the factory. Don't let those people into the plant. It wasn't a mistake inside the plant. If you're engaged in hand-to-hand combat with this virus, knowing that your walls are insecure vs being insecure inside the walls is important.

Another thing that was fascinating to me, and I still can't believe how little attention this has gotten, is that the genetic relationships reveal social relationships. It's important when you're in the middle of a pandemic to have a deep understanding of your society's social relationships. It's important to know that this particular neighborhood has a high concentration of workers who have to leave the neighborhood and go to a place that's not safe, and they're coming back and bringing the virus back with them. Or that these guys sitting on the wall of the park are infecting each other when they're playing chess.

Topol: Our listeners are physicians and healthcare workers. They could be getting the infection from patients, from their colleagues, or when they go to the grocery store. This is the way to sort it out. And now in the world of variants and vaccines, and whether the vaccines are protective, it's all the more important. I hope we'll finally get serious about this. We have the resources at the CDC.

Lewis: The resources are at the CDC, and the first step CDC made was to have privileged conversations with big corporations that are going to make a lot of money out of it, as opposed to opening up the conversation. If I were Biden, I'd call Joe DeRisi and say, "You're in charge. Here's the $1.2 billion. Figure out what to do with it. We may have to install you in the CDC for cosmetic purposes, but just do it."

It's troubling that we have such talent and resources at our disposal and we blow it. I coached a really good girls softball team once. It was an incredibly talented team. When that team lost, I felt like shooting myself — like it was my fault, not their fault. I feel like our COVID team lost because of the coaching and the manager, not because of the resources or the talent. The talent is there.

Topol: The term I like to use is bureaucropathic. Michael, this book is a freakin' masterpiece. I encourage everyone in the audience to read this book. It's not just about the pandemic but also the warmup over 15 years that you nailed through these fascinating characters. Michael, thank you for this book, it's a present for us.

Eric J. Topol, MD, the editor-in-chief of Medscape, is one of the top 10 most cited researchers in medicine, and frequently writes about technology in healthcare, including in his latest bookDeep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

Michael Lewis is the author of numerous New York Times bestsellers, including The Blind Side, The Big Short, and Moneyball. He grew up in New Orleans and now resides with his family in Berkeley, California.

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