The Premonition: A Pandemic Story

In 2003, 13-year-old Laura watches her father, Bob Glass, work at his computer. He’s focusing on a project for his job at Sandia National Laboratories (where scientists find solutions to problems that no one else can). The Federal Reserve has engaged him to help figure out how failures in the US economy could spread to other areas, and he’s refining what he calls an “agent-based model” (4). His model has many green and red dots that stand for people. When red dots touch green dots, the green dots become red.

To Laura, the red dots appear to be infecting the green dots. She asks if the model could study the spread of a disease, since she’s interested in the Black Death and other infectious diseases and wants Bob to help with her project on the subject for the science fair. He agrees, and they work on the project together, with Bob treating her like a graduate student.

He enlists Walt Beyeler, a programmer, to help her. Beyeler programs social interaction variables into the model. Laura wants to pick a pathogen to study that’s relevant to modern times. After learning that the 1918 flu pandemic killed 50 million people, she and her father decide to study influenza and vaccine distribution among age groups. Laura and Bob both conclude that children are far more likely than adults to infect others given the differing nature of their social interactions. They realize their project’s importance when they learn that because of a contaminated vaccine factory in Liverpool, England, only half the projected supply of flu vaccine for the US will be available for the coming year.

The basis for Laura’s presentation is to ask what would happen if, for a particular viral strain, a vaccine wasn’t available in time. She focuses on the 1918 pandemic, during which removing the sick from society was the primary measure of containment. Bob and Laura realize that to mitigate a pandemic, isolating people to make it impossible for them to infect each other—temporarily preventing them from real-life social interaction—is just as effective as giving them vaccines. Laura’s project wins the New Mexico State science fair.

Dr. Charity Dean, the 37-year-old chief health officer for Santa Barbara County, California, learns of a patient who died of tuberculosis (TB) in the brain. Dean hears that the TB moved into the woman’s lungs, enabling it to spread as an airborne pathogen. Dean is interested because Santa Barbara County has a disproportionate amount of TB cases, and she wants to know why. Her task is to find out whom the woman may have infected.

The reason that she took the job as chief health officer was that crisis—and solving crises—intrigued her. As a child, deaths—particularly horrible deaths from diseases—fascinated her. After completing medical school and studying tropical disease, she worked in Gabon and Niger to prepare herself for pandemics that might come from Africa. After accepting the job for Santa Barbara County, Dean realized that she has the legal power to stop diseases. If she sees a measure that looks like it will curb a pandemic, she has the authority to enact the measure. She knows the law better than most people. Dean focuses on the difference between communicable and infectious diseases:

All communicable diseases were infectious, but some infectious diseases were not communicable. Communicable meant a person could give it to another person. You could get Lyme disease, for example, but you couldn’t give it to somebody else. Communicable diseases were the diseases that created crises (16).

She considers it her duty to intervene whenever she suspects the threat of a communicable disease.

She visits the coroner treating the body of the woman who died of TB. When she asks for a sample of the woman’s lung tissue, he refuses and lectures her about TB, even though she has far more experience with the disease. She writes a legal order, compelling the sheriff to secure the coroner’s cooperation. At the morgue, the coroner has the woman’s body outside on a picnic table and says that it’s too dangerous to perform an autopsy indoors. Dean realizes that the threat of TB frightens him. He gives her garden shears and says that she’ll have to open the corpse. Dean cuts the body open, and the coroner helps her with the lungs. They see that the TB never left the woman’s brain, so it couldn’t have reached her lungs.

When Charity Dean got the job of deputy public health officer for Santa Barbara County, Paige Batson had been a nurse with the county for 10 years. She says that no one was exactly sure what a public health officer did but that Dean surely did things that no other public health officer would have. She saw patients, learned from nurses, and always seemed to be present for strange events. Paige comes to think that Dr. Dean is the cause of these events.

Dean reviews the case of a woman who tested positive for hepatitis C after donating blood. She didn’t have hepatitis C months earlier—when she last gave blood. Dean asks Paige to follow up with the woman and learn how she’d spent her time in the months between the two blood donations. Paige learns that the woman underwent many procedures that could have resulted in infection.

To give insight into Dean’s approach to this case, the narrative reveals that as a first-year resident, she worked for Dr. Stephen Hosea. He was skilled at figuring out what was wrong with patients but often learned critical details through conversations that seemed irrelevant to observers. He thought that a patient’s social history could be the most important piece and saw his role as something like a medical detective. After that year, Dean focused on her patients’ stories in the same way rather than simply trying to diagnose from symptoms.

Dean learns that the woman with hepatitis C received stem cell treatments at the Thomashefsky Clinic. After a visit to the clinic, Paige reports to Dean that the clinic disturbed her. Dean returns with Paige, and they search the offices. She finds that the processes for tracking blood vials are haphazard. She watches Thomashefsky with a patient and notes that he follows no rules to prevent the spread of infection. Dean shuts down the clinic and then asks Paige to contact each of Thomashefsky’s patients from the prior 18 months to tell them that they may have hepatitis C. The CDC resists her efforts, and she receives no government support. However, tests reveal four more positive hepatitis C cases. California strips Thomashefsky’s license, and he closes his Oregon practice.

Dean knows that she can’t rely on the CDC’s support. She recalls how she learned this, after becoming chief health officer in 2013, when she investigated a meningitis B case. A 19-year-old boy contracted the rare disease, and the student health doctors panicked. Dean wanted to shut down the fraternities and intramural sports teams but received no support from the conflict-averse CDC. The campus followed her orders. Unhappy with the CDC’s response, Dean cut ties with them.

Dean’s temperament and tenaciousness are equally clear in her work after a mudslide in Montecito. On December 7, 2017, a fire in Ventura County, California forces the evacuation of over 100,000 people, and ash make breathing difficult. On January 8, a rainstorm leads to a massive mudslide, and Dean must figure out what’s in the toxic, ash-saturated mud that covers many homes. The only people unwilling to evacuate are residents at Casa Dorinda, a rest home for the affluent. It now rests in the middle of millions of gallons of toxic material. Some of the residents are too frail to move, but Dean knows that another mudslide will kill them. She tells the medical director that they must move the residents, and seven deaths result. The medical director blames Dean. Dean is upset but thought that the potential fatalities had she left Casa Dorinda occupied would have been worse.

After the mudslide, Dr. Karen Smith offers Dean a job as her deputy in Sacramento at the Department of Public Health. She wants Dean’s help because she acts boldly and decisively to make decisions. She accepts the new job.

Dean has a premonition. She feels that something bad is coming but doesn’t know why:

What scares me most, and what I think about most […] is our ability to respond to a new pathogen, maybe one we’ve never seen before, or an old pathogen, like influenza that’s just mutated. The H1N1 pandemic of 1918 was over 100 years ago now. The world is overdue for a pandemic like that, whether it’s influenza or something else. And in public health, we know that we have to be prepared for that (49).

In 2015, a doctor named Rajeev Venkayya drafts a plan to fight a pandemic. George W. Bush asked him to write this plan after reading John Barry’s book The Great Influenza: The Story of the Deadliest Pandemic in History. Venkayya is the head of The Biodefense Directorate, a small branch within Homeland Security that focuses on biological threats. He finds that Homeland Security is reluctant to talk about weaponized flus and instead focuses on anthrax and ricin. The department doesn’t treat naturally occurring threats as urgent.

The cabinet secretaries sign the report. Bush announces the plan and outlines its three parts: detect overseas outbreaks, stockpile vaccines, and be ready to respond when the threat arrives. Congress supports the strategy, committing 7.1 billion dollars but outlining no clear strategy the money’s use. Bush hires seven people to help. One is a doctor named Richard Hatchett, who was involved in post-9/11 talks about bioweapons. His research on the spread of smallpox led him to the idea that simple social distancing was an effective containment strategy, just as Bob and Laura Glass’s research had led them to that conclusion.

Another member of the group is a doctor named Carter Mecher, who works in the Intensive Care Unit (ICU) at a Veterans Affairs (VA) facility in Atlanta. Carter has attention deficit disorder (ADD) and can focus only when working with his hands or trying to solve a problem, so the intensity that the ICU demands suits him. Emergencies help him focus. Carter views the sub-optimal workings of the VA system like a sick patient. He creates new metrics for success and manages to turn the Atlanta system around to an unprecedented degree. His primary concern becomes identifying mistakes before they can happen. He wants to create environments that make it impossible for mistakes to occur, so he develops what he comes to call the Swiss cheese strategy. Carter doesn’t think that a pandemic can have one solution but that a meaningful response must employ as many effective solutions as possible, layered on top of each other, like Swiss cheese, until no visible holes remain.

In 2006, Bob Glass has become obsessed with his daughter’s project. He thinks that their model could help stop disease. However, no one will pay attention to their ideas, so he writes a paper for a journal. Every publication rejects him because he’s unknown in the field. Then Bob receives a call from Richard Hatchett, who invites him to the White House. Carter Mecher sent Glass’s recommendations to Hatchett, and he recognized that Glass would be useful. Hatchett knows D.A. Henderson, the man credited for eradicating smallpox. Henderson is anti-model at first. He’d responded to a flu in 1957 and 1958, and he’d urged isolation of the sick.

Hatchett’s primary focus is to lower the reproductive rate of pathogens. Glass thinks that diseases could be wiped out without a vaccine and that if each infected person infected less than one other person, the disease would wither. Carter and Richard support Glass’s convictions. Carter turns Glass’s numbers into a graph, which leads to one striking conclusion: closing schools and enforcing social distancing between children would have a massive payoff. In the US, this would prevent a disease from beginning to spread among 50 million K-12 kids and on 500 thousand school buses. Carter calculates that in school, kids have a 3.5-foot radius from other children. He visits a school for a day of observation and concludes that as the most socially dense places, schools are the best environment for transmitting diseases.

Hatchett names their strategy Targeted Layer Containment, or TLC (a more formal version of the Swiss cheese moniker). Carter finds lots of skeptics and knows that he and Hatchett will have to change the minds of the CDC people. Carter writes up the strategy. The CDC flags nearly every line, and all the flags are from one woman, Lisa Koonin, whose comments all show subject knowledge. Carter visits the CDC.

Carter appears on a panel with the author of The Great Influenza: The Story of the Deadliest Pandemic in History, John Barry. Carter begins studying the Philadelphia outbreak and sees that Philadelphia’s leaders were too slow to respond. Earlier restrictions would have resulted in fewer deaths, but in 1918, officials didn’t order closures until the pandemic had raged for a month. St. Louis had fared better during its outbreak than Philadelphia even though their citizens had initially resisted government interventions. In May 2007, Hatchett and Carter write a paper on their findings for Proceedings of the National Academy of Sciences. Their paper shows the importance of timing during a pandemic.

ealth

Laura Glass goes to Washington, DC for her final science competition. She doesn’t win a prize like she did at the New Mexico state fair, but her findings on using targeted social distancing strategies to effectively limit the local progression of a virus are already beginning to shape CDC policy (through Hatchett and Carter’s Targeted Layer Containment strategy).

As Barack Obama’s term begins, Carter Mecher stays at the White House as an advisor to the new administration. He’s shocked by the government’s inefficiency and spends most of his time without clear direction. In April 2009, a friend calls to tell him that two people in Southern California, 100 miles apart, have a novel swine flu virus—and Mexico City has a deadly flu outbreak. Carter tells Heidi Avery—his new boss—that the flus are related. He tells President Obama that he worries about a repeat of the 1918 pandemic and outlines a potential strategy. Carter brings Hatchett to the White House to help him. Hatchett keeps a journal of their response to this swine flu and thinks they get off easy.

In Mexico, officials follow their recommendations and close schools. In addition, they institute social distancing. In the US, Carter and Hatchett’s response plan gets little support from the CDC: It lets each school decide for itself, and few close their doors. Fewer than 13,000 US citizens die during the swine flu outbreak, although the potential was much higher. Hatchett thinks that the perceived victory will instill a false sense of confidence. Nevertheless, he’s confident that the discussions they had gave them options for the future, such as school closures. Carter notes that if a serious pandemic ever returns to the US, New York’s response will be crucial.

In a flashback to 1967, the book tells how when Carter was 11, his mother took him and his siblings to a Chicago fallout shelter as volunteers. He decided that the shelters were a bad idea and that a real nuclear war wouldn’t resemble this. He felt similarly at the end of the 2009 pandemic, when people congratulated themselves for not closing schools.

Avery asks Carter to stay in the White House. He agrees to remain through Obama’s first term but in 2011 returns to the VA. He knows that the next pandemic will be worse and almost feels as if he must be clairvoyant.

The narrative switches to another flashback, revealing that Charity Dean grew up poor in Junction City as a member of a “divisive and fear-based” (127) church. In school, the instructors wouldn’t allow her to learn about evolution. When missionaries returned from Africa, their stories of plagues had her spellbound. She studied microbiology at Oregon State and then went to Tulane Medical School. The church approved but only if she married a pre-selected man. She agreed but divorced him when he complained to the elders that she worked too hard at school. The community shunned her, and she often compared herself to David, overcoming giant challenges.

In 2019, in Sacramento, Gavin Newsom hires a New York City health official, Sonia Angell, who eventually becomes Dean’s boss. Dean makes a list of resolutions on December 21, 2019. She writes a prediction: “It has started” (131).