• Once it became clear that swine flu would come and go, like a massive hurricane that dissipated before making landfall, it became something else. A message in a bottle. A premonition. A warning.
• I think this particular story is about the curious talents of a society, and how those talents are wasted if not led.
• If this story speaks to that management in any way, I hope it is to say: There are actually some things to be proud of. Our players aren’t our problem. But we are what our record says we are.
• American society had no ability to deal with what she felt was coming. “The United States doesn’t really have a public-health system,” she said. “It has five thousand dots, and each one of those dots serves at the will of an elected official.” (Charity Dean).
• But we should be prepared for the possibility, even if we are going to accompany modern firefighters into Mann Gulch, that the terror of the universe has not yet fossilized and the universe has not run out of blowups. —NORMAN MACLEAN, Young Men and Fire
Michael Lewis, The Premonition: A Pandemic Story
(Note: this is a pretty long post. This book has so much that is valuable and useful…)
It is my job to prepare synopses of books. I read the book; I prepare a comprehensive, multi-page synopsis handout. I present my synopsis.
In most cases, it feels like a challenging but doable task. When I finish, I feel like I’ve done a pretty decent job.
And then along comes The Premonition by Michael Lewis. I felt…overwhelmed. How do I reduce this masterpiece of storytelling and detail to a simple synopsis?
Let me get this out of the way. I have a lot of favorite writers. But, for contemporary nonfiction, Michael Lewis stands at the top of my list of favorites. He is a remarkable storyteller! He wrote: Liar’s Poker; The Blind Side; Flash Boys; Moneyball; The Big Short; The Great Undoing; The Fifth Risk; and now, The Premonition. They are all very much worth reading. With The Fifth Risk, and now The Premonition, if you read these two, you will wonder how in the world we can ever make a great, great big complex government work.
In this book, The Premonition: A Pandemic Story, Michael Lewis tells the story of…how a few people got it, and so, so many missed it.
With all of my synopses, I ask “What is the point?” of this book. Here is my answer for this book: We had warnings. We had a premonition. But we did not get ready for the Great Pandemic of 2020. And it cost us dearly.
And I ask “Why is this book worth our time?” Here are my three reasons for this book:
#1 – This book is a master class in story-telling.
#2 – This book is a reminder that one person, in the right place at the right time, can make a difference.
#3 – This book is a stark reminder that we weren’t ready. And it raises the question, will we be ready the next time?
I always include many Quotes and Excerpts from the book – the “best of” Randy’s highlighted Passages. Here are the best of the best that I included in my synopsis:
• For years the University of Texas football team, with its vast resources and sway with voters, always seemed ranked more highly at the start of the season than at the end. The United States was the Longhorns of pandemic preparedness. It was rich. It had special access to talent. It enjoyed special relationships with the experts whose votes determined the rankings. Then the game was played. …As the legendary football coach Bill Parcells once said, “You are what your record says you are.”
• By her second year on the job, (Dr. Charity Dean) found herself quoting the law so often that she asked her assistant to laminate a copy of that one passage, so that she might carry it with her in her briefcase. Each health officer knowing or having reason to believe . . . “What does that mean??!!” she’d cry, and point her finger in the air. “It means suspicion! You only need to suspect!”…shall take measures as may be necessary to prevent the spread of the disease or occurrence of additional cases. “ ‘Shall’!” she’d exclaim. “Not a may. A shall. Not think about it. Not consider it. Not maybe get around to it one day if you feel like it. It’s your duty. If you suspect disease, you can do whatever the hell you want.”
• There is no shortcut to courage. Courage is a muscle memory.
• A lot of people had died because doctors had allowed their minds to come to rest before they should.
• “People don’t realize what it is until something bad happens.”
• The root of the CDC’s behavior was simple: fear. They didn’t want to take any action for which they might later be blamed. …They wanted to observe it as if it were a science experiment on how meningitis moves through a college campus. And I was like, ‘Are you kidding me: a kid just lost his feet.’
• The big thing about her boss, Paige thought, was that an American public-health officer, at some risk to herself, had taken the job of protecting the public’s health as seriously as it had ever.
• The call for doctors and nurses after the 9/ 11 attacks struck Richard as so haphazard that afterward he wrote a crisp memo to the people who ran the Alfred P. Sloan Foundation, arguing that they should use whatever political clout they had to push for a national medical reserve corps. …In his 2002 State of the Union address, President Bush would call for the creation of a reserve medical corps. …By the time they’d finished, the medical reserve corps had one hundred offices and two hundred thousand medical volunteers.
• Like Rajeev, Richard thought that the United States government was paying too much attention to the threats posed by people and too little to those posed by nature.
• The New England Journal of Medicine had just published a study of medical mistakes. It showed that for every thousand people admitted to a hospital in the United States, three would die from error.
• “They don’t come to work with the intention of harming anybody,” Carter said. “People make mistakes.”
• One way to reduce medical error, he thought, was to redesign the environment to make it more difficult for bad things to happen. He found a book called Human Error, by a British psychologist aptly named James Reason. “It was like reading the owner’s manual of the human mind,” he later recalled. He was struck especially by Reason’s argument that the best way to guard against error is to design systems with layered and overlapping defenses.
• He spent the next year making himself expert on why, and in what circumstances, people learned—and why, and in what circumstances, they did not. 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. For people to learn, they need to want to learn.
• Sandia National Laboratories had been created back in the mid-1940s in part to help the people stuck in various boxes to think outside them.
• There were seventy thousand buses in the entire U.S. public transportation system, but five hundred thousand school buses. … Kids are like those close talkers on Seinfeld. Look! They’re so different. They’re not little adults. They have a different sense of space.
“I couldn’t design a system better for transmitting disease than our school system,” he said after his visit. …Adults imagined their spaces smaller than they were and children’s spaces larger than they were. …“They’d forgotten childhood,” he said. “Adults just forget what it feels like to be a kid.”
• Richard’s other takeaway from his second tour of duty in the White House was just how little government was able to do quickly.
• “When you are looking at a disease, the disease you are seeing is from last week.”
• She (Charity Dean) learned that while there was only one road to heaven, there were a great many to hell.
• When space in the migrant shelters ran out, ICE workers would drive these people into cities in the dead of night and just leave them there. “I’d heard that Trump was trying to create a crisis,” said Charity. “Trying to turn people against immigrants. It was just a rumor. But when I get there I find this is all true. They’re just dumping families on street corners at two in the morning. They were trying to create a disaster.” …She got on the phone with this Duane guy and another colleague, a tough, bullying type from Texas who began by mansplaining to her how to manage an outbreak and then tried to deny the existence of the flights. “At which point I was like, Fuck you. I was there. I saw it.” A few days later the flights stopped. Charity never learned why.
• On February 19, the UC Davis Medical Center admitted a patient who had symptoms and no history of travel—and so did not meet the CDC’s criteria for testing. In any case, the hospital did not have the ability to test; for that matter, no one in Sacramento County had the ability to test. “By then Zimbabwe could test but California could not, because of the CDC,” said Charity. “Zimbabwe!”
• Donald Trump had said that it was every state for itself. In that one phone call, the Newsom administration had signaled to the local health officers that it was every county for itself, too.
• They would learn the lesson Charity had been forced to learn during her time as a local health officer: No one’s coming to save you.
• The cure meant nothing if the patient never received it. Standing between the cure and the patient, in this case, was a U.S. medical-industrial complex that lurched between lethargy and avarice.
Here are are a number of points, and people, and lessons, that I emphasized from the book:
- The warning:
- If there is the faintest possibility of a catastrophic disease, you should treat it as being a lot more likely than it seems. …you should treat the patient as if she has Ebola, because the consequences of not doing so can be calamitous.
- The lesson of the Mann Gulch Fire (1949):
- In fire you could see lessons for fighting a raging disease. He jotted them down: You cannot wait for the smoke to clear: once you can see 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. …The Mann Gulch fire captured the difficulty people had imagining exponential growth, even when their lives depended on it. …“We are reactive and tend to only intervene when things are getting bad,” wrote Carter. “And what we underestimate is the speed that what’s bad moves.”
- Yes, we got it wrong…
- He further guessed that, if left unchecked by the government, it would infect between 20 and 40 percent of the U.S. population.
- No more than 10,000 will die – (John Ioannidis, Medical Professor, Stanford, Spring, 2020).
- We were late on this; asymptomatic spread:
- The first time Gelman had written to Carter, it was to ask if Carter might help him with some complicated problem about hospital management. “Thirty-seven minutes after I wrote to him, he responded with this long, perfectly thought-out answer,” said Gelman. “He’s the vampire at the door, waiting patiently to be invited in.” …“Here is the scenario I would prepare for and why,” Carter wrote to the young VA doctor. …It is very likely that we have undetected community transmission in the United States and in many of the other 26 countries with confirmed cases in travelers. Except for the evacuees from Wuhan, nobody was screening asymptomatics.
- Really, really inadequate testing…
- How can you keep saying that Americans are at low risk from the virus if you aren’t even testing for the virus?
- Let’s get this out of the way: who made the mistakes?
- Barrack Obama, Donald Trump, the CDC, Gavin Newsome, and many others… There is equal opportunity blame in this book…
- “No,” wrote Charity in a comment. “The single most important part of this plan is IT IS NOT RUN BY THE CDC.
- On Churchill and Chamberlain — thanks to Dr. Charity Dean
- “The leaders with the worse judgement smugly claim they have the best.” A bit farther on: “Don’t prepare a white paper when you need to be bombing the shit out of Germany!” (Chamberlain had spent the final few days before the war writing a white paper that defended his strategy of appeasement.) After that: “There will be no standing ovation when you are proven right.” And, finally, “Churchill was a dragon too.”
- Everywhere she turned in government she saw this distinction, in leaders, between Churchills and Chamberlains.
- The people:
- Dr. Charity Dean, County Health Officer, and then…
- Then she saw the phrase “Communicable Disease Controller.” It was an official state role. Played by local health officers. “What I like is a crisis.”
- The President who read a book; and the Doctor in the midst of it…
- As it happened, the United States of America had a plan to fight a pandemic. The first draft had been written back in October 2005, by a man named Rajeev Venkayya, in the basement of his parents’ house in Xenia, Ohio.
- The story of how the United States more or less invented pandemic planning began when George W. Bush, in the summer of 2005, read a book. John Barry’s The Great Influenza: The Story of the Deadliest Pandemic in History.
- Bush returned to the White House from his summer vacation with a new interest in pandemics.
- Then Bush read John Barry’s book, and asked, What’s our strategy? “We didn’t have a strategy,” said Rajeev Venkayya.
- “The president said, ‘This is bullshit,’ ” Rajeev recalled. “ ‘It’s just health. We need a whole-of-society plan. What are you going to do about foreign borders? And travel? And commerce?’ ” And how were you going to stop hundreds of thousands of Americans from dying while they waited for even a speeded-up vaccine? …It was new and a bit odd for the White House to put itself in charge of creating a new strategy for disease control, especially as there was an entire federal agency down in Atlanta called the Centers for Disease Control.
- To this day, Barry has never heard from Bush.
- (The team of) Dr. Carter Mecher and Dr. Richard Hatchett and Lisa Koonin
- “We used to tell ourselves, ‘You’re going to make a mistake,’” said Carter. “The sin is making the same mistake twice. The best is to learn from other people’s mistakes.”
- Joe DeRisi and his red phone… …If you’ve tried everything else and you don’t know what it is, you can pick up the phone and call us.”
- Three years earlier he’d been handpicked by UCSF’s faculty to skip the usual postdoc stage of formal scientific training and been given his own lab—because they didn’t want to waste a moment of his mind. “It’s a mind without boundaries,” said Don Ganem, a UCSF microbiologist and medical doctor who had pushed for DeRisi’s hire.
- MacArthur recipient
- “You start looking only for things that you are trained to expect,” said Joe. “And you miss what’s there.”
- Some Key ideas:
- Learn – really, learn — from the past
- Cross Pollinate (work across silos) – In other words, thinking outside the box means THINKING OUTSIDE YOUR BOX
- Inside the United States government were all these little boxes. “How to ensure our food is safe to eat,” for instance, or “how to avoid a run on the banks,” or “how to prevent another terrorist attack.” …But here was the real waste. One box might contain the solution to a problem in another box, or the person who might find that solution, and that second box would never know about it.
- Look at things differently – remember the lessons of Moneyball
- In professional sports, for example. For decades, former players went unquestioned as experts in the evaluation of both players and strategies. Then came the statistical revolution. Complete outsiders, armed with mathematical models, had made a mockery of the experts. — If models could improve predictions about some basketball player’s value in a game, there was no reason they couldn’t do the same for the value of some new strategy in a pandemic.
- The CDC has to change; Government has to change – (maybe read The Fifth Risk) –
- And after Obama’s election, the entire building was basically drained of humanity. Still, Carter remained. He marveled at the inefficiency of his government. “No wonder you want people to stay behind. All that’s left of the work is what’s in their heads.” “I would be considered—what do you call it?—the deep state,” he said. “I was part of the old crowd.” There was no hostility, merely indifference.
- There is no silver bullet
- “The specific thing that blew my mind was using multiple semi-effective strategies together. There was no silver bullet.”
- Tell stories – tell stories well
- The way to change minds was by first changing hearts. He stopped making an argument and began to tell a story. His story, at its core, was about the hole left when someone dies, especially when the death is preventable, and the someone is a child.
- For big problems, we need big government…
- “Our federal government should be doing this in a coordinated way,” he said.
- “She’d had the odd thought that the country didn’t have the institutions that it needed to survive.”
And here are my Seven Lessons and Takeaways:
#1 – To understand one disease, we need to understand other diseases; especially how they spread. And, so much more…
#2 – Our government focuses on what is in front of them at the moment. We need our government to work on what is not yet in front of them.
#3 – Though systems matter; really matter; we need some superstar, really stellar individuals in key places. Individuals who are: smart; narrowly AND widely knowledgeable; yet fearless.
#4 – Sometimes, we simply have to have national programs; not local, decentralized programs.
#5 – If we are not getting what we need, we have to do workarounds. The result is what matters.
#6 – This will not be the last such crisis. Will we be more ready the next time?
#7 – We need to read some books really carefully — to let them sink in.
I think that many of my synopses will give people “enough” of the book to help them be more informed, more knowledgeable, more effective. But there are some books that really do require a thorough, careful reading. Consider this blog post, and my synopsis, a pretty-detailed teaser. But, I really encourage you to read The Premonition. It is a wonderful, engaging read. And, you will learn; and be scared, and think….
We’ve got other problems coming, you know… This book just might help you get ready.
Note: The 19 year old daughter of Michael Lewis and his wife Tabitha Soren, Dixie, was tragically killed in a car accident, along with her boyfriend, while Michael Lewis was in the midst of interviews about this book. Comfort and peace to the parents at this tragic loss…
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