From Michael Lewis’s superb 2021 book, The Premonition: A Pandemic Story:
* Charity had taken away other lessons from Dr. [Stephen] Hosea.
The simplest explanation is usually the best. If the patient turns up with two separate symptoms—say, a fever and a rash—the cause is more likely than not a single underlying disease.
If there is the faintest possibility of a catastrophic disease, you should treat it as being a lot more likely than it seems. If your differential diagnosis leads to a list of ten possibilities, for instance, and the tenth and least likely thing on the list is Ebola, you should treat the patient as if she has Ebola, because the consequences of not doing so can be calamitous.
When something doesn’t quite seem right about your diagnosis, respect the feeling, even if you can’t quite put your finger on why the diagnosis might be wrong. A lot of people had died because doctors had allowed their minds to come to rest before they should.
A doctor needed to be a detective for the patient: that was Dr. Hosea’s big message. Charity had grafted it onto her job as health officer. Her patient was Santa Barbara County. To keep it healthy, she needed to think about it the way Stephen Hosea thought about his patients. She needed to keep her hands on it. To be its detective.
* She watched Dr. [Charity] Dean tell this important doctor, on the spot, that she was issuing a health order to shut him down.
* At which point Charity needed to let the California Department of Public Health and the Centers for Disease Control in Atlanta know what she’d done. That was the moment she sensed just how far out on a limb she had climbed. “The CDC was aghast,” she said. “They were aghast that I hadn’t asked their opinion. They said no local health officer in the history of local health officers has ever issued an order to close down a doctor’s office based on a suspicion.” They tried to argue that, as a mere local health officer, she lacked the authority to close a doctor’s practice. Charity didn’t understand, first, that the CDC could not know just how broad her authority was—but then she too had only just learned that the power in most of the rest of the United States resided with the state health officer rather than the local ones. California was unusual in having conferred on its county health officers the same powers that, say, Texas and Mississippi reserved for their state health officers. Yet even after the CDC people conceded her authority, they refused to condone how she’d used it. “They told me that if I’m wrong I’m going to get fired,” she said.
That threat actually wasn’t all that original. As Kat DeBurgh, head of the Health Officers Association of California, put it, “To do the job of local public-health officer, you basically always need to be willing to lose your job.” To be a public-health officer—to really own the role—you needed to be prepared for your only appearance on the front page of the local newspaper to be in a story about a call you got wrong. That might be the only time anyone ever looked up and noticed who you were: the moment they chopped off your head.
Apart from the uninsured poor she treated in the clinics and homeless shelters, few citizens had any clue what Charity did—until she did something that infuriated them. “Rich white people would look at me like I was a relic from the past when I explained my role,” she said. “Like they’d stumbled across a candelabra from the Titanic . How lovely—but what does one need it for today?” The illness you prevented, and the lives you saved, went unnoticed by the people sitting on top of society. That’s why her role was, every year, less well funded than the year before. The fax machine was the new tech in the office that still kept its records on paper and filed the paper in red manila envelopes. “If I wanted to send a letter, I needed to fill out a form, and the form had to be approved—all to use a county-funded stamp,” said Charity. “I was the county health officer, and I wasn’t allowed to use a stamp. But that’s okay! I learned to live within the system.”
That system was the front line of defense against disease, not just in the county but in the whole country. Seventy percent of Santa Barbara’s cases of communicable disease came through one of its five public-health clinics, overseen by the health officer. The math was the same everywhere. But because people who had health insurance thought it had nothing to do with them—that it was just government —the society had starved the system of resources. “People don’t realize what it is until something bad happens,” said Charity. “It’s protecting the entire society, the whole economy.” The economy, for its part, understood her role only in its own narrow financial terms. “I learned the way to make the argument to elected officials for money for disease control was not ‘It is the right thing to do to take care of the most vulnerable in our community,’ ” she said. “Rather, make the case of the dollar return on investment to prevent the disease from spilling over into the rest of the community.” Yet even then—even after she showed a return—the investment often went unmade. It had taken years to get the money to buy a machine that allowed her to test quickly for tuberculosis, and to prevent some number of new cases. “The cost of a single TB case is between thirty and a hundred thousand dollars,” she said. “Higher if it is drug-resistant TB. So why are we haggling over a seventy-two-thousand-dollar machine?”
* Charity expected the state medical board to dig deeper. They never did. “I called them and said, ‘We thought you were launching an investigation.’ They said, ‘We are. But it consists of you telling us what you’ve found.’ ” The subsequent report by the Medical Board of California explained that Dr. Thomashefsky had violated a great many standard operating procedures. The state of California stripped him of his license to practice medicine, and he eventually was asked to close his practice in Oregon. With that, his career in medicine ended.
By then Charity Dean knew that, in her quest to stop the spread of disease, she was more or less on her own. She had her friends and allies. The public-health nurses, for example, who were among the more impressive human beings she had ever known. She was also growing to adore Santa Barbara’s chief counsel, who kept handing her enough rope to hang herself, by confirming that, yes, the law allowed her to do whatever the hell she thought needed doing to protect the public. She felt a deep connection to the fifty-seven other California county health officers—though they were, she had to admit, a mixed bag. Some were ancient doctors who viewed the job as a sinecure; some were part-timers who didn’t even seem all that interested in the job. “There’s no defined career path to becoming a public-health officer, and that’s a problem,” she said. “You get the retired anesthesiologist who is spending most of his time as a professional dog breeder.” But some of her fellow local health officers, like Charity herself, were so deeply committed to the job that they experienced it more as a mission. These people she loved best. But their needs and issues were too diverse for them to function as a single, powerful unit. And they weren’t in a position to have her back in a crisis.
The larger apparatus of American public health was very different on the inside from how Charity had imagined it from the outside. The Centers for Disease Control, the apex authority, wasn’t of much practical use to her. The distance they had put between themselves and her when she closed Thomashefsky’s clinic was of a piece with their general behavior. She’d repeatedly seen the tendency to flee when conflict arose.
* Charity instructed the Santa Barbara medical community to test any young person who turned up with a low-grade fever. “It’s not those people with mild symptoms you worry about,” she said. “It’s the people they infect, and the exponential growth.” As the CDC dithered, three more UCSB students tested positive for meningococcal disease. Each case presented differently. One student, with only a rash, had been diagnosed initially with chicken pox; the other two had slight fevers and had been initially misdiagnosed as having nothing special. “None of them lived together,” recalled Dr. Ferris, UCSB’s medical director. “It was really sort of hard to understand why we had these random cases.” Within days the school had set up hotlines to field calls from panicked parents, along with complaints from citizens of Santa Barbara who thought that the school’s twenty thousand students should be confined to their rooms.
Charity stayed up nights staring at the whiteboards in her office, on which she had charted the social relationships of the infected UCSB students. At the top of the board she had written “Cross-Pollination,” a term of art she’d picked up from Dr. Hosea. “It’s when you don’t want to say ‘he had sex with her’ and what kind of sex they had,” she said. “But I was basically trying to figure out who had shared saliva with whom, and where they’d shared it.” All signs pointed to the Greek system. She decided to shut down the college sororities and fraternities and give the twelve hundred students in them a prophylactic drug.
“With meningitis B you have a very narrow window to give the prophylaxis,” she explained, “and it was a weekend. You had to do it fast and all at once, or else the pathogen just keeps circulating.”
She got on the phone with the main guy at the CDC and his silent crowd. The guy strongly disagreed with her doing anything. “What he actually said,” recalled Charity, “was, ‘That decision is not supported by the data.’ I said, ‘Oh, really—there is no data.’ ” She outlined a plan she’d created: thin out the dorms by moving some of the students into hotel rooms; shut down the intramural sports teams; and administer a vaccine that had been approved in Europe but that the FDA had not yet signed off on. “The CDC guy said, ‘We’re not going to do any of that, and if you do that, we’re going to put it in writing that it was your decision and we disagreed with it,’ ” Charity recalled.
There followed other calls with the CDC, each more dismissive of her than the last. After one of them, Paige Batson turned to her boss and said, “Dr. Dean, I’ve never heard anyone at the CDC speak to someone like that!” But in the end the campus ignored the CDC and did everything Dr. Dean recommended. “It was kind of a stern order,” said Dr. Ferris, “and it had never been done before. But after she stopped all the parties and administered the prophylaxis, we had no more cases.” From start to finish, what Dr. Ferris and everyone noticed was that, as Dr. Ferris put it, “the CDC wasn’t pleased with her. The CDC kept saying, ‘There is no evidence to back it up.’ They didn’t have any evidence, because there is only one case every four years.”
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. “The message they send is, We’re better than you and smarter than you, but we’re letting you stick your neck out to take the risk,” said Charity. “They would argue with me about how kids behave in fraternities and sororities. And I had been president of Kappa Delta!” In the middle of the crisis, Charity figured out what it would take to appease the nation’s highest authority on infectious disease. “It was when they said, ‘If any of this works, you won’t know which one worked,’ ” she recalled. “They said, ‘You need to do these things one at a time and gather evidence.’ They wanted to learn from this meningitis outbreak, and I wanted to stop it. My goal was to stop it, and that was not their goal. 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.’ ”
Charity never would know which of the measures she took had controlled the disease; she knew only that all of them together had. To her, all that really mattered was that the disease had been contained. The job of the public-health officer—or at least her job as the public-health officer—was a series of intense firefights. There was no standard operating procedure for many of the situations in which she found herself: usually, they were sufficiently different from anything that had ever before happened. If she waited until she had enough evidence to publish in a scientific journal, the battle would be over, and she’d have lost. Kids would lose limbs, or die. The decisions she was forced to make were less like, say, those made by a card counter at a blackjack table, and more like the ones made by a platoon leader in combat. She never had all the data she wanted or needed when making her decisions—enough so that afterward she could defend them by saying, “I just did what the numbers told me to do.”
The hard truth was that there was never time to wait for more data. The moment an infectious disease appeared, decisions cried out to be made. The longer you waited, the more likely it was that people would die waiting for you to decide—or waiting for you to gather the data you needed to cover your ass if your decisions proved wrong.
Two years after the UCSB meningitis outbreak, the CDC finally published a report on how to deal with a meningitis outbreak on a college campus. On its list of best practices were most of the things Charity had done at UCSB. After that, from time to time, someone would call her from the CDC and ask her if she’d please get on the phone with some college health officer somewhere in the United States and describe how she handled the UCSB outbreak. But by then Charity had washed her hands of the CDC. “I banned their officers from my investigations,” she said. The CDC did many things. It published learned papers on health crises, after the fact. It managed, very carefully, public perception of itself. But when the shooting started, it leapt into the nearest hole, while others took fire. “In the end I was like, ‘Fuck you,’ ” said Charity. “I was mad they were such pansies. I was mad that the man behind the curtain ended up being so disappointing.”
In theory, the CDC sat atop the system of infectious-disease management in the United States. In practice, the system had configured itself to foist the political risk onto a character who had no social power. It required a local health officer to take the risk and responsibility, as no one else wanted to. Charity could see that the CDC’s strategy was politically shrewd. People were far less likely to blame a health officer for what she didn’t do than what she did. Sins of commission got you fired. Sins of omission you could get away with, but they left people dead. The health officer’s job was to choose, all by herself, the direction in which to err: do too much, or too little? “I did not sign up to be that kind of brave,” said Charity. “That wasn’t my plan. I was always saying to the CDC, ‘This is your job! Do your job!’ But after the UCSB outbreak, my motto was, ‘Stop waiting for someone to come and save you. Because no one is coming to save you.’”
* Inside Casa Dorinda, Charity had thirty minutes. “I knew what I had to do,” she said. “I didn’t want to do it. I was asking myself: Is there any way out of this?” The answer came back: no. She looked around and found that the fire sprinklers didn’t work—and that alone, she told the medical director, was grounds for shutting the place down. “I told them, ‘We can do this the easy way or the hard way,’ ” said Charity. “They were very upset, but they decided to do it voluntarily. Sure enough, there were seven deaths. Their medical director sent me a scathing email saying, ‘Their deaths are on you.’ He was right.” The second mudslide never came.
* The most disorienting aspect of the job by far was her new boss. Charity had assumed that she herself would replace her old boss, Dr. Karen Smith, whenever Dr. Smith stepped down. That’s why Dr. Smith had brought her in in the first place. Dr. Smith had left in June 2019, and for the next few months Charity had filled her shoes—but then, in October, she was returned to her original position. The new governor, Gavin Newsom, broke with the tradition of naming a former local California health officer to run the state when he instead brought in Sonia Angell, a former CDC employee in the agency’s Noncommunicable Disease Unit. Angell had experience in neither California nor communicable disease. Her most recent job had been working on heart disease in New York City’s health department. Only later, in August 2020, at the press conference where he announced Angell’s abrupt resignation—without going into why she was resigning so abruptly—would Newsom explain why, in part, she’d been recruited by his administration: her work in righting racial injustice in health care. Charity was later told that she herself had never been a serious candidate. “It was an optics problem,” says a senior official in the Department of Health and Human Services. “Charity was too young, too blond, too Barbie. They wanted a person of color.” Sonia Angell identified as Latina.