I just read Michael Lewis’s superb 2021 book, The Premonition: A Pandemic Story.
* The problem, as he [Richard Hatchett in 2005] framed it for the Pentagon, was how to slow the spread of a communicable disease until you can produce a vaccine. As communicable disease spreads through social networks, Richard reasoned, you had to find ways to disrupt those networks. And the easiest way to do that was to move people physically farther apart from each other. “Increasing Effective Social Distance as a Strategy,” he called it. “Social distance” had been used by anthropologists to describe kinship, but he didn’t know that at the time, and so he thought he was giving birth to a phrase. (“But I don’t think I turned it into a gerund,” he’d later say.) What he also didn’t realize was that he was giving new life, to a dead idea: that apart from isolating people who were ill, you needed to do anything you could to slow the spread of a disease before you had drugs to help. “I was this emergency room doctor,” he said. “I didn’t know that people said all this stuff had been tried in 1918 and it hadn’t worked. I wasn’t rejecting anything. I just didn’t know any better.”
* There was, most importantly, a passage that suggested what the federal government might do, at the start of a pandemic, before a vaccine was available. It would, they’d written, “provide guidance, including decision criteria and tools, to all levels of government on the range of options for infection control and containment, including those circumstances where social distancing measures, limitations on gatherings or quarantine authority may be an appropriate public health intervention.”
It was hard to imagine anyone wading into that passage voluntarily, much less giving it a second thought. The words mattered less for what they said than for what they could be made to say. Like the words in the Holy Bible or the U.S. Constitution, they invited the problem of how they might be interpreted, and by whom, and for what purposes. As read by Richard Hatchett and Carter Mecher, those words gave them cover to answer the most important medical question they’d ever faced: How do you save lives in a pandemic before you have the drugs and vaccines to do it?
* The graph illustrated the effects on a disease of various crude strategies: isolating the ill; quarantining entire households when they had a sick person in them; socially distancing adults; giving people antiviral drugs; and so on. Each of the crude strategies had some slight effect, but none by itself made much of a dent, and certainly none had the ability to halt the pandemic by driving the disease’s reproductive rate below 1. One intervention was not like the others, however: when you closed schools and put social distance between kids, the flu-like disease fell off a cliff. (The model defined “social distance” not as zero contact but as a 60 percent reduction in kids’ social interaction.) “I said, ‘Holy shit!’ ” said Carter. “Nothing big happens until you close the schools. It’s not like anything else. It’s like a phase change. It’s nonlinear. It’s like when water temperature goes from thirty-three to thirty-two. When it goes from thirty-four to thirty-three, it’s no big deal; one degree colder and it turns to ice.”
* In the end he plotted both the deaths [in the 1918 Spanish Flu] and the restrictions imposed to prevent them, and saw that the earlier the restrictions imposed in any given outbreak, the fewer the deaths. In the case of Philadelphia, he wrote, “the closing of schools and churches, banning of public meetings, and banning of large public gatherings occurred relatively late into the epidemic”—nearly one month after the outbreak began and just a week before its peak. He wondered if other cities had reacted more quickly, and if their specific reactions might explain the huge variation in the death rates from city to city.
…“Others use the stories in Barry’s book to support the position that the infection control and social distancing measures would probably be ineffective,” he wrote. “On the flight back to Atlanta I went thru Barry’s book carefully and tried to reconstruct the events in a particularly hard hit city—Philadelphia . . . The bottom line is that anyone using the 1918 Philadelphia experience to argue that infection control and social distancing measures would be of little help needs to recognize how ineffective the overall response was in Philadelphia and how late the measures were instituted (within one week of the epidemic peak and after tens of thousands and perhaps hundreds of thousands were already ill).”
* It took just a few months for them to piece together what had actually happened in 1918. Their paper appeared in the May 2007 issue of the Proceedings of the National Academy of Sciences . A coauthor and friend, the Harvard epidemiologist Marc Lipsitch, did the statistical work and the other stuff that made it seem as if it were written by proper scholars. § Titled “Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic,” the piece revealed, for the first time, the life-or-death importance of timing in the outcomes of 1918. Cities that intervened immediately after the arrival of the virus experienced far less disease and death. The first reported flu cases in Philadelphia had been on September 17. The first case wasn’t spotted in St. Louis until October 5—which also happened to be the day the United States surgeon general, Rupert Blue, finally acknowledged the severity of the disease and recommended that local leaders take action. The death rate in St. Louis was half that of Philadelphia because St. Louis’s leaders used the cover provided by the federal government to distance its citizens from one another.
That didn’t mean that everyone in St. Louis appreciated what had happened. “We’re reading the newspapers in St. Louis,” said Richard, “and they know for a fact that they are having a better experience than other cities, and they still couldn’t keep their interventions in place for more than four to six weeks.” The paper analyzed the effects of that inability, and showed that American cities that caved to pressure from business interests to relax their social distancing rules experienced big second waves of disease. American cities that didn’t did not. The paper offered a real-world confirmation of what Bob Glass and the other mathematical modelers had discovered in their fake worlds. However you felt about the strategy of Targeted Layered Containment, you could no longer say there was no data to show that it had any effect. “Until then, the people who hated our ideas could throw up smoke screens about modeling,” said Richard. “They couldn’t throw up smoke screens about what had happened in 1918.”
The paper’s more subtle message appeared between its lines: people have a very hard time getting their minds around pandemics. Why was it still possible, in 2006, to say something original and important about the events of 1918? Why had it taken nearly a century to see a simple truth about the single most deadly pandemic in human history? Only after three amateur historians studied the various interventions, and the various death tolls in individual American cities, did the importance of timing became obvious. Carter wondered why this had been so hard to see. A big part of the answer, he decided, was in the nature of pandemics. They were exponential processes. If you took a penny and doubled it every day for thirty days, you’d have more than five million dollars: people couldn’t imagine disease spread any better than they could imagine a penny growing like that. “I think it’s because of the way our brains are wired,” said Carter. “Take a piece of paper and fold it in half, then fold it in half again, for a total of 50 times folding it in half. If a piece of paper is 0.004 inches thick to begin with, by the time you fold it 50 times, it is more than 70 million miles thick.” Again, it feels impossible. The same mental glitch that leads people to not realize the power of compound interest blinds them to the importance of intervening before a pathogen explodes.
It was seven months before the United States public-health system fully bought into the power of social distancing. The story of those months was dear to Lisa Koonin. She saved every email and every version of the fifty or more presentations she and Carter made—to everyone from the Department of Education to state and local public-health officers who filled hotel ballrooms. She thought she might one day write a book about it.
The big theme of her book would be the power of storytelling. It had taken Lisa, Richard, and Carter some time to see that they were in a war of competing narratives, and that whoever had the best narrative would win. Public-health people who did not actually know all that much about the subject, for instance, would insist that if you closed schools, all sorts of bad things would happen: crime would rise with kids on the streets; the thirty million kids in the school-lunch program would lack nutrition; parents wouldn’t be able to go to work; and so on. American society now leaned on schools to care for children in a way that would have bewildered Americans of an earlier age, as that other institution, the family, was failing at the job. “The sub-rosa conversation was that families weren’t safe places for children,” said Lisa.
To refute knee-jerk arguments about the costs of social distancing, Carter had marshaled so much data from so many corners of the U.S. government that a senior public-health official who passed through the White House called him Rain Man. He’d show his critics that crime rates actually fell on weekends, for instance, when kids were out of school. The FBI keeps all these stats, he’d say. Juvenile crime peaks at 3:30 p.m. on weekdays. Because they’ve been cooped up all day and they’re just going nuts. He’d show his critics exactly how many households would need help minding their children—and it was not nearly as many as they had assumed. During the summers, only 2.6 million kids used the school-lunch program: Did that not suggest that the number of kids without access to proper nutrition was far smaller than the number of kids using the program? He showed them a survey that Lisa Koonin commissioned, of parents with children who used it: just one in seven, or 2.8 million, said they’d have trouble feeding their children if schools could not. If schools were closed, Carter concluded, the problem was not 30 million kids but fewer than 3 million; they could be fed with supplemental food stamps.
* Carter sat at a desk and, consulting with Richard over the phone, wrote the CDC’s new policy, which called for social distancing in the event of any pandemic. The nature of the interventions would depend on the severity of the disease, of course. The CDC recommended that schools close, for instance, only when some new communicable disease was projected to kill more than 450,000 Americans. But school closure and social distancing of kids and bans on mass gatherings and other interventions would be central to the future pandemic strategy of the United States—and not just the United States. “The CDC was the world’s leading health agency,” said Lisa. “When the CDC publishes something, it is not just the CDC talking to the U.S. but to the entire world.”
* Two months after the CDC published its new pandemic strategy, Laura Glass, now sixteen years old, returned to Washington, DC, for her final science competition. The Young Epidemiology Scholars Competition, this new contest was called. Her mom had somehow found out about it and suggested she enter her science fair project and make a trip of it. On her giant foam boards, she’d honed her mission statement. “Could the oldest of strategies, social distancing, be designed to target specific age groups and zones of high infectious contact within a social contact network and thus limit the spread of disease?” she’d written. On her boards, she walked the science fair judges through all the work she had done. She explained the computer model she had helped to build, the surveys she’d done of the citizens of Albuquerque, New Mexico, and the insights that her work had led to, with the help of the model. “I found that if schools are closed AND preschoolers, children and teens are restricted to the home epidemics that would have infected 65% of the population COULD BE REDUCED BY NEARLY 80%,” she wrote. “If adults also restrict their contacts within non-essential work environments epidemics from such highly infective strains can be ENTIRELY THWARTED!”