by Sanjay Gupta
Regardless of wherever and whenever the new coronavirus came from and when (and we’ll be exploring that shortly), at least one truth prevailed that no one could deny: the human race had met its first catastrophic global pandemic in the twenty-first century. And despite our twenty-first-century medicine, glitzy computer modeling, and pandemic planning, we weren’t ready.
In late 2018, I penned an op-ed warning that the Big One was coming and called for new vaccine platforms to prepare for the inevitable.12 I stated that the Big One would likely have a greater impact on humanity than anything else happening in the world. At the time, I thought it would be a rogue and never-before-seen influenza virus from a bird or pig. Flu had always worried me, and I’m not alone in that thinking. I’d already covered the earlier strains of H1N1 (swine flu) and H5N1 (avian flu) and produced a documentary about pandemic flu. Coronaviruses were also candidates, as evidenced by SARS and Middle East respiratory syndrome or MERS (both coronaviruses), but these were thought to be too lethal to also be contagious on a level that could take off as a global pandemic. The macabre truth was that if a pathogen was highly lethal, the infected often died faster than they could spread the germ. The thought of a superbad coronavirus that could be so prismatic, wily, and deadly as SARS-CoV-2 simply did not figure even in my wildest imagination, but again, it doesn’t mean we couldn’t still have been so much better prepared. (For simplicity’s sake, I’m going to refer to the virus, SARS-CoV-2, and its resulting disease in humans, COVID-19, as “COVID” going forward. Whether we’re talking about the actual virus, the infection and the disease it causes, or the pandemic in general, “COVID” fits the bill.)
In October 2019, just months before the pandemic became a cruel global reality, the Johns Hopkins Center for Health Security and the Economist Intelligence Unit released the Global Health Security Index.13 While the report found that “no country is fully prepared to handle an epidemic or pandemic,” the United States ranked highest of all 195 countries evaluated, coming in at #1 (receiving a score of 83.5 out of 100), ahead of the United Kingdom (with a score of 77.9). While it is now clear that we didn’t live up to that high standing, it is also worth recognizing the countries that were ranked poorly and truly rose to the moment. New Zealand, for instance, scored a measly 54 but had only a couple thousand cases and a handful of deaths in the first nine months. In that period, by mid-September, the United States had more than 6.5 million cases and nearly 200,000 deaths. The United States is 4 percent of the world’s population but suffered more than 25 percent of the world’s total infections by midsummer 2020.
In December 2020, scientists helped put the COVID numbers into perspective by comparing the daily US mortality rate with other tragedies.14 At the time, we were experiencing a September 11, 2001, level of mortality—nearly three thousand deaths every two days. It was as if ten Airbus 320 jetliners, each carrying 150 passengers, were falling out of the sky and crashing every day.
It was a surprising and disturbing trend. Across the world, it was the wealthiest countries that generally fared worse in this pandemic, while many poorer countries emerged relatively unscathed. This was especially true throughout the first year of the pandemic. Later in the book we’ll see how some nations looked relatively good a year later, only to let their guard down and suffer a catastrophic new wave of cases and deaths. The reasons for the discrepancies, good or bad, are as much about the virus itself as they are about human behavior.
As my friend and fellow truth seeker Jamie Metzl says, “We are all one interconnected humanity who must work together to get through this crisis.” I couldn’t agree more. Nowhere is our interdependence and communion more tangible than with a pandemic. We made mistakes, and that’s the bad news. The good news is that we now have the chance to learn from them. No matter what you think, whom you blame, what frustrations you harbor, or whom you vote for, keep an open mind as you read this book. And, if there’s one thing I’ve learned this past year, it’s humility. I have always been Mr. Fixit. It’s probably the surgeon in me, and maybe the war zone reporter as well. Get in fast and solve the problem. But sometimes, the right approach is to thoughtfully collect information, synthesize, and allow yourself to be surprised. Sometimes you have to listen intently before you can best act. My wife once told me that one of the reasons my daughters don’t always come to me with their problems is because they don’t want me to necessarily propose solutions; they just want me to listen.
One of the most challenging things about writing a book like this is figuring out where to end the story. In many ways, we are just beginning to understand this bug’s wizardry. It still remains to be seen how effective vaccines and therapeutics will be in mitigating COVID’s destructive march and ushering in the normalcy we all crave. I worry about the story of the third-world and low-income places where people are likely to be vaccinated last as wealthier nations buy supplies first. The greatest impact of COVID may be not on those whom the virus directly infects but on those shattered by the collapse of economies and health and education systems. Remote corners in Africa, Asia, South America, and India may seem distant, but they are very much a part of our global health security. You will read these words more than once: An outbreak anywhere in the world is an outbreak everywhere in the world.
One thing we do know: The virus is here to stay, so we must get used to it. Vaccines will help, but they will not give us a fairy-tale ending. There is no on/off switch here. Another pandemic-worthy pathogen may be right around the corner, so we need to learn how to better predict, prepare, and respond. Scientists right now are surveilling hot spots in the world where they think the next new disease-inducing piece of genetic code will emerge. As I was finishing this book, Russia reported the first case of a bird flu strain, H5N8, being passed from poultry to humans.15 Seven workers at a poultry plant became infected and recovered, and luckily the germ did not acquire mutations fast enough to spur human-to-human transmission. But what if it had? Soon thereafter, China’s National Health Commission reported the world’s first human case of the H10N3 bird flu in a forty-one-year-old man who recovered and again, luckily, did not transmit the germ to others.16 What many people don’t realize is that we’ve had a handful of close calls in our lifetimes alone. And the chances of a pandemic happening are the same at any given time. Pandemics are random, which means they don’t follow a pattern. Experts who study risk perception have a term for the mistaken view that random events are patterned: the gambler’s fallacy. It’s “named for the tendency of many roulette players to imagine that a number is overdue because it hasn’t come up all night.”17 The probability of another pandemic hasn’t increased or decreased because we’ve just gone through COVID. As Yogi Berra said: It’s tough to make predictions, especially about the future.
One of the most important lessons we may learn is about navigating risk. Throughout this pandemic, I have been reminded that people can look at the same level of risk and respond very differently. For example, while we are still not sure what the overall mortality of COVID is, let’s say it is ~0.5 percent. For a certain group of people, they may hear that number and become unquestionably worried. After all, that means a 1 out of 200 chance of dying. They are likely to take protective measures and be particularly cautious. For others, however, it means 99.5 percent in the clear; they may not bat an eye at that risk and go about their merry way. Same data, but very different behavior. There are risks to both perspectives, either being too cavalier or too cautious, which I will explain more in chapter 6.
There are reasons we’re so terrible at evaluating risk in our lives, especially under the duress of uncertainty and anxiety. And when making risky decisions breaks with social norms or personal experience, the task can feel outright paralyzing. But part of winning the next WWC is gaining the tools now to put risk into the right perspective for later.
Former White House coronavirus task force coordinator Dr. Deborah Birx calculated risk every day starting at three o’clock in the morning when she woke
to evaluate new data for the Trump administration’s response. Her mind raced through viral transmission numbers and mitigation strategies before she brushed her teeth. Famous for her predictive prowess, Birx had a knack for seeing things well in advance of anyone else. It was certainly true for predicting surges and new outbreaks but also in more subtle ways. In one of her last to-dos in her role, Birx told me that she had scrambled to immunize all the past presidents and their spouses. She realized that they would likely be asked to attend an important gathering sometime soon: the inauguration of President Joe Biden. If they hadn’t been vaccinated, they likely wouldn’t have been able to attend, but she told me she was the only one who anticipated that need. Some of the details of how she got all those dignitaries vaccinated have never been shared before.
It started with Birx forecasting, as she described it—picturing all the people soon coming to Washington from all over the country and how gregarious and social those like the Bushes and Clintons would be. “This is President Clinton with comorbidities,” Birx reminded me when I interviewed her after Biden had been sworn in. She had been in a panic in the weeks before the inauguration, knowing she needed at least twenty-one days to get it done so they’d have at least some protection from a shot. She was also thinking about the former First Ladies, whom she worried about “all the time.” She was wise about what role they could play: “We cannot lose our institution of kindness and they are part of those marketers—they’re going to be key to the healing.” She was already forecasting possible vaccine hesitancy in the future and wanted willing and trusted ambassadors, like the First Ladies (and future First Gentleman).
Inauguration Day was a potential superspreader event in her mind, because the virus was everywhere. She imagined the invisible enemy waiting for new hosts in all the little holding rooms where guests would be that day. But again, there was no plan for these VIPs to be immunized. Nor was any testing plan in place to screen the thirty thousand National Guard troops who would also descend on Washington from all over the country and set up camp for security. I would have thought that vaccinating the Who’s Who would have been planned and an easy thing to accomplish, especially since two vaccines had been authorized for emergency use by then. Even I had been vaccinated at that point. But this turned out to be hard. Birx called everyone she knew as the days ticked by. When she desperately reached out to Jared Kushner, she was down to Plan F and told him so. He had a solution—a contact Birx could call who knew all the hospital CEOs. This led Birx to finding the vaccines through New York University’s Langone Hospital, and the job was done in forty-eight hours. But for Birx, the whole exercise was a reminder that no one was beyond the reach of COVID and that it had left everyone unprepared for even the most obvious and predictable challenges.
While covering this pandemic, I marked my twentieth year as a medical reporter. I started at CNN in 2001, and within weeks I was reporting from New York following the 9/11 terror attacks. That fall, I broke several stories regarding the anthrax attacks, and over the next few years, I found myself reporting from Iraq, Kuwait, and Afghanistan. I wanted to tell the stories of the human spirit under the most challenging circumstances. At times, I was thrown into the story and asked to call upon my other skill set to perform brain operations in the desert, on ships in the ocean, and after natural disasters all over the world. A couple of years before I covered the devastation of Hurricane Katrina, I traveled to Sri Lanka to show the aftermath of the tsunami that claimed more than 155,000 lives in Southeast Asia. I covered the earthquake in Haiti and the tsunami in Japan. In 2014, I was the first Western reporter who traveled to Conakry, Guinea, to investigate the deadly Ebola outbreak that would soon find its way to the United States. In many ways I have been sprinting for the last two decades, but never before have I ran so fast for so long than while covering this pandemic.
Throughout 2020 and well into 2021, I repeated the same day, over and over, waking up before sunrise to sneak in a quick run before making breakfast (and waking the whole household) and then disappearing into my makeshift basement studio. My sense of time was meaningless—a month felt like a decade, and all the typical boundaries society uses to divide time just went away. There has been no line between my life and this pandemic. I think about it all the time. When I’m not thinking about it, I’m reading about it, and when I’m not reading or thinking about it, I’m dreaming about it. My wife tells me that I’m murmuring about viral replication in my sleep. (She also says that if I were not doing such work, she would shoot me up with tranquilizers and make me sleep for a week.) Other than the virus, I was mostly thinking about my girls, really wondering how a major world disaster like this might affect them long term.
As we all go through this, I realize that for our children—despite having been born when the country was in two wars, suffering through economic recessions, and being continuously bombarded with messages about climate change—this pandemic is the most significant thing that has happened to them directly. They feel an enormous burden and responsibility, one that will shape them and their choices for the rest of their lives. When I spent time with my grandparents and asked them about their childhood, they would often talk about the flu pandemic of 1918, and I saw the impact of that experience on their behavior. The same will be true here. Whether or not children are crushed by these events or emerge more resilient depends in part on all of us, and how we proceed going forward.
We are in a war, but like all other wars, they offer infinite opportunities. They allow us to notice cracks and holes in our society and give us an urgent reason to mend those broken places, confront our failures, and move forward. World War C will change how we govern, lead, interact, travel, shop, educate, worship, and work, as well as how we think, socialize, participate in the world, parent, and take care of one another. No industry, from agriculture to animal conservation, from urban design to information technology, will be spared change.
The ultimate good news is that what we learn from this pandemic will undoubtedly change all of our lives. The hope is that we will learn how to better respond as a world, as nations, and as individuals. That the pace of medical innovation will forever be accelerated, paving the way for radical revolutions in the treatment of diseases, including intractable ones such as cancer, heart disease, and Alzheimer’s that claim millions more lives. And perhaps most importantly, it will remind us that we are truly interconnected and that no matter what, we all rise, or fall—together.
At this time in the history of the Earth, many infectious disease experts believe we are entering the pandemic era. While it was previously thought to be a once-in-a-century event, they now believe most of us will experience another pandemic in our lifetime. And, if that is the case, COVID may have just provided the ultimate dress rehearsal. The pandemic has been so undeniably brutal, but the experience has also equipped us with the knowledge to not only better survive the next time around, but perhaps to even thrive. The obligation is to embrace the lessons and never forget what really happened during World War C.
PART 1 Humanity, We Have a Problem
CHAPTER 1 Postmortem
Throughout this pandemic, when I have reflected on the hundreds of thousands of lost lives, I am deflated and breathless. One in three Americans knows someone who died from the virus.1 I think of the untold number of COVID orphans, the children and grandchildren left behind, and wonder how they mourn. Alone. Early on, I realized there is no center of grief inside this tragedy. The virus kept us apart. We experienced our individual losses behind closed doors—closed funeral home doors, closed nursing home doors, closed hospital doors, closed front doors.2 With an invisible enemy in the air, we’ve had to set aside our emotional pain. And we can’t even share our suffering with one another, as we did after other national tragedies such as 9/11, Hurricane Katrina, and the Sandy Hook Elementary School shooting. Then there’s the kind of grief that isn’t routinely acknowledged; it’s called disenfranchised grief. From lost time with friends, grandchildren, and olde
r family members to missing the milestones of life, each one of us has something to mourn.
Because we can’t see the grief of others, it can feel distant and abstract. Psychologists know that during times of tragedy, we empathize with those who are suffering; we’re moved, and we want to help them. But if we don’t have a center of grief and all we hear are the death counts rising, we can start to experience what Azim Shariff, a social psychologist at the University of British Columbia in Canada, calls compassion fade or empathy fatigue.3 Not only is our compassion divided among all those who are suffering, but our overall amount of compassion goes down. As Shariff explained to me, “Large numbers are not good for empathy; people who are far away from us are not good for generating empathy.”
