by Sanjay Gupta
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Yet there are lessons to be learned from the people who have died. Olivia knew something unkind was descending on her quickly. First came the tickle in the back of her throat, then a wave of fatigue that sent her to bed early. An active and vibrant twenty-two-year-old nursing student who moonlighted as a waitress, she had been through a stressful period in early 2020 with too many competing demands. It was now the first week of February, and although the media buzzed about a mysterious outbreak from China that could spread widely in the United States, the idea that she could be infected by a potentially deadly virus never entered her mind. Olivia had not traveled lately, and the news coming from the White House quelled her fears that a life-changing pandemic was afoot. “The overall risk to the American public remains low” went the official statement from the Department of Homeland Security.4
Later that night, when a dry cough and fiery sore throat woke her up, accompanied by fever, a volcanic headache, chills that no blanket could quash, and a touch of nausea, she thought it was a bad cold or perhaps a case of the flu. She was strong, she was young, and she had survived cancer as a kid, so this was nothing. She couldn’t taste or smell anything, but that’d happened numerous times before with colds and sinus infections. Olivia called in sick at work the next day, skipped class, and assumed she would bounce back after some rest with chicken soup and Tylenol. The registered nurse she briefly spoke with on the 24/7 telemedicine line available to her also agreed that she’d be fine and to “weather it out,” reminding her to stay hydrated.
Olivia soon lost track of the hours and days as her condition rapidly deteriorated to the point she could barely breathe or make it to the bathroom. Staunchly independent, she didn’t want to burden any friends to help out, which in retrospect was a good thing because that would have given the virus an opportunity to find new hosts. Olivia died alone of respiratory failure on the couch in her tidy apartment, her family in another state still struggling to reach her and unaware of the gravity of her condition. Nobody would ever know if she died of COVID; the outbreak was still silently circulating and who knows how many others died alone as she did before the nation had any idea what it was facing.
Patrick was a fit, athletic forty-one-year-old who radiated light and had established himself as a political organizer and social entrepreneur with degrees from Georgetown, Harvard, and MIT.5 The fifth child of Cuban exiles, he’d worked in the Obama administration and was cousin to Francis Suarez, Miami’s mayor. Two days before his death, Patrick had spoken at an Elizabeth Warren campaign event in Miami, where he lived. On the last day he was seen alive, Florida announced its first confirmed COVID cases; Patrick led a prayer group in his apartment that evening and told the doorman he did not feel well.
At 1:00 a.m., March 1, he sent a text to his siblings saying something was wrong—he was gasping for breath. Paramedics found him on March 3, Super Tuesday. The autopsy ruled his cause of death as “undiagnosed hypertensive heart disease” due to an enlarged heart. His family was flummoxed, unable to make sense of it because Patrick had never been diagnosed with any heart condition. Seven months later, in October, the family finally learned that the autopsy had also uncovered acute lung injury, including bleeding in the tiny air sacs called alveoli. Such a finding reflected similar discoveries in many early COVID deaths in New York when the first wave hit.
Alina, fifty-three years old, didn’t think much about her positive COVID test in June 2020. She barely felt anything—just mild fatigue, a congested nose, and small headache—and she grew antsy staying housebound in quarantine. Her two teenage kids also tested positive, but they had a little fever and took naps. A few days later, they were seemingly ready to be teens again. Her husband was also diagnosed with the illness but escaped being hospitalized and regained nearly 100 percent of his health within a month. When the family all tested negative for the virus and were cleared to resume life, Alina thought the chapter was closed, but it was only beginning for her.
Several weeks after the rest of the family fully recovered, Alina still could not perform her normal routines. Unexplained low back pain, persistent fatigue, insomnia, and crippling anxiety she’d never had before now ruled her days. A once-avid runner, Alina fought shortness of breath, chest pain, and an unusual rapid heart rate that kept her from exercising altogether. The simplest tasks took an enormous amount of physical and mental exertion from the moment she hauled herself out of bed in the morning. On some days, walking up the stairs, preparing a meal, or engaging in a conversation felt like too much. Her intestinal system rebelled too, giving her abdominal pain and surprising diarrhea despite no changes in her healthy diet. Migraines, which she had never had before, sidelined her for days.
“My brain is broken,” she told her younger sister over the phone, “and it scares me.” In the car, she would reach an intersection and not know what to do. In addition to the debilitating migraines, the mental fuzziness not only took Alina far away from meeting goals in her work as a paralegal, but she started to worry about cognitive decline and dementia. How could an otherwise healthy middle-aged woman suddenly have serious problems with focusing and even forming new memories?
A quick online search led her to thousands of others complaining of “brain fog” who were deemed “long-COVID” or “long-haul” patients (more technically, post-acute COVID-19 syndrome: PACS). She also learned that this strange sequence of events—going from asymptomatic to symptomatic with no end in sight—was more common than most people realized. Doctors didn’t know what to make of this. And yet according to the most recent studies, fully one-third of COVID patients become long-haulers, and nearly a third of these individuals started with asymptomatic infections.6
Here is what doctors do know: Persistent symptoms, including brain fogginess, are not unique to COVID. They have been documented in the medical literature going back to 1889 related to the flu.7 In a recent historical review, early reports of the “common symptom of altered cognition” surfaced during the Russian flu pandemics of 1889 and 1892, and again during the Spanish flu pandemic of 1918.8I With COVID, however, the biggest concern—more so than the symptoms—was the possibility they would never go away, coming to define a person’s life going forward. A full year later, Alina continued to search for pieces of her former self.
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You’re going to meet more COVID patients in this book. They tell harrowing stories of courage, patience, optimism, and hope. They also showcase the breadth of this disease, which has affected individuals in spectacularly different and varied ways. I’ve spoken to identical twins who contracted the same virus as housemates but one ended up on a ventilator while the other coped relatively well. How can that be? As we’ll see later on, the baffling nature of this virus that kills one person in a matter of days while leaving another unscathed is partly what makes this pandemic such an urgent mystery to solve. In the millions of lives lost, there are important lessons, and we must take the time to learn them, no matter how painful.
In medicine, it can sometimes take decades to critically dissect a new disease and fully comprehend the biology and behavior of a germ and how it affects people across the ages, sometimes disproportionately. The answers are not nearly as intuitive as you may think. With the 2009 H1N1 pandemic, those most likely to require hospitalization were under the age of ten. The thinking was that the youngest had never been exposed to anything close to this novel strain of flu and therefore had no innate immunity. With avian flu, or H5N1, those most affected were between the ages of ten and forty: It was the body’s own overzealous inflammatory response that probably increased the risk of death, something more common in young adults. With COVID, though, it was the elderly who were most likely to get sick and die of this disease: 80 percent of the mortality happened in those over the age of sixty-five. But in the early days, even this simple insight had not been recognized or documented.
And that insight would later lead to confusion and deadly missteps. Thinking COVID was an “old
person’s disease,” younger Americans were inclined to ignore the government directives, believing they would not get infected or could recover easily. As the virus mutated, however, it began to find younger and younger hosts to infect—especially once older generations gained protection through vaccination. And by spring 2021, hospitalizations of people in their twenties and thirties with COVID, some with severe symptoms, jumped. The experiences of Olivia, Patrick, and Alina show that despite the stereotype of COVID decimating those sixty-five and older, COVID has been underestimated as a virus with the power to kill people in their prime or leave those who survive with lasting symptoms. It also has the power to modify itself as it seeks to spread. That’s why collecting the lessons of this pandemic will help prepare for a better, safer future. We cannot get pandemic amnesia.
Cause of Death
Doctors often like to joke that internal medicine docs know everything—but do nothing. Surgeons know nothing—but do everything. And pathologists, well, they know everything and they do everything—but a day too late. A version of this is often attributed to serial suspense writer Robin Cook who used it in his 1983 nail-biter Godplayer. Cook is famous for popularizing the medical thriller genre; many of his books address topics affecting public health, and he had written plenty of infectious disease–themed novels, including Outbreak, Contagion, and Pandemic. In his books, and those of most physician authors, I have often seen another important theme emerge as well: introspection. Contrary to what most people think, I believe doctors are a lot more self-reflective than we are reputed to be.
That’s partly because most doctors I know are defined by their failures far more than their successes. We are tormented at the idea of a patient dying a preventable death, and we have codified ways that force us to evaluate our mistakes, our complications—and, yes, the deaths themselves—in a formal way. Most hospitals have a regular meeting behind closed doors where we openly discuss these outcomes among ourselves. In some places the conference is called D and C (for Death and Complications) or M and M (for Morbidity and Mortality). Take it from me: It is hard to bear witness, to stand at that lectern baring your soul.
In some ways, the autopsy is the physical embodiment of these introspections. It is gruesome and emotionally devastating to watch, especially knowing the work will do nothing for the patient on the table. We conduct this postmortem so that others in the future can live and not suffer the same preventable death.
Postmortems on COVID victims have begun to reveal more about the virus’s wrath in a human body—from its debris in the brain down to “COVID toes.” But before we get to those details in chapter 3, there’s another type of postmortem to consider first. About a year into the pandemic, after we surpassed more than half a million American deaths and Joe Biden had been sworn into office, I conducted a postmortem with six of the doctors Donald Trump had charged with leading the way out of the pandemic.9 Of the six, many of whom were seen momentarily at the lectern in the White House briefing room, Dr. Anthony (Tony) Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID) since 1984, was the only one who made the transition to the new Biden team as the president’s chief medical adviser. The others are private citizens now, unbridled and unrestrained.
Over a few weeks, in Houston, Washington, DC, and Baltimore, our team secured nondescript, large hotel ballrooms with plenty of space and ventilation to allow these extraordinary one-on-one conversations to take place in strict confidence. Given our shared medical backgrounds, I explained to each of the doctors that I was going to frame the discussions in a way that would be tough but familiar: as an autopsy.10 We were going to meticulously dissect and discuss how the United States became home to the worst COVID outbreak on the planet.
We are one of the richest countries in the world with a sophisticated and expensive health care system. I remember reflecting on our #1 ranking for pandemic preparedness by Johns Hopkins when I watched what was happening in Los Angeles during the 2021 winter surge of COVID cases that hit after the holidays. These were scenes I had previously witnessed only in disaster-stricken areas around the world. By mid-January, one person in L.A. was dying every six minutes, and hospitals were cracking under the strain as ambulances circled for hours trying to find emergency rooms that could take one more patient.11 We were nearly a year into the pandemic and were still unable to stop it.
On top of that we also have the largest income inequality in the developed world and most of the developing world. This pandemic had illuminated that stark racial and economic divide. By mid-February, COVID had killed Black residents in L.A. at nearly twice the rate and Latinx at nearly three times the rate of white Angelenos.12 Yet halfway around the world in Asia’s largest slum, Mumbai’s Dharavi, where a million residents live in closely packed shanties and multigenerational families share a single room, the death rate was curiously minuscule (this would soon change and shockingly so, but I’ll get to that later because it’s part of the story—and the lessons). Similarly, in Nigeria, with a population of some 200 million, the reported death rate was less than a hundredth of the US rate. Black and brown Americans were not only the most adversely affected in the United States; as an independent demographic, their infection and mortality rates were among the highest in the world.13
What struck me a year later when I sat down for more than twenty hours of these interviews with the people initially in charge of the pandemic response was the realization that their background and credentials would have led anyone to believe they were the best people for the job. We had our Avenger team in place. They may not have all agreed on what steps to take and lively, heated discussions would take place, but they respected one another’s expertise and were the most qualified people to make decisions. Consider Dr. Robert Kadlec, who was appointed by President Trump in 2017 to head the Office of the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services. Interestingly, ASPR was created by legislation and signed into law by President Bush in 2006—just a year after Bush, while vacationing in Texas, could not put down a copy of John M. Barry’s book about the 1918 flu pandemic. Detailing the mysterious plague that “would kill more people than the outbreak of any other disease in human history,” Barry, a historian, scared the breath out of Bush, prompting the president to call his top Homeland Security adviser, Fran Townsend, into the Oval Office when he returned to Washington.14 He shared his copy of The Great Influenza with her and said, “You’ve got to read this.” He then added, “Look, this happens every hundred years. We need a national strategy.”
Out of that conversation came our country’s most comprehensive pandemic playbook. According to Townsend who publicly shared the experience with the media, the plan included diagrams for a global early-warning system; funding to develop new vaccine technologies; and a strong national stockpile of crucial emergency supplies that would be in high demand, such as protective clothing, face masks, and ventilators. Many of Bush’s doubtful aides and cabinet officials balked at the efforts, which also included gaming exercises to test the ideas and protocols. But Bush insisted on the plan; one aide even described him as “obsessed” with it.15 He set out to spend $7 billion on it, or about $10 billion in today’s dollars. To Townsend, who at the time felt buried by more pressing crises such as counterterrorism, hurricanes, and wildfires, Bush said something prophetic: “It may not happen on our watch, but the nation needs the plan.” He also stated a truism we’ve all come to learn the hard way fifteen years later: “A pandemic is a lot like a forest fire. If caught early it might be extinguished with limited damage. If allowed to smolder, undetected, it can grow to an inferno that can spread quickly beyond our ability to control it.”16 Although much of the ambitious plan was shelved in subsequent years and never fully realized, some things like the establishment of ASPR remained lying in wait for 2020.
Prior to Kadlec’s role at ASPR, he’d spent his life on biodefense strategy as a physician and career officer in the US Air F
orce. While in the Bush administration, he had helped lead the response to 9/11, the subsequent anthrax attacks, and all the devastating hurricanes including Katrina that I covered as a reporter. Years later, Kadlec was still dealing with a hurricane, this one called Dorian and aimed at Puerto Rico, when news of a strange cluster of pneumonia patients started to surface. At first, it was background noise to his focus on Dorian’s aftermath. Like me, he was somewhat nonchalant when first hearing about the strange new pneumonia on the other side of the world. He could not imagine a viral storm eclipsing the stress he had experienced after five combat tours in Iraq. But it did. “I think I have PTSD from this experience,” he told me, his eyes welling up.
Adding to his feelings of despair was the sinking realization that not only was this pandemic tragic in its scope; it was also nearly entirely predictable and preventable based on a series of tabletop modeling exercises he had code-named Crimson Contagion back in 2019.17 This simulated scenario featured a respiratory virus from China that flew around the world and was first detected in Chicago. Forty-seven days later, the World Health Organization (WHO) declared a pandemic, but by then it was too late: 110 million Americans were expected to become ill, leading to 7.7 million hospitalized and 586,000 dead. Sound familiar?
Despite Johns Hopkins’s optimism, the October 2019 draft report of the exercise showed just how underfunded, underprepared, and uncoordinated the federal government would be for a life-or-death war with a new virus for which no treatment or antidote existed. The report was marked “not to be disclosed.” Crimson Contagion exposed the shortcomings of our response system that eventually, and eerily, played out in reality. Most notable in the mock pandemic were the repeated instances of “confusion.” Federal agencies wrestled with who was in charge. State officials and hospitals struggled to figure out what supplies were available or stockpiled. Cities and states went their own ways on school closings. The fiction would soon turn into nonfiction.
