by Sanjay Gupta
For Kadlec, the three biggest lessons learned from the experiment were that when a pandemic hits, you must know who is in charge, establish the supply chain and source materials for things like personal protective equipment (PPE) and testing kits, and find the money to pay for all the needs in the response. We will talk about leadership later, but the state of our emergency supply chain of PPE, medicines, ventilators, and other medical equipment was a complete mystery at the beginning of the pandemic. With no systems in place, we had to start from scratch. In Crimson Contagion, Kadlec and his team estimated that the United States would need $10 billion—the same number Bush had projected—in order to prepare for such an event. That money was never authorized.
Instead, in the twelve months of Kadlec’s tenure at ASPR during the COVID pandemic, he spent $35 billion and got an additional $23.6 billion from Congress in December 2020 to react to the burgeoning pandemic. But those numbers didn’t even touch the costs related to losing hundreds of thousands of lives, jobs, businesses, and livelihoods. To put $10 billion into perspective, it’s about $30 per citizen or $3 a year for ten years, a pittance that could have made the United States pandemic proof, according to Kadlec. If the virus was a national security threat, protecting the country against it would have cost less than the price of a single aircraft carrier. We have eleven active aircraft carriers, more than any other country in the world, but authorizing some of that money to fight a potential unseen enemy was not a gamble politicians were willing to take. And as a country, we paid an enormous price for that oversight. In one of Joe Biden’s first orders of business as the new president in 2021, the United States passed a COVID relief package that cost nearly $2 trillion.18
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Had a different cast of characters been placed in leadership positions on the task force, would the outcome have been any different? No one can answer that. As I spent time with the doctors during my interviews and countless early-morning and late-night calls, another question came up repeatedly: “If you are being marginalized or even silenced, why stay in the job?”
From all of them came some version of the same answer: “I believed I was the best person for the job, and I was worried that if I left, I would be replaced with someone less effective and more political.” When they realized their input was being increasingly subdued by the White House, they found ways to carry on their crusade against the pandemic. To those of us on the outside, by May 2020 it appeared that the task force had been disbanded because it no longer appeared in the media’s coverage of Trump’s press briefings. In fact, meetings were continuing, but behind closed doors—usually in Birx’s office in person or virtually. Birx privately met with Tony Fauci, CDC director Bob Redfield, and then-FDA commissioner Stephen Hahn three or four times a week in what was called the Doctors Group. The group wasn’t secret, but not many people knew about it. They talked about the medical issues that needed to be addressed and continued to analyze the pattern of the outbreak.
Dr. Birx was candid with Vice President Mike Pence, who had been her ally since she arrived and never hesitated to follow her lead. As soon as she noticed patterns that showed the ferocity of the virus’s spread in mid to late summer, she went to Pence with her graphs and charts. “And when that happens with these kinds of curves,” she told him, “it’s going to be worse than anything we have seen before.” He looked at her squarely and said, “You do what you need to do.” That was permission to hit the road.
Birx used Pence’s plane to go state by state, rolling her suitcase to one rental car after another to meet with people in their communities. Her travels to states turned out to be her secret for having a greater impact. On the road, she met a different tone in the people she encountered from what she’d experienced in the White House. In her words, “There was constant tension between working hard to follow the rules I was given and then working hard to make sure I could get information out that was critical to the states and American people. And it was interesting to me how that played out, and how I would be allowed to be very frank and facilitated to be frank with regional and local press, governors and mayors, and be very clear about mask mandates, closing bars, and severely restricting indoor dining, and all of these elements that I was never allowed to say nationally.”
Most of the governors and mayors listened to and followed her advice precisely. In one school district, for example, she urged testing all teachers with the idea that they would represent the community—not because she thought that the schools were a big spreading event. “It’s why we asked every hospital to routinely test all of their staff and to triangulate that back to a zip code so you can see where the spread was occurring,” she said. This kind of counterintuitive thinking fell on deaf ears in the White House. Despite Trump’s frank “this is deadly stuff” remark to journalist Bob Woodward back in the first week of February, at no time did anyone in the White House give Birx the impression that any of them thought there was significant asymptomatic spread, that the level of contagion was high, and that the disease was this deadly.19 No wonder Birx was nicknamed Dr. Doom in the lower level of the West Wing.
For his part, Tony Fauci delivered his science-based message to every media outlet possible, from comedy shows and celebrity podcasts to Sesame Street. And he often told people in the White House what they didn’t want to hear. At the back of his mind was a sage piece of advice he’d learned from a mentor soon after he became director of the National Institute of Allergy and Infectious Diseases under Ronald Reagan: “Do yourself a favor, Tony. Every time you go into the White House, whisper to yourself This may be the last time I’m walking into the White House.” Fauci wasn’t someone who’d fall prey to the president’s reality distortion field—a term used to describe the unique, often illusionary environment that surrounds an individual in power where sycophants abound, and it can be hard to tell that leader the truth if it goes against their wishes or ideology.20 Fauci stuck to his personal constitution of following the facts, even at the risk of getting ousted by Trump. Resisting the gravitational pull of the White House and Oval Office in particular is a job unto itself.
Politics got in the way for sure, but a tragedy of this magnitude doesn’t have a single cause. The doctors were in agreement about an outrageous reality: The vast majority of deaths in the United States could have been avoided. At the end of my interview with Kadlec, he looked at me and said, “Hubris. Hubris was the cause of death in this autopsy.”
The Numbers Tell the Story
When faced with the unknown, we like to turn away and unsee whatever makes us uncomfortable and afraid. Pandemic denialism is hardly new. In A Journal of the Plague Year, Daniel Defoe wrote that in 1665, municipal authorities in London initially refused to accept that anything unusual was happening, then tried to shield information from the public, until the spike in deaths made it impossible to deny the fearsome bubonic plague. By that point, all the authorities could do was lock victims and their families in their homes in a futile attempt to stop the spread. In the book’s opening pages, Defoe’s words reveal the main differences between the plague of his era and ours: “It mattered not from whence it came.… We had no such thing as printed newspapers in those days to spread rumors and reports of things.”21
Defoe was referring to the fact that authorities knew the scourge was making another death-reaping round, what would be London’s last epidemic of bubonic plague, but they could keep it secret because there was no way to correspond with people easily through the kind of media system we have today, more than 350 years later. The reality of COVID’s spread could not be covered up as people shared the savagery of the illness through media, with an important caveat: Although we have plenty of publications and broadcast media to tell us what’s going on, these vehicles also have the capacity to circulate false ideas and disinformation.
Like the London authorities trying to conceal the plague’s entrance into the city, we similarly experienced division, dysfunction, and lack of truth telling among our leaders a
s this twenty-first-century plague took off. I can only imagine how the Great Plague of London, which claimed nearly a quarter of the population, would have played out with modern technology and savvy modes of communication. Defoe’s book, which was published fifty-seven years after the year-long event, was intended to be a forewarning as well as a practical handbook of what to do and, more importantly, what to avoid during a deadly outbreak, should one happen again. Defoe’s primary source of data for his story was the Bills of Mortality—the one-page weekly reports that documented who died and from what. These pages served as leaflets, or handbills, that were posted in public places to alert people that the plague was spreading. It was the only way to disseminate the news. For Defoe, the collection of mortality bills was his way of charting the course of the Black Death’s rise and fall throughout 1665,II peaking in the hot summer and declining by Christmas. By most measures, the Bills of Mortality offered the first records in the world of the spread of a disease; it was also the first time in human history that a pattern was reflected in the data: You could see the plague take off, kill increasingly more people on a weekly basis, and then retreat.
Today our disease- and death-tracking methods are more sophisticated, but they are equally revealing and instructive. On page 37 is a journal of our plague year from the first week of March 2020 to a full year later.
Within the data and the graphs of trajectories like this one lie so many stories, insights, and lessons. It’s amazing to see such discrepancies among countries, each of which followed its own pandemic response protocol with various forms of mitigation strategies and lockdowns. Most remarkable is the difference between wealthy and poor nations, but in nearly the opposite way we have come to expect. While infectious disease outbreaks typically crush poorer countries, this novel coronavirus disproportionately devastated many of the world’s wealthiest nations. Why? The path of the disease worldwide also took wild and unpredictable lurches in one direction and then another.
Source: Johns Hopkins University CSSE covid-19 Data22
At the beginning of March 2020, for instance, South Korea was averaging more than 550 new daily confirmed cases, compared with just 53 in the United Kingdom, which has a similar population size.23 At the end of the month, however, South Korea had 125; the United Kingdom was at 4,500 and climbing while simultaneously struggling to establish basic systems for supplies, testing, and contact tracing. South Korea may not have had as robust of a health care system as the United Kingdom, but it had a robust public health strategy executed early and strongly to gain control of the virus’s spread. The key difference was that South Korea rapidly adopted a “test, trace, isolate, and treat” plan of action, whereby people with suspected disease were tested, their contacts were identified, strict isolation was enforced, and free treatment was provided to those infected, with compensation for people who had to self-isolate. This did not happen in the United Kingdom, where testing was limited early on and then both contact tracing and community monitoring were abandoned in March. South Korea was also sprinting ahead with its use of mobile phone technology to support its strategy, as well as disseminate emergency information, such as alerting people about the infection hot spots to avoid. The SARS outbreak in 2002–2003 followed by MERS in 2015 had taught and trained South Korea well, as those outbreaks became practice sessions for COVID. The United Kingdom would have to go through those difficult lessons with COVID. As one group of scientists for the BMJ noted in their comparison of these two countries’ responses, “South Korea was quicker to base decisions on the precautionary principle when the evidence was unclear,” whereas the United Kingdom relied heavily on mathematical models and adopted policy led by science that arrived too late.24 In other words, South Korea approached the problem assuming the worst-case scenario, while the United Kingdom depended on knowledge that was outdated.
Former CDC director Bob Redfield thinks the general unhealthiness of the American people also played a big role in our tragic death count. It didn’t help, he says, that we went into this war unfit, with chronic conditions like obesity, diabetes, kidney disease, and cardiovascular disorders, among others—all of which alone demand a lot of attention from our body. These are mostly diseases of privilege—of wealthy nations. We are victims of our own prosperity. Although chronic, preventable diseases like obesity are on the rise throughout the world, including poorer nations, high-income countries like the United States share a much higher percentage of obesity cases worldwide. The large outliers among rich countries are Japan and South Korea, where only around 5 percent of premature deaths are attributed to obesity (as a comparison, obesity accounts for 18 percent of deaths among Americans ages forty to eight-five).25
Some of the poorer countries may have had another advantage as well, one that wasn’t seriously considered for months into the pandemic: preexisting immunity. As we’ll see, a region’s history of infection can have a profound impact on the vulnerability of its inhabitants. Perhaps that helps explain why the coronavirus has not been a “Chinese flu” but rather a Western malady when you consider where the most damage was inflicted. If you want to understand why a particular nation fared poorly or did well, one of the most significant pieces of data would be where on the planet it was located.
Consider that there were close to 9,000 cases per 100,000 people in the United States, whereas in India, it was about a tenth of that throughout the first year of the pandemic, even though Asia has some of the most population-dense areas in the world. Some European countries, for another example, took extreme measures but still went on a deadly roller-coaster ride, while others managed to gain control of the virus relatively early on and enough to look almost normal again long before the start of 2021. What explains this? What is the most effective tool for containing a virus on the loose? Do people in East Asia, a region with far fewer COVID casualties than other parts of the world, have some innate immunity from living where coronaviruses are endemic? Could they have shown up to the COVID war equipped with protective gear already? Studies are underway to explore this possibility. The pattern of the disease’s gravity across the globe is not the same, and in spots where you’d think the virus would decimate a nation, such as impoverished, densely populated places where the public health infrastructure is practically nonexistent, it didn’t happen. Now, there are some exceptions to this pattern that became evident after the pandemic’s first year, but it’s important to note that generally speaking, wealth and advanced health care systems did not necessarily give nations an advantage in controlling the virus’s spread.
All the countries in East Asia, Southeast Asia, and North Asia—a diverse region with a mix of wealthy and poor nations—experienced a lower rate of the disease and death in the first year even though their health care systems, be they national health care systems or patchwork ones, were different. For example, Japan and South Korea had a much lower COVID rate and mortality than the United States or United Kingdom, even after adjusting for the differences in population sizes. Highly populated countries in that region, such as the Philippines and Indonesia, had lower COVID rates and mortality compared to developed countries such as Germany and Norway, also after adjusting for population size. The European Union performed, on average, three thousand times worse than Taiwan, where the death rate was a minuscule 0.42 per million until a slight surge in late spring of 2021. Cambodia reported only a single death and just over one thousand cases by March 2021. This was followed by a new wave of infections but the numbers still paled in comparison to the waves seen in the West throughout 2020 and early 2021.
Such an odd pattern is not new to this pandemic. The lopsidedness of less casualties at a pandemic’s origin—and graver disease in places far from the origin—has also been documented in the three main flu pandemics in the past century. While the 1918 pandemic may have originated in the United States, it took more lives on other continents, such as Asia and Europe. The 1957 and 1968 flu pandemics started in China but caused much more death in the United States and
Europe. The increased aggressiveness of these pandemics in regions far from their origin cannot be fully explained by factors like underlying chronic conditions or age. We know that the highest mortality for COVID is among elderly populations, but we can’t neglect the fact that Japan has the oldest population in the world and still has had a relatively low COVID death rate.
As a group of researchers from Oregon State and the University of Nevada noted, “[A] compelling explanation for the pattern might be a partial preexisting cross-immunity to these viruses in areas close to the origin of the pandemics.”26 In another published summary article, researchers from the Center for Infectious Disease and Vaccine Research at La Jolla Institute for Immunology put forth an intriguing possibility: A large percentage of the population appears to have immune cells that are able to recognize parts of the COVID virus, and that may possibly give them a head start in fighting off the infection.27 In other words, some people may have some unknown degree of protection even without ever being exposed to COVID. This might also help account for the wide range of symptoms people experienced. We’ll be probing more deeply into this phenomenon so that we can better understand what this means for combating future pandemics. One thing is for certain: it casts the word novel under a whole new light.
Novelty
I’ve thought a lot about the significance of the word novel from both a biological standpoint and a cognitive, psychological one. For me, one of the greatest lessons that may come out of this pandemic is the ability to mentally process something novel and bring risk into proper perspective at the same time to inform and possibly modify behavior. After all, when was the last time we, as adults and as a society, truly experienced something for the first time? Do you remember ever being in a situation that was so unfamiliar that you had no sense of up or down?
