World War C

by Sanjay Gupta

  Deborah Birx and Bonnie Henry, two of the most prominent pandemic responders in the United States and Canada, share a lot in common. Both women had careers in the military (Henry grew up a military brat and became a Navy physician). Both dedicated their lives to chasing infectious diseases and preventing pandemics, often at enormous personal cost (long days, lost marriages), and long stretches spent in some of the world’s hottest spots for pestilence. And both had signature styles that the media noticed—veils of femininity that camouflaged fierce, warrior spirits. Birx’s scarves earned their own Instagram account, and Henry’s quirky uniform shoes by Canadian designer John Fluevog spawned a limited edition “Dr. Henry” shoe in support of the fight against COVID (with 100 percent of presale profits going to support British Columbia’s food bank). The Vancouver Canucks added Henry’s name to their playoff T-shirts, and the province’s First Nations bestowed an honorary new name on her: Gyatsit sa ap dii’m, which means “one who is calm among us.”3 In mainstream circles, she became known as the great communicator, soothing British Columbians’ feelings of anxiety and disconnection. She has no children of her own but came across as maternal and comforting, which was exactly what people craved. In a way, every member of her community was her child.

  Henry’s thirty-year medical career prepared her well for the COVID war. She’d been a female fleet medical officer tending to a thousand men at sea, a family doctor at an urban San Diego clinic, an epidemiologist setting up quarantines for families exposed to Ebola in Uganda, and the operational leader of Toronto’s response to the lethal SARS outbreak in 2003. The SARS outbreak was a lasting lesson for her—and her country. When a young man entered an emergency room with a strange, tuberculosis-like disease on March 7, 2003, Henry was sent to figure it out. Truth is, she already had her suspicions because she was paying attention to something most people had been ignoring: the emerging epidemic in Hong Kong. She had raised the alarm weeks earlier about the distant outbreak and warned it could arrive in her country any day; she spotted the signs of a mounting pandemic taking flight. But her requests that hospital physicians be on alert for severe cases of influenza—particularly in otherwise healthy people—were ignored. And so, tragically and predictably, before anyone knew what was wrong, the young man’s infection quickly spread through the emergency department. He became known as Case A; his mother had carried the bug back from Hong Kong and had died in their home two days before. Henry got to work and immediately put in place plans to contain Canada’s SARS outbreak. In the end, SARS killed forty-four in Toronto, many of them linked to the initial hospital. So at the turn of the new year in 2020, when she once again heard noise about a serious respiratory infection spreading rapidly in Wuhan that wasn’t identifiable, Henry’s ears pricked up. This was definitely unusual and “worrisome”; to her, it sounded like the beginning of a pandemic. Even though it was ten weeks before the WHO would follow suit and officially declare one, Henry already knew the “son of SARS” had been born. And now it was all about responding appropriately.

  It was during her time tracing Ebola outbreaks in Uganda for the WHO that she learned another critical and often overlooked component of an effective response. After explaining what people needed to do and why, she had to go the extra steps to make sure it could actually be done and explain how to do it. For example, an effective quarantine would work only if food and housing were prioritized along with frequent communication. Punitive measures like restrictive mandates and fining people who defied public health measures were deemphasized, a lesson she carried out in 2020. Instead, she championed the three Cs: confidence, competence, and compassion. Henry earned her confidence and competence in all those years responding to outbreaks.

  Compassion comes in handy when trying to manage people’s behavior through a crisis. In a crisis, people are anxious, and that’s normal. She had to strike the right balance between fraying people’s nerves with bad, apocalyptic news and telling the truth of the unfolding crisis so they could prepare and keep themselves and their loved ones safe. “For many issues in public health,” Henry says, “knowing when to push—and when to keep the solution in your back pocket until just the right political and societal moment—is a critical skill.”

  It was a superpower for Henry, but it was still a challenge to get the balance exactly right. As cases in her community rose, memories of the fears, grief, sadness, and anger that she’d faced during the SARS outbreak all came flooding back. She fought back tears while delivering public announcements. She knew that kindness and compassion, understanding others’ suffering, would be the best way she and her community could overcome the pandemic.

  Dr. Henry also addressed a question I have often thought about in my own reporting: Do we underestimate people’s capacity to understand complex things? I have concluded that people like hearing from scientists and doctors on the front lines. They like understanding our assumptions and our ability to concede there is not yet a clear-cut answer. The audience can handle the words I don’t know and forgive the lack of a conclusion as long as you are honest and transparent about it. People often like to see the process of how scientists think through a problem and search for solutions. Medical television dramas from Chicago Hope to Grey’s Anatomy actually do this really well, embracing the fallibility and dilemmas of doctors and nurses while also celebrating their lifesaving powers. But in the real world, we probably don’t share our background thinking enough and instead deliver sound bites that lack nuance and are not always useful to the public. After twenty years of medical reporting, I have come to believe that we should not underestimate people’s intelligence and thirst for details even when those details are hard to grasp. When it comes to their own health or that of their loved ones, people can appreciate complexity.

  A fundamental question that remains to be answered is whether COVID will become endemic much like HIV—always around and always changing. Or whether it will more closely follow in the footsteps of other respiratory scourges like tuberculosis and flu, both of which are ailments that annually strike millions around the globe. The truth is, even after a hundred years, we still have a lot to learn about flu. We don’t take the time to create early-warning systems for when flu begins to circulate in communities and there are subsequent surges, to identify and screen many cases of flu, “but maybe we should in the future,” Birx said to me. “Maybe that should have been part of our pandemic preparedness—that we really do understand how many flu cases there are, that we really do diagnose all of them. Is there an asymptomatic component to flu? Are there children in school that we think are spreading flu? Are they really the core spread of flu? You know, sometimes we have the technology, but we don’t utilize it.”

  It is clear now that we need to build a sophisticated monitoring system that not only tells us the extent of spread but detects new variants as they start to emerge. Understanding the moment of spread from animals to humans is more critical than we have previously appreciated. Imagine the number of lives that could have been saved if we had surveillance to identify the first intrusions of these pathogens from wild animal to human. I have always found it so remarkable that humans have such a hard time detecting microbial menaces, given the existential threat they may pose. Think about it. Germs cannot be seen, smelled, heard, tasted, felt, or even suspected. As a result, our evolutionarily ancient “lizard brain” is defenseless against these microbes. Our brain makes us afraid of the dark, jump at loud noises (what’s called your acoustic startle reflex), and have an innate fear of falling, but it demands a high-tech surveillance system to tell us when something is amiss in our pathogenic environment. Some fears must be learned. Unlike those other fears we’re born with for basic survival, we’re not programmed to notice nefarious, microscopic threats. This necessitates two critical actions going forward.

  Testing routinely to know where the virus is and where it’s spreading. Testing is our “eyes” on the virus.

  Performing genetic analyses on the virus as it mutates and sp
awns new variants or strains. Genomic sequencing is a sophisticated tracking of the evolution of the virus.

  There are probably thousands of strains of the virus more transmissible and deadly than others. Scientists are studying how the disease caused by these new variants differs from the disease caused by other variants that are currently circulating, as well as how these variants may affect existing therapies, vaccines, and tests. Initially, the United States fell far behind in such high-tech surveillance as other nations like the United Kingdom sped up this important strategy. But we’re catching up. New variants of COVID are found every week, with most rather innocuous, simply coming and going. Some persist but don’t become more common while others increase in the population for a while and then fizzle out. When a change in the infection pattern first emerges, it can be hard to tell what’s driving the trend. Is it changes in people’s behavior or changes to the virus itself? As fast as our eyes and ears can spot certain threats, a crucial lesson when it comes to pathogens is that we must create new ways to identify pathogenic threats as quickly as possible.

  There was something else that Henry and Birx shared in common: a recognition that their scientific acumen would be greatly diminished if the messaging didn’t properly connect with the masses. During the several hours of conversation I had with Dr. Birx, it was this point she really wanted to convey. And she shared three important lessons that we must consider going forward:

  “People’s perceptions are their reality.”

  “You can legislate behavior. You can’t legislate how people think.”

  “We have to tackle how we talk to people, hear people, and meet them where they are. Who delivers the message is almost as important as the message itself.”

  This last insight was particularly moving for Birx while she was on the road. She tailored the message for her audience and to some extent even tailored herself to be the right messenger. When she was on college campuses, she played the part of scientist and grandmother, warning young people not to be so flippant about getting infected because we don’t know what this will do to someone at thirty, forty, or fifty years old. (As we’ll see in chapter 6, children who contract the virus today may go on to develop complications either during the acute phase of the illness or many years from now for reasons we have yet to understand.)

  When Birx met with tribal nations and spoke with their leaders who were committed to bringing their community together, she was the public health epidemiologist and social psychologist who seized on their unwavering sense of unity to protect one another, understanding that they were living in multigenerational households, that they had one of the lowest life expectancies in the country, and that they could have made a million excuses for why things would not go well for them. And yet, together they rallied against every one of those excuses and made a difference. Standing in solidarity with them, Birx was frank with tribal health officials about their members’ vulnerabilities: high incidence of coexisting chronic health conditions like diabetes and obesity, and underfunded, understaffed health care systems within their communities. She held roundtables to bring together local governors and tribal leaders to show them what to do to minimize the loss of life and take some of the distress out of the raging pandemic on the reservations. She also shared the evidence that following the simplest precautions of wearing masks, physical distancing, and paying attention to their health hygiene—in both public and private settings—could help overcome many of the unique challenges they faced.

  For example, when she met with the Salt River Pima-Maricopa Indian Community in Arizona, she championed their #SHIELDUPSALTRIVER campaign and was gifted a face covering by the tribe’s health officials that was emblazoned with the symbol representing a modified version found on an O’odham (Pima) warrior shield used in battle. Now it represents the tribe’s fight against the virus. Make no mistake, however: Native Americans have been disproportionately affected by the virus compared to their white counterparts. In 2021, President Joe Biden’s $1.9 trillion COVID relief package provides $31 billion for tribal nations and Indigenous people so they can better prepare and at last address long-standing challenges like poor health care that make them starkly vulnerable in a pandemic. Tribal nations are communities within themselves, but they are also part of our larger national community. And as much as each one of us thinks and acts on an individual basis, we must always keep our neighbors—our community—in mind.

  “We must learn how to be part of a community—not separate from the community,” Birx notes. That leads us to the P in P.R.O.O.F.—Prepare. There are three important steps to prepare for your future with this virus: gain perspective; find your sources of valuable and trustworthy information; and be prepared to go into pandemic mode at a moment’s notice. We’ll take each of these ideas in turn.

  Gain Perspective

  In retrospect, I am surprised at how quickly the world changed. I would not have imagined that the vast majority of the country and world would actually stay at home. That the air would get cleaner. That schools would so quickly go online. That restaurants, museums, and gyms would close. Telehealth went from being mostly unused to 80,000 visits in a month at Emory University Hospital in Atlanta where I work. I was surprised at the proactive efforts of organizations like the National Basketball Association to curb the spread despite the huge monetary loss. And once we began to open up again, I watched as we delicately found the right balance between being overly cautious and not being cautious enough; finding a new normal and clawing ourselves back to some semblance of “life.” In chapter 7, I’ll outline essentials to putting health first and practicing extreme self-care that will be helpful to paving your personal path forward, but for now, let’s focus squarely on the broader perspectives.

  Pandemic burnout definitely hit by 2021, a year into the event. Perhaps paradoxically, even though the world slowed down while most of us were under quasi–house arrest, we still found ourselves exhausted and unmoored. We lost track of the days as one blurred into the next. Every mental health professional I’ve talked to has said that rates of depression, anxiety, stress, and malaise are all up considerably from prepandemic 2019. I think every one of us has experienced some level of posttraumatic stress (PTS), whether we or a loved one developed an infection or not. In addition to the loss of life from the virus, which alone must be grieved, there have been gradations of loss across a vast spectrum: loss of jobs, businesses, and income; loss of health and sense of well-being; and loss of signature experiences and milestones in life such as graduations, weddings, vacations of a lifetime, and family reunions. The term brain fog became common not just for people suffering from the illness’s cognitive effects but also for individuals who escaped infection but nonetheless felt the pandemic put them in a fog that would not lift. Some people told me the loneliness of social isolation was the cause: it was harder for them to stay focused or accomplish mundane tasks. And then there’s the greatest stressor of all: persistent uncertainty, the loss of security, and the reduced capacity to be optimistic about the future. So how do you gain and maintain perspective in the midst of all that?

  I’ve reported on and written extensively about the detrimental effects that stress has on the brain and body. The kind of stress brought on by the pandemic is indeed among the most toxic and mentally crippling because it checks all the boxes: it’s relentless, tedious, unwelcome, unruly, and ultimately highly disruptive to our routines—particularly those that contribute to our health. No matter how toxic something is, having an end date can help you mentally prepare. But there was no calendar to follow during this pandemic. Even the most experienced people, infectious disease doctors included, were often left saying, “I don’t know.” When trusted authorities admit they don’t know, that brutal honesty can be unnerving and invite a sense of hopelessness.

  It is why perspective is a critical component of preparedness. Without a well-informed perspective, none of the other preparedness plans can fall into place. It’s an active task requiring y
ou to take stock of the present, look toward the future with resolve, and make sure you are constantly controlling the things within your power along the way. One of the best and most productive places to start is with your own body. Getting a good night’s sleep, eating well, breaking a sweat regularly for your physical health but also diligently engaging with others and even developing new knowledge, hobbies, and skills for your mental health. I realize none of this is easy and that for many, those basic activities of life have been partially sidelined or abandoned during the pandemic. Some people did become fitter and happier in 2020, but my guess is the majority of people would call it the worst year of their lives. That is why proper preparation means that so many of these behaviors must be a constant in our lives—before, during, and after a future pandemic.

  Nicholas Christakis is a physician and social scientist at Yale where he directs the Human Nature Lab. He is also the author of Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live.4 I admire Dr. Christakis because not only does he have immense experience as a doctor, but he also has an esteemed career as a sociologist, studying how our social behavior influences—and is influenced by—health and human biology. He looks to history to try and project our future.