The Rationing

by Charles Wheelan

  “No clue,” I answered.

  “That’s where you find Dermatophagoides mensfarinae. Dust mites. A subspecies of the American dust mite, to be exact.” He advanced to the next slide, which was a highly magnified image of a dust mite. It looked like some nasty invader from outer space in a bad horror film. “That’s it,” he continued. “Endemic to North America.”

  “The dust mite is the vector.”

  “Okay, but now watch this.” He clicked to the next slide, which had the same map of the United States with the purple band, only now there were large green patches that roughly overlapped with the purple. “Those are your counties where more than twenty-five percent of the population tests positive for Capellaviridae.”

  “That makes sense,” I said. “Where you find the dust mite.”

  “Okay, now watch this.” He advanced to the next slide, which had the map of the United States, the same purple band, and myriad red dots spread randomly across the map with no obvious pattern. “Do you see a pattern?” he asked.

  “With what, the red dots?”

  “Yes.”

  “What are they?”

  “Just tell me, do you see a pattern?”

  “Well, the red dots—whatever they are—seem to be pretty random,” I said.

  “Exactly,” Tie Guy agreed. “I ran the numbers, and there is actually a negative correlation.”

  “You still haven’t told me what I’m looking at.”

  “Sorry,” he said, growing more excited. “The red dots are the deaths and serious cases: the people who died of Capellaviridae or became sick and were treated successfully with Dormigen.”

  “That doesn’t make any sense at all,” I protested. “There is no obvious connection with the dust mite.”

  “I know, crazy, isn’t it? The people most likely to get sick don’t live anywhere near the dust mite that transmits the virus—except for five or six places where there seem to be concentrated outbreaks.”

  “That can’t be right,” I said. “It makes no sense. Are you sure you have the right vector? Maybe it’s a coding error. You guys have been working all night—”

  “Watch this,” Tie Guy said, now nearly squirming in his seat with excitement. He tapped a key on his computer, though as far as I could tell, the next slide looked exactly the same: the map of the United States, the purple band, and the red dots. “Just watch,” Tie Guy said, sensing my puzzlement.

  Slowly the red dots began moving on the map, one at a time, from their random locations into the purple band. The pace picked up; the red dots moved more quickly into the purple band. After a few seconds, the motion stopped, with nearly all the red dots in or near the purple band. “Not so random anymore, right?” he said. “That’s where those people lived for an extended period of time before moving away.”

  “So they were infected before they left?”

  “Presumably, yeah. Remember the cluster at the College of Charleston?”

  “No.”

  “There were two deaths and three or four people who got really sick. Charleston is five hundred miles from anywhere you’ll find that kind of dust mite, but each of those students came from somewhere else—Michigan, New Hampshire, upstate New York.”

  “Okay,” I said, trying to digest what he was telling me. “So they acquired the virus at home, and got sick in Charleston. That’s indicative of the pattern we’re seeing.”

  “Yes.”

  “Go back two slides,” I told him. Tie Guy tapped aggressively on the computer and once again we were looking at the red dots strewn randomly across the map. “But if I’m seeing this right,” I said, “people are not getting sick in the places where the virus is most common, other than a few clusters.”

  “Right.”

  “How can we possibly explain that?” I asked.

  “No idea,” Tie Guy said, shaking his head. “One of the strangest things I’ve ever seen.”

  “And what about those clusters—the few places where the virus is common and people are getting sick?”

  “Nothing,” Tie Guy conceded.

  In all the excitement over the utterly bizarre pattern of disease, I had forgotten to ask him for the other crucial piece of information: the incidence rate. “So how bad is it?” I asked. “What’s the incidence rate?”

  “That’s modestly good news,” he said. “It’s a little lower than I predicted.” He clicked quickly through several slides. “There. About two million new cases per month. If anything, I would expect it to fall slightly over time. It’s a big number, but totally manageable. Dormigen works everywhere. The deaths are all people who didn’t seek treatment, or for some reason didn’t get Dormigen.” He waited for my reaction, adding, “It’s not a crisis, if that’s what you want to know.”

  “About five hundred thousand new cases a week,” I said.

  “Yeah, two million a month—five hundred thousand every week. It’s leveled off.”

  I did the math quickly in my head. We would still be about three hundred thousand doses short based on the last numbers I had seen.

  “Right?” he asked.

  “Right what?”

  “It’s not a crisis,” he said. “We can manage the disease for now and then either deal with this dust mite or work up a vaccine. As long as people are smart enough to go to the doctor, we’re fine.”

  “Sure,” I said. “This is good news.” After a moment, I asked, “Who is most likely to get sick?”

  Tie Guy leaned back in his chair and stretched. “No pattern at all, as far as I can tell,” he said. “I looked for every possible correlation: young, old, black, white, preexisting illness. I have no clue who gets sick from the virus, or why. The people who die are the ones who are too stubborn to get treated, but we figured that already.” Tie Guy was in a better mood now, pleased with his work. He said, “I’ll trim it down to five or six slides. Can I at least put in the photo of the magnified dust mite?”

  “If you want,” I said.

  “It’s a sick photo.” He looked up at the food and other garbage spread across the table. “I’ll clean this up before the Director gets here.”

  “I don’t think she’ll care,” I said. It felt like the first completely honest thing I had said that morning.

  27.

  THE DIRECTOR ARRIVED ABOUT TWO HOURS LATER, AS planned. The office was nearly abandoned; most of the team members who had been working all night had gone home. Tie Guy went through the same slides, still excited by the work he had done. “Do you have a slide with the incidence of Capellaviridae outside the United States?” the Director asked.

  “I’ve got a couple of things like that,” Tie Guy answered. After a few seconds of flipping quickly through the slide deck, he stopped at a slide titled “Dermatophagoides mensfarinae Endemic Areas” with a map of the world. There was the familiar purple pattern in the U.S. and a few purple patches in other countries with similar latitudes: Canada, Northern Europe, a few places in Russia and China. “Those are places where you find the vector, the dust mite. It’s just not that common outside the U.S.” I knew why the Director was asking: How much Dormigen was the rest of the world going to need? The less they needed, the more they could give us.

  “What about incidence of Capellaviridae?” I asked.

  “It’s about what you’d expect,” Tie Guy answered. He projected another slide with a map of the world and red dots randomly distributed across it. The only obvious clusters were in major population centers. “The international data are not great, but it seems to be the same pattern as in the U.S. The people who get sick are the ones who have spent time in an area where the dust mite is endemic and then moved to a place where it’s not.”

  The Director asked Tie Guy to assemble his team in the bigger conference room. People were beginning to trickle back into the office, looking showered and somewhat refreshed. The Director (or more likely her assistant) had ordered a catered breakfast, which was being set up hurriedly by two young guys wearing brown shirts that read G
ILLIAN’S CAFÉ. It was not the usual stale muffins and not-from-New York bagels; there was a tray of nice-looking breakfast sandwiches and a huge bowl of fresh raspberries, strawberries, and blueberries—not even watered down with tasteless chunks of unripe honeydew and cantaloupe. The Director saw me eyeing the food. “Grab a plate,” she said. I had not had breakfast. I could not remember if I had eaten dinner the night before. I had fallen into the habit of eating whatever food the White House put out during our meetings, whenever that happened to be.

  As the last few task force members filled plates at the makeshift buffet, the Director called the room to order. “I don’t want to ruin your breakfast with a long speech,” she said, prompting modest laughter. “Thank you. Thank you. That’s really all I have to say. I know how hard all of you have been working. I really appreciate that effort. The American people thank you—or they would if they knew how important this work is. Fifty years ago, a disease like this could have been devastating. Thanks to the work of people like you—steady progress at every turn—science is making our lives safer and better. Too often this kind of work is overlooked, especially the little discoveries and insights, but those little insights add up to huge discoveries over time. I’m here this morning to tell you that the work you are doing is really important. So thank you. Now eat!” There was some awkward applause and then a collective attack on the breakfast sandwiches.

  I was impressed, not just by the Director’s foresight in ordering the breakfast, but by the poise she brought to her talk. It was not the Gettysburg Address, but I could tell looking around the room that her words mattered. She was what my mother would describe as “put together,” though it sounds less patronizing and sexist when she says it than when I write it. The Director was fiftyish and fit, if not necessarily thin. She wore a nicely tailored navy-blue skirt and jacket and a gold necklace of some sort. She looked professional, which I mean not in the bland, meaningless sense of the word, but rather that the people in the room looked to her and believed that she was someone who should be in charge. I had never thought much about leadership, but in that moment I had a sense that I had just seen it, and it felt different than what I had previously envisioned.

  The free food mattered, too, not because the people in the room could not afford a good breakfast sandwich, but because they spent their days doing work that most of their friends and family could not understand, getting paid far less than their dafter college classmates who went to Wall Street or Silicon Valley. Finally someone had shown up and explained to them convincingly that what they were doing really mattered. It never would have dawned on me to do that. I was even more impressed when we climbed into the back of the Director’s car. She slumped against the seat and exhaled audibly. For the first time, I could see how much effort she had mustered to give her little breakfast talk. After a moment I said, “It’s reasonably good news, don’t you think?”

  “I suppose,” she said quietly. The tone of her response ended the conversation for thirty seconds or so. Eventually she continued, “There’s no way to prepare a vaccine in the time we have?”

  “Anything is possible,” I said. “But, yes, it’s hard to imagine how that would happen. We have no handle on who is most likely to get sick, so we would have to vaccinate everyone. That would be logistically difficult in ten days, even if we had a vaccine.”

  “That’s what the CDC people said.”

  “It’s still worth working on,” I offered.

  “There is a team doing what they can.”

  We pulled into the portico at the White House and made our way to a small West Wing office to get ready for our briefing. The Director sat down and immediately began responding to e-mails on her phone. After fifteen minutes or so the Strategist appeared in the doorway, unshaven and looking somewhat harried. I distinctly remember wondering how anyone could look so disheveled before nine-thirty in the morning. “We have a situation,” he said. “The briefing is going to have to wait.”

  “A situation?” the Director asked in amazement. “Are you kidding me? This is the situation.” The Strategist did not reply. He just turned and left.

  28.

  THIS SOON BECAME ONE OF THE MOST FRENETIC DAYS OF the crisis. We sat in our conference room for more than an hour, like two patients in a dentist’s office wondering if our appointments had been forgotten. The door was open and we could see a flurry of officious staffers passing briskly by. At one point, the Chief of Staff appeared in the corridor and the Director leaped out of her chair to ask what was happening. “I’m so sorry,” the Chief of Staff said. “The President is in the Situation Room. Everything is backed up. Maybe an hour or so?” As always, I was impressed by her courtesy and grace amid the craziness.

  It would be closer to three hours before we filed into the Cabinet Room. Only later was I able to infer what had been going on. There had been a coup attempt against the Saudi royal family early that morning by a surprisingly well-organized Islamic extremist group. The President and his team found themselves walking a fine line between protecting the Saudi government, a dependable if oppressive ally in the region, and being seen as a prop for yet another illegitimate regime. The Israelis, who often found common cause with the Saudis because they shared a common enemy (the Iranians), were pushing aggressively to put American troops on the ground in Saudi Arabia to protect the monarchy. The President had refused to commit troops; he had also warned the Israelis against any involvement other than intelligence sharing. According to one account, the President ended up in a shouting match with the Israeli Prime Minister. But I read about all this much later, at the same time everyone else did. For us, on that day, it just made for a lot of waiting.

  The Chief of Staff eventually showed up at the door to our small office and invited us into the Cabinet Room. Our slides had already been loaded and were projected on small screens in front of each participant. The NIH Director walked quickly through the presentation, six slides including Tie Guy’s highly magnified photo of Dermatophagoides mensfarinae. (I was eager to tell him that his “sick” photo made the final cut.) The group had grown larger. I recognized the White House Director of Communications and the National Security Adviser from photos. As we waited for the President to appear, my cell phone beeped with a text. I would have ignored it, but we were just waiting anyway, so I checked. It was from Justman, head of the Capellaviridae task force, and said simply: “Call me.” I got the attention of the Chief of Staff to ask if there was a place where I could make a call. Before she could answer, the President walked in. The participants around the table stood up quickly.

  “Sit down,” the President said sharply. It was not a “Thank you for standing up but now please be seated.” It felt more like he was annoyed that we had stood up in the first place.

  “It’s the task force,” I mouthed to the Chief of Staff. She pointed to a door behind where I was sitting and motioned that I should make the call from there. I got up, drawing a look from the President, and walked out of the room into a small corridor. Justman answered right away. “You told me to call with news,” he said apologetically.

  “Of course. What is it?” I asked.

  “I think we finally have a little good news,” he said. “The fatality rate seems to be lower than we thought. We got another wave of data last night: public health clinics, a sampling of government workers—”

  “Sorry, I’m in a meeting here. Can you just summarize for me?”

  “A lot of people are fighting this thing off on their own,” he explained.

  “So what’s your best guess on the fatality rate?” I asked.

  “Best guess—probably three to five percent,” he said.

  “Is there a pattern as to when it’s most likely to be fatal?”

  “That’s about what you’d expect,” Justman said. “It’s most likely to be fatal for people who are weak or immunocompromised to begin with.”

  “But there is no pattern as to when, where, or why Capellaviridae turns fatal in the first pla
ce?”

  “Not yet,” Justman answered. “That could be more or less random. For now, it probably makes sense to think of it like the flu. You don’t really know who is going to get it, but among those who do get sick, it’s those who are weak to begin with—the very old, the very young, that kind of thing—who are most likely to succumb.”

  “What about the college students?” I asked. “The UVM athletes?”

  “If they don’t seek any treatment at all, this is still a pretty nasty illness,” Justman reminded me.

  “Right,” I said. I was becoming aware of how long I had been away from the Cabinet Room. “I’ve got to go. I appreciate this. Please text me again if you learn more.”

  “No problem.”

  I turned the knob on the door to the Cabinet Room as quietly as I could, hoping to slip back into my chair without drawing undue attention. That was not to be. The Speaker of the House was asking something about Ohio when I walked in; the President turned to me and said acerbically, “Thank you for joining us.”

  I instinctively looked to the Chief of Staff, who gave me a look that said, “Just ignore it,” like my dad turning around from the front seat of the car and admonishing me to ignore my sister’s repeated jabs in the rib cage. The NIH Director was briefing the room on our meeting with Tie Guy that morning, working her way through the six slides. I never did figure out what the Speaker had been saying about Ohio.

  “We’re still looking at a huge number here,” the President said.

  “It could be much worse,” the NIH Director said.

  “I have some good news on that front,” I interjected. I explained what Justman had just told me.

  “We’re still looking at a huge Dormigen shortfall,” the President said. “Where are we on that?”