The Plague Year by Lawrence Wright
This is the fifth book I’ve summarized that relates to the pandemic. (Quick quiz - Name them. I thought not. Answer below. *) This is the second one by Lawrence Wright who wrote The End of October, a novel about a worldwide plague that was published just as the world was shutting down because of Covid.
Wright chronicles the spread of the virus from December, 2019, when a doctor was suspicious that an elderly couple who came to the hospital coughing had contracted some type of unknown viral disease. He ends the book in February of 2021 as Joe Biden becomes president. Several doctors at Hubei Provincial Hospital had seen patients that presented symptoms that looked a lot like SARS, which had broken out in China in 2002. The government quashed any reporting about SARS for many months after it hit. Fortunately, that virus was contained. Concerning Covid, the party leadership did the same thing, refusing to acknowledge that there was a problem and not letting doctors in from the World Health Organization until April of 2020, well after the virus had exploded all over the world. Governmental accountability is not a big deal in the People’s Republic.
Despite the government crackdown on providing information, a group of Chinese doctors sent the virus's genome to colleagues in the West. That was a big help in developing the vaccine. Dr. Li, one of the first people to figure out what the disease was, contracted it and died in February of 2020 after having been severely chastised by the government for his whistle-blowing. China quarantined about half of the population. That helped contain the virus.
The coronavirus hit the US just as the country was struggling with political change, Donald Trump as president had changed the civic landscape of the country and disrupted both the Republican and Democratic parties. The timing wasn’t great.
One problem which was a bipartisan creation was the hollowing out of the country’s public health system, especially the Centers for Disease Control. Both Democrats and Republicans routinely cut CDC funding to the point that in 2017 Dr. Fauci warned that we would face a pandemic at some point and that the system’s disease response infrastructure would not be up to the task of dealing with it.
Since anything the previous administration did was tossed out, the Trump administration threw out the 69-page action plan about how to respond to a serious disease outbreak developed by Obama’s people. Ironically, Trump’s Secretary of Health and Human Services Alex Azar and his team developed a plague scenario that was very accurate in predicting what would happen if a pandemic hit. Around 600,000 Americans could die. Businesses and schools would have to close. The economy would crater. There would not be enough personal protective equipment. Government agencies would wing it and not coordinate responses.
While the CDC had been gutted, there were still a lot of competent scientists working there. John Brooks led the Covid response team at the CDC. He began working there in 2015 in the HIV/AIDS division where he learned that a horrible disease could play tricks on us. Just when you thought you had it figured out, it threw a nasty curve at you. One problem he noted was that as development worldwide encroached on previously wild space, animals became closer to humans and became carriers of disease that could jump species and infect people more easily. Another task force member, Greg Armstrong, figured out one of Covid’s tricks – that it was transmitted through the air by people with no symptoms. That fact changed everything and greatly increased the degree of difficulty of containing the virus.
Early in the plague year, the CDC was doing a good job of getting a handle on the challenge. However, President Trump’s people muzzled them so that the president could peddle his own fake take, that Covid would be over by Easter and there was no need to socially distance or wear masks.
Wright recounts research going back to the early 2000s that built the foundation for the mRNA work that would lead to the rapid development of effective vaccines. The 2002 SARS outbreak in China gave researchers the opportunity to study a coronavirus carefully, although that one fizzled. The MERS outbreak in Saudi Arabia in 2012 provided more insights into how infectious viruses worked.
Barney Graham worked at the National Institute of Health. Dr. Fauci considered him to be the leading expert on vaccines in the country. He spent many years working at Vanderbilt University in Nashville where he learned all about what made an effective vaccination. He wanted to develop vaccines that weren’t based on the traditional model which essentially injected the patient with a weak version of the actual virus so that the body’s immune system could develop antibodies to ward off infection. That approach sometimes led to people getting sick with the disease, not a good thing. Graham and his colleagues paved the way for the mRNA approach to vaccination, a much safer alternative to the old method that dated back hundreds of years.
Moderna in Cambridge had used mRNA to treat rare diseases for years, and they were confident that the company could quickly develop an effective vaccine. Moderna received the Covid genome from China on January 10, 2020. Ten days later, they produced the vaccine. Sixty-five days later, the FDA approved the shot for emergency use, and trials began on March 16, the fastest development of a vaccine ever.
Just as Donald Trump’s second impeachment trial was beginning in mid-January of 2020, Dr. Fauci opined that he didn’t think Americans had much to worry about with the virus. At the same time, Mike Brown, who owned a surgical mask-making company, contacted his friend at the federal medical emergency agency and suggested that it might be time to ramp up domestic mask manufacturing. The request never got a chance to go up the food chain and was ignored. This was really early in the pandemic, but if Mike’s suggestion had been taken seriously, we would not have had the PPE crisis that we had early as the virus was spreading.
China was blocking any visits by scientists to try to figure out what was going on. Many people at CDC and NIH (National Institute of Health) were convinced that the virus was going to be a big problem. The president’s team pushed back, led by Larry Kudlow, Trump’s chief economic advisor. Trump did close travel to people from China, much to the disgust of Kudlow. It was probably too late then for the travel ban to be effective.
President Trump gave his State of the Union speech on February 4, after he had easily beaten back impeachment. His popularity was up; the Democrat’s attack had kicked up his approval rating. He correctly touted the strength of the American economy which was roaring ahead and showing signs of solid growth. All of that would change soon.
Howard Markel was the director of the University of Michigan’s Center for the History of Medicine. Once Covid hit, he assembled a team to look back at the 1918 Pandemic to try to figure out what, if anything, had worked to reduce infections. He and his team went to the New York City Public Library which had extensive digital and microfiche files for many American newspapers going back to 1918. They found that the cities that shut down businesses or reduced operating hours and closed schools had much lower rates of infection. San Francisco was the only major city to impose a mask mandate and their infection rate was very low. During the second and third wave of the 1918 virus, San Francisco didn’t do as well but that may be due to the fact that citizens got sick of wearing masks. That didn’t change the fact that masks greatly reduced infections.
St. Louis did the best job of containing the 1918 virus. The city leaders quickly closed schools and banned public gatherings. Educational brochures about the disease were handed out that convinced most people to not leave their houses. The city had a very low rate of infection.
Author Wright makes the point that in some ways fighting the virus in 1918 was much easier than doing that in 2020. In the early twentieth century, people trusted the government and the media. The cities that figured out how to beat the virus could easily communicate with citizens who would do the right thing. It didn’t matter if you were a Republican or a Democrat; you trusted society’s institutions. In 2020 people believed what they believed based on political ideology, and many people of all partisan persuasions did not trust the government or the media to be straight with them.
Secretary of Health and Human Services Azar, a big pharma guy, seemed to understand the need to do massive testing to control the virus, but his boss didn’t like that. Trump said that if you test more you’ll get more positives and that’s bad for the economy. He got it totally wrong. If you test more you’ll know what you’re up against and you can develop appropriate responses to beat the virus, which is good for the economy. While Azar was a pro-testing guy, he didn’t communicate that to Trump who would have yelled at him for being off-message.
CDC was determined to develop its own Covid tests although Germany had already developed good tests that were available for our country to use. China was slow in delivering actual samples of the virus which slowed down the process of creating testing kits. When CDC did deliver the tests, they didn't work, despite having passed CDC quality control tests. Secretary Azar insisted on using the kits - they sometimes were correct but there were a lot of false positives. Germany once again offered its kits but we didn’t want them. Since CDC had dropped the ball, many independent labs were developing their own kits. The FDA took a long time to authorize labs to produce tests, a regulatory requirement. We lost at least a month of testing because of the FDA’s nonchalance, a time when millions of Americans were infected but couldn’t be tested to confirm that. The failure of CDC and the FDA to get their acts together really helped spread Covid.
In late February, President Trump reassured the country that the virus was just going to disappear “like a miracle.” At the same time the Biogen company was having a big meeting in Boston that brought in people from all over the world. We all know what happened. Researchers say that if only one person at the conference were infected, that would infect the whole conference since people met for hours in closed rooms. Since the virus hadn’t exploded yet, masks and social distancing weren’t part of the meeting.
Researchers were thinking that Covid was an airborne virus so wearing masks was a good idea. At first there was pushback in medical facilities because masks would scare people. Once the infection rates and the number of deaths spiked, scaring people was OK.
By now, the Covid response team was regularly meeting at the White House. Dr. Fauci and Secretary Azar were on the same page in seeing the need to get as much personal protective equipment out to hospitals as soon as possible, develop therapeutics, and encourage labs to develop a vaccine. The government would pay the bill. They thought the tab would be around $3 billion. President Trump disagreed. He authorized only $800 million, woefully inadequate.
Many people on the task force disagreed with the White House that the virus was just like the flu. They needed help. They reached out to Dr. Deborah Birx, a respected epidemiologist and pandemic expert who was in South Africa when she got the call to come back home. She foresaw that working with the White House that was in denial about the seriousness of the virus would probably end her career but she did agree to help out.
February 2020 was a major reference point for the pandemic. It was the month that we learned that cruise ships and nursing homes were super spreaders. The death rate in those venues dramatically increased over the next few weeks. That was a wake-up call for the country. By the end of the month, there was probable local transmission - often by asymptomatic people - in 38 states. By late February it was too late to contain the virus the way China, Hong Kong, and South Korea had by quarantining early and aggressively. CDC announced that Covid was “rapidly evolving and expanding.” They finally got something right.
The stock market crashed, greatly upsetting the president, who bounced Secretary Azar from being the chair of the Covid task force and replaced him with Vice President Mike Pence. Azar has deservedly taken a lot of criticism for his actions around the virus, but initially he got a lot of things right and worked with Dr. Fauci to try to respond aggressively to the challenge of the virus. That got him fired. Mike Pence would do what the boss wanted.
On March 6 Trump visited CDC and told folks that he understood medicine because his uncle was a doctor. The president reminded people that there were only 240 cases in the country and that the virus would soon be gone. (A month later, on April 6, there were 35,000 cases and the count was increasing geometrically.) At the CDC, Secretary Azar announced that 4 million tests would be available in a week. None were available and they wouldn’t be for a long, long time.
Donald Trump wasn’t the only public leader who didn't get it. New York City Mayor Bill DeBlasio announced that NYC and the schools would stay open. After all, most Covid patients didn’t get too sick and, when enough people had contracted the virus, we’d have herd immunity.
During the early spring, the White House Covid task force meetings were totally disorganized. The group was huge, with no rules. Mike Pence could not structure the meetings to be productive. Dr. Birx was one of the few people who actually understood what they were up against. She was hated because she was off-message, the message being, “No problem. Nothing to see here folks.” The administration was all-in on keeping the economy wide open even when told that they were looking at hundreds of thousands of deaths unless parts of the economy were shut down.
By mid-March, most leaders realized that the economy was going to shut down on its own. People would not venture out into crowds or go to shows or restaurants. Washington was working to find a way to help small businesses get through the pandemic. Senator Marco Rubio, a conservative from Florida, ended up leading the charge for massive federal spending to keep businesses alive. The virus did unite Republicans and Democrats for one brief shining moment – the Senate passing of the massive $2.2 trillion stimulus package on March 25, 96-0. Two days later it was law.
Bellevue Hospital is a huge public care facility that took the brunt of the Covid explosion in New York City. Halls and storage areas became emergency care areas. Staff was overwhelmed but they hung in there and provided care to thousands of patients. The city was overwhelmed with Covid cases. Over 30,000 health care workers from out-of-state came to the city to help out. Over 20,000 people died during the spring of 2020 in NYC. We’ve all seen the pictures of the 133 refrigerated trailers that had to be brought in as temporary morgues.
On March 15, the Coronavirus Task Force finally agreed about what needed to be done. Essentially, the country would be shut down. President Trump pushed back hard, saying that the virus was “something we have tremendous control over.” Dr. Fauci pushed back and said that the worst was yet to come. The president reluctantly issued the guidelines.
The next day Trump had a conference call with all 50 governors and told them that his people were working hard to get a vaccine but that the states were on their own for getting PPE and ventilators. The governors were shocked. This was the first national emergency that Washington moved away from. The states expected help from the federal government. Even the Republican governors were shocked by Trump’s hands-off attitude. One governor said that this was like FDR on December 8, 1941, saying, “Good luck, Connecticut, you go build the battleships.”
It turned out that the expected national stockpile of PPE wasn’t there so governors had to get their own supplies. Massachusetts Governor Charlie Baker bought 3 million N95 masks from China which were seized by federal authorities at the Port of New York. No dummy, Charlie learned his lesson. He got another 1.2 million masks but this time he didn’t use a commercial carrier. Bob Kraft, owner of the New England Patriots, had the PPE flown directly into Boston on the Patriot’s charter plane.
Without federal involvement, states had to bid against each other for the PPE. Even when they won the bid, the feds often stepped in and seized the shipment. When the feds finally got involved they screwed up. A $55 million contract for PPE was awarded to a Virginia tactical training company for the production of N95 masks. It turns out that a training company that has no manufacturing capacity can't make anything. Besides, the company had gone bankrupt and had no employees. There are many stories in the book about how a governor would order something (PPE, ventilators) through the White House, complete the deal, pay the money, and then have the order never filled. Were these people not public employees, they would be indicted for commercial fraud. Calling this a “clown show” insults clowns.
Jared Kushner jumped in and got some orders filled. The trick was that you had to flatter Jared and tell him what a great job that he and the president were doing. Even some Democrats crossed their fingers and bowed to the White House in order to get desperately needed material, although not much was ever delivered.
By late March, it was obvious that people out in public needed to wear masks but there weren’t many available. Matthew Pottinger (UMass Amherst, class of 1996) was a deputy national security advisor whose wife, Yen, was a virus expert. He understood how dangerous the virus was and that masks were a key to defeating it. Matthew attended White House meetings wearing a mask, the only person who did. He felt weird, being gawked at. He was appointed to the Coronavirus Task Force and wore a mask at meetings, again, one of the few. On April 3, CDC finally issued a finding that masks were important in beating the virus. Matthew went to the next task force meeting wearing a mask, but few others were. Mike Pence congratulated him on the CDC advisory and then announced that going forward, masks would not be allowed at the meetings. Matthew never attended another task force meeting.
President Trump’s refusal to mask up, and his open disdain for those who did, sent a powerful message to people, especially his supporters. It would be an interesting dissertation project to calculate how many people in Trump states got infected or died because wearing a mask was almost forbidden.
Several major manufacturers, including Hanes Underwear, offered to make reusable, effective cloth masks. The company couldn't get the task force to even consider the proposal. The White House had always been consistent about how you don’t need to wear masks, and if you do, it’s a sign of weakness. (See “clown show” comment above.)
George Floyd’s murder in late May of 2020 led to a wave of protests across the country. These mass gatherings gave researchers a chance to ascertain how contagious the virus was out-of-doors. They found out that it wasn’t very infectious in the open air.
Deb Birx continued to stand by the president at his press conferences. She pushed back in private but got nowhere with her boss, the nephew of a doctor. In August, Trump gave Scott Atlas, a Stanford professor with no virus experience, a 6-month appointment to advise him. Dr. Atlas agreed with the president that schools and the economy should be opened up and that you didn't need to test people who had no symptoms. (Note to readers: The overwhelming percentage of infected people had no symptoms or very light ones. They still spread the virus.)
Atlas was anti-mask and thought that doing nothing – waiting to get to herd immunity – was the best way to beat Covid. Trump liked that. Birx asked Pence to dump Atlas to no avail. She left the task force and did a series of road trips with Irum Zaidi, a respected epidemiologist. They drove across the country eight times, racking up 25,000 miles. They talked to elected officials and governors, asking them to have people use masks. They had a positive impact. Many governors of both parties saw masks as a sensible approach to preventing infections.
Wright talks about the difference between Dr. Fauci and President Trump. Fauci is disciplined, organized and self-effacing. He’s been married to the same woman for decades. He runs a lot and works 10 or more hours a day. Trump is the opposite. He is loud and boisterous and tells everyone how smart he is. He's been divorced twice and paid off women who are not his wife, to be quiet.
Donald Trump needs to be the center of attention, not unlike many politicians. He resented Dr. Fauci’s connection to the people. One poll showed that 67% of people trusted Fauci to give them correct Covid information compared to 27% for Trump. That irritated the president.
Tony Fauci was on the cutting edge of the AIDS epidemic in the 1980s. For years, that virus baffled doctors. He learned then that diseases often are elegant in their resistance to human’s understanding them, knowledge that would help him navigate through Covid.
Wright points out that Trump rewrote the political playbook in beating Hillary Clinton in 2016. Despite his vulgar talk about having his way with women, he got the same percentage female vote as had Mitt Romney in 2012, which was more impressive because he was running against the first female presidential candidate. He got a landslide vote from Evangelicals, Protestants, Catholics, and Mormon church-goers. Usually Republicans get the votes of healthy people. Not in 2016. Trump romped in areas where poor people with poor health lived. Places that had major opioid epidemics overwhelmingly voted for Trump. Healthier folks went for Hillary. Wright postulates that Trump’s connection to poor, white, unemployed, unhealthy citizens made sense because these were the people whose communities had been hollowed out by factories closing down and wiping out the local economy. The Democrats stopped paying attention to them several election cycles ago as the party became captured by identity politics. Poor and white was not an identity Democrats embraced.
Trump continued to downplay the virus. He placed a sketchy political operative, Michael Caputo, at the Department of Health and Human Services to recruit celebrities to reinforce the president's rosy position that the virus was no big deal and that everything was under control. Despite having an unlimited budget and calling from the office of the president, Caputo could not get one celebrity to come on board. Some expressed initial interest but once they figured out that they’d be essentially lying about the seriousness of Covid, they backed out.
On September 26, 2020, newly-minted Supreme Court Justice Amy Coney Barrett was feted in the Rose Garden of the White House. People were sitting right next to each other, maskless, breathing each other's vapors. More than a dozen guests including Utah Senator Mike Lee, Chris Christie, Notre Dame President Father John Jenkins, and Trump advisor Kellyanne Conway, caught the virus that day. After the event, Trump and a bevy of staffers and reporters took off on Air Force One for campaign events. A NY Times reporter and presidential aide Kayleigh McEnany caught Covid. The president went off to a series of rallies in Pennsylvania, irritating the governor because Trump and his campaign violated every Covid protocol in the state. The president and first lady were supposed to be tested every day but they didn’t bother. Many people got infected during those rallies, possibly from the president.
On September 29, Trump and his crew went to the first presidential debate and violated all of the Covid rules. They were maskless and did not get tested as required for entry into the building. The chief executive was showing the virus who the boss was. Two days later, Trump tested positive. Many staffers who were hanging around him also were positive. The president had a serious case of Covid, but being president – even one who says the virus is no big deal – gets you the best medical attention, so he recovered. Instead of using this as a teaching moment, he showed off his Superman T-shirt from the White House balcony. That was certainly a great message to send to his supporters in depressed communities where Covid was running wild.
What ifs. Lawrence Wright ends the book reflecting on what might have been.
Had China been straight with the world about the disease from the beginning, we would have had a good chance of containing it. By the time the Chinese began to cooperate, it was too late to minimize damage.
Had the CDC developed an effective test kit in a timely fashion, and distributed it, the rate of infection would have been much lower.
Had there been a coherent national response led by the president, states would not have had to waste precious time and money trying to buy needed PPE and ventilators while bidding against each other to get the stuff.
Had the president taken the virus seriously, many deaths could have been prevented just by social distancing and wearing masks. Vermont is a state that did a lot of things right. South Dakota did nothing right medically and had 12 times as many deaths as Vermont which has about the same population. With a national push from the White House, SD Republican Governor Kristi Noem would have had cover to encourage citizens to take basic precautions that would have saved countless lives.
Wright gives President Trump credit where credit is due. He did shut down the borders as advised. He did prioritize getting a vaccine ready.
He did repeat the CDC’s April 2020 advisory on the importance of wearing masks in public. However, in the next sentence said that it’s a voluntary thing that he would not do. It was downhill from there in terms of looking to the White House for serious leadership against the pandemic.
Despite being the wealthiest major power on the globe, the United States has 4% of the world's population and 15% of Covid deaths. That works out to 750,000 and counting in the US, compared to 5 million deaths around the globe. As a nation we blew it. A major international think tank, The Lowy Institute, developed a system to measure each nation’s response to the virus. The US was #94 out of 100.
Lawrence Wright waxed poetically in summing things up:
Imagine a foreign adversary invaded America and killed half a million people. How would the country respond? No doubt the most powerful military in the history of the world would annihilate the invader. Partisan differences would fall away as the American people joined as one to defend their countrymen. History would mark the loss of life, unmatched by any military conflict in our country except the Civil War; but perhaps it would also note that it was the moment when the United States returned to its senses and concentrated on making the world a safer place.
But our invader is not a human adversary; it is nature that we struggle against, and in the face of this conflict there is a curious passivity. We were poorly armed for this contest, due to decades of cutbacks in our healthcare system. After 9/11, we spent trillions on homeland security and counterterrorism. Our military preparedness was unparalleled. We were ready to go to war with any nation, but we were missing the fact that our own country was at war with itself, and that our weakened, broken society was easy prey for the contagion that was inevitably going to come.
Bob’s Take
It’s the economy, stupid! In February of 2020, Donald Trump was presiding over a booming economy. Whatever you think of him, he must have been devastated when Covid crashed the good times two months later.
Mike Pence was put in charge of the Coronavirus Task Force because he would do what the president wanted to muddle the nation’s response to the pandemic. On January 6, 2021, the vice president refused to not certify Joe Biden’s victory in the joint session of Congress assembled to count and certify electoral college votes. He finally stood up to Trump, probably dashing his chance to move ahead in the Republican Party.
Dr. Deborah Birx and Secretary of Health and Human Services Alex Azar come off better in the book than I would have expected. Dr. Birx had done a great job during her career in helping contain infectious viruses. She suspected that coming to the White House would ruin her career and reputation and she was right. She did go out on her own with Dr. Zaidi, riding circuit for months all over the US to make leaders aware of what they should be doing to lower the infection rate. They had remarkable success along the way.
Secretary Azar understood a lot of what needed to be done to minimize damage from the virus. He pushed back on the president’s sillier notions but was rebuffed. I suppose you could criticize him for not being more forceful, but I think he figured out that Donald Trump would never change his mind about anything regardless of the facts.
The Black Death in the 1300’s Because of that plague, 75 to 200 million people died worldwide out of a 400 million total global population. As a result of all of the deaths, labor was scarce so pay went up and women got into the workforce. The Plague also led to a change in thinking about life that led to the Renaissance. Author Lawrence Wright is optimistic that this plague will also open the world up to new possibilities. I hope he’s right.
Donald Trump wasn’t the right person to be in charge of dealing with Covid. This country’s public health system is a mess, but a different person in the White House would have done a much better job of dealing with the virus. President Trump primarily sees the world in terms of boosting his brand. That works if you’re a NYC developer or a celebrity TV star. It doesn’t work when you have to take a step back, find experts, and listen to them so you can do the right things to beat the virus. Since he didn’t believe in science, he was in bad place because he had to use science to reduce infections and save lives. His persistent refusal to wear a mask and his belittling of those who did caused irreparable harm and costs thousands of lives.
Vax resistance may not be so bad. One-third of the country will never get a vaccine. The good news is that those people get infected at a much higher rate than people who are vaccinated. When you add up the unvaccinated people who caught the virus together because of so many infections, with those who are immune after getting the shots, you get close to reaching herd immunity which will stop the virus. We’re getting there. From the Wall Street Journal, October 31, 2021:
Public-health experts say factors driving the surge’s decline likely include an incremental uptake in vaccines, the return of precautions like mask-wearing in certain areas and growing immunity in the population due to Delta’s rapid spread in hard-hit states including Mississippi and Florida.
Ironically, the unvaccinated states may reach herd immunity because of having so many infections before the vaccinated states get there.
(*Quiz Answer: The Stand by Stephen King; The End of October by Lawrence Wright; The Great Influenza (1918) by John M. Barry; and Ten Lessons for a Post-Pandemic World by Fareed Zakaria.)
