The Plague Year: Book Review

The Plague Year: America in the Time of Covid (2021), Lawrence Wright. Granted, there will be dozens of books written about the pandemic, many from authors with insider background and credentials. This was a good one, mainly because Wright is a terrific writer with another useful perspective. The downside is the complete picture is years away; consequently, Wright’s perspective (and all the rest) is limited to who is willing to talk to him, what they he find out, and the incisiveness of descriptions before the draft goes out to publication. It’s still worth the effort. Wright talked to important people connected to various aspects of the pandemic. He also goes off on interesting tangents, not always overly relevant to Covid—fine with me, they’re still interesting.

A useful point is the presentation is usually based on someone’s story or interpretation, which may differ considerably from someone else. In theory, history would work this out. Alternatively, who has the best story. People writing reviews of the pandemic books already show disagreements among key players.

The story starts in Wuhan, with Dr. Zhang Jixian discovering an elderly couple with flu and cough and pneumonia on Dec. 26, 2019. Then healthcare workers getting sick. No acknowledgement from the government for a month. It sucks being in a police state. Epidemics had started in Wuhan before, like the SARS of 2002. Supposedly, new transparency rules were introduced globally, but China was a continued violator. Chinese scientists got the word out and sequenced the virus (at great risk). Wright called the indifference to life as a Maoism legacy.

Chapter 1: It’s Going to be Just Fine. The Chinese government stopped all communication, both inside and outside China. The virus hit several states before the first case was detected. Matthew Pottinger in introduced and plays a big part of the analysis. A journalist who speaks Mandarin, he is hired by the Trump administration as deputy national security advisor (under Michael Flynn). Flynn is quickly fired, but Pottinger stays on until the end. He was not a Trump true-believer, but thought he could serve as a voice of reason. The NSC analyzes global developments and presents options. “The coronavirus would act as a hurricane of change, flattening the most powerful economy in the world” (L269). Rather than the emergency uniting everyone in a common purpose, politics played a critical and destructive role. The government was not prepared as stockpiled equipment was not replenished, supplies relied on China, budgets cut. The healthcare system joined business in maximizing profits. Obama’s playbook for infectious disease was dumped. HHS head Alex Azar did conduct an exercise in 2019 showing how poorly the system was prepared, but no meaningful change occurred. “When the Trump administration came into office, it was handed the keys to the greatest medical-research establishment in the history of science” (L332). Too bad.

Chapter 2: The Trickster. CDC history is reviewed, showing it’s many achievements: “the gold standard of pubic health, operating above politics” (L356). John Brooks, an epidemiologist, was the chief medical officer of the Covid-19 response team. One of the problems with Covid was asymptomatic infections transmitting the disease, unexpected and unprepared for. Of course, CDC was muzzled by the administration. The virus caused blood clots, often killing by triggering excess response. It can affect the brain and heart.

Chapter 3: Spike. Much of the chapter is about polio and how it was handled. The anti-vax movement started with the swine flu scare in 1976. A vaccine was quickly developed, but gave hundred Guillain-Barre syndrome—the flu never developed into a pandemic. The CDC head became a political appointee. According to Wright, Dr. Barney Graham of NIAID was the chief architect of the first Covid vaccines by Moderna and Pfizer. Before that, vaccines were made from real viruses. Moderna developed an mRNA platform. Moderna had a vaccine by January 13, ready to be manufactured; shipments for trials started within six weeks: the first human inoculated on March 16.

Chapter 4: An Evolving Situation. The CDC had teams to screen passengers from Wuhan. The result: several screeners caught Covid. Rick Bright ran the Biomedical Advanced Research and Development Authority of HHS. He clashed with political Trumpers who wanted to ignore science and give contracts to political connections. He wanted to buy masks and equipment, but HHS was unresponsive. Of course, “global health security” was ignored by Trumpers. Pottinger noted four camps in the White House: public health establishment like Fauci, Azar & Redfield; chief of staff Mick Mulvaney and others interested in economic damage; State Dept. concerned with logistic issues (like getting Americans from Wuhan), and Pottinger looking at a national security threat. Economist Peter Navarro called for drastic action, not gradualism favored by scientists without data.

Chapter 5: Flatten the Curve. Howard Markel looked at the 1918 epidemic curves city by city (he worked in the GW Bush presidency), using papers from these cities and census records. They faced roughly the same issues, like what to close down, and often had more than one episode. Responses differed as did results. Business interests blasted the shutdowns. San Francisco issued mandatory face mask use. [Interesting analysis of the various cities.] What’s changed? We have better face masks. The CDC testing failed and health facilities used or developed local platforms which worked better (even though they were not authorized).

Chapter 6. It’s Coming to You. The CDC testing fiasco was a failed opportunity to control the virus. Although Azar agreed on the need for rapid testing, nothing was done—that lack of execution permeated the administration. Who was responsible? The CDC developed a test and turned it over to the FDA, then bottlenecks apparently by the CDC: few tests, then two weeks to be processed. A German test was prepared before and quickly disbursed. The CDC tests turned up many false positives. Pottinger’s wife was a public health lab advisor and assisted his understanding. Other hospitals and labs developed their own tests and used them despite no authorization. A CDC problem was testing was done in the same room as where test ingredients were put together—a super blunder (common when no one is in charge): “Bureaucratic inertia, compounded by scientific incompetence, handicapped America’s response. Secretary Azar held the FDA responsible” (L1115), which was disputed by FDA commissioner Stephen Hahn.

Hospitals and nursing homes were underfunded, focusing on profit rather than healthcare. Healthcare workers feared for their lives—seemingly not a concern of management. Deborah “Birx was known to be effective and data-driven, but also autocratic” (L1183). Eventually, it was determined that asymptomatic spread was happening and catastrophic, often superspreaders. Using masks and social distancing was reasonably effective—implementation was a problem. Chaos happened early on cruise ships and nursing homes.

Chapter 7: Nothing Can Stop What’s Coming. Some five million people left Wuhan before their lockdown; those coming to the US landed in LA, San Francisco and New York; those going through Italy, landed mainly in New York. The WHO declared a pandemic about the time 100,000 cases were reported globally. Domestic politicians apparently did not understand exponential growth and behaved without urgency—until utter chaos came. Nightmare scenarios generally happened. Many politicians called for fewer tests. Trump put Pence in charge of the Coronavirus Task Force. “The CDC was now a captive agency” (L1360). Azar made far-fetched claims like the number of tests available.

Chapter 8: The Doom Loop. Anthony Fauci was considered too blunt and outspoken; “out of control” according to Kushner and Navarro. They disliked Birx. The debate was saving lives or protecting the economy. According to Pottinger: “When [Trump] was taking in new information, the president was receptive. He asked questions. He was open to hearing both sides. He didn’t try to be the smartest guy in the room. Once he made a decision, though, God help you in trying to change his mind” (L1490). Early on, Trump was helpful, shutting off travel from Europe and providing billion to the CDC and other agencies to fight the virus. Up to this point, the problem was just lack of information and experience.

Economist Glenn Hubbard compared conservative economist Hayek to liberal Keynes to approach the pandemic. Keynes would favor government stimulus and intervention. Hayek opposed government action (crushing individual freedom and creating tyranny) and enhance future progress. Hubbard worried about a “doom loop” of negative feedback that would bring down economic potential. (Basically, economic growth depends on optimism). Hubbard wanted politicians to focus on the scope of government (what government is supposed to do) rather than the size of government. Government was effective during the Civil War to increase opportunity (including the transcontinental railroad and Homestead Act). The Paycheck Protection Program was an attempt to help small business as part of the Coronavirus Aid, Relief, and Economic Security Act, which also included increased unemployment, cash payments, and forgivable loans to small business. Hubbard: “Nothing like a big shock to help people become more bipartisan” (L1603).

Trump did not want responsibility for taking control for a federal plan, which also meant taking blame for errors.

Chapter 9: Let It Be March. About 30% of Covid patients were “long-haul,” with physical damage and waves of recurrent problems.

Chapter 10: It’s Like a Wind. Gianna Pomata retired from Johns Hopkins and returned to Bologna. She talked about the 14th century plague (1347). Cities lost up to half their populations. Ships were quarantined. Boccaccio wrote the Decameron, set during the plague in Florence. It had burned through China and India and spread west. Doctors abandoned classic texts and turned to empirical evidence.

Chapter 11: Bellevue. “Bellevue was the vanguard of public health in America, providing the first maternity ward in the US, the first emergency pavilion, the first ambulance corps, and the first nursing school. The mission of Bellevue is that no one is turned away” (L1849). Dr. Nate Link did his internship there and stayed. He directed the special pathogens team to prepare a protocol. Then they were flooded with patients. Part of the mission became helping the patient die well. Relief was not coming, leaving deep scars to the healthcare workers.

Chapter 12: The No Plan Plan. The Coronavirus Task Force made their recommendations, which Trump reluctantly approved. He called the governors, telling them to get the supplies themselves. Trump was not mobilizing the federal government. There was no national plan and little backup in the strategic reserve—even if Trump would release it. “Most of the governors steered a wavering course between competing disasters” (L2033). Then the governors discovered that the Trump administration was sabotaging their efforts, often seizing supplies ordered. The governors started stealth operations to hide from the feds. Kushner turn over managing supply-chain issues, which went as well as expected, basically accomplishing nothing. Except he had “friends” who might get stuff for the right price. Apparently, the only way to get anything from Trump was praise him to the hilt. Trump: “I want them to be appreciative” (L2084).

Kushner “redirected purchasing orders that had already been promised to certain states, telling FEMA to send them to other states whose governors had called him personally. The White House had turned aid to states and hospitals into a form of patronage” (L2118). Trump pushed hydroxychloroquine, which was found to be ineffective except for serious side effects. 40% of deaths were in nursing homes, demonstrating the devaluation of the elderly—big factors were incompetent management and inadequate staff.

Chapter 13: Little Africa. Ebony Hilton is introduced as an anesthesiologist (the first Black female anesthesiologist hired at that hospital), with her first Covid patient in March. Blacks and Hispanics were hit much harder than whites (about three times), because more of them were essential workers and had poorer healthcare.

Chapter 14: The Mission of Wall Street. “Fort many Americans, Goldman [Sachs] represents the pinnacle of avarice. … Buy in the upper chambers of power, Goldman is revered because it has created a culture of success. Winning is what matters, in Washington as well as on Wall Street” (L2329). The Dow was going up to record levels as Covid was spreading and the economy sinking, partly because of low interest rates and the structure of stimulus (which wasn’t well targeted). Steve Strongin is a Goldman advisor (and systems analyst). His analysis: A key point was for business to stick to what they do well and outsource everything else; plus, resilience: keep operating, connect to clients/customers. Wall Street provided liquidity. Investors go to perceived winners; in this case, high tech (Facebook, Apple, Google, Amazon). Political failure was attributed to failure to perceive people’s needs and deal with their real pain. Hayek’s perspective does not work then. Keynes also is unworkable as “mitigating community damage.” First, stop things that are not working and don’t prop up failures. Large companies and markets adjust to “the new post-Covid economy (more or less consistent with Hayek. Spend real money on those having difficulty with the transition (Keynes).

The US has had structural problems for decades. Census Bureau data (e.g., by census tracks, congressional districts or zip code), which can differentiate the impact of the pandemic. Health became the big issue and in person services (consider essential workers). Durable goods were doing fine. Small businesses like restaurants were devastated; even low-income Silicon Valley workers lost jobs. The Paycheck Protection Program worked poorly at a high cost (fraud was also a problem). Likely, extended unemployment was the most efficient program.

Michigan Governor Gretchen Whitmer issued stay-at-home orders in March, which proved okay until Trump tweeted “liberate Michigan!” The result was protestors attacking the Michigan capital and an attempt to kidnap the governor. The Republican legislature refused to cooperate.

Chapter 15: The Man Without a Mask. Masks became the obvious answer to limit the spread, encouraged by Pottinger in the White House. The public health contingent disagreed, based on previous epidemics. Then masks became a political litmus test. Then studies showed up demonstrating the effectiveness of masks starting in April. The CDC then concurred. Trump rejected the CDC guidance and refused to wear a mask, even touring a mask-making factory without a mask (Wright noted his immunity to irony). This did not promote trust in the government. On the positive side, the food chain was resilient (ignoring the food chain workers) and liquidity continued. Wright noted that his earlier novel on a pandemic thought the crisis would have been worse.

Chapter 16. Waves. The idea of Covid-19 coming in waves. A problem in Europe was austerity funding which cut healthcare, including heavy debt loads in southern Europe: roughly the Hayek rationale. Wright (actually Pomata) discussed Petrarch: “It was about disliking his time and his age and the condition of Italy” (L2784). The end of the Middle Ages could have been the fall of Constantinople in 1453 as scholars fled to Europe. One result was the Renaissance men of the period.

Inflection points are when radical changes are made, either good or bad. The Plague of Athens in 430 BC ended democracy. The Spanish flue of 1918 and the First World Was led to women’s suffrage and the Roaring Twenties. Also, the rise of fascism. The Great Depression brought the New Deal. The Second World War transformed to US into a superpower, dominating the world both economically and militarily. 9/11 brought invasions of Afghanistan and Iraq.

Chapter 17: I Can’t Breathe. George Floyd’s death caused outrage and demonstrations. The police “performance suggests a presumption of impunity. … Minneapolis has stunning wealth disparities. … Whites are richer and Blacks are poorer than the national average. … Society has built in safeguards to protect itself from structural change. In Minneapolis, the police have served that function for many years” (L2872-98). Reforms were announced but improvements didn’t happen.

Gianna Pomata as a medical historian: “What I see right now in the US is that the pandemic has not led to new creative thinking but, on the contrary, has strengthened all the worst, most stereotypical and irrational ways of thinking” (L2987).

Chapter 18: Tulsa. General Gordon Granger announced the end of slavery in Galveston, June 19, 1865). [This is Juneteenth, now a holiday, as I’m writing this.] Trump planned a rally in Tulsa on this date, 2020. The Black part of town, Greenwood, was utterly destroyed and hundreds killed 100 years ago. Herman Cain was in the audience and later died of Covid.

Chapter 19: Thelma and Louise. Deborah Birx was generally detested by those in the administration, Trumpers (the science thing) and Trump opponents because she didn’t correct Trump on TV (“an enabler”)—like using bleach. She was replaced as head by Dr. Scott Atlas, a Trumper who disparaged just about everything promoted by science. Trump then listened only to Atlas. Birx went on a road trip with epidemiologist Irun Zaidi to meet with state and local political leaders and healthcare specialists, explaining the purpose of masks and social distancing. Chief complaint: “Folks wouldn’t listen as long as the president refused to set an example” (L3165). Evidence suggested that most deaths were of people with comorbidities. Birz and Zaidi were good bringing diverse groups together.

Chapter 20: The Hedgehog and the Fox. Wright is looking at this from Isaiah Berlin’s 1950 essay on Tolstoy. He claimed Fauci and Trump were opposing archetypes. I agree, but then Wright claims Fauci is a hedgehog (in intensity); Trump was chaos; not remotely correct according to Tetlock in Expert Political Judgment (see my review). Fauci is a fox based on Tetlock, willing to change his mind as soon as new, better information becomes available; not so for Trump—a hedgehog. “Fauci’s institution had not been bullied into submission by political appointees. … For Fauci, science was a self-correcting compass, always pointed at the truth. For Trump, the truth was Play-doh, and he could twist it to fit the shape of his desire” (L3225). Basically, to remain in the Trump White House required total loyalty, while he would not hesitate to throw you under the bus anyway.

“The president always encouraged fringe groups. … He had assumed office with little understanding or interest in governing; he demanded loyalty above all, and filled the offices of government with people whose sole mission was to please him. They became an occupying army to subjugate what Trump called the Deep State. Suspicious of experts, the president relied on his ‘instincts,’ which allowed him to entertain alternative realities and convenient delusions” (L3373).

Chapter 21: Dark Shadows. “Trump knew that we are essentially a vulgar nation” (L3400). The other 16 Republican competitors in 2016 had varied levels of rectitude, which Trump mowed down; even women voted for him more than for a woman candidate. Blue-collared people, religion people and soon were expected to vote against him. “He was brutish, cruel, and demeaning, but he lived without apparent regrets. This was read as strength” (L. 3412).

Michael Caputo in HHS controlled information from CDC, FDA and NIH. Trump wanted the pandemic to be considered as not dangerous and under control. This included Trump’s war with Michigan governor Gretchen Whitmer; a kidnapping attempt followed by white supremacists, the Watchmen. A key to a leader was “the distance between who he was and who he wanted to be” (L3500). Trump blasted “literate Michigan, the “liberate Virginia.”

Chapter 22: The Rose Garden Cluster. Ruth Bader Ginsburg died and Trump nominated Amy Coney Barrett to replace her. A Rose Garden ceremony had 200 people to introduce her. A dozen guests got covid at the unmasked ceremony. The president soon tested positive and developed a severe case. His care at Walter Reed included treatments (included remdesivir) not available at most hospitals and he recovered quickly.

Chapter 23: The Search for Patient Zero. The Huanan Seafood Wholesale Market in Wuhan or the Wuhan Institute of Virology (or the Wuhan Center for Disease Control)? Bat virus engineered as a biological weapon? Navarro promoted the lab, back by Pompeo. Scientists favored the market. Bats do contain many coronaviruses, and cross-species jumps happen. Navarro was the one first proposing tariffs on Chinese goods starting a trade war. Redfield noted the virus a mature human virus, suggesting the lab. A WHO team was not admitted in January 2021, suggesting limited ability for analysis.

Chapter 24: Survivors. “About 3,000 healthcare workers in the US who took care of Covid patients in 2020 have died of the disease. Nurses are the most likely to perish” (L3881). “Operation Warp Speed, the government initiative to accelerate vaccine development, may prove to be the Trump administration’s most notable success” (L3923). Apparently, it was Jared Kushner who pushed it through. The FDA approved the Pfizer vaccine, then Moderna.

The Covid 2020 recession was substantial: GDP down 3.5%, Large number of small businesses gone, giant unemployment claims. Pottinger noted the failure of leadership, especially lack of good judgment. Experts still have biases with narrow approaches and egos: “You need broadminded leaders who know how to hold people accountable, who know how to delegate, who know a good chain of command, and know how to make hard judgments” (L4038).

Chapter 25: Surrender. “The vast differences in outcomes among the states underscores the absence of a national plan” (L4071). “High-tech medical advantages proved of little use when the main tools for countering the spread of the disease were social distancing, hand washing, and masks” (L4092). On March 16 Trump issued guidance on school closures and so on, but indicated these would be voluntary. “By his words and his example, the president became not a leader but a saboteur” (L4121). He continued to hold rallies, including: “People are tired of hearing Fauci and all these idiots” (L4141).

Epilogue. Trump called Georgia Secretary of State Brad Raffensperger to claim he won Georgia by a lot and demanded Raffensperger find the votes: “The people of Georgia are angry” (L4278). Then he added implicit threats. “January 6, 2021 would be a day of reckoning. … Trump had fixed on that day as his last stand. … Pottinger thought that, so long as no Biden supporters or Black Lives Matter counter-protesters got into the fray, there was little likelihood of violence” (L4328). But the internet had a multitude of conspiracy threats and militias showed up for war. “None of this got into the daily terrorism briefing. It was the most inexcusable intelligence failure since 9/11” (L4340). “One could still call them demonstrators or protesters, but a crowd so large is aware of its power; and inside the ranks were some who had trained for this. … How slender was the line between order and chaos” (L4394). This was also a superspreader event with dozens of cops and lawmakers testing positive after. Republicans (8 senators and 139 house members) voted against accepting the election results—after the attack.

The vaccine rollout has expected stumbles—still no national plan. The states made their own rules. Wright, who also lives around Austin, had a similar experience to me in getting the vaccine from Austin Public Health (except he was earlier). My actual experience once I had appointments was professional and worked well.

“I think of journalism as having two axes; one, which we can call the horizontal, consists of speaking to as many people as will speak to you. … It also draws in contrasting narratives that provide a corrective to slanted perspectives. The horizontal axis creates a consensus about what has happened. The vertical axis is more about deep understanding” (L4617).