The Plague Year

Chapter 1

“It’s Going to Be Just Fine”

One minute before midnight on December 30, 2019, ProMED, a closely watched online publication of the International Society for Infectious Diseases, posted an article translated from Chinese media stating that twenty-seven cases of what was termed a “pneumonia of unknown cause” had been found in Wuhan. The Centers for Disease Control and Prevention (CDC) and the World Health Organization learned of it almost immediately.

Robert Redfield, the sixty-eight-year-old director of the CDC, was vacationing with his family in Deep Creek, Maryland, when he read the ProMED notice on New Year’s Eve. Several alarming details jumped out. The pneumonia appeared to be associated with a seafood market in Wuhan. Patients suffering from the pneumonia were placed in isolation, which was prudent, but suggestive that the health authorities were concerned about human-to-human transmission. “Whether or not it is SARS has not yet been clarified,” the document said, “and citizens need not panic.”

On January 3, 2020, Redfield spoke with his counterpart in China, George Fu Gao. Like many similarly named organizations around the world, the Chinese Center for Disease Control and Prevention was modeled on the American original. Redfield had heard that the first twenty-seven reported cases included three family clusters. It was unlikely that each of them had been simultaneously infected by a caged civet cat in a wet market. When pressed, Gao assured Redfield that there was no evidence of human-to-human transmission. It seemed to Redfield that Gao was only just learning of the outbreak himself. Redfield offered to send a team of CDC disease detectives from the U.S to investigate, but Gao said he was not authorized to invite them. He told Redfield to make a formal request to the Chinese government. Redfield immediately assembled a team of two dozen epidemiologists and disease specialists, but no invitation ever arrived.

The specter of SARS hung over both men. Gao was teaching at Oxford during the 2003 outbreak. He returned to China the following year to head the Institute of Microbiology at the Chinese Academy of Sciences, and in 2017 he was appointed director of the Chinese CDC. A world-renowned virologist and immunologist, Gao had published over five hundred papers in medical journals. His hiring was a part of the intense investment that China made in medical science after the SARS debacle, establishing almost from scratch the world’s largest reporting system for health emergencies and infectious disease outbreaks, building clinics and specialty hospitals, expanding research budgets, and providing free universal healthcare for almost all citizens. In short order, China appeared poised to become a leader in global health. The Chinese CDC was a critical part of that design, and its main mission was to detect emerging diseases, including anything that looked like SARS. In fact, the Chinese public health system had totally failed. There was no way of really knowing how many people were infected.

When Redfield first spoke to Gao, the “unknown pneumonia” was presumed to be confined to China, not yet posing an imminent threat to the rest of the world. In fact, the virus was already present in California, Oregon, and Washington State, and within the next two weeks would be spreading in Massachusetts, Wisconsin, Iowa, Connecticut, Michigan, and Rhode Island—well before America’s first official case was detected.

In another conversation that first week of the new year, Dr. Gao started to cry. “I think we’re too late,” he told Redfield. “We’re too late.”

Matthew Pottinger was getting nervous. As the Trump administration was entering its final year, he was one of few who had been there from the start. Perhaps his durability was because he was so hard to categorize. Fluent in Mandarin, he had spent seven years in China, reporting for Reuters and the Wall Street Journal. He left journalism at the age of thirty-two and joined the Marines, a career switch that confounded everyone who knew him. In Afghanistan, he co-authored an influential paper with Lieutenant General Michael Flynn on improving military intelligence. When Trump picked Flynn to be his national security adviser, Flynn lured Pottinger to be his Asia director. Scandal evicted Flynn from his job almost overnight, but Pottinger stayed, serving five subsequent national security chiefs. In September 2019, Trump appointed Pottinger deputy national security adviser. In a very noisy administration, he had quietly become one of the most influential people shaping American foreign policy.

Pottinger is of medium height, with blue eyes, his dark blond hair still cropped in a military cut. His eyebrows are a brighter blond, lending him the quality of appearing extra awake. In 2003, he was in China reporting on the SARS cover-up for the Wall Street Journal. Now, when Chinese authorities were assuring the U.S. that there was little evidence of human-to-human transmission, that the virus was fragile and would not stand up to warmer weather, and that the situation was under control, familiar alarms were ringing in Pottinger’s mind.

He was struck by the disparity between official accounts of the novel coronavirus in China, which scarcely mentioned the disease, and Chinese social media, which was aflame with rumors and anecdotes. Someone posted a photograph of a sign on the door of a Wuhan hospital saying that the emergency room was closed because staff were infected. Meantime, the WHO—relying on Chinese assurances—tweeted that there was no clear evidence of human-to-human transmission, countering a statement made the same day in a press briefing by a WHO scientist who said the opposite.

The National Security Council (NSC) addresses global developments and offers the president options to consider. On January 14, Pottinger authorized a briefing for the NSC staff by the State Department and the Department of Health and Human Services, along with CDC director Redfield. That first interagency meeting to discuss the situation in Wuhan wasn’t prompted by official intelligence; in fact, there was practically none of that.

The next day, two hundred guests assembled in the East Room of the White House to witness the signing of the first phase of the U.S.-China trade deal. Cabinet members and corporate leaders mingled with members of Congress, governors, Fox News stars, and the Chinese delegation. “Together we are righting the wrongs of the past and delivering a future of economic justice and security for American workers, farmers, and families,” the president said, in front of a bank of American and Chinese flags. He called Chinese president Xi Jinping “a very, very good friend.”

On January 20, the coronavirus officially arrived in America. “This is a thirty-five-year-old young man who works here in the United States, who visited Wuhan,” Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), said on a Voice of America broadcast. “There was no doubt that sooner or later we were going to see a case. And we have.” President Trump took note of the event at the World Economic Forum in Davos. “It’s one person coming in from China, and we have it under control,” he remarked. “It’s going to be just fine.”

Covid-19 arrived in America at a vulnerable moment in the nation’s history. The country was undergoing a wrenching political realignment, brought to a head by the 2016 election of Donald Trump, whose policies on trade, deficit, alliances, and immigration were at odds with traditional Republican conservativism. His election pulled the country further into a cataclysm of identity politics, shrinking the GOP into a pool of aging white voters who felt disparaged, resentful, and left behind. The #MeToo movement had ignited an edgy dialogue between the sexes. As the stock market soared, long-delayed questions of income disparity and racial justice were pressing forward. Every dissonant chord among the parties, the races, and the genders was amplified within the echo chambers the fractured communities had made of themselves.

Into this turbulent, deeply troubled, but prideful society, the coronavirus would act as a hurricane of change, flattening the most powerful economy in the world, leveling not the physical cities but the idea of cities, strewing misfortune and blame and regrets along with the tens, the hundreds, the thousands, the hundreds of thousands of obituaries. No country would escape the destruction the virus inflicted, but none had as much to lose as America. Wealth and power breed hubris, and perhaps Covid-19 was the force that America needed—to be humbled, to reckon with itself, to once again attempt to create the democracy it had always intended to be.

On the other hand, America’s moment at the forefront of history might have passed, and Covid-19 was a blow it was no longer strong enough to fend off. Rival powers—with China at the top—were competing for control of the new millennium. This was a challenge to democracy, which was America’s cause in the world. The alternative to American preeminence was not a globe full of mini-Americas but a world dominated by tyrants. Freedom was at stake, as it always is, but America had tied itself into a political knot. The cyclonic forces of fascism and nihilism gained in power as the center weakened. The only thing that kept democracy from winding up in a suicidal brawl of self-interest was a sense of common purpose, but the pandemic exposed that the United States no longer had one.

In those early days, when politics mattered most, few paid attention when nature entered the ring. It had been a century since the last great pandemic, which was nursed in the trenches and troop ships of the First World War and spread even into tropical jungles and Eskimo villages. That flu lasted two years and killed between forty and a hundred million people. Back then, scientists scarcely knew what a virus was, so how could they fight it? By the twenty-first century, however, infectious disease was considered a nuisance, not a mortal threat to civilization—at least, this was a common assumption among the elected officials who were charged with protecting the country. This lack of concern was reflected in the diminished budgets that nourished the great institutions that had led the world in countering disease and keeping Americans healthy. Hospitals closed; stockpiles of emergency equipment were not replenished. The specter of an unknown respiratory virus arising in China gave nightmares to public health officials, but it was not on the agenda of most American policymakers. In January 2017, days before Donald Trump was inaugurated, Dr. Fauci had warned there was “no doubt” that the incoming president would be dealing with an infectious disease outbreak. “We will definitely get surprised in the next few years,” he predicted.

And yet there were so many reasons to feel complacent. In October 2019, the Nuclear Threat Initiative, together with the Johns Hopkins Center for Health Security, the Nuclear Threat Initiative, and the Economist Intelligence Unit, compiled the first-ever “Global Health Security Index,” a sober report of a world largely unprepared to deal with a pandemic. “Unfortunately, political will for accelerating health security is caught in a perpetual cycle of panic and neglect,” the authors observed. “No country is fully prepared.” Yet one country stood above all others in its readiness to confront a novel disease: the United States.

During the transition to the Trump administration, the Obama White House handed off a sixty-nine-page document called the “Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents.” A meticulous, step-by-step guide for combatting a “pathogen of pandemic potential,” the playbook contains a directory of the government’s resources in time of need and is meant to be pulled off the shelf the moment things start to go haywire.

At the top of the list of dangerous pathogens are the respiratory viruses, including novel influenzas, orthopoxviruses (such as smallpox), and coronaviruses. The playbook outlines the conditions under which various government agencies become involved, and how. With domestic outbreaks, the playbook specifies that “[w]hile States hold significant power and responsibility related to public health response outside of a declared Public Health Emergency, the American public will look to the U.S. Government for action when multi-state or other significant public health events occur.” Questions concerning the severity and contagiousness of a disease, or how to handle potentially hazardous waste, should be directed to the Department of Health and Human Services (HHS), the Federal Emergency Management Agency (FEMA), and the Environmental Protection Agency (EPA). Is there evidence of deliberate intent, such as a terrorist action? The FBI has the lead. Have isolation and quarantine been implemented? How robust is contact tracing? Is clinical care in the region scalable if cases explode? There are many such questions, with decisions proposed and agencies assigned. Because the playbook was passed to a new administration that might not be familiar with the manifold resources of the federal government, there are appendices describing such entities as the Surge Capacity Force in the Department of Homeland Security, consisting of a group of FEMA reservists and others that can be enlisted as “deployable human assets.” The Pentagon’s Military Aeromedical Evacuation Team can be assembled to transport patients. HHS has a Disaster Mortuary Operational Response Team, with the dry acronym DMORT, consisting of “intermittent federal employees, each with a particular field of expertise,” such as medical examiners, pathologists, anthropologists, dental assistants, and investigators.

The Trump administration jettisoned the Obama playbook. In 2019, HHS, headed by Alex M. Azar Jr., conducted an exercise called Crimson Contagion. It involved a number of government agencies, including the Pentagon and the NSC; healthcare organizations and major hospitals, such as the Mayo Clinic; public groups with a specific interest in healthcare, including the American Red Cross; and twelve state governments. The exercise scenario envisioned an international group of tourists visiting China who become infected with a novel influenza, and then spread it across the world. One of the tourists, a middle-aged man, returns to Chicago with a dry cough. His son attends a crowded public event, and the contagion races through America. There’s no vaccine and antiviral drugs are ineffective. Within a few months, the hypothetical flu kills 586,000 Americans.

The Trump administration’s own exercise was spookily predictive of what was to come, including how chaotically the government would respond. Federal agencies couldn’t tell who was in charge; there was a lack of production capacity for personal protective equipment (PPE); ventilators were in short supply; and states were frustrated by their attempts to secure enough resources. Cities defied a CDC recommendation to delay opening their schools. Businesses struggled to figure out how to keep their employees working from home. The longer the hypothetical contagion went on, the more bollixed the government response became. The Public Health Emergency Fund was dangerously depleted; needles, syringes, hospital-grade N95 masks, and other medical essentials were in limited supply and difficult to restock because of an absence of domestic manufacturing capacity. The report on the exercise was briefed to Congress but kept under wraps. By the time Covid-19 arrived in America nothing meaningful had been done to address these shortcomings.

One could say that the Trump administration was in an enviable spot at the beginning of the pandemic. It had a step- by- step playbook that could serve as a guide through bureaucratic snares that accompany such a disaster. It had been alerted to its own failings by the Crimson Con-tagion exercise. And it was blessed with institutions that were envied and admired throughout the world. Beyond the matchless government medical and research institutions such as the CDC, National Institutes of Health, Walter Reed National Military Medical Center, the U.S. Army Medical Research Institute of Infectious Diseases, and the Biomedical Advanced Research and Development Authority, America also com-mands the world’s top medical schools and many of the largest pharma-ceutical companies. When the Trump administration came into office, it was handed the keys to the greatest medical- research establishment in the history of science.

Robert Kadlec, the assistant secretary of HHS in charge of prepared-ness and response, had led the Crimson Contagion exercise. He would later admit, “We knew before the movie started it was going to have a bad ending.”