This Is How Covid Crushed Us

A review of "Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Defeat the Next Pandemic" by Scott Gottlieb

Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Defeat the Next Pandemic

Scott Gottlieb

Harper, 512 pages, 2021

You could easily stage Oedipus Rex against the backdrop of March 2020. The story begins with a plague, after all—and very likely was the product of the one that swept an Athens sealed against wartime incursions in 430 BCE, the year before its first performance.

Sophocles wrote about more than Oedipus’s quest to discover who killed his predecessor: this begins as a way to rid Thebes of a pestilence that’s killing people, cattle, and crops. Oedipus seems like the man for the task. He’s a rationalist and empiricist, clearly the smartest person in Thebes. His intellect has already rid them of one threat—the Sphinx—and brought him to the kingship. Sophocles pits Oedipus’s method—secular, almost scientific—against a view that looks to prophecy and believes in fate’s control. It’s not so much that Oedipus’s methods fail as that his personality does. What he examines, he examines with rigor. But there are things he simply can’t allow himself to know.

It won’t be too long, I suspect, until we see that production, its stage filled with terribly smart people devoted to public service who, cut off from the information they need, compounded their errors by refusing to acknowledge them. After all, that’s the one-sentence summary of Scott Gottlieb’s account of America’s failures in the first year of Covid-19. 

Uncontrolled Spread is most valuable as a clarifying and dispassionate history of those early months. In its pages, the former FDA Commissioner and current Pfizer board member shows that once SARS-CoV-2 escaped China—once it went pandemic—our plans for mitigation and containment and the agencies tasked with carrying them out were simply too fragile to succeed.

Fragile systems might be complex, effective, and well-constructed—but they can suffer cascading failures when faced with the unanticipated. They can’t, as economist Nassim Nicholas Taleb has illustrated, learn from errors. America’s pandemic response, like Oedipus’s intellect, proved fragile in this way, each suffering the curse of knowing what we already knew a little too well.

One thing we knew—and knew early—was that, as the public health refrain went, “Covid-19 is not like the flu.” It’s strange to think of this as a kind of failure; it shouldn’t have been. But it was. The two diseases were dissimilar in infectiousness, in death rates, and in the ways they affect the body. Such differences helped raise public alarm.

But there were more ways, ways more important to shaping a public health response, in which the illnesses were not alike. These differences were not only unknown, or overlooked—but actively resisted: that, unlike influenza, Covid spreads primarily not by microscopic droplets but by much smaller aerosolized particles; that schools and schoolchildren play a far smaller role in transmission than is the case for influenza; and—most importantly—that those not yet showing symptoms could be important, perhaps even primary, drivers of viral spread.

The pandemic response plans which the CDC, White House officials, and other public health agencies followed, however, were designed on the assumption that a pandemic would be caused by a strain of flu. It’s not an unreasonable prediction. But the result was systemic fragility: a plan designed for a single category of virus and the specific ways it spreads.

So, in the absence of Covid-specific diagnostic tests, the CDC relied on

its Influenza Like Illness surveillance system to track the virus. This network offers a bird’s-eye-view, but it’s a crude and backward-looking tool: it notes the possibility of a new respiratory epidemic by tracking the proportion of positive and negative flu tests, utilizing data ranging from several weeks to several months old.

It was also confounded by the atypical patterns of that year’s unusually intense and late flu season. And as news of Covid spread, the steps people did take—disinfectant wipes, all that hand sanitizer, things geared toward surface transmission—were more likely to slow the spread of other respiratory pathogens. In isolation, that’s a good thing: but falling flu numbers would, in essence, “cancel” rising Covid numbers in this dataset.

Not knowing how far or how fast Covid was already spreading was a serious shortcoming. But it hid more than raw case numbers, or even the locations of outbreaks. It also allowed public health officials to avoid confronting the fact that it did not spread like the flu.

Not even the most highly-regarded were immune from these errors. In “all the history of respiratory-borne viruses of any type, asymptomatic transmission has never been the driver of outbreaks,” Gottlieb quotes Anthony Fauci declaring in late January 2020, referring to those who haven’t yet shown symptoms as well as those who never do. “Even if there’s a rare asymptomatic person that [sic] might transmit, an epidemic is not driven by asymptomatic carriers.” We’ve learned, though, that the likelihood of transmission peaks in the days immediately before and immediately following the onset of symptoms—meaning that significant transmission was driven by those not yet experiencing symptoms.

To explain the result—more and more cases that couldn’t be connected to contact with a symptomatic individual—the CDC pointed to fomite transmission: touching a surface contaminated by a cough or a sneeze, and then transmitting the virus by touching your own eyes, nose, or mouth. When a school or business brags about their sterilization or sanitation procedures, they’re talking about fighting fomite transmission—through which, it turns out, Covid-19 doesn’t really spread. Doubling-down on what we already knew delayed responding to the facts clamoring for our attention.

A generous response might emphasize how little we knew at the time and how low the cost seems: a two dollar bottle of Purell. And why not continue, “out of an abundance of caution”?

As it turns out, “an abundance of caution” can be dangerous when it misallocates limited resources, creates a false sense of security, and interferes with the acquisition of new, more accurate information—pre-symptomatic, aerosolized spread—by offering an explanation that seems sufficient.

These kinds of messaging errors have continued. Just as early underselling of mask efficacy combined with a focus on surface transmission fueled resistance to their use, now overconfidence in the efficacy of masks serves as a justification offered by some vaccine holdouts.

All this was exacerbated by the CDC’s failure to produce a working Covid test. FDA staff, Gottlieb reports, believe that the error was the CDC’s choice, in its rush to manufacture a huge number of tests quickly and without outside help, to assemble them in the same building it was processing samples sent to its lab for testing—the “live” samples cross-contaminated the kits so that even testing sterile water would return a positive result. They were useless.

When its tests didn’t work, the CDC reacted like an agency worried about encroachment on its turf: it stonewalled, denied, and ignored the problem. The CDC knew, Gottlieb writes, before it shipped its tests to public health labs across the country, that at least one in three kits would fail. In practice, things were worse: fewer than three percent of public health labs could get them to work, a fact that the FDA, which holds regulatory authority over the tests, learned not from the CDC, but a Politico article.

But this, too, probably didn’t matter, at least not initially. In any event, the United States had no good way to manufacture the number of tests it needed.

The problem was not that its components were too complex to make and distribute. The problem was that the global supply chain was operating efficiently—something else that we’ve learned to do a little too well. Efficiency created a bottleneck around the low-margin components: in particular, the swabs needed to collect viral samples. This meant profit required huge scale—and that there had been little incentive for anyone to compete with the handful of global manufacturers—one located in hard-hit northern Italy.

The risk of efficiency, as Taleb notes, is that it’s fragile, designed for normalcy, not crisis. When the unexpected happens—in this case, massive increase in demand for test components—an efficient system has little to no excess capacity. Moreover, it meant no American manufacturer was already prepared to produce test swabs at scale, leaving us reliant on a limited global marketplace during a worldwide run.

Then, once we had working tests, the same fragility undermined our ability to process them: the U.S. simply did not have excess lab capacity. From the very beginning, even before production ramped up, the number of tests we could manufacture far outstripped the rate at which they could be processed. And this, in turn, was exacerbated by the CDC’s reluctance to work with academic and commercial labs for no reason other than it had not done so in the past.

America’s pandemic response broke down early—and because of this, the failures cascaded. Because we couldn’t test nearly enough, we couldn’t see where Covid was and wasn’t. We now know, for example, that Covid had been widely seeded in Detroit by early March. Yet Michigan was among the last states to report a single confirmed case. Since we couldn’t test, we couldn’t see it; since we couldn’t see it, we used non-pharmaceutical interventions—lockdowns, school closures, business regulations—everywhere, even though even flu-oriented pandemic planning had explicitly called for hyperlocal targeting of NPIs.

This decoupled the perception of Covid’s severity from that of our response—burning through the public’s trust too quickly. And this brings us back to Oedipus, who loses public trust not because of his approach, but because the citizenry (or at least the Chorus) can clearly see him, though still the smartest person in the room, insisting that his and only his interpretation of the evidence could be correct.

“During Covid,” Gottlieb observes, “the general refrain, quite appropriately, was that our policy decisions should be guided by, and shouldn’t get ahead of, the science.” But there’s more complexity to that slogan than it looks like, he points out. Not unlike Oedipus, “It wasn’t the scientific data that the CDC didn’t want policymakers to ignore or second-guess; it was the CDC’s interpretation of that data.”

But this analysis was slow and often incomplete; its guidance on fomite transmission and other flu-oriented measures only officially changed in 2021; its advice to school districts has veered between noncommittal and incoherent. More damningly, it meant that we continued “implementing a plan that was crafted with flu in mind, not a coronavirus.”

Understanding the roots of what went wrong matters for the future. Like many, Gottlieb does not believe that Covid will be the only pandemic the world faces this century. The next might emerge through natural spillover from animal host to humans, through an unintended but no less lethal leak from a research laboratory, or through its weaponization: “respiratory pathogens are a poor man’s nuclear weapon,” he declares—especially so after Covid exposed weaknesses specific to Western democracies.

So what’s to be done? Uncontrolled Spread ends on a call for resiliency and flexibility: Covid revealed the struggles and failures of American health care and public health in emergencies: in implementing large-scale diagnostic testing, in successfully carrying out contact-tracing programs, in viral sampling and genomic sequencing. And it showed weaknesses brought on by both American manufacturing capabilities and our reliance on a global supply-chain for medical goods: an inability to produce reagents needed to process Covid tests, a global rush on nasal swabs and surgical and respirator masks, rotting national stockpiles.

The answer to these problems may be a kind of un-learning: to build slack back into the system and deliberately over-invest and maintain excess production capacity in key areas of manufacturing and distributing pharmaceuticals and health care equipment, perhaps even over-investing in hospital capacity, particularly in under-served communities.

But pandemic preparedness isn’t something that can be solved with barrelsful of money. It also requires institutional reorganization. The CDC is Gottlieb’s chief target: an agency with a retrospective approach that “produces academically oriented after-action reports in an effort to define new scientific principles.” This is valuable, Gottlieb argues, but not effective crisis-management. In essence, he wants to free the CDC and FDA to do what they excel at, even (especially) in emergencies.

Unfortunately, Gottlieb’s vision for agency-level reforms echoes the first administration he worked for, George W. Bush’s. “If our goal is to head off a potential pandemic entirely,” he declares, “and prevent the next contagion from ever getting a grip on America the way Covid did, we’ll have to involve our instruments of national security.” More than involve: what we need is “a new doctrine for national security.”

The CDC’s leadership, in this vision, would be replaced by “the equivalent of a Joint Special Operations Command for biothreats … that has an operational focus, that has a national security mind-set, and has the ability to work across the classified and unclassified world.” This leadership would largely come from the intelligence community, not public health.

Such a doctrine, to be fair, would build toward two needed organizational changes: greater interagency cooperation, particularly between the intelligence and public health communities as a way to counter international stonewalling, and a clearer division of labor that lets the CDC study and the FDA evaluate without being called on to make decisions at the pace a crisis requires.

Yet I can’t help but hear notes lifted from the early rhetoric of the War on Terror, now applied to the virome. The Afghan front in our forever war may have finally been abandoned, but we’re still mired in it—still taking off shoes and belts and throwing away slightly-too-large tubes of toothpaste at the airport out of “an abundance of caution.” As Ross Douthat recently averred, “certain forms of security theater, once established, become extremely difficult to dislodge as long as there is still any arguable threat.”

The risks of proclaiming a forever war on the virome go beyond mere theater. Consider the surveillance regimes that some colleges have attempted to impose on their students in the name of public health and safety. I’m not talking about mask or vaccine mandates, but mandatory geolocation apps, biomonitoring devices, the use of facial recognition software on personal devices, and the deployment of campus police to enforce anti-Covid measures. That all of these have met pushback, often successful, should be small reassurance. These, after all, are the steps deemed necessary before the invocation of national security. In his account of the pandemic’s early months, Gottlieb observes that it was China’s military, not its CDC, which steered its response. There are reasons that he notes this as an ominous sign—and it’s troubling that by page 400, he’s forgotten them.

The rhymes between our current response and the War on Terror already jangle a little too sharply. The month of August was spent discussing, again, the question of exit strategy from Afghanistan—what it was, whether it should have existed sooner (or at all), how the goals of this operation drifted and changed over time until it came to the point that we were fighting not to achieve something concrete but merely because stopping would have acknowledged some slate of earlier errors.

For two years now, different agencies, different government officials, different presidents and governors have been better and worse at designing and implementing pandemic policies. What almost all have failed to do—and certainly have failed to articulate clearly—is an exit strategy (though on the home front we call them “off-ramps.”) These off-ramps should be engineered by people with greater expertise than I possess. But they should exist in the first place—and be communicated clearly and openly, or else we have no definition of when the emergency ends.

If the last two decades have shown anything, it’s that unending crisis is a defining feature of national security mindsets. Those who possess them, as Gottlieb himself points out, are “always scanning the horizon for new threats”—the endpoint remains impossible to define even as more and more falls under their purview.

In fact, no concrete step Gottlieb calls for requires the creation of a new national security doctrine for national security or mindset. Our goal should be the recognition and correction of evident fragility within our previous—our current—pandemic response, public health agencies, and supply-chain networks. If we need a new cliché, “a new doctrine for national resiliency” or “antifragility” should work just fine.

We know that national security mindsets aren’t necessary because where we have succeeded in the last two years, we have succeeded in their absence. I’m thinking, specifically, about the development of mRNA vaccines.

It’s frightening to consider how much worse things could have been if this pandemic had been the one we actually prepared for—an avian flu. mRNA vaccines are easily adaptable—flu vaccines, deeply fragile. Seasonal flu shots are less effective at disease prevention because of how long they take to make—an artifact of their production in fertilized chicken eggs. But beyond this longer timeline, the entire system of production would be precarious: “A bird flu, by its very nature, kills poultry,” Gottlieb writes, stating the terrifyingly obvious. Dead poultry can’t lay eggs; their infected embryos need to survive long enough to grow viral stock for the vaccines. mRNA vaccine production, on the other hand, is an adaptable platform not at risk from what it inoculates against.

Unlike Covid-19, we already knew how to produce flu vaccines. The risk taken on mRNA stemmed in part from the fact that we had never produced a vaccine for a coronavirus before. There was no “safer” way. We couldn’t rely on what we knew how to do; we had to put our minds—and our money—into learning new things.

Whatever the odds of an avian flu pandemic wiping out our vaccine production capacity, we now know this won’t happen. That’s not because this scenario didn’t play out over the last two years—the next pandemic may well be an avian flu—and it’s not simply, as Gottlieb summarizes, because our response to Covid has been plagued by problems of institutions rather than problems of technology.

It’s a matter of knowing what to do with that technology, of letting ourselves know what we know and what we don’t know. Had this pandemic been avian flu, and had we eschewed mRNA vaccines—unproven, untested—for conventional vaccines, we would have failed because we insisted on using—as our response did and often still does—only what had worked in the past.

Gottlieb, for all the clarity he brings to the institutional history of Covid-19, ultimately makes the same mistake: a call to prepare for pandemics with the rhetoric, institutions, and ways of thinking that we tried and found wanting during the War on Terror, from which we still have no off-ramps. It’s Oedipus all the way down.