THE HIGH COST OF NOT ELECTING GOVERNORS:

While a majority of Americans are now almost completely protected against severe disease, hospitalization, and death from COVID-19, the Biden administration seems to have almost no meaningful strategy to bring the pandemic to an end beyond magical thinking that vaccine uptake will increase with some polite prodding and artfully produced briefings. The country is racking up over a million COVID cases a week, pediatric hospitalizations have reached or exceeded their winter peaks in some states, and the vaccinated public is receiving very mixed messages about the state of their immunity, whether and when to get a booster and the kinds of activities they should be engaged in.

The worst and most public dysfunction seems to be coordination between regulatory bodies and the private sector regarding boosters and pediatric vaccines. The Food and Drug Administration (FDA) is mysteriously slow rolling not just third shots of the existing mRNA vaccines from Pfizer and Moderna for the general population, despite clear data from Israel that efficacy against infection wanes as times marches on, but also new boosters from Moderna specifically geared to fight variants. Last month, the Biden administration suddenly announced that boosters would be administered starting on Sept. 20 for anyone eight months or more out from their second shots. Six days later that timeline was bumped up to six months. Then scientists at the FDA and CDC balked at their marching orders and publicly called that timeline into question, accusing the White House of rushing them for political reasons.

To make matters worse, the administration announced on Sept. 3 that Moderna vaccine boosters would be delayed at least several weeks to complete a review of the company's trial data. There remains no timeline for a Johnson & Johnson booster even though the company says a second shot of their vaccine produces a robust immune response. The 14 million people who got that company's single-shot vaccine will remain in limbo indefinitely. The whole fiasco has rendered the "one vaccine is just as good as the other" discourse from the spring maddeningly hollow.

And what are ordinary people to make of our immunity levels right now? It's waning, some say, based on Israeli data suggesting that those who got their shots first are getting sick with breakthrough infections more often than those who got their jabs recently. On Aug. 27, Dr. Anthony Fauci said that boosters are not necessary for the time being and vaccinated people should be confident in their protection from severe disease -- but last week he seemed to endorse the idea that all vaccinated people will need a booster for maximum protection. The administration has not addressed studies suggesting that the Moderna vaccine provides longer-lasting immunity than Pfizer. Meanwhile, Moderna and the FDA are fighting over dosages for the company's proposed booster vaccines. Biden's team promised that it could quickly roll out boosters for any variant, but here we are more than six months into the Delta nightmare, and they are nowhere to be seen.

The Premonition's story begins with the first and mightiest of the modern pandemics. In 1918, an avian flu mutated and killed 50 million people worldwide, including 675,000 in the United States.1 Since then, the specter of influenza has haunted the world's public health agencies. Much smaller pandemics in 1957, 1968, and 2009 kept the danger to the fore. But the first national pandemic preparedness plan was only created in 2005, after President George W. Bush read John Barry's The Great Influenza, the classic study of the 1918 pandemic, and concluded that "[i]f anything like the 1918 flu occurred, the basic functions of the society would come to a halt, and no one in the federal government seemed to have worried about it."2 Rajeev Venkayya, the youthful head of the Biodefense directorate of the Homeland Security Council, was tapped to draft a pandemic strategy embracing not just the production and stockpiling of vaccines, but also immigration, commerce, tourism, and whatever else would affect the course of a pandemic. He put together a team of brilliant and dedicated oddballs whose accomplishments and frustrations are the storyline of The Premonition.

To begin with, Venkayya's team concentrated on modeling. They were led by an oncologist, Richard Hatchett, who had once been a gifted undergraduate poet--he had chosen medical school because "[w]riting is too hard."3 But however elegant their models, the verdict of the Centers for Disease Control (CDC) and other health experts was always, "Not enough data." Then Carter Mecher, an intensive-care physician from Veterans Affairs studying the pandemic of 1918, noticed that, even though the two cities took similar preventive measures, St. Louis had half the death rate of Philadelphia. There was a crucial difference: the measures were only instituted in Philadelphia several weeks after the first reported case in the city, while St. Louis had acted almost immediately. As a result, the exponential spread of the disease exacted a heavy toll on Philadelphia; much less so in St. Louis. And there was a further lesson. Philadelphia was reluctant to act without federal guidance, which did not come until three weeks after the city's first reported case. Fortunately for St. Louis, the US surgeon general spoke out recommending school closure and social distancing on the same day as the first case was reported there, giving the city authorities political cover to take unpopular measures. Clearly, federal leadership would be crucial to any future pandemic response.

Though Mecher, Hatchett, and their colleagues would never be taken seriously by the CDC, the National Institutes of Health, and other public health organizations, it must be some comfort to them that the paper in which they reported the above results, "Public Health Interventions and Epidemic Intensity During the 1918 Pandemic," became phenomenally popular.4 As of October 2020, it ranked as the eighth most cited paper out of 86,622 published in the Proceedings of the National Academy of Sciences.5

The administration's pandemic plan was completed and the Mecher-Hatchett team dispersed by the end of Bush's final term. Despite reaching this milestone, a number of political problems had not been overcome. The new strategy called for closing schools as soon as the infection rate reached 0.1. That sounds small, but only because exponential growth is hard to grasp intuitively, especially when, as with politicians and school boards, one has angry constituents demanding to know how so few apparent infections could justify so much inconvenience. Of course, by the time the number of infections has grown, controlling the pandemic will be many times more difficult.

A political test for the new strategy soon arrived in the form of a swine flu epidemic in early 2009, just a few months after the inauguration of Barack Obama. The new president asked for advice. Mecher was asked to provide a briefing and advised closing the schools; the CDC counseled against it. Obama declined to close the schools. The swine flu infected 40-80 million Americans, but luckily only 12,500 died.6 The right decision was made, it turned out, but for the wrong reasons--the numbers could easily have been much worse. Did the failure to take action this time make it even harder to do so the next time, in 2020?

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