Uncontrolled Spread by Scott Gottlieb

The book is a tour de force on the pandemic from one of the best authorities on the subject. Gottlieb served as FDA Commissioner for two years under Trump and previously worked in the second Bush Administration. He currently sits on the Pfizer board and regularly appears on CNBC and writes op-eds in the Wall Street Journal.

The book chronicles the many missteps that happened that led to the pandemic being as bad as it was and lays out what could have been done differently. Gottlieb has been a prominent voice since the pandemic started and is one of the best sources of information on it. He has certainly helped me understand things much better and is one of the people I recommend reading and listening to if you want to really learn about the pandemic and almost anything related to it.

What I think is best about him is that he is as non-partisan as you can be while not being wishy-washy. He has been a Republican and probably still is, but it is very hard to discern that from his commentary and writings. He is very fair and even-handed and is able to balance the taking of necessary safety precautions while not going completely insane. The book spends very little time talking about either Trump, Biden or any other political figures, which is a feature, not a bug. Plenty of books have been and will be written about which politicians are at fault, but this book does not do that, which is what makes it so helpful.

There is not any central villain or even any villains in the malicious sense of the word. Internationally, the biggest failing was the inability of previously agreed to standards regarding reporting disease outbreaks to be enforced. That had happened before earlier this century when China hid the initial SARS outbreak. Other countries had also been slow to report outbreaks of other diseases when they first emerged.

Gottlieb is not a fan of travel bans in general. He has been vocal against them during the pandemic, including the latest ones against South Africa and other neighboring countries. He discusses his concern that travel bans can only buy a little time and can have the unintended effect of punishing countries that report outbreaks, which might make them less likely to do so in the future. I have to say I agree with him after being uncertain of where I stood just a month ago. A travel ban could maybe help before a virus shows up for the first time, but now the CCP Virus is everywhere and so are its variants. Travel bans will not make any real positive difference at this point.

Domestically, the biggest failing was the CDC. It is not equipped to deal with a pandemic or any present or future problems because its mindset is retrospective. That has its place, but does not work for a pandemic. From the beginning, the CDC showed itself to be completely in over its head. It lacks the capabilities to do almost everything people expected it to do when the pandemic first hit. It does not have manufacturing capabilities, for example, but declared itself to have the only right to make test kits. The one it did make did not work. Meanwhile, private manufacturers waited for the CDC to get its test kits out and delayed putting out their own, which cost crucial time and helped guarantee the virus would spread rapidly.

Gottlieb discusses how very few efforts were made to prevent a future pandemic before 2019. Beginning in the second Bush Administration, discussions began about it, but never went very far. The same was true in the Obama Administration. Not only was there little pandemic preparation, but it was focused on the wrong kind of pathogens. The assumption was that the next pandemic would be a flu strain and so plans were drawn out to deal with that. That belief influenced a whole lot of the ineffective guidance recommended when the CCP Virus first hit. For example, the flu can spread on surfaces, which is why surfaces were cleaned so heavily even though it did nothing about the CCP Virus.

Previous efforts, Gottlieb notes, at trying to formulate a pandemic strategy tended to get short shrift in part because they were prompted in response to recent threats. When SARS and MERS showed up, interest in pandemic prevention spiked, but when both turned out to not be pandemics it waned. The same was true for Zika.

When a pandemic finally happened, the US was not ready at all. The lack of preparation and ignorance about how the CCP Virus spreads were arguably the costliest errors. The lack of testing at the beginning of the pandemic all but guaranteed any efforts at containment were hopeless. Guidance issued for how to avoid spreading it, most notably the 6-feet apart rule, were not based on anything sound. The 6-feet rule, Gottlieb says, is not based on anything that anyone can pinpoint to. No scientific studies, for example, have shown it to be effective compared to other distances. Initially, the CDC wanted it to be 10-feet apart, but in a dispute with the Office of Management and Budget reduced it to 6-feet. Essentially, it was a political compromise not rooted in science. In reality, 3-feet probably would have been sufficient.

The 6-feet rule was especially costly because that was the main reason schools were closed. Many schools did not have enough space to spread students out that far and so wound up shutting down entirely. Remote learning has been an unmitigated disaster and it turns out to have largely been the result of a rule not based on science. I understood the closing of schools during the initial outbreak when everything else was closed and it was unclear whether schools would contribute to spreading the virus. Since then, we have known that schools are not virus spreaders and since we opened restaurants and bars it was senseless to keep schools closed. We also now know that kids are at very little risk from the CCP Virus.

Gottlieb’s core thesis is that we have to change our mindset on how we view pandemics. They cannot be seen as just health issues. They have to be seen as national security threats. I could not agree more. We have seen how much damage they can cause. Everything from health to the economy to public order is threatened. We cannot allow another one to hit us like the CCP Virus did. Gottlieb advocates for creating a new agency that deals with pandemic threats and having our intelligence agencies focus on looking for outbreaks. That sure sounds like a good idea to me.

What is critical in a pandemic is consistent and clear communication. From the beginning, we have largely not had that. The CDC has been ground zero for that failure and still is. Just yesterday, the CDC reduced the number of days that healthcare workers who test positive should isolate from ten to seven. That’s better than nothing, but raises some questions. For starters, why just healthcare workers? Yes, their jobs are critical, but there is nothing biologically different about them from everyone else. There is no reason that new guidance cannot apply to the rest of us. Also, why seven days and not five? For those who test positive, but are asymptomatic, five days should be plenty. I’m sure the CDC will update their latest guidance sometime in the next decade. Sarcasm aside, it is this kind of lousy and senseless communication that costs public health officials credibility and winds up needlessly causing a lot of harm.

The single biggest mistake Biden has made in his pandemic approach is that he has deferred to the CDC at every turn. The CDC has no actual authority and cannot make anyone follow its guidelines. It does have persuasive authority, but that is it. I have written recently that the CDC has forfeited the right to be deferred to and that belief becomes stronger every day. The CDC is a deer in the headlights and cannot even communicate on a pre-school level. At this point, their guidelines should not be paid attention to by anyone and Biden should issue his own. The CDC is hopelessly behind the curve and is too slow to change in any significant way. Biden should be consulting scientists (although not exclusively scientists) for advice, but they should be scientists who live in the real world, are not wedded to arcane ways, are not lunatics and have the risk tolerance of a normal human.

It is not just the CDC that has bungled things. Gottlieb says a major error was the nationwide shut down beginning in March of 2020. Some places needed to be shut down at the time, but not others. The places hardest hit at the time like New York, New Orleans and Detroit were justified in locking down, but other places were not. By locking everything down, it sapped the will to lockdown again in places that needed it later on. The southwestern states could have benefitted from it over the summer of 2020 when their outbreaks were worse, but there was no desire to do it and so the pandemic raged on.

When it comes to Trump, the biggest criticism Gottlieb has of him is that he made mask wearing a culture war issue. By mocking and downplaying it, he made it a partisan thing and many people did not wear masks when they needed to, which contributed to more spread and death. I really believe that had Trump encouraged mask wearing or handled the pandemic with even the most nominal amount of competence, he would still be president.  

Trump’s terrible performance notwithstanding, what the book really drives home is that the failures in dealing with the pandemic are much wider and deeper than just him. I wish it was all his fault because things would be perfect now. Clearly, they are not. The reality is no matter who was president, the US was going to get hit hard and suffer immensely. We were completely unprepared for a pandemic in every possible way. From testing shortages to preparing for the wrong pathogen to the CDC being completely out of its league, we were flying blind and no president would have had the foresight to right all of those things in time.

Beyond leadership, it is just not in our nature to process things like pandemics. Because they happen so rarely, it is not something that 99.9999999% of us ever think about. Pandemic preparation necessarily involves planning for the future on something that we have no way of knowing whether it will happen. What makes it so hard is that while we can make educated guesses about what will cause the next pandemic, they are just that. Most people who thought about pandemics believed the next one would be from a flu strain. Few were expecting it to be a coronavirus in part because SARS (which was a coronavirus) turned out to not spread nearly as easily as other known viruses. Nobody has any way of knowing for sure what will cause the next pandemic.

That is why we have to think about all kinds of possibilities and not be dogmatic. It is why we have to avoid groupthink. Gottlieb says our pandemic preparation should be akin to preparing for an invasion of which we do not know how it will happen or when. That is why the sharing of information internationally is so important. Gottlieb advocates for creating an international agency like the IAEA to monitor disease outbreaks. I do not know how effective that would be, but I am certainly open to learning more.

The big concern I have is how to deal with a country like China. We know that their government lied about the CCP Virus for weeks (that’s why I call it that). We know that they lied about SARS. While lying about and trying to hide outbreaks is not unique to China, it has been a source of origin for many diseases and may well be the source for the next big one. I have no doubt they will lie about it just like they have before. Unlike democracies with free presses and whistleblower protections, where a government that tries to cover up an outbreak can be held accountable, China is a dictatorship and does not have a free press or whistleblower protections. Their government lies all the time because they can and there is nobody who can stop them.

The question is what can the US do about that? I do not really see how there can be any answer other than nothing. China is a separate country that is way too big to be pushed around by sanctions and other punishments. Worse, much of the rest of the world trades with them and does not want to risk that so they will be unlikely to push to make sure they are transparent in the future. I see no way around this although I am hardly an expert so hopefully someone who knows way more about it than I do has a satisfactory answer. I think a good rule of thumb going forward is to assume the opposite of whatever the CCP is saying when it comes to diseases there absent evidence suggesting otherwise. If news comes out about any kind of outbreak and the CCP says all is well and they have it under control, we should assume things are not well and they do not have it under control. That is to say the default assumption should be that they are lying.

Domestically, it may be tempting to think that the CDC just needs to be funded better, but that will not solve its problems. It is fundamentally not an agency that deals with controlling diseases, despite its name. Its culture is not accustomed to that and no amount of money will change that. The same is true of the FDA. Both agencies are wedded to their ways and cannot comprehend doing anything differently. The CDC should still exist and do its retrospective looking work, but it cannot deal with pandemics. A new agency is needed for that and preferably one that is not staffed primarily, let alone exclusively, by public health officials. Public health officials have their place, but they are not people with a national security mindset and that is what is badly needed regarding pandemic preparation.

As for the FDA, it does not need to be reformed so much as lose some of its discretion. It would be great to see Congress enact a law requiring automatic approval for any test kits or CCP Virus medication that has been approved by an equivalent agency in the EU or any other developed country. Ideally, Congress would go even further and apply that to any medicine for any ailment. The FDA is far too risk averse and turf guarding to change its ways on its own. Luckily, Congress has power over the FDA and can change it. That should be done right now.

The book is a great read overall. A lot of it was new to me, especially explaining the science behind vaccines, test kits and viruses and I would be lying if I said I understood it all. It is a level-headed, matter of fact, mostly dispassionate account of what happened over the last two years and what should be done now and in the future. I certainly recommend it for anyone who wants to understand the pandemic and how to avoid the next one. In general, I recommend reading Gottlieb as much as you can and watching him if you watch CNBC. Along with David Leonhardt, he is one of the two people I recommend following if you want to learn about the pandemic and what to do in your own life about it.