I had a piece go live this morning. It’s my fourth cover story for the New York Times Magazine, and you can check it out here. It’s been in the works since late March and turned through about three news cycles (and as many drafts) before crossing the finish line. Lots of little bits of writing didn’t make the final cut — for good reason, but not because they didn’t speak to important facets of the story we were trying to tell. Posting them here in case they of interest to anyone, and with the caveat that they may not make much sense if you’re not versed in the bigger story.
FLU PANDEMIC, 1918, NYC:
On August 11, 1918, the Norwegian vessel Bergensfjord arrived at a Brooklyn port bearing at least 10 passengers who were infected with what looked like a particularly nasty strain of flu — at least four had succumbed at sea to the illness, which appeared to drown its victims from the inside with a mix of blood and froth that filled the lungs. The ship’s captain had wired ahead, so that ambulances and health officers were ready to shepherd the sick to Norwegian Hospital in Brooklyn. That transport – from dock to ambulance to hospital — marked the beginning of a months-long battle between New York City health officials and what would turn out to be the deadliest virus the world had yet known.
The timing could not have been worse: The nation was at war, and New York City was the main point of departure for tens of thousands of American soldiers heading to the European front. Any rigorous quarantine would thwart those movements and imperil the war effort. Normally, the city’s health department — one of the best in the country, if not the world — would have been well equipped to navigate such tricky terrain. But at the moment, it too was embroiled in war. Royal Copeland, the department’s newly minted commissioner, had been appointed just a few months earlier in a blatant act of Tammany cronyism. He had no valid medical training, and he was aggressively dismantling his own agency from the inside – firing experienced civil servants, often on trumped up charges, so that their positions could be filled by party loyalists. When the first deaths came, Copeland insisted that flu was not the cause. As bodies piled up, he denied that an epidemic was underway. And when he could no longer deny, he insisted that everything was under control.
Fortunately, the institution proved stronger than the individual: The New York City Department of Health had more than a century’s worth of experience fighting off contagions of every kind, and it had the protocols and muscle memory to show for it. Within a few weeks of the Bergensfjord’s arrival, the department’s beleaguered staff managed to hang some 10,000 posters around the city so that everywhere New Yorkers looked — in street cars, subway stations and shop windows, in police precincts, hotels and restaurants — they were reminded to cover their coughs and sneezes, and to refrain from spitting. The department eventually codified those strictures, and fined violators as much as $1 per offense.
Still the virus spread. And so health officers took more extreme measures against it. They banned large gatherings and smoking in public places. They ordered businesses to stagger their hours, so as to minimize congestion on city streets and in the burgeoning public transit system. They forced theater operators to ventilate their establishments rigorously, on penalty of closure; and they tasked teachers with inspecting their students daily and sending any coughers or snifflers home. Their moves were controversial (other cities closed their schools completely), but calculated. While all public venues posed a clear risk of further viral spread, they also provided an unparalleled opportunity for the department to do what it did best: inform and implore the public.
The health department did not stop at public messaging. By late October, it had established more than 150 emergency flu clinics around the city, and embarked on a mammoth effort to identify, isolate and treat every single infected person within its jurisdiction. Staff from other city agencies were reassigned to the task, new recruits were hired and volunteers solicited; and when those legions proved insufficient, Commissioner Copeland himself (a tardy convert to the effort, but a convert none-the-less) conscripted the whole of Tammany Hall into service.
None of these measures were enough to spare the city, which lost some 20,000 residents to the great influenza, as it has since been dubbed. But as research has since made plain, public health departments had a substantial impact on how cities everywhere fared during the pandemic and how well they recovered afterwards. Those with robust public health departments and rapid public health responses lost fewer lives and enjoyed faster, stronger economic recoveries than their peers. In Philadelphia — a city whose public health operations paled in comparison to New York’s — more than seven out of every thousand deaths during the pandemic were flu-related. In New York, fewer than five were. That difference may not sound like much, but if New York’s fatality rate were as bad as Philadelphia’s, between 10,000 and 15,000 more people would have died.
“They knew what they had to do and they did it,” Francesco Aimone told me. Aimone studied New York City’s response to the 1918 pandemic as part of his graduate training in public health. He had planned to make a career researching such histories and applying their lessons to the present day; but by the time he obtained his master’s degree, health departments everywhere were cutting their staff. “It was 2009, so it was the middle of the recession,” he says. “At that point, there were zero positions for people with my skill set, and no interest at all in the history of global pandemics.”
At this point of course, things are different.
PUBLIC HEALTH, 1980s, NEW JERSEY:
Shelly Hearne, a doctor of public health at Johns Hopkins University, has spent most of her life thinking about the disconnect between responding to health crises and preventing them from happening in the first place. Hearne grew up in the 1980s, in a community surrounded by industrial parks, and plagued by asthma and cancer. “Everywhere you turned there was some kind of odd illness that you knew in your gut had something to do with the factories and waste sites,” she told me. “I wanted to figure out why people were getting sick, and how to stop it from happening.”
After obtaining her doctorate in Public Health, she received two job offers from her home state: one in the Department of Environmental Protection and one in the Department of Health. She chose the DEP because the public health department had little funding and no real resources, the environmental movement was thriving. “There were hundreds of advocacy groups cropping up,” she says. “And there was this sophisticated understanding of how to use that momentum to affect change. When the environment commissioner wanted to tackle a problem, she literally had me call the local environmental groups and ask them to make a lot of noise about it, even take her to task publicly, so that she could then pressure the legislature to give her the resources to address it.”
There was nothing like that on the public health side, Hearne says. Capitol Hill was dense with high-powered health care lobbyists — what some of her colleagues referred to as the Gucci Gulch set — and with individual nonprofits dedicated to curing individual diseases. But none of those factions was focused on prevention. “It was all about getting money for NIH, for the cure,” she says. “Nobody seemed to be asking why all these numbers for asthma and cancer and bad birth outcomes were going up in the first place, and if and how we could stop that from happening. And nobody was talking about our infectious disease system, which hadn’t been modernized since the late 1800s.”
TUBERCULOSIS, 1990s, NYC:
“Even among clinicians, there’s a tendency to sort of dismiss public health, or to think of epidemiology as a little bit like the weather. You can describe it, and predict it and complain about it. But you can’t really change it.”
Frieden learned the folly of such assumptions during his first big public health job – steering New York City’s health department through an outbreak of drug resistant tuberculosis in the mid-1990s. The infection was spreading like wildfire through the city’s poorer quarters, and both drug resistance and nosocomial transmission (where doctors and nurses become infected and unwittingly pass the disease on to other patients) were thwarting efforts to resolve the crisis. Frieden was doing everything he could to increase the number of cases the city identified and treated, when a senior colleague by the name of Karel Styblo asked him a question that he says changed his life. “He looked at our data,” Frieden told me recently. “And it showed, you know, all the thousands of patients we had treated and so on. And he said ‘Ok, that’s great. But how many of them did you cure?’ And I was so embarrassed, because I had no idea.”
Styblo was legendary for his success in eliminating tuberculosis from certain low-income countries, something that was still widely considered impossible. His lesson that day was clear, Frieden says: Clinical medicine focuses on numerators, meaning individual sick people who need to be treated. Public health is concerned with denominators, which is to say population-wide outcomes. “If we wanted to stop tuberculosis from decimating Manhattan, we would have to start thinking about denominators,” Frieden says. He began tracking the outcomes of every single patient diagnosed in the city, and he modified his program until the total incidence of tuberculosis was down by 90 percent. In the years that followed, similarly “denominator-focused” strategies helped his team tackle the longstanding problem of hypertension, and bring smoking rates to an all-time low.
COVID-19, HARRIS COUNTY TEXAS, 2020:
When Lina Hidalgo signed the order closing the county’s bars and restaurants, her phone rang off the hook. Her political career would be over, operative after operative warned. This lobby, and that union and those voters would be furious, would attack her relentlessly in the press, would maybe bankroll her opponent in the next election. Like Shah, Hidalgo was struck by the realization that there would be no winning. If they managed to stop the virus, people would never believe the threat had been real in the first place. And if they failed, people would die. “I had this sensation of my brain as a physical space that was completely filled with covid,” she told me. “I thought if I let the politics in it would actually explode.” So she decided to stick to the science, continue erring on the side of caution, and let the chips fall where they would. She placed one call before issuing the order, to her chief of staff. “Hey man,” she told him. “This one might be the end of the road.” And then she pressed on.
***
By May, Shah’s team was still struggling with testing shortages. The problems were innumerable. In theory they could erect as many test sites as they needed to, thanks to an earlier funding boost. But they only had enough actual test kits to set up four for the entire county, which meant that most people would have to travel scores of miles to reach one – which meant that most people would not go, even if they had been exposed and were exhibiting symptoms. On top of that, all sorts of different labs were now processing the tests, and each of them seemed to have its own haphazard way of reporting the results. There were faxes and phone calls, and one guy even tried to email Shah directly. Half the department was now tasked with sorting through the deluge and figuring out who any given test result belonged to, where that person lived, and what the result itself actually meant. And all of that was after they got the test results, which could take anywhere from four to eight days after the test was taken. “We are trying to figure out the state of the forest,” Shah told me at the time. “But we can’t even find the individual trees.”
In the meantime, Dana Beckham, Shah’s chief epidemiologist was trying to expand her team three-fold. She hired 100 new people in the space of a few weeks that happen to coincide with a surge of cases in Harris County, a task that gave the sensation of building an airplane mid-flight.
It was easy enough to find applicants: furloughed students and recent graduates from the region’s medical schools and universities were eager to help. But the work required a particular skill set.
It involved calling anyone who tested positive and explaining the basics of viral transmission and incubation, then asking detailed questions about every place the person had been in the previous two weeks, and with who and for how long. After that, they had to be persuaded to get tested if they were showing symptoms, and to self-isolate for at least two weeks, even if they were not. You then had to follow up, every single day for those two weeks, to see how they were doing, and if symptoms had developed or changed. None of those were easy asks. “People are suspicious,” Beckham explained to her recruits. “They don’t necessarily want to give a bunch of personal information to some random stranger on the phone.”
For March and part of April, the tracers worked 15 hour days, sometimes for six days a week. Burnout became such a concern that Beckham brought therapy dogs in for the staff, and instituted an hour-long board game break, where the group played family feud. Eventually she had to order people to stay home on their days off: no coming in just to follow up with one contact or another. Stay home and rest when. “Part of the job is building relationships with the people you call, because you need them to be honest with you about what’s going on,” Beckham says. “But that takes a toll, especially when one of the people you’re talking to everyday get sick, winds up on a ventilator, and then doesn’t make it.”
By May the contact tracing system had been partly automated. A retired NASA engineer that worked for the department – they called him the rocket scientist – had created an app with which contacts could log their own temperatures and other symptoms, and tracers could monitor those reports and call only if there was a problem. It made the work go much faster, but Shah worried that they would still not be able to outrun the virus. Other counties, not only in Texas, but also in California, had already abandoned containment efforts (tracing all the contacts of every single positive case in order to stop the virus from spreading) in favor of mitigation (accepting that they virus had spread beyond their ability to contain it, and working to minimize the impact in high-risk communities). Eventually, he thought, Harris County would have to do the same.
The community outreach team was doing everything they could to prevent that from happening. There were just 12 of them, but they had divided the county into four categories — live, learn, work, play — and were now spending 12 hours a day, six days a week calling every single restaurant, nursing home, apartment complex, retail shop and house of worship to ask the same string of questions: Do you need information on testing? Do you need hand washing signs? Do you need facemasks? Can I schedule a presentation for you, or provide you with any pamphlets, and if so how would you like those delivered? Their work, which amounted to thousands of phone calls a week, was utterly thankless; it had not attracted any media attention and seemed unlikely to inspire nightly rounds of public cheering. But the course of both the Harris County outbreak and of the wider pandemic would depend at least in part on how well or poorly such efforts fared — especially given how much elected officials had deemed a matter of personal choice.
I asked Elizabeth Perez, who leads the outreach team, what her professional wish list consisted of. “You know that big anti-smoking campaign that the C.D.C. did a long time ago,” she asked. “I would love to do a massive campaign like that. With print and broadcast and online. They spent more than $100 million just to change that one behavior. And you saw all these intense graphic ads all over the place. And you know what? It worked.” It was a pipe dream, of course, given that they still didn’t have enough testing sites or personal protective equipment. But she couldn’t help thinking of how it might help. She suspected that many of the people who still thought the virus was a hoax, or that face masks were useless and social distancing pointless authoritarianism, were being deliberately swayed by the rampant misinformation that had become so commonplace. It reminded her of the tobacco industry and the anti-vaccination movement, both of which had created major public health crises because their ability to promote a message dramatically outpaced her team’s ability to counter it.