Review: Uncontrolled Spread

From Uncontrolled Spread by Scott Gottlieb, MD:

Watching the scenes unfold—of Elmhurst Hospital being overrun with COVID patients, of refrigerator trucks parked outside, and of doctors and nurses describing their harrowing experiences—was hard to bear. It was stunning, and it was shocking. But above all, it was terrifying."
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Book Review: Uncontrolled Spread: Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic. A former FDA Commissioner and Trump White House advisor gives us his view of COVID-19. A balanced, neutral look at the things we did right and the things we got wrong. A-

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Grade: A-

Scott Gottlieb, MD, opens his book with a sobering look back at the frightening scenes that played out in America, which had prided itself on having the best health care in the world, during the early months of the pandemic. Gottlieb is a former commissioner of the FDA. He also served on the board of directors of Pfizer. He also served in the Trump administration, stepping down in 2019, before the COVID-19 pandemic. So he has the training, experience and knowledge to know what he's talking about.

Gottlieb writes for an educated general audience, people who can understand writing about scientific and medical subjects, but who aren't necessarily experts in the field, although I believe the experts are reading his book with great interest. The book is broad enough to be, I imagine, the definitive history of COVID-19 (so far). But it was published in September, 2021, that is during the pandemic. It's impressively comprehensive and authoritative for it being contemporaneous with the events it describes.

What does he have to say?

"The virus didn’t arrive with a group of visitors from China." Instead, he suggests it probably arrived from multiple places on the breaths of hundreds of people. He suggests travel bans are probably futile and even counter-productive.

China's "behaviors proved we cannot rely on global cooperation alone to alert us to emerging threats." Gottlieb has a lot of criticism for China's behavior, while going only as far as the evidence can take us. He also says flatly, "Nobody believes COVID emanated from a deliberate act."

"Early on, the president was convinced enough of the seriousness of the risks that he supported a historic forty-five-day national shutdown of nonessential activity to slow the spread." Gottlieb says the President hurt this policy by sending mixed messages about it. He eventually came to believe that the costs of mitigation outweighed the benefits, eliminating any hope of the policy being effective.

"A big part of the challenge was that officials at the CDC were applying a flu model to coronavirus." But the two behaved very differently. The CDC doesn't escape its share of blame for its response to the novel coronavirus. The CDC overestimated the risk of spread from contaminated surfaces, and it underestimated the risk from asymptomatic transmission.

"What we needed next were readily available diagnostic tests to identify cases, along with a whole-of-government mobilization. We needed to produce supplies like masks to protect healthcare workers and ventilators to care for the sick. We needed to invest immediately in the development of countermeasures like vaccines and drugs. We needed to shore up our healthcare delivery system to expand its capacity. We needed to protect vulnerable communities like nursing homes." Gottlieb identifies this as our whole health care system's overall failure. As stellar as our vaccine development was, our ability to manufacture, distribute, and administer the vaccines was as big a failure.

"The data showed that masks were not a panacea, but they could help reduce spread." Gottlieb exhibits scientific nuance, the opposite of political ideology.

"The CDC’s single biggest breakdown in its response to COVID was the abortive rollout of its COVID test." The CDC didn't have the capacity to quickly develop and produce a test in the volumes needed. Worse, mistakes were made. Then, when tests were finally rolling out, the CDC didn't have the capacity to process the tests. Even the private hospital labs were overwhelmed.

"Operation Warp Speed was a bright spot: one of the greatest public health achievements in modern times." Gottlieb praises the scientists, labs and drug companies behind this. He also is not reluctant to praise the Trump administration when it does things right.

"In the future, we cannot rely on global manufacturing for key components. We’ll have to build domestic capacity for making commodity products like gloves and masks and greater resiliency for making high-technology products like biological drugs and vaccines." This is probably the most important prescription Gottlieb offers. The problem is that it goes against everything that business has honed over decades to reduce business costs and increase profits. Deliberately building up capacity at home instead of relying on lower cost foreign suppliers is expensive. Deliberately building in excess capacity is expensive. It's hard for a for-profit business to defend costs that might never have a payback. Will we learn that lesson?

"The new document encompassed three pillars. First was preparedness, which would include the production and stockpiling of vaccines and medical countermeasures, and the creation of diagnostic tests. Second was surveillance and detection, which relied on our ability to detect and report outbreaks, and to use testing and tracing to limit spread. The final piece was response and containment. This spoke to the need for a surge capacity in our healthcare system that could care for waves of sick people, and a plan for mounting a coordinated response among the states to limit the national spread."

The new document Gottlieb refers to here was written in 2005 and released by President George W. Bush. COVID-19 is proof of how poorly we listened.

Towards the end of his own book, Gottlieb says, "We ended up being one of the nations brought lowest by the virus, with continuous waves of infection that stalled our economy and claimed more than 600,000 of our fellow citizens' lives." As of today, the CDC reports 1,027,370 deaths among Americans. Scott Gottlieb's book issues a clarion call. It's in the subtitle: "How We Can Defeat the Next Pandemic." I wish he could offer reason to hope that we'll listen this time.

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"Now, I understand what you tried to say to me
And how you suffered for your sanity
And how you tried to set them free
They would not listen, they did not know how
Perhaps they'll listen now."

— "Vincent", by Don McLean