The Rationing

by Charles Wheelan

  “Give it at least a half an hour,” the Strategist advised. “The Indian PM is a rug merchant—”

  “Can we show some respect, please?” the Secretary of State interrupted, casting an exasperated look across the table.

  The Strategist, not one to back down when he believed himself to be right, said, “Isn’t that literally true? His family traded carpets. Wasn’t his family in the carpet business?” the Strategist asked the U.S. Ambassador.

  The Ambassador replied uncomfortably, “I do believe his mother’s family exported carpets from Kashmir.”

  “He wrote about it in his autobiography,” the Strategist explained.

  “Fine, but for my benefit, can we please not call him a rug merchant?” the Secretary of State said. (In her memoir, she would describe herself as “horrified” by the Strategist’s manners but “simultaneously impressed” by his depth of knowledge on myriad topics.)

  The Strategist, taking no offense, replied, “I don’t care what we call him. The point is that he sees the world as a zero-sum game—everything. If we win, he loses, and vice versa.”

  “I would agree,” the Ambassador offered. “He’s hard to deal with that way.”

  “We need to make him think he’s getting a huge win and that we’re somehow losing,” the Strategist said.

  “That seems difficult, given the circumstances,” the Ambassador said earnestly. “How does the U.S. lose by getting Dormigen that’s going to save thousands of lives?”

  “We suggest that we can’t give him what he most wants,” the Strategist said.

  “Publicity,” the Secretary of State offered.

  “Exactly,” the Strategist said, impressed his pupils were keeping up with him. “The PM wants a political win, domestically and on the international stage. We tell him that won’t be possible. We appreciate his Dormigen offer, but the President is not comfortable appearing dependent on a developing country to protect—”

  “Do not refer to India as a developing country,” the Ambassador said firmly. “He will be very sensitive to that.”

  “Of course he will!” the Strategist blurted out, now exasperated that one of his pupils was falling behind. “Not that people tend to confuse India with Switzerland, but still, you’re correct, so we need to exploit that sensitivity. What better way for India to signal its economic progress than to bail out the richest country on the planet?”

  “I agree,” the Secretary of State said.

  “Okay, so what next?” the U.S. Ambassador asked.

  “You need to set up a meeting with someone in the Prime Minister’s office,” the Strategist instructed the Ambassador. “Tell them it needs to be confidential. Request to meet in a shopping mall, or a restaurant, or someplace like that. Tell them the President is very sensitive to appearing as a supplicant—yes, use that word, ‘supplicant.’ ”

  The Secretary of State added, “Especially after the polling data showing what a huge political win this would be for the PM.”

  “Yes, exactly! Good,” the Strategist said. “And then when they hint at a Dormigen offer, which they will, you must make clear that the President would be willing to accept the Dormigen, but the deal would have to be confidential, or at least very low-key.”

  “And how does the President really feel?” the Ambassador asked.

  “What do you think?” the Strategist answered impatiently. “The President just wants the Dormigen. The Indian PM can ride it down Fifth Avenue on a white horse, if that’s what he wants.”

  “This feels like a long shot,” the U.S. Ambassador said. “We’re treating a head of state like Br’er Rabbit.”

  “First of all,” the Strategist said, “Br’er Rabbit was the one who got thrown in the briar patch, so technically we’re treating the PM like the fox. Second, we’ve got no other fucking options. And third, I’ll bet you my left testicle it works.”†

  73.

  THE CONGRESSIONAL BRIEFING BY THE ACTING HHS SECRETARY was somewhat anticlimactic after the Speaker’s press conference. The President had already spoken at length with the Senate Majority Leader and many of the Conventioneers. The Communications Director had released the key points of the briefing five minutes before the Acting Director began speaking, creating an odd situation in which members of Congress were getting texts from their staffs giving them the key points of the briefing they were waiting to receive. The Speaker tweeted that this was “beyond insulting,” prompting the Communications Director to tweet back (publicly, of course), “Key 4 America should be content of briefing, not who gets it when,” at which point the Chief of Staff ordered him to disengage.

  For those of us working on the Outbreak from the beginning, the congressional briefing was old news. The Acting Secretary walked through the details of how we got to this point (including the arrest and indictment of the Centera Pharmaceutical executives); the efforts the administration was making to gather Dormigen from other countries; the scientific advances that had been made with regard to the virus. The chamber was loud and unruly, as staffers scurried about and members studied their devices for details of what the Acting Secretary was about to tell them. After a few minutes of what felt like prefatory remarks, the Acting Secretary turned to the essence of the briefing, the “what now” part, and although nearly everyone in the chamber knew what was coming, the noise dissipated and most eyes turned to the Acting Secretary as he stood in the well of the House. “As you are well aware,” he intoned, “even with all of the efforts I have just described, it is increasingly likely that we will find ourselves with an insufficient supply of Dormigen to meet our basic needs.”

  There were hisses and catcalls in the chamber. “Not in America!” someone yelled from the Acting Secretary’s left. “No rationing!” came another cry. The outbursts felt choreographed, as they probably were. Someone who heard only the audio, as opposed to sitting in the august House chamber, might assume they were listening to a high school principal lecturing unruly students. Of course, if I am being honest, the briefing itself was mostly theater, too. The President had instructed the Communications Director, “Just tell them enough to keep them busy.” Still, it was the public’s first official glance at what lay ahead as the Dormigen stocks were depleted.

  The Acting HHS Secretary continued: “Despite our best efforts to conserve Dormigen in recent days, we are now projecting a shortfall for several days before plentiful new supplies of Dormigen can be produced. This is a short window, not quite four days according to our most recent calculations, but during that period we anticipate that not every patient who would normally benefit from Dormigen will have access the drug.” There was more hissing and jeering, but the Acting Secretary’s calm, avuncular tone took some of the negative energy out of the chamber. He continued: “In consultation with physicians and medical ethicists, we have developed a contingency plan—a plan, by the way, that we still hope will not be necessary—to allocate the available Dormigen supplies in a way that will offer the greatest possible health benefits. The available Dormigen will be prescribed where it can do the most good, and doctors will be discouraged from using the drug when the benefits are likely to have the least impact.” This last bit had been run past focus groups repeatedly, despite the confidential nature of the plan. The Strategist had been able to get groups to respond to a “hypothetical situation” in which the captain of a cruise ship adrift at sea had to explain how the dwindling food supplies would be allocated among the passengers. “The exact details of our plan are explained in the briefing packet that we have distributed,” the Acting Secretary said.

  “Old people to the right!” someone yelled from the floor.

  “Rich people to the left!” a different voice responded.

  The Acting Secretary seized on a momentary pause to interject, “I will now answer any questions you may have.” The exact details of the Dormigen rationing were laid out in small print in the documents distributed in the congressional briefing packets: the age cutoff; the kinds of illnesses that
would render patients ineligible for Dormigen; the penalties for physicians who did not comply with the protocol; and, of course, “a range of estimated incremental preventable fatalities”—right there, two-thirds of the way down page eleven. Many of the members of Congress scurried out of chamber, eager to get on camera or to push their inspired thoughts out on social media. Predictably, these missives were long on vitriolic criticism of the “White House rationing scheme”‡ and short on alternative suggestions. The Acting Secretary patiently answered questions from the members of Congress and staff who remained behind, but it soon became apparent that most of the questions were not really questions (“Isn’t it true that . . .”). Nor were most of the Acting Secretary’s answers really answers. He showed remarkable discipline, repeatedly referring questioners to “the briefing document you have received” and answering even the most asinine suggestions with, “We will take that under advisement.”

  The Communications Director had forbidden most of us from speaking to the media: “I don’t even want you to say, ‘No comment.’ That’s too much talking. Just shake your head no. Your lips should not be moving!” For those who would be speaking in public, beginning obviously with the Acting Secretary, he was equally emphatic: “Do not, under any circumstances, say anything specific about who gets Dormigen and who does not. It’s in the briefing document. Refer to the briefing document. If someone asks, ‘My grandfather is a hundred and nine and has emphysema. If he were hit by a bus, would he be eligible for Dormigen?’ you say, ‘The specifics of the plan are in the briefing document.’ Is that clear? I don’t want to see anyone on camera saying anything remotely newsworthy about who gets Dormigen and who does not. They’re going to have to get their sound bites about Grandpa from somewhere else.”

  The Communications Director distributed a press release in which he tried to find a kinder, gentler way to point out that most of the people who would be denied Dormigen were going to die soon anyway. He quoted an NIH epidemiologist: “The temporary shortage of Dormigen will have only a modest impact on the two-year mortality rate.” (More accurately, the Communications Director wrote that sentence and then called the NIH epidemiologist to tell him how he would be quoted in the press release.) The release offered several other euphemisms for “they were going to die anyway.” Only NPR figured this out at first, with a story that included the following exchange:

  PUBLIC HEALTH EXPERT: “I don’t mean to be insensitive, but most of these people are very old or very ill, so their life expectancy is limited, even if they were to receive Dormigen.”

  MORNING EDITION HOST: “So you’re saying they were going to die soon anyway.”

  PUBLIC HEALTH EXPERT: “Obviously each one of these cases is difficult—we are denying a lifesaving drug, after all—but yes, that is the essence of what would happen if we were forced to ration the Dormigen as the administration has described.”

  MORNING EDITION HOST: “And do you agree with that plan?”

  PUBLIC HEALTH EXPERT: “Obviously as a physician I am very uncomfortable denying lifesaving drugs to anyone—”

  MORNING EDITION HOST: “Yes, of course, but do you see a better option here?”

  PUBLIC HEALTH EXPERT (after an uncomfortably long pause for radio): “Given the horrible circumstances, I would be hard-pressed to come up with a better option. Obviously, I hope we don’t get to that point.”

  Our efforts to calm the public kept running smack into the reality of what was happening in the Seattle intensive care unit. Cecelia Dodds was taken off the experimental German medicine because it was harming her kidneys. Doctors put her in an induced coma in a last-ditch effort to help her body fight off the infection. As the Acting Secretary was answering questions in the Capitol, Cecelia Dodds’s daughter gave a short briefing in front of the hospital. “I spoke to my mother this morning,” she began. “There was about half an hour when she was lucid and comfortable and we were able to talk.” Her twin daughters—Cecelia Dodds’s granddaughters—were clinging to her legs, one on each side. “My mother is a strong woman and I have every hope she will pull through. She asked me to thank all of you for your love and support. And she asked me to convey to you . . .” The daughter paused to compose herself. Her children gripped her legs more tightly. They no longer had the care-free jauntiness of little girls; they either intuited the seriousness of the situation, or someone had explained it to them.

  Cecelia Dodds’s daughter continued, “My mother asked me to convey to you, to the nation, that whatever lies ahead in the coming days . . . that each of us should aspire to be as brave and magnanimous and selfless as we can—as she has been. Let’s aspire to be the best of America . . .” Her voice choked up and she paused. After a moment: “Love, share, include, and improve. Thank you so much.” This was not exactly the nightmare scenario that the Acting Secretary had feared—that Cecelia Dodds would die while he was explaining to Congress that things would not be so bad, but it was close. As the President began to speak from Air Force One, many media outlets ran a split screen: the President on one side and the large crowd gathered in front of the Seattle hospital on the other.

  The Communications Director had drafted a speech for the President that was long on language putting the Outbreak in historical perspective and short on Dormigen rationing details. The President urged the nation to face the challenge with the same vigor and bravery with which Americans had faced other adversities—and so on, and so forth. He reminded the country that his administration was still working around the clock to “beat this virus” (true) and, if that were not successful, to procure additional Dormigen stocks (also true). The President looked tired and drawn, almost grim, as he delivered the eight-minute talk. Anyone watching his speech would assume the Outbreak had taken a heavy toll on him. While this was undoubtedly true, the more immediate explanation (we now know) was that he had just spent two hours speaking to his national security staff, most of whom were sequestered in the situation room back at the White House, to devise a response to the hostage situation in Saudi Arabia. Any kidnapping situation is difficult, but this one—in which parents were being told by the terrorists to swap places with their children—was particularly fraught with ethical and strategic challenges.§

  Near the end of the President’s talk, the Strategist and the Secretary of State had inserted a paragraph (drafted as they stalled before returning the call from the Indian Prime Minister’s office): “The people of the United States are deeply thankful for the contributions of Dormigen that have poured in from around the world. But for that generosity, this crisis would be far more devastating. We have been taught, yet once again, the role the world’s great democracies must play in fighting our collective global challenges.” This was more bait for the Indian Prime Minister—a big, bloody decapitated tuna being towed slowly behind the boat.

  India, of course, is the world’s largest democracy. That paragraph had been drafted explicitly to suggest that by shirking its Dormigen duty now, India was putting its claim to global leadership at risk in the future. “Too subtle?” the Strategist had asked as the two of them polished the prose.

  “Just right,” the Secretary of State assured him. “Even a hint that India is not one of the ‘world’s great democracies’ will send him into hysterics.” We have no account of what was happening on the India end of this. We do know there was a second phone call from the Prime Minister’s office to the U.S. Embassy (where the U.S. Ambassador was still waiting to return the first call, like a teenage girl playing hard to get). A senior American diplomat fielded this call, and a meeting was fixed at a California Pizza Kitchen in a large mall on the outskirts of Delhi. “This better be important,” the American diplomat warned his Indian counterpart. “Because we’ve got a lot going on right now.”

  74.

  I WATCHED THE PRESIDENT’S SPEECH ON MY LAPTOP AT THE NIH headquarters, along with Giscard and the rest of our impromptu team. After a flurry of activity, our work was temporarily stalled while the biochemists at the C
DC examined the protein structure of the dormant and virulent forms of Capellaviridae. As we waited for those results, we confronted yet another theoretical conundrum: Suppose the dust mite did somehow deliver an antibody for Capellaviridae to its human host—then why was this effect not permanent? Antibodies typically last a long time, if not a lifetime, which is why a childhood immunization (or bout of the disease) is usually sufficient to provide immunity well into adulthood. This is where our dust mite theory collided with biological reality. We hypothesized that Capellaviridae—all lurking viruses, for that matter—bestowed some evolutionary advantage on the vectors that spread them, the North American dust mite in this case. Humans do not like having dust mites around; their bites are itchy and annoying. But Capellaviridae turns the North American dust mite into a lifesaver, literally. The dust mite somehow renders Capellaviridae impotent, making it nice to have around, all things considered.

  Yes, we had some crucial details to figure out, but the theory was at least consistent with evolution—elegantly so. The three species were poised in a symbiotic relationship. Humans are more apt to thrive when the North American dust mite is present. The dust mite is more successful as a species because of the existence of Capellaviridae. And Capellaviridae thrives (in its benign form) when humans and dust mites live in proximity to one another. This is how nature is supposed to work.

  So far, so good. But we were still missing the last twenty points on that Huke final exam. The only protection against viruses we were aware of consisted of antibodies, and antibodies are long-lasting—rendering the dust mite no longer relevant. “At that point, our theory consumes itself,” Giscard said dramatically as he tried to explain our theoretical conundrum to the NIH Director.

  “I have no idea what you are talking about,” she said impatiently.

  One of the biochemists followed up with less dramatic flair. “We’ve reached a contradiction,” he said. “Our hypothesis is that the North American dust mite makes itself valuable to humans by providing protection against Capellaviridae.”