Book Review: 'Hot Spot: A Doctor's Diary From the Pandemic' by Alex Jahangir

On September 15, 2022 — nearly 30 months after President Trump’s federal task force’s declaration of "15 Days to Slow the Spread"— a who’s-who of Nashville politicos gathered downtown at the Nashville Public Library. The occasion? A launch party for Hot Spot: A Doctor’s Diary From the Pandemic, the much-anticipated memoir by the chair of Metro Nashville’s COVID-19 Task Force, Dr. Alex Jahangir. Highlighted extensively in local outlets and praised effusively by everyone from Alex Maraniss to Bill Frist, Hot Spot is a painstaking account of the COVID Czar’s efforts to steer the city through “uncharted waters.”

The event, much like the book, seemed intended as a victory lap for Nashville leadership,  with Mayor John Cooper and Director of Schools Dr. Adrienne Battle alongside Jahangir on the panel. To a crowd that mostly consisted of upper-middle-class, politically-connected, left-leaning folks, this made sense — it was a crowd that endured few of the hardships felt by the city at large, and with ostensibly no interest in examining whether the response to COVID (in Nashville or elsewhere) was proportionate to the threat posed by the disease, let alone whether the course we charted in 2020 even accomplished anything.

In the book — formatted as a “pandemic diary” of sorts, with a smattering of entries attached to specific dates and associated events — Jahangir often brushes up against the costs and second-order effects of the city’s pandemic response while largely avoiding any reflection that might be seen as remorse or apology. Here are several examples which best illustrate his failure (or, more likely, refusal) to connect the dots.

“It was a lockdown, pure and simple” (34).

In an entry dated March 22, 2020, Jahangir recalls pulling over on 12th Avenue South on his way to the Office of Emergency Management to announce the city’s Safer at Home Order, overcome with the emotion of it all:

The shops were closed, fear was palpable, and I knew that in one hour the Metro Coronavirus Task Force would announce an order that would force all of Nashville into more of the same. Though we would call it the Safer at Home Order, it was a lockdown, pure and simple. We had decided to put it in place for at least two weeks, but I had no idea how long it would eventually stay in effect. I did know it would hurt the economy and scare families. Based on my own experiences at the Trauma Center, I was also fearful it would lead to serious mental health issues, including suicides.

Absent from Jahangir’s account is any indication that his concerns were discussed with the broader task force before adopting the plan–or afterwards when determining how long to maintain strict public health orders. Despite overwhelming evidence that these considerations were well-founded, they are not mentioned or discussed again in the book’s 200+ pages. A World Health Organization report “observed a decline in mental well-being since summer 2020, measured using the WHO-5 mental well-being scale (0–100), especially among those who had lost their job,” and noted that “a review of 23 multi-wave studies similarly found that mental health problems increased during lockdown then decreased slightly after lockdown.” Another meta-analysis of 18 studies found an alarming connection between lockdowns and domestic abuse. This manifested locally in Nashville to the tune of a 25% increase in overdose deaths from pre-pandemic baselines, mostly at ages for which very few COVID deaths were recorded (Nashville Health reports just 38 deaths under the age of 35, as compared to more than 200 overdose deaths at these ages in 2021 alone).

Absent, too, is any evidence that implementation of the city’s “Safer at Homer” order actually accomplished anything in terms of COVID-19 disease burden or mortality. No comparison is made to neighboring counties or regions which did not enact similar orders. Given the volume of evidence suggesting that these measures did little to nothing to curb the pandemic, one would think that a discussion of efficacy would be a prerequisite for the prideful descriptions of the task force’s leadership that followed.

“One of the biggest national COVID stories … was that minority populations were getting hit far harder with the disease than White populations” (38).

Throughout the panel discussion at the book launch—not to mention in the book itself—equity is a major focus. Jahangir is right to point out that many causes of mortality and morbidity disproportionately impact minorities due to a combination of socioeconomic factors, access to care, and historical injustices. He does not, however, examine with any real interest how the task force’s decisions during the pandemic impacted these inequities.

Consider his reflection on racial disparities just pages later, for example:

Members of these communities tended to fall into the category of “essential workers,” a nice way of describing low-wage earners we take for granted but can’t do without. Their jobs do not allow them to stay home and often afford them no benefits (53).

Jahangir fails to reach what would appear to be a fairly straightforward conclusion: the city’s “Safer at Home” order did nothing to protect these people. In fact, it pushed the burden of the disease onto them and away from more affluent segments of the population who were better equipped to hunker down at home with virtual work until the arrival of vaccines and therapeutics. Jahangir, like many politicians, seems content to pay lip service to equity without examining its root causes— particularly those causes in which he may have had a hand.

“I wasn’t involved in the school decision, per se” (Nashville Scene interview, September 8, 2022).

While Jahangir has largely avoided discussing specific policies or public health measures during his book tour, he has taken the opportunity to distance himself publicly from his role in the decisions of Metro Nashville Public Schools. Criticism directed his way regarding school decisions is “misinformed”, he says, since he “wasn’t involved in the school decision, per se”—a point he echoes in the book (“I did not control the reopening of MNPS”).

Per se is doing a lot of work here. Jahangir had been actively helping schools director Battle as early as June 2020: in fact, his signature is affixed to the school district’s original “Nashville Plan: Framework for a Safe, Efficient, and Equitable Return to School”. The plan called for alignment between the city’s “roadmap” phases for lifting restrictions on businesses and gatherings and the school district’s operation mode; not ideal, but at least logically consistent.

In the district’s June report, co-signed by Jahangir, there are 10 references to studies from Europe, the CDC, and elsewhere, which “suggest that serious COVID-19 illness in children is rare” and found “very low rates of transmission from a child to more senior members of the family.” Yet by August, Jahangir began casting the reopening debate along socioeconomic, racial, and political lines, emblematic of the broader national discourse surrounding schools. That change in discourse came after a tumultuous summer in which the American Academy of Pediatrics issued guidance urging school districts to reopen their doors before turning an abrupt about-face brought about by President Trump’s foray into the debate.

Given the political persuasions of the local bureaucracy, Metro Nashville Public Schools remained closed until October, when a brief glimmer of hope shined through in the form of the district’s youngest students being invited back to class. Having two months to observe that in-person learning had not invited disaster in neighboring school districts, and having heard the many evidence-based pleas (including my own) to reopen Nashville public schools, Jahangir had an opportunity in his capacity as task force chair and district health adviser to correct course, to advise Dr. Battle and the school board that in-person learning was essential for students.

Instead, he provided them all the cover they needed to entrench.

Just two days after welcoming its youngest students to the classroom, Metro Nashville’s school board called a special session, to be held on a Friday afternoon, with less than 24 hours' notice and without public comment. In attendance was Dr. Jahangir, whose provided testimony to the board would result in the district indefinitely postponing the return of grades 5–12 to school. These students ultimately would not see the inside of a classroom until almost a year after the doors were shuttered in March 2020.

Jahangir is technically correct: he didn’t make the decision to keep Metro Nashville Public Schools closed, “per se.” He did, however, advise that body’s board and director at every turn for nearly a year as a public health official whose voice carried substantial weight. Along the way, he shielded from criticism a schools director and board hellbent on enforcing COVID orthodoxy at the expense of the one populace MNPS exists to support: children.

The above might seem to be intensely uncharitable to Alex Jahangir. Certainly, his willingness to volunteer his time in a position for which no one in the city of Nashville could have possibly been prepared is laudable. He also gets some things right in the book, including his criticism of Tennessee Governor Bill Lee’s unwillingness to staff “alternate care sites,” which were built out in summer 2020 but never activated during the height of the state’s COVID wave the following winter.

I believe Jahangir is a well-intentioned man who cares deeply about his community. I believe that the harsh, personal criticisms of him such as the cries that he “hates” children, are unfounded and over the top.

But I also believe Alex Jahangir, like many others in similar positions of leadership and crisis management in 2020, quickly lost sight of public health as a holistic, all-encompassing objective meant to serve all members of a deeply interconnected society, instead focusing narrowly on COVID-19 case counts and mitigation efforts.

If his book is any indication of the true thoughts and feelings of the author, he does not shoulder the weight of any regrets. Nor does he have anything meaningful to say on the topic of what he may have gotten wrong, and what we as a society might want to approach differently in the next emergency. This is not because he lacks empathy; rather, it is because he’s actively avoided reflection on the matter. Hot Spot is a carefully polished effort to preserve the historical record as Jahangir wishes it to appear, rather than as it actually was: a mess of convoluted, intrusive orders which appealed to science without invoking its tenets, accomplished little, and created a host of negative side effects. For that, its readers are strongly encouraged to seek a second opinion.