Imagine the Worst, or We're at Our Own Peril: Osterholm

; Michael T. Osterholm, PhD, MPH


May 14, 2021

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol with Medscape, and I'm really delighted today to welcome Dr Michael Osterholm, who is a friend and colleague and is one of the leading lights in the pandemic. Michael, welcome.

Michael Osterholm, PhD, MPH: Thank you very much. Eric, it's great to be with you.

Topol: It's really been a great privilege to get to know you over the past year or more since the pandemic started, and to also learn about your background in Iowa and setting up shop in Minnesota. Can you tell us what brought you to the University of Minnesota and ultimately to develop the Center for Infectious Disease Research and Policy (CIDRAP)?

Osterholm: Thank you for your kind introduction. I must add that you have been a source of incredible information and intelligence on this pandemic throughout the duration. At CIDRAP, your name is golden in the sense of the information and perspective you provide — it's an incredible public service.

I have been on a journey, for lack of a better way to describe it, that I actually envisioned to some degree as a young boy. I was born and raised in a small Iowa farm town, and the owners of the newspaper where my father worked were quite remarkable individuals in kind of a renaissance way, despite living in a small farm town. One of the editors of the paper actually subscribed to The New Yorker — one of very few people in all of northeast Iowa back in the 1960s to do so. I found that the stories of the Annals of Medicine, the Berton Roueché columns, just really intrigued me. I had an opportunity to read one, and after that, every time that an issue of The New Yorker with an Annals of Medicine article in it arrived, she would call me and I would run the six blocks from my home to her house to pick up the Annals piece. I couldn't wait to read it.

This went on since I was in junior high. It was something that just intrigued me. I love the "medical detective" kind of environment; that's what these articles were. Many of them were recounts of what the CDC had done in terms of outbreak investigations. If you haven't read Berton Roueché's work, I would urge you to do so.

I had the good fortune later in my career (knowing that I wanted to do this) to attend Luther College in Decorah, where I found out unexpectedly that I had a double major in biology and political science. I didn't know that I'd taken enough courses in political science to be a major until almost before graduation.

But it was then that I realized that the issue of biology was as much about political science as it was about science itself. In fact, policy, if not well informed by science, is often bad policy, and science that doesn't inform policy is often wasted and left on the cutting room floor. So my whole career has been oriented toward that combination.

As a senior in college, I decided to go to the University of Minnesota for graduate work. Remember, in 1975, when I graduated, infectious diseases were on their way out; they were done — horse-and-buggy material. I was fortunate to have a mentor there who still understood the importance of infectious diseases.

But the biggest break of my career was who I roomed with, which turned out to be someone who was doing an internship at the Minnesota Department of Health. They were in the middle of a large encephalitis outbreak in northwestern Minnesota, and they needed more help, so I volunteered as a graduate student to do an internship. I started working at the State Health Department in 1975 when there were just several bachelor's-level individuals working there. When I left to come to the university, we had a team of over 70 people — a third of them doctorate level — and we built it into an academic-based health department.

So I've been continuously at the University of Minnesota since 1975 and was at the State Health Department for almost 25 years. I started CIDRAP because I understood the need for a national and international location for the merging of science and policy. I've always assumed that they were like chocolate and peanut butter — they deserve to go together. That's what CIDRAP is all about today.

Preparing for Pandemics From Both Sides of the Aisle

Topol: The roots of your early training in both biology and political science are extraordinary. You have helped multiple administrations, both Republican and Democrat, in guiding the management of infectious diseases, most recently on the Biden COVID-19 advisory board. You have worked with Tommy Thompson and Mike Leavitt. You've been on both sides of the aisle, so you would be well qualified to speak about the admixture of politics and science and what you've seen, particularly in recent times.

Osterholm: I can say with absolute certainty that I've never experienced a time like the past several years, in terms of mixing science and policy. At the State Health Department, I served two Republican governors, two Democratic governors, and one independent governor as a state epidemiologist. I enjoyed incredible relationships with every one of them. They were all very supportive of our public health work. And I've counted them not only as governors of my state who I worked for, but also as dear friends.

Topol: Does that include Jesse Ventura?

Osterholm: It does include Jesse Ventura. In fact, some of my most interesting days were with Governor Ventura. I had been serving as an adviser to His Majesty King Hussein of Jordan on issues around bioterrorism before Jesse was elected, and for reasons that are very interesting, Jesse and His Majesty became friends. King Hussein thought Jesse was a character right out of the wild, wild west and was very fond of him. I would meet with King Hussein from time to time on issues around bioterrorism. Most recently, just several weeks before he died, I was with him at Ascot, outside of London. I always had a message to carry from Jesse to His Majesty, and one from His Majesty back to Jesse. It was a wonderful experience, and to this day I count that as one of my more unusual challenges.

I've also served roles in the past five presidential administrations. Most recently, before the Biden-Harris advisory board, I was a science envoy for the State Department during the Trump years and traveled around the world representing the US government in planning for pandemics, ironically. My roles have always been based on being a member of this public health army. Our job is to provide support to whoever is in office and give them the best and most unvarnished information possible.

You mentioned Secretary Tommy Thompson, a period of time that was a great tragedy in this country — 9/11. I had written a book that was published on September 11, 2000, called Living Terrors: What America Needs to Know to Survive the Coming Bioterrorist Catastrophe. It was about preparing for bioterrorism. When the 9/11 event occurred, I was surprised that everybody knew about the book because I thought that I had bought 11 of the 12 copies sold that year. It became a New York Times bestseller after 9/11.

Tommy Thompson asked me to come and work at HHS, so I split my time between the University of Minnesota and HHS as a special assistant to him. When I started, I said that I would be respectful and didn't want to cause any problems, but I had to speak the science. And never once during that entire time did I feel any pressure to speak a party line vs giving good scientific advice. I had the good fortune of working closely with D.A. Henderson, Phil Russell — giants in the business who are no longer with us — and Stewart Simonson, who was one of the most important and effective government workers I've ever worked with. It was an experience, but I've had that with every one of the administrations I've worked with. I remain close to a number of people in this administration and appreciate the opportunity to work with them.

Topol: Your book in 2000 was prescient. More recently, you wrote a book in 2017, Deadliest Enemy: Our War Against Killer Germs. Are you usually a year or two ahead of the rest of the world?

Osterholm: If you really think about it, we shouldn't be getting all that much credit. It was inevitable in a way. It's like predicting blizzards in Minnesota. I can do that in July and usually be right in January.

The challenge we have today is how to take that kind of information and actualize it into real planning. Chapter 13 of my book is on coronaviruses; the title is "SARS and MERS: Harbingers of Things to Come." In two of the chapters, I lay out what a pandemic scenario would look like in regard to influenza. It was about how the world would respond, what would happen to supply chains, governments, people, media, and what would happen to our everyday lives. All it took was a little creative imagination to tell these stories. It wasn't brilliant or smart. It was just basically anticipating the future. And I hope, if nothing else, this pandemic has taught us that we are at our own peril if we don't consider these kinds of creative imagination situations.

We had another wake-up call this past week when an oil pipeline from the southern part of the United States to the Northeast was disrupted by cyberterrorists. You know how easy it is today to break into infrastructure systems and to do just that. This is what we have to plan and prepare for in the future. Infectious diseases and pandemics are on the table. The one we are experiencing now doesn't take them off the table, but it surely illustrates the challenges we have going forward if we don't start planning and preparing for things like this right now.

Osterholm's Rules for Science and the Media

Topol: The link between bioterrorism and cyberterrorism is really important. These days, I see you on Meet the Press on MSNBC, with Brian Williams, Lawrence O'Donnell, or Anderson Cooper on CNN. Tell us what it's like to be representing the biomedical community on these TV shows and how you get put on the spot. You are supposed to guide us, provide predictions, and give us the status report.

Osterholm: The most important thing when you do any kind of public information service is to know your information. The way to do that is to have colleagues and respected friends around you. You know how many times I've contacted you, asking, "What does this mean? What do you think? What does this suggest might happen in the future?" Anybody who goes into public relations related to a pandemic without having a team of really smart people around them has a challenge. Be informed.

The second thing is always tell the truth. If you don't know, say it. Say why you don't know and what you're going to do to try to find out. Far too many people who get into media situations, particularly live television, feel pressured to have an answer, and in many cases, it's the right answer. But it also may be a wrong answer. And that leaves a permanent footprint on video. People will come back to you and say, "See what you said?" That's a challenge.

The third thing is to be out there pushing the envelope, but at the same time, it has to be based on good data. You aren't always going to be right. Last October when I was on Meet the Press, Chuck Todd asked me: "Now that Florida has completely opened up again, will we see more activity there, or will it be fine because, as they say, they have herd immunity?" And I said, "They're going to light up again." And then October came and went — nothing. November came and went — nothing. The first 2 weeks of December came and went, and nothing happened. And, of course, many people reminded me, "Oh, boy, were you wrong!" Then look what happened in January. A third of the ICUs in Florida were filled. I can't explain to you why it took from October, when they opened up completely, until January to light up.

The same thing is true with the B.1.1.7 variant from the UK. We were very concerned, based on what we saw in Europe, that this was going to sweep into the United States because we were opening up rather than closing down, and with our low level of vaccination. In January, we were still debating whether it was likely that the administration could deliver 100 million doses in 100 days. We ended up delivering 220 million doses in 100 days, which was incredibly important. But at the same time, at least 12 states today have vaccination levels that aren't much higher than they were when Michigan took off.

Anybody who's been in this business for any amount of time can tell you that they are not aware of any respiratory pathogen that lit a single state on fire, causing the kind of damage that happened in Michigan, yet the adjoining states (eg, Indiana) saw very little activity, even though they had relatively low levels of vaccination. Minnesota was the closest in terms of what happened with that spring surge. If you had predicted that B.1.1.7 was going to take off in this country, you were wrong. But would I say we would be in error for trying to get people into the mindset that B.1.1.7 could be as big a challenge here as it was in Europe? I'd do the same thing again.

The More We Learn, the Less We Understand

Topol: What you are getting at here is really important. The UK variant poses an incredible threat. As you said, we could be in the eye of the hurricane. We saw that in the UK, Ireland, Portugal, Israel, Jordan, and many other countries, not just in Europe and the Middle East. At that time, vaccinations had not taken off and, in fact, you put together a report at CIDRAP that suggested that if we were to be really aggressive with vaccinations, we should give as many first doses as possible to get that protection started. And that fell on deaf ears. Can you describe what constituted the basis for the report and then, unfortunately, the fact that it did not get any traction?

Osterholm: In retrospect, the administration far surpassed the delivery potential for a vaccine. I give them, and the manufacturers, great credit. Delivering on 220 million doses was very important in taking up that slack. Our concern in January was that we had a largely unvaccinated population in this country. We weren't sure how much vaccine was coming when we saw what the B.1.1.7 variant was doing in Europe and, even with lockdowns, what was happening in the United Kingdom. I mean, at one point in January, if the United States had the same rate of infections as England, we would have seen 195,000 hospitalizations a day. We had 130,000 hospitalizations a day in January, and we saw what that did to much of our country.

Imagine if there had been 195,000 hospitalizations a day here. We had no choice but to prepare for that type of event. The report that we put out said that the British response has been quite remarkable in that they are getting one dose out. They are getting quite good protection, but they're getting twice as many people protected. We saw the same thing initially in Israel. Nobody wanted to dismiss the second dose. We were all very supportive of getting a second dose. But if you had limited vaccine, we should get as many people vaccinated, particularly those over age 65, with even a single dose.

Imagine that you're sitting across the table from your elderly parents who have underlying health problems. You have two doses of vaccine, one in each hand. And you look at them and say, "I can give one dose to each of you, I can give two doses to you, or I can give two doses to you. What would you like me to do?" It's that commonsense issue of just saying, Do you want to have a better chance of surviving a severe illness, hospitalization, or death? Or do you want to see half the number of people vaccinated and many more people become seriously ill and die?

The good news was that B.1.1.7 did not take off, which is something we're going to be studying for many years to come — why that didn't happen or why it still may happen in some states, looking at what is happening in the Seychelles right now. Ultimately, we are going to have to ask ourselves what we are going to do in the future to scale up. How quickly can we scale vaccine? Getting so many people vaccinated in the United States surely, I believe, has taken the potential for a national surge like India's off the table, but it has not taken off the table what could still be substantial activity in any given state or region. We'll have to try to understand one day why we didn't see more regional activity or, for that matter, even more national activity after B.1.1.7 emerged.

Topol: I'd like to get your thoughts on why Michigan lit up and went through a horrible surge, whereas similar rates of B.1.1.7 arrived in Florida around the same time and they never really had a significant bounce. It was similar in Texas and other highly populated southern states. What are your thoughts about the explanation for that kind of dichotomy?

Osterholm: The more I learn about pandemics, the less I understand them. That's a point of honesty that would serve many of us well. We need a real dose of humility. I can't explain to you what happened in 2009 with the appearance of H1N1 (an influenza pandemic, not a coronavirus pandemic). But as you may recall, we saw early activity in March in Mexico, spreading around the world literally within a month. And in the United States we saw a peak of cases occurring into mid-April, and then that number came down quite precipitously. Through much of the summer we had activity, but it was limited. And then we saw it take off again in mid-August here, particularly in the southern states, with 100-degree weather. It took off. And then we saw the big peak of cases that occurred right through the end of September and then dropped off again precipitously. Vaccine didn't arrive in any meaningful way until October as the number of cases was dropping. Why did that influenza virus go up? What brought it down? There were no mitigation activities in place. Nobody was masking, nobody was distancing.

The second thing is, why did we see all influenza virus activity in the Northern and Southern Hemispheres virtually stop circulating except for H1N1? Why did we see such a precipitous drop in things like respiratory syncytial virus? It wasn't because people were mitigating with the purpose of protecting themselves from flu. We don't know why. How can a pathogen that didn't infect everybody at once (10%-20% at most) have such population-based impact on other pathogens? We're seeing the same thing with this coronavirus, if you look at influenza virus circulation in each of the hemispheres and what's happened this past winter in North America, in particular, with things like respiratory syncytial virus (which virtually disappeared). What's going on there? We don't know. Why did we see 70,000 cases a day of COVID-19 in the United States in July, largely from lighting up the southern Sun Belt states, have it go quiet, and then see those very same areas light up again in January? What caused that? We're going to have a lot of study on our hands for years to come to better understand this.

Topol: I couldn't agree more with you there. And you know, the way that B.1.1.7 affected European countries heterogeneously, despite essentially all being in lockdown — it really hit some exceptionally hard and others were relatively spared. These are some unexplained phenomena.

A Potential Pan-Coronavirus Vaccine

Topol: One thing that has come up recently has been the idea of a pan-coronavirus vaccine, a betacoronavirus family vaccine that would knock them all out and basically protect us from future pandemics — no less this idea of a variant-by-variant approach, which is kind of a bivalent, put in the South African spike protein, mRNA, or whatever. Can you comment on that? Because we now not only have the idea, but we have CEPI funding it. Today there was a paper from the Fred Hutchinson Cancer Research Center and the University of Washington showing that there are these shared cryptic epitopes. And just the other day from Duke, there was the first evidence of a pan-coronavirus virus vaccine against all SARS-CoV-1, bat CoVs, and multiple variants. It looks like things are warming up. Do we need that? And should we put the accelerator on the gas to get there?

Osterholm: I'm going to make an editorial comment here, whether I'm permitted to or not. But I want the audience to remember what just happened here. You want to know why I talk to Eric as often as I do? There is an incredible opportunity to learn so much just in his questions because he stays so current. So thank you for that.

First of all, the issue of vaccines and what they can do in terms of life- and economy-saving measures has not really been appreciated until this pandemic. We have talked about this for decades related to influenza, largely using post–World War II technology to make flu vaccines for so many years with a very limited manufacturing capacity. And as I just pointed out, in 2009, just like in 1968 and in 1957 when vaccine technologies were available, in every instance, pandemics of influenza went largely unchallenged from vaccine because it took so long to get vaccines out there in any meaningful way.

At CIDRAP we have been heading up an international effort with support from the Wellcome Trust, the WHO, and a number of different partners, including the Gates Foundation, to look at and develop a comprehensive roadmap for influenza vaccines that would be more of a universal or game-changing flu vaccine that would deal with both seasonal and pandemic influenza, and also address the issue of the timeliness of the availability of these vaccines for a pandemic.

Wouldn't it be great if you had a vaccine that protected all the time against seasonal flu, but also it kicked in when the next pandemic strain emerged? You didn't have to just try to play catch-up and vaccinate the world; you were vaccinating them already. We are publishing our roadmap in the next month; it has just recently been out for review and had over 120 comments from organizations around the world.

It serves as a model for the coronaviruses. We now realize the importance of these viruses and what they might do — and God knows what the next coronavirus might be that might emerge. We no longer can count on it being a SARS- or MERS-like model where, when it emerges, it can sure do damage, but because one is not highly infectious till day four or five of illness, as a public health activity, we can get in quickly, identify these contacts, isolate them, and shut down transmission as we did with SARS and largely with MERS, even though we haven't eliminated the MERS reservoir of the camel. SARS-CoV-2 is a very different model for coronaviruses. We may not have time with the next one to scale up, so what are you going to do beforehand?

This is a very important topic area. And having talked to many economists, including Nobel Prize–winning laureates, they have all said that if it takes us billions of dollars to make and deliver these vaccines, they're worth every penny because they will save lives and trillions of dollars. So I'm hopeful that we've now gotten beyond the point of this being academic — pointy heads getting together, saying, oh, we should have this or that vaccine. The healthcare community and all those who might support these vaccines and their research and development are in place now. It's our job to capitalize on that and do whatever we can to move big-picture vaccines forward, and not just take it one antigen at a time.

A Modern Manhattan Project

Topol: Speaking of big picture, I want to get your perspective. We had the sequence of the virus in January last year. And by November, we already had completed multiple large-scale studies — some of the largest trials ever done in medicine — showing validation of the vaccines' high efficacy and safety, and then, of course, rolling them out in December in multiple countries around the world. Have you ever seen anything like this in your career spanning many decades?

Osterholm: None of us have. And more importantly, none of us probably actually believed it would happen. Remember, in July and August, we were all saying, boy, if we can get a vaccine that's 50% effective among the population against the coronaviruses, because of the challenges, we're going to be really lucky. The mRNA vaccine technology, and how it was brought forward, was nothing short of a modern public health Manhattan Project success. Now what we need, however, is a second Manhattan Project with a Marshall Plan attached to it. The second Manhattan Project is, how are we going to manufacture enough vaccine for the world? Because this is no longer just about humanitarian aid. That is critical and should be front and center. But this is about protecting the integrity of our current vaccines, as you have so very thoughtfully taught us over recent weeks. It's still unclear what these variants are doing to vaccine protection. I don't think it's nearly as bad as some might think it is, but what's the next variant to come down the pike? We need to stop transmission globally — not just for humanitarian reasons, but to protect the integrity and the functionality of these current vaccines. So that's our next project on top of the one we just finished.

Topol: We sure need that. We're all in this together and we've got you pushing 8 billion people to get on the same page to be protected so we can get this thing squashed. In closing, Mike, I want to say that what you've done in your career at CIDRAP is just so formidable and impressive, being able to work with both parties in multiple administrations, no less, and with other countries. So, thanks for all your efforts. Thanks for representing the medical community on multiple occasions and trying to help provide guidance when it's tough. This is not an easy feat at all. We'll continue to follow you on your CIDRAP podcast and all the things you do to lead the way. I know everyone listening to the Medicine and the Machine podcast will enjoy getting to know you a bit more. Thank you.

Osterholm: Thank you very much, and thanks for your leadership and for mentoring me. I take responsibility for the mistakes I make. But I have to tell you, sometimes when I get it right, I'm just one word away from having said what you just said.

Topol: You're kind. I really appreciate it. Thank you.

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