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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Podicy. I'm your host, Rob Lott. It's time for another very special episode of A Health Podicy where we look beyond the pages of Health Affairs Journal to speak with the luminaries of our community and take the pulse of the state of health policy in America today. Now in homage to our guest, doctor Michael Osterholm and his new book, we might also call this episode The Big one, which is the title of his newly published examination of public health in America right now, where he and his coauthor assess our government's performance during COVID-nineteen and ask some hard questions about our preparedness for the next big pandemic. But this episode isn't just about the new book.
Rob Lott:From June 2018 through May 2019, he served as a science envoy for health security on behalf of the US State Department. He's advised countless city, state and federal health officials, and he's also formerly served over many years as a boots on the ground style epidemiologist for the Minnesota Department of Health. I can't wait to hear his perspective on the challenges facing public health today and maybe even some potential solutions as well. Doctor. Michael Osterholm, welcome to A Health Podicy.
Michael Osterholm:Thank you. It's my honor to be with you.
Rob Lott:So one of CIDRAP's current efforts is the Vaccine Integrity Project. And I was thinking we could start maybe by having you tell us a little bit about that project, when it was formed, and why it was formed.
Michael Osterholm:Well, first of all, maybe I could just give you a little bit of background because it kind of sets the foundation for why we're doing what we're doing right now at CIDRAP. I've now been in public health fifty years. I spent half that time at the state health department in Minnesota as well as at the university and then another twenty five years at the university. And as you noted, I've been involved with a lot of issues of global importance. I've had a role in every presidential administration dating back to Ronald Reagan when I worked actually on the HIVAIDS Commission.
Michael Osterholm:You had pointed out my work previously with Trump won and, of course, having served on the Biden Harris transition team. And I tell you this because it's important to understand, I've always just been a private in the public health army. My job is to do my job and is to support whoever is our leader. And from that perspective, I'm not a partisan appointee in any way, shape, or form. And my comments today will reflect that.
Michael Osterholm:My job is just to call balls and strikes and to do the best job I can in doing that and the people I work with. Clearly vaccines have been a critical tool in our public health response of the last century. They saved millions and millions of lives around the world. Most people forgot, for example, that just in the first half of the twentieth century, almost three hundred million people died of smallpox. That was last century.
Michael Osterholm:And today, it's eradicated from the face of the earth. And the importance of vaccines cannot be overstated for all the ones we have. Well, when the election results came in in last November, I recognized right away that, in fact, it was likely that mister Kennedy was going to hold a very senior position in this new administration, if not likely to be nominated for health and human service secretary. And I that night, rather than going to bed, I stayed up most of the night reading the 2025 document and understanding if this was the platform that was likely to be used, we were in for some real challenges with vaccine.
Rob Lott:Just to clarify, you're referring to project twenty twenty five, the Heritage Foundation. Yep.
Michael Osterholm:The Heritage Foundation. Yep. Thank you. And, and, in fact, in, in mid November, I wrote an op ed piece in the New York Times with Zeke Emanuel in which I said, wake up, world. Mister Kennedy wants to take your vaccines, and it's likely he's gonna do in the advisory community immunization practice, what we call ACIP, that, expert group that advises the CDC on vaccine recommendations.
Michael Osterholm:And at the time that that piece went out, I had a lot of colleagues that thought, Oh boy, you're just scaring people needlessly. This is not going to happen. Well, as you saw, by mid to late January, it was happening. And so we recognized that we had to have some kind of response to protect the vaccine enterprise because, in fact, CDC had been such a critical expert voice on vaccines through the ages. And now that was suddenly neutralized, if not weaponized, then we really had a challenge.
Michael Osterholm:And so we formed what we call at that time the Vaccine Integrity Project. I was able to receive support from Christy Walton, her private foundation, the Alumbra Foundation, a nonpartisan effort in which we initially brought together the experts of the vaccine enterprise system all the way from research and development to people who deliver the vaccines into the arms. And we did these six focus groups and said, What are the things that are going to likely be missing that are critical to public health practice and vaccines if, in fact, we see ACIP neutralized, if we see CDC now used as a political arm, not a scientific arm? And soon that all became realized. Our focus groups provided information on eight different areas that were really important.
Michael Osterholm:One of those areas was who's going to make the determination of what the fall vaccine recommendations should be for the seasonal viral pathogen vaccines, COVID, influenza, and RSV. And in the past, ACIP had been the expert group that would spend many hundreds and hundreds of hours updating and summarizing the data on the safety, the effectiveness, the usefulness of these vaccines. And so we took that eye. And we did basically a type of detailed, what we call protocol approach, where we assessed all the information that we could to provide a body of data that would be akin to what ACIP would do. We're not an ACIP.
Michael Osterholm:We never will be. And we recognize that we were not recommendations. We were the group to bring the data to the table. So we basically provided the information that we gleaned from this effort and provided that to each of the medical societies that make recommendations, like the American Pediatrics, Infectious Society of America, that type of groups. And they did make their recommendations, and this was important that they have a database to base it on, as it all is about the payer, because in many instances, payers were tied to what did the ACIP recommend.
Michael Osterholm:And if they had no recommendation or adverse recommendations, we were in trouble. And so I'm very happy to report that the payers were able to use that kind of information that we provided to say, We will support payment for these vaccines, even though it goes against what the ACIP recommends. And we have done that, and that's where we're at now. We're also working right now on mis and disinformation. We are ripe with that throughout our communities.
Michael Osterholm:Unfortunately, much of it's coming from this administration's leadership, and we're working to take that on. And then finally, also just to help with collaboration. There are a number of groups who want to help, who want to be part of a response that's effective in protecting vaccines, but they really lack coordination or collaboration. And so what we're trying to do right now with that, too, is again, not run the show, but merely help run the show of show to help people get together and to work collectively.
Rob Lott:So you mentioned the sort of risk or the danger of misinformation and disinformation. And, you know, if we can take a step back when we think about the challenges of communicating about complex science with the general public, I think there's a sense that it's a lot easier to plant seeds of doubt than it is to convey complicated, you know, concepts in ways that give people confidence and certainty about the outcomes. And I'm wondering how you think about that imbalance of power, if you will, in that dynamic, and what, if anything, we can do to rectify it.
Michael Osterholm:Yeah. Well, you've really raised a very, very critical point, one that I think was, for many people, left behind because it's too hard to deal with. Well, we agree. I think the challenge we have is that in today's world, there isn't a group of individuals against vaccines and for vaccines. It's much more complicated than that.
Michael Osterholm:For example, if you just look at age, the difference in perception of vaccines, their effectiveness, the trust in public health to deliver truthful information varies dramatically by your age. 18 to 30 year olds have very different views of worldwide information than does, for example, grandpas and grandmas, like me. And you can't just prepare information that counters misinformation in a single way. And so one of the things we have to understand is that there isn't a there's not a single way to communicate mis- and disinformation rebuttal and to to deal with it. I think the challenge we also have is trust, and trust is something that, I think with this last pandemic response, we surely were challenged by that.
Michael Osterholm:You know, if you've been following my work, I've been preaching the word of humility for a number of years, saying, you know, we need to be humble and acknowledge what we know and what we don't know. And with what we know, show the information that supports that. If we don't know, say what we're going to do to find out, but don't sell it as if you know, because if it turns out to be different than what you told them, you'll not be believed again. And I think that's one of the issues. So your point's a very, very important one.
Michael Osterholm:And in this world of social media in particular, basically, a lie, a piece of myths or disinformation travels around the world with the speed of light, And that's a real challenge that we have.
Rob Lott:So another challenge I think that we've seen in response to the sort of confusion coming out of the federal government is a number of states teaming up to sort of offer their own vaccination guidelines. And what was once a national approach is now looking more like a quilted patchwork. And I'm curious how you're thinking about the relationship between the Vaccine Integrity Project and the work that folks are doing at the states. Is this the best we can expect at this point in time, or is there anything we can do to make sure that the state's response is as robust as possible?
Michael Osterholm:Well, first of all, we have to understand that there's real differences between the responses as they relate to the actual recommendations for vaccination versus the means to make those vaccinations happen. And so part of what you're seeing are regional efforts to assure that vaccines are available and that they can be purchased, that they, in fact, will be covered by a payer. That's different than making the recommendation of the science of the vaccine and why we're recommending it. So at this point, it's fair to say that we walked into this world of mass confusion in March and April when, in fact, we saw the kind of changes occur to the ACIP that we did. We saw Mr.
Michael Osterholm:Kennedy and some of his senior leaders making major policy decisions on a sixty second or seventy second TikTok recording. We saw this happen over and over again, where there was no science behind the statements that they made. So at that point, that's when we as a group came together to say, How can we provide the data that will allow organizations to do that? That's still a very, very important need to be standardized because, again, the payers need to have a standardized set of data to say, We'll cover that and this is why, because the science supports it. And so our efforts have really been to provide the data to those making those decisions.
Michael Osterholm:And state health officers, governor's offices are all very important in this issue. But in the end, we're hopeful that the science will draw us to a common set of recommendations. And so we're working hard, I think, help standardize that. How vaccines get paid for, how they actually get distributed is very different. And that could have a regional basis to it that is very important to understand.
Michael Osterholm:And that's different than the actual recommendation for the vaccine. And so what you're seeing right now in some of the regionalization, particularly the Northeast and the Northwest, part of what they're looking at is that very issue. What happens if the Vaccine for Children's program, which supplies over half the vaccine in this country, which is a federal program, what happens if that goes down? Which it surely could. Who buys the vaccine?
Michael Osterholm:How does that vaccine get distributed and paid for? And so I think that's what those groups are really concentrating on, which is really important, and we congratulate them for doing that. So I think, wait for another couple of months. I think you're going to see more and more of this work itself out as to what people are trying to do. And people are trying to find their own lanes of expertise and the ability to respond at this time.
Michael Osterholm:You know, this was never in the playing cards of a year ago. No one had envisioned this. No one had put together the idea that, Oh, wow, could this really happen? And so I think that's what you're working through right now. So I'm optimistic that actually we will have a much more seamless like response over the months ahead, which will take into account the differences between the science and the practice.
Michael Osterholm:And those could very well differ for the practice between areas of science. Think we're really hopeful that that will in fact start to kind of come together, and we'll come up with one set of quote unquote recommendations.
Rob Lott:Well, in just a moment, I want to talk to you about your new book. But first, let's take a quick break. And we're back. I'm here talking with doctor Michael Osterholm about his new book called The Big one, How We Must Prepare for Future Deadly Pandemics. Doctor.
Rob Lott:Osterholm wrote the book with Mark Olshanker. And part of your book, Doctor. Osterholm, assesses the failures of our government to handle COVID-nineteen. And I won't ask you to repeat your fine grained dissection of the numerous frustrations and disappointments along the way, but I did take note of sort of one of the big picture learnings that you point to, which is that a lot of the problems were structural, which of course you acknowledge are the hardest kinds of problems to solve. And I'm wondering if you could say a little more about some of the most fundamental structural challenges that we faced during COVID-nineteen.
Michael Osterholm:Well, first of all, let me start out this discussion by maybe somewhat providing a perspective of how I view it. The glass is half full here, not half empty. There were millions of lives saved because of the response that took place and the vaccines that were available, vaccines that basically defied gravity almost in terms of their ability to be produced, tested and made available. So from that perspective, I I celebrate the many successes that occurred. But what we are talking about in our book with the big one says, but there should have been lessons learned.
Michael Osterholm:And, you know, I had the good fortune after nine eleven to work for three years, part time for Secretary Tommy Thompson at Department of Health and Human Services on the bioterrorism issue. Of course, you recall, the anthrax attack occurred right after nineeleven. And I had published a book on 2000, one year to the day before nineeleven. And I think I bought 18 of the 20 copies that were sold that year, and it was entitled What America Needs to Notice Our Coming Bioterrorist Catastrophe, in which it laid out what likely could happen and what an anthrax attack could do. And so I was in this position of seeing firsthand what was happening in Washington, D.
Michael Osterholm:C. And one of the things that I came away with at the end of my time there was this incredible admiration for the efforts put forward on the nineeleven commission, you know, with two really senior politicians, one Democrat, one Republican, Lee Hamilton from Indiana, Governor Keane from New Jersey. And it was the most amazing nonpartisan, really well done review of what went wrong, why did it go wrong, and what could be done to make sure it didn't happen again. No finger pointing, just really very thoughtful and hard review. And I think that has served this country very, very well since nineeleven.
Michael Osterholm:What we didn't do with COVID is any kind of hot wash like that, any kind of review, which we needed to desperately do. And we could have learned so many lessons. And so this book really was my effort, having been at the front row of what happened with COVID, having been involved as I was nationally and internationally, to say, these are the lessons we should have learned. This is not to point fingers. This is not to just lay blame, but to say, Wow, what would we do different next time?
Michael Osterholm:And so what I tried to do with that is that and the very first structural difference that I will give as an example is just the mindset of what a pandemic like this would look like. In the earliest days of the pandemic, basically, you know, we recognized this was an airborne transmitted virus that was likely going to last potentially many, many months. On the Joe Rogan podcast on 03/20/2020, before the WHO had even declared it a pandemic, I said, I think we could see 800,000 deaths over the next eighteen months, and it could last a lot longer. And you might have well said, I thought I was saying bad things about your mother, Okay? Because people didn't want to believe that.
Michael Osterholm:Were approaching it like a hurricane. It's going to be a horrible event, but it's going to blow through in eighteen, twenty four hours, and then we can go into recovery. This was one we were going to get hit day after day after day, and there would be different waves where we would be feeling like, Oh, we finally are over it, and then it would take off again, a different variant. And so this first structural problem we had was how we were going to respond. You don't respond to a pandemic like a hurricane, okay, any more than you wouldn't respond to a hurricane like a pandemic who says, Oh, we'll come back in three or four years and see where we're at, Okay?
Michael Osterholm:And so I think that was the biggest challenge initially, was to get people to understand that. And it was not about necessarily right or wrong. It was about what's your perception of what's going to happen.
Rob Lott:After sort of reflecting on COVID-nineteen, your book also imagines a sort of nightmare scenario looking forward, and that is the possibility of another coronavirus that is perhaps as infectious as COVID-nineteen and as lethal as SARS, which folks may recall was very lethal respiratory virus. This is incredibly frightening, but as you point out, also entirely plausible. And I'm curious if you can say a little more about how you approach painting that nightmare scenario and what your goal was, beyond just scaring your readers.
Michael Osterholm:First of all, when we talk about the concept of scaring, I do not apologize for scaring people. But my job is not to scare them out of their wits, it's to scare them into their wits. And that's a big difference. Okay, what can we do to motivate them to make a difference for preparedness for the future? And actually, there was kind of a wind up to this that started actually with my previous book, Our War Against Killer Germs, which was published in 2017.
Michael Osterholm:And I devoted three whole chapters to what a pandemic in the future would look like, assuming it was likely going to be influenza. Although I had a chapter on coronaviruses, and I said in that one, SARS, MERS, a harbinger of things to come. And so I was trying to help people wake up to that it could be a coronavirus. But in that book, I laid out this time sequence and said it's going to last for many, many months. This is going to be a quick hit over with, okay?
Michael Osterholm:And that process of trying to get people to understand that was something that just was a huge challenge. People couldn't really fathom that, and so they didn't plan for it. No one did. And we didn't talk about supply chains. We didn't talk about vaccines in a way that what would we do over the course of three years?
Michael Osterholm:And so one of the issues that we were trying to do with this particular book is to lay out a reasonable scenario, and I use the word reasonable. And I think that's important. As you pointed out in your question, as we look at COVID, the death rate overall was probably less than one to one and a half percent of the population that got infected. Okay? Still a horrible, horrible number of people.
Michael Osterholm:But it wasn't like what we saw with SARS or MERS, where they killed anywhere from fifteen to twenty percent for SARS. MERS, the Middle Eastern Respiratory Syndrome, killed about thirty five percent. But with both of those, they didn't have the ability to be transmitted like COVID. They were much, much more easily to contain virus. Only a few people were super shutters or people that spread it a lot, and we could contain it.
Michael Osterholm:We now have viruses in the wild that we have actually documented that have the ability to spread like SARS, meaning highly infectious, but have onboard the genetic package to kill like SARS and MERS, fifteen to thirty five percent. So what we did is our book is a bit unusual in that we actually have intermixed fictional and nonfictional efforts, where each chapter begins with an ongoing continuation of the unfolding pandemic as a fictional scenario. And, you know, it all ties together, how it evolved, what happened, And then we tie together the nonfiction to each chapter as to the lessons for that. So whether it's mandates or whether it's vaccines, communication, it ties to that. And our job was to really show that there was going to be a lot of different considerations throughout a pandemic.
Michael Osterholm:It was not going to be a simple one and out kind of thing. The whole point, though, but it could be a lot worse. Imagine in our scenario, we imagine it's between seven and eight percent of the people died. That's hardly what SARS or MERS did. But it's still seven times higher than what COVID did.
Michael Osterholm:Can you imagine what our world would have been like if we'd had seven times the number of deaths of COVID as opposed to what we had? And so I think it really no one can accuse us of being on the far edge of fictional nightmare when we know what SARS and MERS has done. And now we know that they've acquired this ability to be rapidly transmitted. And so that's the challenge we're facing, and that's why we have to be better prepared. And at the end, let me just say, this may sound counterintuitive, but this book is truly a love story for me.
Michael Osterholm:It's a love story. It's about my kids and grandkids. You know, as I sit here and record this in my office right now, I have an electronic picture frame just on the other side of my desk. Every thirty seconds, a new shot of one of my grandkids or grandkids together comes up. I never have to wonder why I'm doing what I do.
Michael Osterholm:Every day it's about them. It's what are we leaving this group? And so, you know, that's what motivates me and drives me, is how can we be better prepared? And I'm actually optimistic that with the additional vaccine research that we point out, we could actually have a great impact on future pandemics with vaccines that would be readily available, that would dramatically reduce serious illness, hospitalizations and deaths, and could turn what could be a catastrophic pandemic into something much, much less than that.
Rob Lott:Well, against that optimistic backdrop, if you will, while we're in the course of imagining scenarios, I thought we could do a fairly quick lightning round here in which we sort of imagine a US health infrastructure that's being run by, let's say an open minded technocrat and one who is perhaps a fan of Michael Osterholm. They've read your book and they agree it may be just a matter of time before the next big pandemic. And so they ask you for advice on specific changes that you'd like to see in the many different agencies and public sector entities that we rely on to ensure we're prepared. So let's do this lightning round. I'll list some of the various entities and I'd ask you to suggest in just a few lines, maybe some one or two urgent changes or priorities that you'd recommend for those agencies.
Rob Lott:And one last thing, a caveat, while you can certainly recommend maybe undoing some of the changes we've seen over the last ten months, I would encourage you to perhaps make some suggestions that go beyond simply, you know, rolling back the clock. Alright. Are you game?
Michael Osterholm:I listen. I'll try to do my best. I can't promise I'm gonna do as well as you want, but I'm gonna try to do my best.
Rob Lott:Alright. Let's Let's go for it. All right. First, tell us about the CDC. How would you apply some changes or recommendations there?
Michael Osterholm:You never really value something as nearly as you should until it's gone. CDC is gone right now. There are still some highly qualified professionals, incredibly dedicated public health professionals there, but the large part of the leadership is gone. And you would have to basically do what you could to restore CDC to what it was before. I think there surely are structural changes that can be made that would improve CDC, but we need CDC desperately.
Rob Lott:Okay. FDA. The same thing
Michael Osterholm:is true there. I think for all the federal agencies, I would say the same thing for FDA or NIH. We need these three organizations very much. Each of them surely are open for thoughtful renewal, revision and changes. But I think on the whole, we're going to one day realize how much we lost with them being gone.
Michael Osterholm:And this idea that there's this gold standard of science that now is applying to what we do in government is just so counterintuitive to the truth.
Rob Lott:What do you think of the decision to roll back some of the research around mRNA vaccines?
Michael Osterholm:A disaster. An absolute disaster. Let me just quickly this may not be quite as quick as a lightning round, but right now, if we had an influenza pandemic emerge tomorrow, we could make enough vaccine of our current vaccine approach to vaccinate potentially potentially two billion people in the first twelve to fifteen months of the pandemic. Okay? That's sure short.
Michael Osterholm:That's one fourth of the world's population. It's short of 8,000,000,000. Okay? That's because we're growing our current flu viruses for vaccines in imburated chicken eggs, the same thing we did in the 1950s, okay? MRNA technology, which is now being researched or applied, or at least was with mRNA technology, could give us enough influenza vaccine to possibly vaccinate the whole world in the first year.
Michael Osterholm:The difference between those two scenarios is millions and millions of deaths. Well, our government just took away all the funding at HHS for these vaccine research activities. And the rest of the world is kind of standing back and saying, Well, if The US is not going to invest, how much are we going to invest? And we're going to wake up one day with an influenza pandemic if things don't change and say, How the hell did we get here? When we had a tool that we know was not going be the perfect vaccine, but it could be available and it could still have a big impact.
Michael Osterholm:And now we don't have that.
Rob Lott:Say a little bit about state and local public health departments. Where would you like to see changes there?
Michael Osterholm:State and local health departments are the actual foundation of public health in this country. That is where the rubber meets the road, and we need them to be as strong as possible. What people haven't realized that over the years, we created an environment where it is state run but heavily dependent on federal funding. The average state health department today in this country uses about 94 to 95% of the money that it gets for infectious disease work, and it comes from the federal government. 94, 95%.
Michael Osterholm:So if that gets cut, which we're in the process right now of watching, you're going to see basically a very quick erosion of any capacity at the state and local level. So, you know, at this point, it would be like having a major auto accident in a given community and you call in the local sheriff and, you know, the highway patrol. They're all gone now. You have to call Washington, D. C.
Michael Osterholm:To get someone from the Department of Transportation to come out and help deal with this auto accident. What a mess. And so we need state and local health departments so badly, and I fear that they will be gone soon in a way that will very seriously compromise our public health response in this country.
Rob Lott:Wow, well thank you for going on that journey with me through this lightning round. That was great. I appreciate it. Before we wrap up, I do want to ask you about sort of this moment in time with regard to the experience of perhaps students and early career professionals who may be considering the field of public health and epidemiology. For many, I imagine it may be tempting to simply choose another path or an easier option.
Rob Lott:And I'm curious what your answer is to people who may ask if it's even worth going into the field at this moment.
Michael Osterholm:Well, that is one of the toughest questions I get, and I don't have a great answer. Let me just say that it's critical that we not lose this generation of upcoming scientists, public health professionals. They are our future. And frankly, there are a number of them who, I think, bring a skill set to the experience that none of us had, at least in my generation, and they're incredibly capable. What are we going to do?
Michael Osterholm:I don't know. We're doing our part as best we can. I have reached out to multiple foundations, have now secured eight different scholarship funds that I can keep my students on, which I've had hundreds of graduate students over the years, and I appreciate how tough it is right now for them. And so we're trying to do our part. I hope that others will maybe reach out to their foundations or local sources of support to keep these graduate students moving forward.
Michael Osterholm:We need them badly. But in the meantime, we're going to take a hit. We're going to take a hit. And we have to understand that we will have a big dent in this generation, even into the recent generation, those in their 40s, who are still really building careers that suddenly got cut off at the knees. The funding was cut.
Michael Osterholm:And so we will pay a price for this. And how big it will be, I don't know. I think all we can do is keep it front and center. I hope you keep asking questions like this. This is really important.
Michael Osterholm:We ought to be asking every leader out there, What are you doing today to support this upcoming generation of scientists? And for nothing else, again, it fits in with part of the love story sense of my book. You know, these are going to be the leaders that will make the world a safer place for my great grandkids, my grandkids. And that's what I hope we can do.
Rob Lott:Well, Doctor. Michael thank you so much for taking the time to chat with us today. Really enjoyed it. To our listeners, Doctor. Michael Osterholm's new book, The How We Must Prepare for Future Deadly Pandemics, is in bookstores now.
Rob Lott:You can check it out. And, of course, if you enjoyed this episode, please leave a review, subscribe, recommend it to a friend, and, of course, tune in next week. Thanks, everyone. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health podcast.