Michael Osterholm, PhD, MPH, one of the world’s leading experts on infectious disease threats and pandemic preparedness, joins The Future of Medicine for a wide-ranging conversation about COVID-19, vaccines, airborne transmission, public trust, and what the world must do before the next pandemic arrives.
Osterholm is director of the Center for Infectious Disease Research and Policy at the University of Minnesota and has spent nearly five decades investigating outbreaks and advising public officials. In this episode, he reflects on the experiences that first inspired him to become a “medical detective,” including an unusual outbreak linked to thyroid tissue entering the food supply through hamburger meat.
The conversation then turns to COVID-19 and the lessons that remain unresolved. Osterholm explains why he believes the United States needs an independent, nonpartisan review of its pandemic response—one focused on identifying what worked, what failed, and how changing evidence shaped decisions about schools, hospitals, masking, and public gatherings.
“The pandemic clock is ticking,” Osterholm says. “We just don’t know what time it is.”
He also discusses why public health guidance must be able to evolve. As Osterholm puts it, “Science is not truth. Science is the pursuit of truth.” New variants, new evidence, and changing risks do not necessarily mean earlier recommendations were made in bad faith; they reflect the reality of responding to a rapidly developing threat.
The Intro
“We could be much better prepared for the future. As I keep telling people, the pandemic clock is ticking. We just don't know what time it is.”
Dr. Michael Osterholm is an epidemiologist and the director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
“Science is not truth. Science is the pursuit of truth.”
He has served in a formal role for every presidential administration since Ronald Reagan, advising on topics related to public health, pandemics, and biosecurity.
“Living during SARS-CoV-2, where 1.5% of the people died — now imagine if you put a 15 or 20% case fatality rate on that. What would this world be like?”
We talk about lessons learned from the COVID pandemic, including how to communicate evolving science to the public, the value of conducting a formal review of the governmental response, and the risks of defunding pandemic preparedness.
Welcome to Stanford Department of Medicine's Inside Look at the Future of Medicine.
The Transcript
Dr. Euan Ashley: Well, Michael, welcome to Stanford.
Dr. Michael Osterholm: Well, thank you. It's a real honor to be here.
Dr. Ashley: We're so happy to have you. And you just played our Medicine Grand Rounds to a packed audience — standing room only. I'm excited to talk to you today for so many reasons, and for the important voice you've had for the US and for the world in relation to many threats, but of course particularly pandemics. Before we get to that, though, I'm always fascinated by people's stories — how did you get to be one of the world's leading voices on pandemics? And as we'll get to, somebody who really saw it all coming. But take me back further — take me back to your childhood. Where did all this start? Where did you first get an interest? Tell me where it all began.
Dr. Osterholm: Well, thank you. Actually, I do know to the moment almost how it all began. My father worked in a small Iowa farm-town newspaper, and the owners — a husband and wife team — were really what I would call renaissance individuals in this town, and the woman subscribed to The New Yorker. I think probably the only person back in the early '70s in Iowa who subscribed to The New Yorker. And one day I was at their home and I saw the magazine, and there was a story in it by Berton Roueché — an Annals of Medicine story. I looked at it and I thought, "This is interesting." I started reading it — I couldn't put it down.
Dr. Ashley: How old were you?
Dr. Osterholm: I would have been in eighth grade.
Dr. Ashley: Okay, pretty young for The New Yorker.
Dr. Osterholm: Yeah, well, this story just absolutely captured me. And so every time there would be a New Yorker article, including Berton Roueché, I would run up to their house and get it and read it. And I knew I wanted to be a medical detective. And people thought I was a little —
Dr. Ashley: Yeah, that's quite specific.
Dr. Osterholm: So I never lost that love. And in fact, even during college, when people said, "Well, infectious diseases are dead and gone — horse and buggy," I only found myself more interested. And I had the most amazing experience that brought this early childhood interest full circle. When I was a state epidemiologist at the Minnesota Department of Health, we had a very large outbreak of a thing called thyrotoxicosis — this is where there's too much thyroxine in the blood, and thyroxine is the metabolism-related agent. And we couldn't figure out why, because their thyroids were actually shrunken and small — these people were in very serious condition. Well, it turned out that the government had just started allowing a thing called neck trimming in their meat processing, where they would trim two or three more pounds off the neck. What had happened was the companies that used bovine thyroid — thyroxine — no longer needed it, because they now had a genetically modified alternative, so they didn't harvest it. And as a result, this was being dumped into the meat that went into hamburger. So people were eating thyroid burgers. Well, the reason I tell you this story is because Berton Roueché wrote this up as one of his stories, and I had an opportunity to tell him just how important he was to me in my career and my life — and unfortunately he died shortly thereafter. So I had that opportunity to go full circle with Berton Roueché.
Dr. Ashley: Well, that's remarkable — I have to dig that article out and read it. Thyroid burgers, that's incredible. But it was also published in the New England Journal of Medicine?
Dr. Osterholm: Yes — Sid Ingbar, who was an endocrinologist and a senior editor at the New England Journal, actually got so into this with us that he flew out to Minnesota and went to the plant with us where this was happening, and needless to say the article got published in the New England Journal of Medicine. But more specifically, what had happened was we needed to get some kind of estimate of how much impact this meat would have. So, through human subjects approval, we brought in a number of Harvard medical students who got paid to eat this hamburger, and then we measured their thyroxine levels. They were getting about the equivalent of three to four replacement doses a week extra by eating one hamburger. So it was clear and compelling. Thank you to the Harvard medical students who participated in our work.
Dr. Ashley: We're making these cells voluntarily thyrotoxic for you. That's — yeah, I mean, that's layers and layers of — that's what I love about the long-form New Yorker writing, that there are just layers of elements that can get peeled back. What stage were you at when you were doing that work?
Dr. Osterholm: Well, it would have been 1984. I was, at that time, state epidemiologist in the state of Minnesota. I had been in Minnesota for nine years, and I was very fortunate to enjoy a wonderful experience as a state epidemiologist in Minnesota, while also being affiliated with the University of Minnesota. So I always had two jobs — I've not necessarily been fired from any, but I always had two. I also, for example, right after 9/11, because I had written a book that was published in 2000 called Living Terrors: What America Needs to Survive the Coming Bioterrorist Catastrophe, and it was all about bioterrorism — when 9/11 happened, Secretary Tommy Thompson, who was at that time the Secretary of Health and Human Services, asked me to come to Washington. So I split my time fifty-fifty with him, back in Minnesota, and did a lot of work on bioterrorism related to that.
Dr. Ashley: Amazing. You really have spent many years thinking about things that can kill us, and that's going to be the theme here — but also, somewhat of a soothsayer. I think one of the really striking elements of the talk you just gave — you showed us some emails and some of the early warnings you'd sent, not least a whole book. You talked about one of your books, but you have another one called The Deadliest Enemy, which was published in 2017. Tell us about that.
Dr. Osterholm: Well, that one was kind of a landscape review of infectious disease issues. As you mentioned earlier, some people wanted to know why we went into infectious diseases — this book was really a way to say: this is why, because there are a lot of significant issues ahead. Three chapters were devoted to a future pandemic, which we rolled out almost exactly as it actually happened — however, we ascribed it to an influenza virus, not a coronavirus. And one of the chapters was actually titled "SARS-MERS: The Harbinger of Things to Come."
Dr. Ashley: And wasn't it — I think this is one of the points you made early in your talk today — that all we do is think back. There hasn't really been a formal investigation, a formal kind of post-mortem. We're familiar with that in medicine — if a patient dies unexpectedly, we do a very careful post-mortem. Despite the global pandemic and everything we lived through, there has never really been a formal review at the government level in the US.
Dr. Osterholm: I had an opportunity to really understand how important that formal review can be, because part of the time I spent after 9/11 as an adviser to Health and Human Services was also when the 9/11 Commission came together. It was led by a Republican and a Democrat — very comprehensive. It did not spare anyone anything; it turned over every rock it could. But it was never partisan — it was always about what are the things we could have and should have learned. That document served a very important purpose in helping us plan, over the years after that, for what we can and should do to be prepared for another event like that. And so I think that if we had the same kind of review — nonpartisan but comprehensive — we could be much better prepared for the future, because we are going to have another pandemic. As I keep telling people, the pandemic clock is ticking; we just don't know what time it is.
Dr. Ashley: And we're definitely coming to that, because you've been saying this for years. I think it's also important to note you've worked across the aisle, with multiple administrations — this is a reminder that pandemics are not a partisan issue. The viruses don't care.
Dr. Osterholm: And I think this is where public health is an important entity.I've served a formal role in every national presidential administration since Ronald Reagan, when I worked on HIV/AIDS and the AIDS Commission, and even during the first Trump term I served as a science advisor to the State Department — a science envoy working to get the world better prepared for a pandemic. So much for the success of that one. The bottom line is that in public health, it's never about partisanship — it's about calling balls and strikes. And I think right now, one of the things we're missing with the review of what happened with COVID is a review of the balls and strikes. It's not there.
Dr. Ashley: Yeah. So, talking about your ability to predict — you also showed a couple of slides that were even more remarkable to me. Not because you were among the more prominent voices making us think about the possibility of a pandemic, but because of how it was evolving. In December and January of 2020, when things were so new and we were literally just getting the first news reports out of China, out of Wuhan specifically, you showed us some of the work from your center and also some personal emails. So — this isn't you rewriting history here; these were written by you in the moment. Tell us about those.
Dr. Osterholm: Well, I think one of the challenges I've had with any discussion about the pandemic is that it seems to keep changing in people's minds what happened. There's a lot of rewriting of history, and that's one of the things I think is a real challenge, because it doesn't help us. I talked today, for example, about lockdowns — what a lockdown really is, how long they last, what they could or couldn't do. And I think the challenge is that if you go back objectively — not on a partisan basis — and ask what we could have learned: in a pandemic that's going to last three or four years, a lockdown will never work. It's temporary — like a hurricane. It's really bad for twelve hours, but then we go into recovery. So what we needed to do was figure out how to sustain protecting as many people as possible. Back then, the one thing we had to offer — the only thing we had to offer — was good medical care. We didn't have a drug, we didn't have a vaccine, we didn't know what to do. But if your hospital is running at 140% capacity and people are in the hallways, in the parking-garage stalls in beds, that's not good medical care. So one of the things we talked about was: instead of lockdowns, have "snow days." What if every hospital in this country had to publish its bed census every morning? And if we were suddenly at 120% capacity, let the public know: now's the time to back off — if you can avoid group activities, this would be the time. And when the numbers come back down, we'll say, okay, you can go do more things. Just practical things like that —
Dr. Ashley: It's both an early warning system and a way to make sure there's a bed available if you get ill. So it sounds like you weren't supportive of full lockdowns, but some degree of distancing.
Dr. Osterholm: Absolutely — but tied to the moment when people felt, "Why am I doing this?" Well, because I know why: my hospital right now is at 140% capacity. If I get sick with COVID in the next couple of days, what am I walking into? Or can I even get into the institution? I think if we had communicated to the public more on events like that, explained our logic — what I just shared about snow days is pretty simplistic, but it's also powerful, because we could then hopefully deliver the best medical care we could. That was all we had. Once we had vaccines, drugs, and so on, that started to change things. But in those early days, it didn't.
Dr. Ashley: I wanted to make sure we don't miss something that really struck me as we're moving through the pandemic timeline — you'd sent an email suggesting we need to wake up and take this seriously, and at the time people were not. You said you were worried we might lose 800,000 citizens, and it turned out a few months later that was pretty much on the money.
Dr. Osterholm: I made that statement in late March, early April, that I thought this was going to last some time — more specifically, that over the next 18 months we could lose up to 800,000 people. In an interview I did, a publication went back 18 months after my statement and found there had been 790,000 deaths, as opposed to 800,000. I think the other important part is that none of it was black-box magic — it wasn't a computer program nobody could understand. Mine was on the back of an envelope, straight math, looking at what percent might get infected. And I think that's another lesson: we over-promised the certainty of the information these models could provide, and people then wondered, "Wait a minute, that's not what you told me three or four months ago."
Dr. Ashley: I think this is a recurrent theme, not just in COVID but elsewhere, where the complexity of modeling can belie the fragility of the underlying assumptions.
Dr. Osterholm: Exactly — I couldn't agree with you more.
Dr. Ashley: At the time it seemed like everyone capable of quantitative science was doing some kind of modeling, but the reality was there are a few key variables that change the entire outcome, and those are the ones you need to know.
Dr. Osterholm: The other thing that was important is that because I'd had an opportunity to work on SARS and MERS earlier, I had some familiarity with coronaviruses. One of the challenges we never really understood was what would happen with different variants — from the ancestral strain to Alpha, Beta, Delta, Gamma, Omicron — and as those changed, that changed a lot of what happened. I provided some data today on children, and the fact that if you look at deaths in children in the first year versus the next two years, it was incredibly different. A lot of the data we used to describe the risk of COVID to children came from that first year, not realizing that once Delta and Omicron showed up, it was a very different picture.
Dr. Ashley: That's not particularly widely known — I don't think I'd remembered that.
Dr. Osterholm: That's the kind of thing where we then tried to explain why, in the first year, you probably could have kept schools open more, but in the second and third years — particularly with Omicron — you were in real trouble. Had the public better understood that we're not changing our minds, we have new data — the point I try so often to emphasize with my students is: science is not truth, science is the pursuit of truth. That's so important to understand — that's what we're doing. And if the public is given that explanation — this is what we're doing to learn more, this is what we hope to know in a couple more months —
Dr. Ashley: It's a system of rules and rigor to pursue. I usually find myself saying it isn't a belief system, other than a belief that using certain rules and rigor you can pursue truth.
Dr. Osterholm: Exactly —
Dr. Ashley: It's our best attempt at that as a human species. It's not a belief system.
Dr. Osterholm: There are a lot of mornings I wake up and sit on the edge of my bed before I get up and say to myself, "Man, I wish I could know today what I'm going to know six months from now" — and how to convey that as a message to the public. It's like the weatherman: I'm not going to give you the same forecast 27 days in a row — it's going to change. That doesn't mean the last one was wrong, but I need to explain why it changed, and report that to you when the estimates change.
Dr. Ashley: The current narrative on the lockdown question is that we lost a lot of education among children, and that we should have at least kept schools open, or that if we'd known how much we'd lose — there's a generation of people, including my daughter, who was in high school at the time, who lost a great deal. Of course there's no right answer to this, but knowing what we know now about the downside of school closures — and having a clearer view in the rearview mirror of each of these variants and their impact — do you think, in retrospect, looking at the data, we would have made the same decisions? We talked about the Great Barrington Declaration and the whole approach to that, which was a challenge.
Dr. Osterholm: You know, I don't really think we would have changed much, in the sense that in the early days of the pandemic we were obviously sensitive to children dying — that's very different from somebody my age dying, and how people perceive that. But we never really put that into perspective — what would happen if we didn't shut down schools? I'm not always a proponent of saying shutting down a school reduces risk, because if your kids all get together at somebody's house on the day they're not in school — maybe with an elderly relative present — that doesn't necessarily reduce risk either. I think the other part is that in years two and three — 2021, '22, '23 — we actually had a big increase: 87% of the deaths that occurred in kids in this country occurred in the second and third years of the pandemic. Would we have thought, maybe now's the time to shut down our schools, with the recommendation that that not just become a community event where kids socialize together anyway? I think the other part is that we've never really understood — if you don't have teachers, if you don't have janitors, if you don't have administrators, can you even have a school open? Many schools closed down for the primary reason that there was nobody to teach. Do you want to send your kids to a place where there's one janitor serving as the monitor in a huge study hall? That's what we saw. So it's not a right-and-wrong answer — it's about how we have these discussions, how we should think about the path of least negative impact versus the benefits of a positive outcome.
Dr. Ashley: One of the things I was always fascinated by, having learned as a medical student about aerosolized viruses, was the extent to which we were still stuck in a kind of hand-washing, touch-based mode of thinking about transmission, despite knowing this was a respiratory virus. And it was interesting how everybody with expertise that might be relevant suddenly flooded into that zone — we had a lot of physicists and aerosol scientists suddenly in the mix. But what you were saying today was that you already knew this, that we'd already learned it from earlier SARS experience.
Dr. Osterholm: One of the things that happened during the early days of the pandemic is that NIOSH, a division of the CDC, was really silenced a lot by the administration — and they had state-of-the-art information on airborne transmission, and on how certain kinds of N95 respirators versus surgical masks work and how effective they are.
Dr. Ashley: That was known.
Dr. Osterholm: It was all known. And we also knew, from the standpoint of an airborne-transmitted virus, that plexiglass shields did nothing.
Dr. Ashley: That seemed obvious to everyone, actually.
Dr. Osterholm: You know, I'll tell a very brief story as an example of aerosol transmission. I worked on a very interesting outbreak of measles when I was again at the state health department. We had the International Special Olympics come to Minneapolis, and the opening night session was held in the old Hubert H. Humphrey Metrodome — held 68,000 people, plus everybody in the infield and outfield area. That night, one young boy from Argentina on Team A was breaking with measles. We had not had measles in the Twin Cities area in the previous three years. It turned out that a number of people associated with the games did develop measles, but we also had several cases in residents of Minneapolis–St. Paul whose only contact with the entire event was that opening-night session. And it turned out we had cases only in the farthest-away seats, way up in the upper right-field bleachers, where the air outflow was — air that came off home plate, 420 feet away. Nobody between home plate and that little section got infected; in that section, people did. And to the best of our knowledge, following up with people who had been sitting in that section, the only people who got infected were people who had not been vaccinated before and had not had measles before. Think about how dynamic that transmission was — that's airborne transmission. So that's why we have a number of real-life experiences showing you can't dismiss airborne transmission.
Dr. Ashley: And I think one of the things we all became experts on — your slide reminded me — is just how much more effective N95s are than a surgical mask.
Dr. Osterholm: Right, and we had to explain to people why. One is fit — how many people have had their swim goggles leak? It leaks at the seal. If you get something fitted so tightly it's airtight, you'd suffocate. What makes an N95 respirator so special is what's called melt-blown material — a type of material that has an electrostatic charge in it, and the pore size is big enough to let air move through. Technically, a virus could come right through, except for the charge — so it stops it. Nobody's going to suggest N95s today are the most comfortable thing — "I can't wait to wear one" — but because of that melt-blown material, you can breathe for hours without having to change the seal around your face. And that's what protects you.
Dr. Ashley: Well, I don't know where everybody listening is in terms of masking now. Some people never mask; some of us are sensitive to the fact that we don't want a cold virus either, never mind flu or COVID or RSV. There are a few places where it's almost impossible, but traveling is often a time we worry about — though sometimes people worry in the wrong place. I think the airport, where everybody's moving around and there's a huge airspace, is actually fine — we saw with carbon dioxide monitors that it's where the air isn't moving, like the little corridor down to the plane, or on the plane before they turn on the HEPA filters, that matters. Yeah. So I think it's still possible to be quite rational about how to use masks to reduce our general chances of airborne viral illness. But that's a great reminder of some of the science that was front-page news for a while and maybe isn't quite front-page news anymore, even though perhaps it should be. So, moving through our pandemic timeline, we get to vaccines. I think people have forgotten what a miracle it was — I remember the New York Times had built a predictor of the most likely timeline for a vaccine if everything went well, based on previous viral vaccine development, including the fact that for some things, like HIV, there was never a great vaccine developed. If you moved the sliders around assuming everything went really well, it got down to maybe two and a half years — but it could go up to fifteen. The most likely estimate seemed to be four or five years, and that was the accepted wisdom. And yet ten months in, we basically had phase three trials for four different vaccines. You have a unique perspective on this — how do you think of it now?
Dr. Osterholm: Well, first of all, it's remembering what happened in the past in a way that helps you reflect on why you're doing what you're doing now. The year I was born in this country, there were 55,000 cases of polio, of which over 21,000 were paralytic — 21,000 people paralyzed. You have to remember we likely will never return to those days, because enough people are vaccinated — that surely reduces the risk. But there's still the potential for huge outbreaks. One of the things I mentioned today is that we're watching very carefully what's happened in Canada with measles — last year they had over 5,500 cases. Their vaccination rates prior to last year were very similar to what ours are now in terms of actual hotspots of low vaccination. Canada has a population of 40 million; we have 340 million. If you just do the population adjustment, given what happened in Canada, that could translate to 40,000 to 45,000 cases of measles here. People say, "Well, that's never going to happen." But if you'd told Canada three years ago they'd suddenly have 5,500 cases of measles, they'd have said the same thing. So I think part of what we have to do is keep reminding people how dynamic an infectious agent can be, and how quickly it can change — that's why vaccines are so very important. It's the one stopgap measure we have that's still a powerful tool. Our treatments are limited for many infectious diseases, but we know vaccines can be very effective.
Dr. Ashley: I think it's a short-term memory issue in many ways. You mentioned polio — I recently had reason to read about the history of smallpox, and I hadn't done that since I was a medical student. That's terrifying reading.
Dr. Osterholm: It's likely to potentially get much worse. I say that because I had the good fortune to work closely with Dr. D.A. Henderson at HHS right after 9/11 — D.A. was a mentor to me for many years. As many of you know, he led the WHO effort to eradicate smallpox, with very important support from people like Bill Foege, who helped lay that out. One of the things D.A. and I used to talk about was what would happen now if somebody could make the smallpox virus. As you may or may not remember, the decision was made to sequence the virus back in the 1990s, because the debate was whether to destroy it, with two stocks left — in the former Soviet Union and the United States — and the decision was, let's sequence it first. So the sequence for the virus that causes smallpox is all public information. There was a group in Canada, several years after that, that actually took the published sequences and made horsepox de novo — they created a pathogenic horsepox virus. It can be done. And I worry that today, with modern technology twenty years later, it's even easier to do that. What would happen if somebody brought back smallpox? You can say that'll never happen, but it's real — it's terrifying. And right now, since 1978, almost no one has been vaccinated against a pox virus like that, except more recently with mpox. Think of what the world would be like if we suddenly announced a smallpox outbreak sweeping through the United States.
Dr. Ashley: That's a terrifying prospect. The vaccines, however, are our way out — whether someone has created a virus or not.I also loved your response to the lab-leak-versus-natural-origin question — please repeat it for our audience.
Dr. Osterholm: I just say: move on. We will never know. There's data that clearly supports a lab leak, there's data that supports a spillover — the point is, we're fixated on this and we're not planning for the future. We have to plan for either one. I'm willing to accept there could be a lab leak in the future; I'm willing to accept there's going to be a spillover. What we're doing right now is not preparing for either, because we're hung up on trying to say who's right and wrong about the original source of the virus.
Dr. Ashley: I think the demonstration — I'm a genomics person — that genomic technology, understanding viruses and the delivery of RNA in particular, but even the DNA delivered as part of the adenoviral vaccines, means we essentially have digital vaccines now that we can dial up and be prepared for, and potentially scale globally. We haven't done that. In fact, virtually nothing has happened since the end of the pandemic in terms of preparedness for the future.
Dr. Osterholm: I'd go so far as to say it's gone backwards.
Dr. Ashley: Is that right?
Dr. Osterholm: Before the Biden administration left office, they identified $500 million to go to NIH/BARDA for the development of mRNA technology vaccines for influenza and coronaviruses, and to improve the existing coronavirus ones. This was really important work, because right now, if we had an influenza pandemic, the primary source of vaccine would still be the embryonated chicken egg, and that, unfortunately, is at risk with H5N1 right now, even in the barns that raise those chickens. On top of that, if you look at total global manufacturing capacity — we just published on this — it's about 20% of the world we could make enough vaccine for in the first year to protect them. Whereas with an mRNA technology vaccine, we believe in the first year we could make enough effective vaccine to vaccinate 100% of the people in the world. The difference between those two scenarios is millions and millions of deaths. And yet this administration took away those resources, and we're not doing that work.
Dr. Ashley: I think we're all global citizens — we lived it together. That was one of the few times we truly understood we were global citizens. I'm a sci-fi fan — think about all those sci-fi movies where the aliens come down to the planet: humanity has to come together. But where is the forum where humanity comes together? If one country that happens to be richer than others is willing to lead, that's good — but where's the body, like the one the aliens talk to in the movies, that can decide as a global community that this investment has to happen, and we're all going to pay into an account pro rata to make it work?
Dr. Osterholm: We keep hearing this mantra, "America First." Right now, we are so far behind on mRNA technology for influenza vaccines that we would be in line to get vaccine from countries that have already advanced this work. Imagine us getting in line right now — do you think we'd get a lot of sympathy from other countries, who'd say, "You made this case for yourself — get in line"? I think that's a challenge — it's not "America First" right now; we'd potentially be way down the line for vaccine.
Dr. Ashley: So this is a tale of two chapters — one where we have a biotechnology revolution that has delivered something we didn't have 100 years ago, when the Spanish flu pandemic hit and they couldn't sequence it or produce a vaccine. We have that potential now, but we're not only not poised, we're making no preparations as a country, or even as a global community. You shared some rather frightening possibilities — I think we all knew them, we just choose not to think about them. You talked about bats in particular, because I think we forget that although this version of coronavirus had a fatality rate — and it was mostly hitting older people with comorbidities — we know there are flu strains with a much higher case fatality rate. Without scaring us too much.
Dr. Osterholm: Well, I come back to the issue of SARS and MERS. What helped us contain those viruses was the mechanism by which they infected people — not nearly as efficient as what we saw with COVID. The problem is we've now identified viruses that have the package on board to kill, like MERS and SARS, 15 to 30% of the people who get them, and at the same time they now have the ability to transmit at a very high rate. That's a scary proposition. I tell people, if you want to know what that would be like, think of living through SARS-CoV-2, where 1.5% of people died, and how bad that was — now imagine a 15 or 20% case fatality rate on top of that transmissibility. What would this world be like?
Dr. Ashley: This isn't theoretical.
Dr. Osterholm: This isn't even a stretch in terms of "that can never happen." As we do more and more work in jungle environments and so forth, we're going to see more of these viruses emerging. We kept focusing on China relative to these potentially very serious coronaviruses — now we've found them in the Amazon too. So it's a much larger picture that poses a lot of risk.
Dr. Ashley: So what would you do if I handed you the checkbook for the US government? What can we do? We can't make a vaccine for everything.
Dr. Osterholm: Vaccine for those that pose the greatest risk.
Dr. Ashley: Do we make them in advance and store them in a freezer, in a data vault, ready to go?
Dr. Osterholm: If you design the technology appropriately, you can very quickly plug and play — we can make some of these vaccines, like mRNA technology, very quickly. But what we have to have is the template to do that — the preclinical data that says, if I put this into you as a vaccine, it'll work. I think we can do a lot of that preparatory work that would allow us to move quickly. I wouldn't say stockpile a bunch of vaccine right now, because you want to make sure you have the vaccine that really works — that's the first step. The second step is that we do need better vaccines beyond mRNA technology too. As many in this field would say, the first dose out will be an mRNA vaccine — it'll prime the system, protect you some — and then we need a different vaccine later on. Our center actually leads global efforts around developing roadmaps for both coronavirus and influenza vaccines — if you go to our site, you can find out where every vaccine under research stands right now. I do believe we can get better vaccines — it's not just a pipe dream — but right now, let's cover that initial hit; have the mRNA technology available.
Dr. Ashley: That makes sense. I think people will often ask about — and you touched on this a bit in your talk — the difference with a truly seasonal virus. You made the joke that with coronavirus, it could be any season.
Dr. Osterholm: It's seasonal because it occurs in every season — every season.
Dr. Ashley: But I think people are used to thinking, "I got the flu vaccine last year and I still got the flu — that's a terrible vaccine." That was the bar; we were hoping the coronavirus vaccine could leap over it. It cleared it by a mile.
Dr. Osterholm: I tell people, you're absolutely right, but on the other hand, had you not been vaccinated, you might have been hospitalized, seriously ill — and we have data that clearly show that can be the case. This is an example of what I said earlier about mandating vaccines or not — because of the lack of total protection, and because it isn't clear the vaccine really interferes with transmission, this may not be a vaccine you'd mandate for the whole community. But it should be for you — meaning I strongly encourage flu and coronavirus vaccines. I get mine. Just know it may be a situation where you could still get infected, but the data are clear and compelling that it substantially reduces serious illness, hospitalization, and death. I'll take that any time, and I hope most people would choose to do that. But it's complicated.
Dr. Ashley: I think most of the health conditions we think about and talk about aren't ones where whether you decide to treat yourself or not could decide whether your neighbor survives — so it is complicated, and we've certainly all lived through years of trying to think that through. Your new book is here — this is the newest one, I think — it's about how we might prepare for the potential of future deadly pandemics.
Dr. Osterholm: Yes, thank you.
Dr. Ashley: We're excited to learn about it. We're a little scared to read it, but we should be. I think it's very different from the fear we should have had in 2019, when this technology wasn't proven and we didn't know we could do it. When we saw, within ten or eleven months, going from sequencing the virus to delivering a phase three trial with a 95% outcome measure — just remarkable. Well, I think another remarkable thing is your incredible career, and we're really grateful to you for coming to Stanford today to give our Merigan Lecture.
Dr. Osterholm: I'm very honored. I think one of the things most people don't necessarily know about the Merigan Lecture is who Tom Merigan is. Tom was very instrumental in my early days as a real leader — he went into virus treatment and antivirals when nobody was going there. He was very helpful in establishing what we could do, and how, to actually treat virus infections. He's always been a pioneer and a hero of mine, and it was an incredible honor to be here today, to have him right there in the front row.
Dr. Ashley: So, thanks for coming to Stanford. Thanks.
Dr. Osterholm: Thank you for having me — I appreciate being on the podcast here with you.
