Infectious Disease

Stanton Shanedling: Hello, everybody! Welcome to Health Chatters. Today's show features a special guest that many of you will recognize. We'll get to him in a second. We'll be covering topics on infectious disease, where we've been, where we are now, and where we're going.

But first, I'd like to recognize my crew. They’re second to none, really. Without their help, these shows wouldn’t be a success: Maddie Levine, Wolf, Aaron Collins, Deandra Howard, Matthew Campbell, Sheridan Nygaard, and of course, Dr. Barry Baines, our medical advisor. All the logistics are handled by the crew in the background, who also do the research and ensure the shows get out to the listening audience. Clarence Jones is my great colleague. We do these shows together and have had many good chats with great people. Thanks, Clarence—it’s a pleasure working with you.

Also, our sponsor is Human Partnership, a great community health organization. You can check them out at humanpartnership.org. You can also visit us at healthshatterpodcast.com, where you’ll find research for all our shows, including this one. You can also submit questions or comments as you listen. Thanks to all of you.

Today, we have a fantastic guest, Dr. Michael Osterholm. Mike and I go back a long way in the field of public health. We’ve done some great things together, including HIV training and other initiatives. Mike has served this community locally and nationally, dealing with infectious diseases.

Mike is a Regents Professor and the McKnight Presidential Endowed Chair in Public Health. He’s the Director of the Center for Infectious Disease Research and Policy at the University of Minnesota (also known as CIDRAP). Many of you may be familiar with CIDRAP. He’s also served as the Science Envoy for Health Security on behalf of the U.S. Department of State. He’s the author of Deadliest Enemy: Our War Against Killer Germs (2017), a book I highly recommend. From 2001 to 2005, Mike also served as Special Advisor to the HHS Secretary, Tommy Thompson, on issues related to bioterrorism and public health.

I first worked with Mike when he was the head of the Infectious Disease Department at the Minnesota Department of Health. It’s a true pleasure to have you on the show today, Mike.

Michael T. Osterholm: Thank you, Stan, and Clarence. It’s an honor to be here.

Stanton Shanedling: All right, let’s get the show started. We’ll talk about the past, present, and future. Let’s clear the airwaves a bit and talk about COVID-19. You were entrenched in dealing with this at both the state and national levels, trying to get information out to the public as quickly and honestly as possible. So, what has Mike Osterholm learned from it? It’s been such a complicated issue, both from a health perspective and a political one. What have you learned?

Michael T. Osterholm: Well, first of all, let me say that what’s happened is still happening—it’s unfolding. I hope we can talk about that today. We’re currently experiencing another surge, and the big question is: what do we do about it? How is it different from before, if at all? Are we in a pandemic still, or is it over? A lot to unpack here.

In my 2017 book, Deadliest Enemy, I devoted several chapters to what an influenza pandemic might look like in a more severe way. What unfolded was very similar—it was just a coronavirus instead. What surprised me was how we responded, not fully understanding what it meant to be in a pandemic.

I was one of the lone voices early on in 2020, writing in March that we should not do lockdowns. The reason was that I knew this was going to be a 2- or 3-year journey at the least. You can ask people to do extreme things for short periods of time, but they won’t sustain it long-term, and you risk losing credibility.

Back in March 2020, I predicted we could easily see 800,000 deaths in the next 18 months. Interestingly, my harshest critics were colleagues who thought I was needlessly scaring people. But 18 months later, we hit that 800,000th death in the U.S.

So, what I’ve learned is that we didn’t really understand the full implications of what a pandemic meant. Public health, clinical medicine, and government leaders all had to learn what it truly meant to be in a major pandemic and how to manage it over the long term.

Stanton Shanedling: You also mention that long COVID is a major concern moving forward, in addition to the actual virus. Could you share your thoughts on that?

Michael T. Osterholm: Yes, long COVID is a key component of this. It’s a part of the ongoing fallout from the pandemic. Many people, including yourself, have suffered long-term symptoms, like losing your sense of taste and smell. Long COVID will continue to be a significant issue as we deal with this virus going forward.

We also need to acknowledge the mental health toll COVID has had. The exhaustion, the fatigue, the uncertainty—it’s taking its toll on individuals and societies.

In short, we need to prepare for a long haul, and humility should be at the center of public health guidance. There’s a lot we still need to learn.

Stanton Shanedling: For the public as well. It's like, on one hand, I'm dealing with heart disease. And now, all of a sudden, you're telling me, "Oh, my God, we gotta be careful about COVID."

Michael T Osterholm: And Stan, I would even add an additional context to that. I, personally, am trying hard to get rid of the infectious disease, chronic disease nomenclature. Because today, so many infectious disease-caused conditions are actually chronic manifestations of immune dysregulation. Yeah, and so long COVID is a good example of that. I can go through, I mean, look at the number one causes of cancer—hepatitis B, etc. So when you look at the tie, there's actually a lot of continuity between infectious diseases and what we call chronic diseases. And I mean, I think one day we will find that, you know, whether it's neurologic disease, whether it's immunologic disease, whatever, has its origin in an infectious disease trigger.

Stanton Shanedling: Yeah.

Michael T Osterholm: And I think that's why, you know, we look at these. I look at the holistic view, the whole picture. A good example is just what you said with long COVID. You know, what's going on there? There are probably at least five or six different immunologic dysfunction issues that are occurring. You can't just treat one or the other. It may be this one you have, somebody else has another one. Why do you have such fatigue? You know, why do you have the kind of conditions like brain fog that we're talking about? Our studies today show that there's not a one- or two-diagnostic test approach here because it's really about major immunologic dysfunction in a number of different ways.

Stanton Shanedling: Yeah. Clarence?

Clarence J. Jones: I want to tell you, Dr. Michael, how much I appreciate your opening comments. First of all, I really wish I would have read your 2017 book as we were going through this.

Michael T Osterholm: Well, you know, Clarence, I have... I tell you what, I have a problem here that you might want to be aware of. Okay? In 2000, I wrote a book called Living Terrors: What America Needs to Know to Prevent the Coming Bioterrorist Catastrophe. 2000. I think I bought 14 of the 18 books sold in the next year. Okay? And then, when 9/11 happened and anthrax became a New York Times bestseller, okay. In 2017, it got a little more circulation than me buying copies. But then, when COVID hit, it became a New York Times bestseller. Okay, now I have another book coming out next year on The Big One: What We Need to Do to Prepare for the Real Pandemic of the Future, and I'm terribly afraid to put this out because I'm afraid it might predict...

Clarence J. Jones: Wow!

Michael T Osterholm: I don't have it. No, don't care.

Stanton Shanedling: What you are...

Michael T Osterholm: Just bury that, okay, and bring it out later. So yeah.

Clarence J. Jones: You have futurist in your titles.

Michael T Osterholm: No, you know, this is where I think in public health, we need to offer more what I would call just plain common sense. Because all the things I've just talked about—why these diseases are increasing—has nothing to do with some magical mystical insight. It's just how A plus B plus C. How do you get there? What does it mean when we see all of this? And so I think that, you know, it's an issue of, well, let's walk this through and see what this means. Okay? And, you know, for example, today agriculture has changed dramatically, with large animal production facilities, millions of birds, etc., that poses this whole new way of amplifying viruses and mixing it up. I could go through a laundry list. Look at antibiotic resistance today. I mean, we use antibiotics, unfortunately, as the defensive drug of the century. If in doubt, over medicate. And we're losing our antibiotics because of that. You don't have to be a superstar to understand these kinds of things. So I think it's more a matter of how do we bring reality to our educational experiences to those who are out there and understand what's going on? Let me just give you one other example. You know, I happen to spend some time working on prairie restoration and boreal forest restoration, etc. People are all talking about climate change right now as being very critical as it relates to tick movement and potential Lyme disease. Well, ironically, it's not climate change. Climate change can play a role, but ultimately, it's about the fact that 120 years ago, we started stopping forest fires. As a result of that, we've seen the successional forests in the East, the Middle East. You know, we used to be prairie oak savannas in the Upper Midwest, right up towards the boundary waters. And today, because there are stopped fires, we've seen the white-footed mouse in a whole different environment emerge. And at the same time, we've seen population centers develop in those areas. So, you know, we should not be surprised that we're seeing these whole new efforts or involvement of ticks, because they're now living in forests that never existed before, because every 50 to 100 years they burned.

Stanton Shanedling: Hmm.

Michael T Osterholm: No, I mean, it's just something else. Simple. It's just that simple.

Clarence J. Jones: So, let me do a follow-up question with you. With all the things that you said, how do we create trusted sources? Because I think that there are so many different things that are happening. Where do you go? What tips do you have for us, as a community, to create more trusted sources?

Michael T Osterholm: Well, you know, Clarence, you hit on the question of the century for public health. I think you said it so well. This is a huge challenge. And one of the reasons that in my new book coming out, I say we're less prepared for a future pandemic than we were before is because of the loss of trust.

Stanton Shanedling: Yeah.

Michael T Osterholm: And I think that that is a huge issue. You know, my own personal approach to it is, first of all, humility, humility, humility. Say when you know, and if you say you know it, why do you know it? How do you know it? It can't be personal opinion. It can't be, you know. If you don't know, say that. But then tell people what you're going to do to try to find out and tell them, "I'll let you know when we find something new. It may not answer the whole question, but the bottom line is this is where we're at." I think we need a major new understanding of how we do public health communication. I think it's one that we're desperately needing much more work in. We won't gain back the trust as long as people perceive that we think we know everything, we're gonna tell them exactly what to do, and oh, by the way, that didn’t work.

Clarence J. Jones: Hmm, yeah.

Stanton Shanedling: You know, there was a recent, actually very recent, I think it was yesterday—what's today? Today's the... yeah, it was yesterday in The New Yorker. There's an article that came out, The Veterinarians Preventing the Next Pandemic, and it was really an interesting article in the sense that it really focused on animals overall and their linkage to us as humans as far as pandemics are concerned.

Michael T Osterholm: Yeah.

Stanton Shanedling: Well, you know, at the risk of raining on a parade here, I think that article was in some ways misdirected.

Stanton Shanedling: Okay.

Michael T Osterholm: And what I mean by that is that clearly, the zoonotic issues of animals and humans is very important, and the next pandemic will have at its root cause an animal reservoir of some kind that spills over into humans. So that's not even a question. But the challenge is there really are only two infectious agents today that have the potential to cause a pandemic: influenza and coronaviruses. For a virus to cause a pandemic, it's got to be able to be what I call a "virus with wings." In other words, it will move quickly around the world. It will be one that respiratory transmission will play the most critical role. And I'm talking about effective respiratory transmission. We will not have seen it before in a way that immunologically some of us might be protected by having previous experience. So, the article did a great job of laying out these events that occurred. I think the group, for example, in the zoos in New York, were absolutely essential in identifying what happened with West Nile. They were very important. But West Nile has never posed a challenge with a worldwide pandemic. It's going to cause problems, it's going to continue to cause problems, but that's not where it's at. Impacts, you know, unless MPox takes on a virus with wings-like issue where it's respiratory-transmitted. Contact, and particularly sexual contact, will not be a reason for a worldwide pandemic. So I think one of the things that we need to understand is, you know, what are the diseases that kill us? What are the diseases that hurt us? What are the diseases that concern us? What are the diseases that scare us? And how do we distinguish between them all? Right now, we need to focus heavily on coronaviruses and influenza. Today, I have the lead article out in Foreign Affairs on our lack of preparedness for influenza or coronavirus pandemics of the future, and really go into what we need to do. You know, our influenza and coronavirus vaccines are good vaccines, but they're not great. They lack long-term durability, are easily evaded with new variants or new strains. We don’t really understand that yet. We're still using, for influenza, largely 1940s technology. We make it in chicken eggs. I mean, it’s crazy. So we can do a lot better. So I think that's where we want to focus on. Taking pandemics off the table would mean having coronavirus and influenza vaccines that could be pre-delivered, meaning that they cover such a broad brush that if I got vaccinated today, no matter what Mother Nature threw at us tomorrow, we'd have some pretty good protection. I actually believe that's possible. Our center at the University of Minnesota, SIDRAP, actually leads the world in that. We are responsible for the overall influenza vaccine roadmap work as well as the coronavirus vaccine roadmap. So WHO, NIH, all these use our materials. We’ve seen real advancements made in these vaccines, but we’re still a decade or more away from having game-changing flu vaccines at the rate that we're supporting it right now.

Michael T Osterholm: So, I think that article was helpful in illustrating how, in the meantime, we're still going to have a lot of these skirmishes that show up. There are still challenges, and they’re still very important. But they’re not pandemic-causing. And, you know, one day, maybe there’ll be a new virus class that will come into play. That will be a pandemic virus. If Ebola ever becomes airborne, if, in fact, MPox becomes much more efficient at airborne transmission, then I might be saying there’s a third category. But right now, it’s flu and coronaviruses.

Stanton Shanedling: Barry.

arry Baines: I have one statement and a question for your comment. One of them involves humility, and I think that’s very important. In science, you develop a hypothesis or theory, and it seems to hold up, but there's always the expectation that something will challenge it. As we learn more, we may need a new theory or hypothesis. Unfortunately, the public often thinks that if you change your mind, you lose trust. They might think, "Well, wait a minute, you told us one thing, and now you're saying something else." They don't account for the fact that we have new information. It's an educational challenge to explain to the public that things will evolve, though hopefully not as quickly as the coronavirus variants did. If you have any thoughts on that, I’d love to hear them. The other point I want to bring up is that most TV commercials now are about these new biological treatments for various ailments, especially immunotherapy. The small print always mentions that these drugs can increase susceptibility to diseases like tuberculosis, and I wonder how you think this might affect the spread of infectious diseases as more people turn to these kinds of medications.

Michael T. Osterholm: Well, thank you for the point and the question. I’ve always said that science isn’t about facts—it’s about learning. The process of science is trial and error. You try things, and when something doesn’t work, you try another approach, and from there, you learn. Over time, facts can change as we learn more, but it’s important to communicate this to the public ahead of time. We should prepare them by saying, "This is what we know now, and as we learn more, this may change." For me, that’s never felt uncomfortable, and I don’t get defensive. I simply say, "I don’t know," and explain what I do know and how I know it. Too many of us feel obligated to be right and present facts as fixed, but that’s not the nature of science. People understand that things can evolve as new information emerges.

Barry Baines: Yes, I agree. We need to communicate that evolution of knowledge to the public.

Michael T. Osterholm: Absolutely. A good example of effective communication is how the U.S. Weather Service works with hurricane models. They give you different models and show you the variability, and people generally don’t feel misled. They understand that predictions can change. We need to do more of that in science and medicine, saying, "Here’s what we know, here’s what we don’t know, and here’s what we’re still learning."

Stanton Shanedling: That’s true in medicine too.

Michael T. Osterholm: Exactly. But some of the biggest challenges I’ve had are with my own colleagues in public health. For example, during COVID, there was a lot of misinformation about masking. Some people said anything covering your face was a mask, even if it didn’t cover the nose. But that’s not how masks work. The public saw this inconsistency and got confused. It’s important to have credibility and be clear about what works and what doesn’t.

Barry Baines: It’s a challenge when everyone gets a platform, even if they don’t know what they’re talking about.

Michael T. Osterholm: Exactly. The problem is that anyone can have a voice, and sometimes TV producers or reporters don’t know the difference. That’s when misinformation gets out. All you can do is stick to your track record, acknowledge what you know, and admit when you don’t know something.

Barry Baines: Regarding the biologics you mentioned earlier, it’s interesting because the kinds of immune-compromising conditions these drugs can cause—like increasing susceptibility to tuberculosis—are more of a concern in low- and middle-income countries, not in high-income countries where these drugs are marketed. If you gave these drugs in places like Gaza, they’d have very different side effects compared to high-income countries like the U.S. For most of these drugs, they won’t be a problem here, but they could be in places with high disease burden.

Michael T. Osterholm: That’s right. The challenge is that these drugs aren’t intended for low-income countries, where the diseases they cause are more prevalent. But for high-income countries, they pose less of a concern, aside from immunological issues they might cause.

Stanton Shanedling: It’s interesting how disease spread has changed. Historically, epidemics were somewhat self-contained within regions, but now we have air travel, technology, and rapid global movement. For example, we saw COVID spread from China to cruise ships and then to the U.S. It’s much harder to contain diseases now.

Michael T. Osterholm: Yes, that’s a great point. During the pandemic, I worked in every Presidential administration since Ronald Reagan, and my role during the Trump administration was as a science envoy for the State Department. I was also on the Biden-Harris transition team for COVID. Despite this, I often found that my biggest challenges came from my colleagues in public health, not from the public. There was no single public health voice, and differing opinions caused confusion. But, we can learn from programs like the black barbershops and hairstylists programs, which reached people in their communities. These barbers became trusted voices, giving better information than many experts or media outlets. When people trust the source, they’re more likely to listen.

Clarence J. Jones: I agree with you, Michael. Barbers are trusted figures in communities. They have a unique relationship with their clients and can communicate health messages in a way that resonates. The barber chair is a space where people feel comfortable and open, and if we can use that to spread health information, it can make a real difference.

Michael T. Osterholm: Exactly. These kinds of trusted voices are crucial. The black barbershop program was one of the greatest successes of the pandemic in terms of outreach. When people hear health information from someone they trust, it can make all the difference.

Stanton Shanedling: Yes, we worked on teaching people to check their blood pressure in barbershops. The same concept applies—trusted community members can have a major impact on public health.

Michael T. Osterholm: Absolutely. Effective communication within a community, by people who are trusted, is key.

Stanton Shanedling: Speaking of new health concerns, let’s talk about monkeypox, now referred to as mpox. What do we need to know about it?

Michael T. Osterholm: As I mentioned earlier, global immunity to the poxvirus has diminished with the aging population, as smallpox vaccination ended in 1979. This means that most people today, especially those born after 1979, have never been exposed to smallpox or the vaccine. Smallpox immunity provided protection against other poxviruses, like monkeypox. Now, without that immunity, there’s more susceptibility to diseases like monkeypox, especially in populations with lower immunity levels.

Stanton Shanedling: Right, right. And I wonder if it was almost dictating to the public a false sense of security. You know, it's like, "Hey, we identified someone at your place of work who came down with COVID, so now we’re telling you to do XY and Z." Well, if you're not feeling well, you should stay home anyway, no matter what the illness is.

Michael T Osterholm: Yeah. And that’s the challenge. I mentioned earlier about lockdowns. I wasn't supportive of them. The vast majority of lockdowns that actually took place were really not lockdowns. They were an illusion. For example, in Minnesota, the governor put in a stay-at-home order except for essential workers. That clause was key. It turned out about 83% of Minnesota's workforce was considered an essential worker. Is that a lockdown?

The poor governor got blamed for shutting down the economy, but the reality was people were too afraid to go into public spaces due to fear of getting infected. It didn’t matter what the political leader said. This whole thing is about setting the facts straight: what makes a difference and what doesn’t. We’ll hear more discussions about the economy being destroyed by lockdowns, but when you look at it, calling them lockdowns was just an oversimplification.

Stanton Shanedling: One thing I became really sensitive to was proper funding. So, if the nation is going to be proactive based on what we've gone through, what’s your sense of appropriate funding and focus for the funding?

Michael T Osterholm: Well, first of all, there’s never enough funding. But what does that mean? Today, I mentioned earlier, the lead article in Foreign Affairs is my piece on vaccine preparedness for influenza and coronavirus, and the lack of funding. We have a model for public health funding that’s based on a biennium—every two years—with very limited foresight.

Take the defense department funding: when they decide to build a new aircraft carrier, it’s a 14-year process, and they fund it for the whole 14 years. Now, compare that to the funding for influenza vaccines, which is mostly from the U.S. government, but less than a billion dollars. There’s no long-term planning for funding. It's biennium to biennium. If we want to prevent a pandemic, we should invest in vaccines like we fund the defense department. Right now, we’re still making the vast majority of our flu vaccine in chicken eggs—that’s 1940s technology! We need to think long-term, and we’re missing that.

Stanton Shanedling: So, we're very strategic but only react to what’s immediately in front of us. That can be dangerous, as we saw with COVID. History shows that something like this will happen again.

Michael T Osterholm: You know, C.S. Lewis once said, "If you don’t know where you’re going, any road will get you there." That’s where we are right now. We’re all going to die someday, but it’s about living healthy lives as long as we can, free of pain and with good cognitive function.

We need to focus on investing in public health to achieve that. Kids shouldn’t be dying from vaccine-preventable diseases. That should be a clarion call. We need to set our priorities straight.

Stanton Shanedling: During COVID, I was focused on cardiovascular issues and contact tracing, but I couldn’t help but notice how politics became a negative factor. It was getting in the way of public health, especially in terms of providing accurate information.

Michael T Osterholm: Yeah, that’s true. It’s tough.

Stanton Shanedling: Mike, this has been great. Last thoughts?

Michael T Osterholm: First of all, it’s an honor to be with you. If you’re a student of public health or considering it, this is a great time to get involved because we have a lot of challenges. I’m encouraged by the graduate students I have right now—they’re as good as any I’ve had in my 50 years in this field. I hope our conversation today helps people understand where we’re at and what we need to do.

Stanton Shanedling: I agree. Clarence, last comments from you?

Clarence J Jones: This has been phenomenal. It’s been a pleasure to finally put a name and a face together. As a health leader, you’ve set the standard for me as a community member. I appreciate how you break down complex issues in an understandable and doable way. Thank you again.

Michael T Osterholm: Thanks, Clarence. It’s an honor to be with you.

Stanton Shanedling: Barry, last thoughts?

Barry Baines: The discussion has been wonderful. I also wait until November to get my flu vaccine!

Michael T Osterholm: You’re a smart man, Barry.

Barry Baines: Yes, and every communication from my family medicine group is talking about a surge in COVID. Public health messaging can get confusing, especially with conflicting advice on when to get vaccinated. But thank you, Mike, for being on the program. It was wonderful to hear about all the great things you’ve done. Please continue your great work.

Michael T Osterholm: If Stan asked me to walk over broken glass barefoot, I would. It's a good honor.

Stanton Shanedling: Well, one last thing: you have your own podcast, The Osterholm Update, which comes out every other week. I encourage our listeners to check it out.