Episode 191: 'The Big One' with Mark Olshaker, Ann Hennigan Grace, & Dr. Sydney Redepenning

Chris Dall: Hello and welcome to the Osterholm update, a podcast on COVID-19 and other infectious diseases, with Doctor Michael Osterholm. Doctor Osterholm is an internationally recognized medical detective and Director of the Center for Infectious Disease Research and Policy, or CIDRAP, at the University of Minnesota. In this podcast, Doctor Osterholm draws on nearly 50 years of experience investigating infectious disease outbreaks to provide straight talk on the latest infectious disease and public health threats. I'm Chris Dall. Reporter for CIDRAP news. And I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update Podcast. At an unspecified date, sometime in the future, a farmer in the southern tip of Somalia, near the border with Kenya, has come down with a nasty virus that's given him a cough and chills, made his head and muscles ache and left him gasping for air. One of his sons appears to have caught the same bug. Not far away, The one-year-old daughter of a Somali family traveling to a refugee camp in Kenya starts experiencing similar symptoms. Within a few days, all three will be dead. Felled by a mystery illness that appears to be spreading. A community health worker in the region and the doctor overseeing the camp's hospital soon start seeing more patients with eerily similar symptoms and relay what they're seeing to regional health officials.

Chris Dall: Meanwhile, a young French aid worker who's recently been at the camp. An Indonesian importer exporter who's been conducting business in the region, and an American college student volunteering in Kenya with members of his church over the break are all on flights back to their home countries, and some are starting to feel unwell. These are the opening moments of a chillingly familiar but hypothetical pandemic scenario presented in the new book The Big One by Doctor Michael Osterholm and his longtime collaborator Mark Olshaker. The book walks the reader through the challenges faced by a fictional cast of US and world leaders as they grapple with the coronavirus that wreaked even more havoc than SARS-CoV-2. Hampered by many of the issues that plagued the COVID-19 response. Along the way, Osterholm and Olshaker review and dissect the many mistakes that were made during the COVID-19 pandemic, highlighting the key lessons that will be critical to mitigating the impact of the next pandemic. For this episode of the podcast, I'm joined by Doctor Osterholm and Mark Olshaker to discuss The Big One. Also joining us for the discussion are Ann Hennigan-Grace and Sydney Redepenning, who conducted the research and fact checking for the book. Mike, Mark, Ann and Sydney, welcome. I'm looking forward to this conversation.

Mark Olshaker: Thank you Chris.

Ann Hennigan-Grace: Thanks, Chris.

Chris Dall: Mike, let's start with the concept for this book. You and Mark have concocted what you call a scientifically plausible and very possible tabletop exercise involving a pathogen that you ultimately call SARS-CoV-3, and you weave that hypothetical scenario with lessons learned from the COVID-19 pandemic. Why did you take this approach?

Dr. Osterholm: Well, Chris, first of all, the entire book evolved over time from the beginning of the pandemic. As you know, Mark and I had written a book back in 2017, Deadliest Enemies, of which Ann was also a very important part of that book. And at that time, we laid out what a pandemic would look like of influenza, not at that time realizing that it would be a coronavirus, but there were so many similarities. And unfortunately, as we walked through this pandemic of COVID, Mark and I recognized that we were making mistakes in how we were responding to this pandemic. And at that point, we said, you know, we really need to write a book about this pandemic. When it finally ends and what lessons should be learned. We were realistic with this in going to our publisher, who also had published our 2017 book, and saying, this is not going to get written soon. We are going to likely be in a pandemic state for a number of years two, three, maybe even four. And to really understand lessons learned, it's going to mean we're going to have to take in that whole pandemic. So that, first of all, was one of the challenges we had because things did change over time. But one of the things that we also realized in working with our editor is the fact that to really make this sink in and to show what a different kind of pandemic could look like, one that was much more severe than COVID and one that is realistic, we needed to lay out a story. How does a pandemic really unfold? One that may kill 25 or 30% of the people, as opposed to 1.5% of the people? What does that mean? And so, the scenario really was a tool that was developed to build throughout the book in a chronological order, in which we then could also cover the very issues that came up with this recent pandemic by time. And what did we learn? And so, it was a tool that initially we hadn't considered, but one that I think has now served the book very well.

Chris Dall: So, Mike, one more question before I get to the rest of the team here. The virus you describe in the book has characteristics of both SARS-CoV-2 and Middle Eastern respiratory syndrome, or MERS. Why those two viruses? Well, first.

Dr. Osterholm: Well, first of all, COVID was a wakeup call to what actually we might experience with a pandemic of a coronavirus. Remember, the SARS appeared in 2003 and was relatively easily contained. When I say easily, I don't mean that it was easy, but relative to what we saw with COVID, it was very different because it wasn't nearly as infectious as we have seen with COVID. Well then along comes MERS, another coronavirus that caused, again, a very similar type of illness, severe illness in humans in 2012 and 2015. I was familiar with the original SARS virus because I was still at that time consulting at the Department of Health and Human Services following  9/11 to actually get involved with SARS. But then with MERS, which picked up in 2012, I actually had an opportunity to go to the Arabian Peninsula where that emerged, serving as an advisor to the royal family, the United Arab Emirates. And then when we had a traveler from South Korea who was in the Middle East, who came back to Seoul in 2015 with MERS and actually started a major outbreak within Korea and including a very significant outbreak within one hospital. And again, I was in Korea helping with that. And what I was struck by was the ability for this virus to kill. With SARS, it killed about 15% of people.

Dr. Osterholm: But with MERS, we got up to as high as 35% of the people. And what was different, again, as I pointed out, was it was not nearly as infectious. Well, we now recognize what made COVID very infectious, but fortunately kept the case fatality rate less than 1.5% might actually just be a harbinger of things to come. That, in fact, what happened if you had a virus that had the capacity to infect like COVID, but the ability to kill like MERS or SARS? And believe it or not, we have now found viruses in bats, in caves in China that have very much that construct of what they could do. And so, this is not just science fiction. We actually know these viruses exist. We know that this could be a possibility. So, we chose this one as the virus to use because it was so current in terms of people's sense of a coronavirus. Yeah, it can do harm. But now put this as a coronavirus that might kill this very high number of people, 25, 30% of people. And it surely gives you a perspective that says, wow, this could be really bad.

Chris Dall: Ann would you like to chime in?

Ann Hennigan-Grace: I only wanted to build off of your question about the use of a fictionalized virus in the beginning of each chapter of the book. And I think one benefit of including the fictionalized story is that, as Mike has noted many times, your understanding of how bad COVID was really depended on where you were located, and so that if you experienced COVID in the very beginning days and you were living in New York City, you might have a different sense of how bad things were than if you were living someplace rural, that really wasn't very badly hit. And the nature of this fiction, really, although it is fictionalized, ironically, it gives everybody the same understanding of the truth who's reading the book. So, it becomes easier for us to pull from that story and give examples as well as from COVID, and make sure that everybody is on the same plane in terms of understanding the point.

Chris Dall: So, Mark, let's get you in here. As I noted in the intro, the scenario is chillingly familiar to those early days of the COVID-19 pandemic. So, in a sense, you had a template to work with. And reading the scenario, I just kind of felt this feeling in my gut. It just it just took me back to the reading, the early reports out of Wuhan and then people in Italy and people traveling on airplanes. But without giving too much away, the virus that you describe is more deadly than SARS-CoV-2. How did you think about that balance between creating a scenario that is pretty scary but is still plausible. And did you get some outside input on this?

Mark Olshaker: Well, we certainly got outside input, Chris. Everything we've done is completely vetted, first of all, and went through it all and checked it very carefully. And then Sydney did so then we went to recognized experts internationally to make sure we were on the right track. But going back to the 2017 book The Deadliest Enemy, our chapter on coronavirus was called SARS and MERS Harbingers of Things to come. So, we were kind of on the lookout for something like this. And then, as Mike said, if you combine two coronaviruses, one of which is highly infectious and the other is quite deadly, you could come up with a kind of a nightmare scenario. At the same time, we realized what we were doing. And Ann and I have worked on many books on true crime together, and this is, in a sense, the same thing, only the criminal is a microbe rather than a human being. And what we have here is a great mystery story, which is what public health really is, as well as high technological drama as you try to deal with one of these viruses. And we're pretty sure that the next pandemic, the big one, if you will, will be an airborne virus. So, to answer your question, we tried to come up with something which was completely realistic, not over the top science fiction, but something that would really get people's attention. And then, as Ann said, this starts out at the beginning of each chapter, and then we go into the various aspects of what a pandemic would really mean and how we should deal with it, whether that's the history of viruses and plagues and other public health emergencies, whether it's communication, virus, vaccine development, public policy, surveillance, all the other things that come into play.

Chris Dall: And for the group, I'll go to Ann and Sydney here.

Mark Olshaker: Excuse me. Let me just interrupt one minute to say we really want to congratulate Sydney on just recently obtaining her PhD. We are all so proud of her and so glad to be part of her team, that just that could not go unmentioned here.

Chris Dall: And I thank you for mentioning that.

Dr. Redepenning: Thanks, Mark.

Chris Dall: So Ann and Sydney, as researchers and fact checkers, were there any moments where you pushed back on Mike and Mark and said, okay, hold on a second. This is not plausible. It wouldn't happen like this. Well, you know, what were the group conversations like? I'll start with you, Sydney.

Dr. Redepenning: Yeah. So, I think in general, there weren't really too many moments of major concern. But what I think most readers might not know just from taking a read through the text, was all of the numbers that we included anywhere in the scenarios that for any reader reading through, they would just pass through the book, reading the number and not thinking much of it, and not knowing that dozens of phone calls and zoom calls and emails and hours of thought behind each of those numbers was considered before we decided whether any of that was going to be plausible. And I remember near the end of working on the manuscript, after we had had some of Mike's colleagues that read the advance copies of the manuscript that had their input on some of the numbers that we included. So, all of those came from not just me and Ann and our input on numbers that were included in the scenario, but also from other experts in the field. And then we compared what we found happened with COVID and in the 1918 pandemic, and that all went into sort of shaping everything that went into the scenario. The other thing that to me, when kind of reading it and thinking about plausibility, that will always remain a question about whether it was plausible is how a politician might respond if this were to really happen. And of course, that's just something that we can't predict because we don't know who will be in office when the big one hits. But the president, without giving too much away in this book, we don't specify the political affiliation or the party of that president, but in general, they are acting from the best interests of the people and based on the available data. And to me, reading that it's a hope and it's a wish for what could happen during the big one, but we really just don't know who will be in office and how plausible that will be.

Chris Dall: And I want to get back to that in a moment. But Ann, this is very different from true crime. I mean, I would assume writing about true crime. You don't have the kind of statistics that you needed for this book. What are the similarities and the differences between writing about this kind of scenario, the true crime work that you and Mark have done?

Ann Hennigan-Grace: I think you've actually accidentally hit on something that's, I know, very near and dear to everyone's heart in this podcast, which is that the real story is the victims. And if the bad guys or the bad viruses didn't kill real humans, I don't know that many people would care very much. But, you know, Mike says all the time that these numbers aren't just numbers. Every number that you hear is somebody's great love, somebody's son or daughter or best friend or other family member, and it touches our lives. So, from that standpoint, it's not that anything that we came up with, the experts said, oh no, that's way too bad. It was almost from the standpoint of having to rein it back so that we wouldn't have so many people. You don't want a virus that's actually so effective at infecting people and killing people that it runs out of hosts and essentially wipes itself out. So, there was that balancing act that Sydney alluded to of trying to get a number that would be big enough that it would live up to the title, The Big One, and would scare people into paying attention to what we need to do to get prepared, and yet not so big that it really would kill everybody before it had a chance to make it around the world. So, I hope that answers your question.

Chris Dall: Yeah, absolutely. Mark, I want to come back to you. This is the second book you've collaborated on with Mike. How did this relationship originate, and how does the conceptual and writing process work between you and Mike?

Mark Olshaker: That's a good question, Chris. As we've alluded to, I've done a number of books with John Douglas, the FBI's criminal profiling pioneer, Special Agent John Douglas. And I was then approached in the midst of all this to write a book with Doctor C.J. Peters, the Chief of Special Pathogens for the Centers for Disease Control. And who, if you all remember Richard Preston's book The Hot Zone, he was kind of the star of that. So, I wrote a book with CJ called virus Hunter, which Ann was also a researcher on. And after that came out and got pretty good notice, Mike actually approached me. He was a friend of CJ's. And so, one day I met him up on Capitol Hill when he was in Washington giving briefings to senators and congressmen. And we kind of hit it off and we said, yeah, we should do something together. And it was several years before the right thing came about. And in the midst of the Ebola epidemic in Africa in 2014, we said, you know, now we finally got the public's attention. Let's try something. And what we said is Ebola is not what's going to cause a major worldwide problem, but other things are. And now's our opportunity to alert the world. And that's where Deadliest Enemy came from.

Chris Dall: And Mike, is there anything you want to say about the relationship between you and Mark and how the two of you work together?

Dr. Osterholm: Well, I think, first of all, I always caveat my comments about Mark by saying, I feel like we're twin brothers of different mothers, and he has a way of helping to communicate what might seem very obvious to a scientist, but to the public would not be an obvious statement in which he helped, I think, lay that out. And that's hopefully one part of the book that people will see that in fact, it is hopefully easy to read. One of the things I think that Mark also gets is he's able to take the science and the whole public health approach that we talk about in responding to an infectious disease issue in such a way as that, because of his understanding of that issue, he's able to tell a story, too. So, I think we work very, very well that way. And I might add that during the pandemic, we published a number of really important op eds in The New York Times and The Washington Post that we talk about in the book, because, for example, in March of 2020, we wrote an op ed in The Washington Post that said, do not do lockdowns, do not do them. Okay. Which turned out to not be the advice that people took. But later we learned why. We also talked early on about airborne related viruses and why this pandemic was going to be such a challenge from an airborne transmission standpoint. And so, you know, the book in and of itself was an accumulation of all this gathered information, but we were actually writing and disseminating this information long before the pandemic. We did a very extensive piece in foreign affairs about being prepared for a pandemic and what that means. And so, the book itself really is a summary, you might say, of what has been a very wonderful and I say with great feeling, a very beautiful relationship.

Mark Olshaker: Yeah. I mean, Mike wants to get it right. And that's what Ann and Sydney have been so instrumental in. I want it to be exciting. I want the reader to keep saying what happens next and trying to use all of my novelistic skills to make that happen. So, I think it's a very good collaboration between us. Mike is the real scientist, no question about that. And virtually everything I know about this field I've learned from him.

Dr. Osterholm: Mark is really very, very good at bringing in outside information. And what I mean by that is if, for example, John Berry, who wrote the very famous 1918 influenza book consulted with us on numerous occasions, provided us with really important information. We had a number of people like that, and Mark's engagement with them was at a similar level as mine. I mean, it was a really good partnership. And so, I think that also helped us a lot, was being able to work with outside individuals to vet it, to get their ideas, to bring those ideas back. And what do we do now? How do we interpret this? And so, I think that surely added to the overall construction of the book.

Mark Olshaker: Yeah. And I think when we would tell a story like that Ann would check us over. And then later when Sydney came on, she would too, to make sure we got all of our facts right.

Dr. Osterholm: Can I add that in this scenario, it is factual. Ann did an amazing job of talking about an airport, how many airplanes fly in and out, or you know what the transportation requirements.

Mark Olshaker: How long it takes to get from one city to the next, and how much incubation time each of these microbes needs.

Dr. Osterholm: And what health agencies or health departments were available to respond to this in that part of Africa. All these things. And so, we owe Ann a great deal for assuring that everything there is technically correct. That just as easily could be a report of a real emerging pandemic from that area.

Mark Olshaker: And our last chapter actually has a real after-action report of our mythical pandemic.

Chris Dall: And that sounds like yeoman's work. I hope you got overtime pay for this.

Ann Hennigan-Grace: It was actually fascinating. Really, really fascinating because as much as I like to think of myself as the person who pulls together Mike's insistence on the science being right and Mark’s wanting everything to be gripping and a page turner. And I'm sort of the buzzkill that brings them both together. So, but it was fascinating because I had to get into the nitty gritty of the reality points that are so terrifying about why we are not prepared, just not prepared.

Mark Olshaker: Just on a practical level, and kept us on track with each iteration. And believe me, this was a very, very, very iterative process. We would go through 17 or 18 separate drafts of each chapter and Ann kept track of them all and insisted that only one of us, only one of the four of us, could work on a draft at one time. And we still had some confusion. But Ann kept us basically on track.

Ann Hennigan-Grace: And then I knew that I had Sydney to make sure that, as my safety net.

Chris Dall: And I will note for our listeners, Sydney and I share an office, and I overheard some of those conversations. I was on Sydney's end of the conversation. You guys really got into some nitty gritty on this.

Dr. Redepenning: We did. I remember one of those. It was a number in the scenario that we had. It was one morning, and I think between my calls to Ann and then I think a few to mark, and then several calls to Mike and then back and forth. You, Chris, probably overheard like 12 phone calls in one morning about just this one specific number, because that's how detail oriented, we all are and how important it was to everyone on this team that we get it right. So, thank you to Chris for bearing with all of us, as you overheard those very detail focused conversations.

Mark Olshaker: I can tell you on more than one occasion Ann and Sydney would say to Mike and me leave us alone. Let us go work this out and figure it out, and we'll let you know when we know what we have to know.

Dr. Osterholm: You know, at this point, Chris, I would just like to add one additional piece as we're talking about this scenario, we owe a tremendous amount to our editor, who is at Little, Brown and was the editor for our 2017 book Deadliest Enemies, Tracy Behar. She also started as our editor at Little, Brown for this particular Book, but left with a very wonderful promotion as we were in the process of writing this. And it was actually Tracy that came back to Mark and I and said, you know, this is complicated stuff. How do we tell the story? And that was the whole point. You got to tell the story. And so, she is the one that encouraged us to actually use the scenario-based approach with each chapter, as well as the nonfiction aspect of it. And I think Mark and I would both agree that we owe Tracy a very real debt of gratitude for all that she did to help make this book I think what it is.

Mark Olshaker: Yeah, she called it a thought experiment that we should do. And that's exactly what this scenario was based on the kind of tabletop exercise that you mentioned, Chris, that Mike has conducted for us, many public health and government officials over the years. And then when Tracy left, we were just as fortunate to have her replaced by another editor, Alex Littlefield, who absolutely got what we were trying to do, completely supported us. And then when we came up with the first draft of the manuscript, really gave us tremendous guidance about putting in more signposts, explaining what we wanted to do. And so, between Tracy and Alex and, of course Ann and Sydney and our publicity team and everybody, we we've really had a tremendous team behind us, I have to say.

Chris Dall: So let's talk about that other element of the book, which is an assessment of how the COVID-19 pandemic was handled. What we got wrong. What we got right and what we can learn from all of it. And you break those mistakes and lessons down into a few buckets. So, Mike, can you talk about a few of the mistakes that you think really shaped the COVID-19 response?

Dr. Osterholm: Well, again I would come back to the op ed pieces that we wrote throughout the course of the pandemic, which served as a basis for our discussion, because I think they were timely. These are not just recollections of what happened 3 or 4 years ago, but they were at the moment. One was an example of where in March of 2020, Mark and I wrote this piece in the Washington Post that don't do lockdowns because they won't work. Why? Because this is going to last for months and months. You know, I said on the Joe Rogan Podcast in early March, you know, this is going to go on for potentially several years, and this is what it could look like. Well, if you go into a lockdown in the first days, what are you trying to do? Are you going to stay isolated like that for 3 or 4 years, if that's what's necessary? Well, we know that's not possible. And of course, if you die in the first six months, that's really unfortunate. But if you die in the second six months of the pandemic or the third six months or the fourth six months, you're still pretty much dead. And what we needed to do was establish a response that actually said, what are we trying to do to get us through this pandemic? And that's why lockdowns, which have been tremendously mischaracterized by a lot of people who have written about this, is they really only existed largely from the end of March until early June in, in this country.

Dr. Osterholm: And in fact, for only 40 states actually had formal government lockdowns. But on top of that was the fact that if you even take a state like Minnesota, where the governor actually issued a stay-at-home order. But if you are an essential worker, you were exempt from that. That was 80% of our workforce was considered essential workers. So that really wasn't a lockdown as such. What we proposed was what is the most important thing that will help people get through this pandemic and stay alive is good medical care. But if your hospital is running at 120%, 140% capacity, you know you're not getting good care. And so, what we propose is this needs to be like snow days, where in fact, if you had a number every day in your community that they knew what percentage of beds were filled. And if you got to a 90, 95% census, you needed to ask the community, like a snow day, please. We now, for the next week or two, pull back public events. Pull back, you know, your pull back, the opportunity for the virus to be spread by you or others in public. And let's try to get that bed census number down in such a way that if I do get infected, which I likely will sometime during the pandemic and as we saw, virtually everybody eventually did. I have a better chance of surviving because at least the hospital can take care of me.

Dr. Osterholm: That was so misunderstood, because what happened when we got out of lockdowns at that point, there really wasn't an announcement saying, we're done. Okay. That's why I think a lot of people perceived this went on and on and on, and it didn't. There were surely things that happened in the community. People shut down restaurants, people altered how they went to professional sports and so forth, but not because the government told them to do it, because that's what the people were demanding. People were afraid to go to a restaurant. And so, in our chapter on responding to the initial days of the pandemic, we go into this, you know, what could have been the option, as opposed to a lockdown concept and the fact that today, how many people are writing articles about what the lockdowns did to the economic aspects of the pandemic, when in fact they had nothing to do with it, they were over with in the first 2 to 3 months of the pandemic, but there still were huge economic implications because that's what a pandemic does.

Dr. Osterholm: And so I think that's one example of something that we tried to deal with where we tried to help people understand that for us to get through this, we needed a long term plan. And that plan was X. One other area that we are thoroughly critical of was a lot of the modeling work that went on. A lot of the modeling work was black box magic. It did not give us really any sense of what was going to happen, because this was about the variance as these variants came through the population. The number of infections, the seriousness, the illness changed dramatically. No one could predict that. And yet we had people from the quote unquote black box world on TV all the time saying, oh, in three months it's going to be this, or in six months it's going to be this. And they had no idea what they were talking about. The fact that we didn't really give people a better sense of we're not sure what's going to happen here. You know, tell the truth and just say, this is what we know. This is what we don't know. This could all change. And I think, again, that that is really a critical part of what we try to take on in the book are these kinds of issues.

Chris Dall: Ann you want to chime in here.

Ann Hennigan-Grace: I just wanted to add that another part of the book's construct is at the end of every chapter, we do have a summary of takeaways so that whether we're discussing lockdowns and mandates, or we're discussing communication trends or we're discussing whatever the topic is, the readers will be able to see Mike's takeaways on each topic about what we could do better. So, whether we've discussed it today or not, they do appear in a in an individual section at the end of each chapter.

Chris Dall: Mike, you know, one thing that I was told by Minnesota Department of Health official early on in the pandemic was we're building the airplane as we're flying it. So, in some sense, you can attribute some of the mistakes we made to that. Just people didn't really know what they were doing. But you target one thing that it seems like was kind of the original sin here, which was the reluctance of the W.H.O. to say this is a respiratory virus that's spread by aerosols. Am I right about that?

Dr. Osterholm: You're not only right about it, but actually the person who is in charge of science at W.H.O. when they retired several years into the pandemic. In their reflection upon their time at W.H.O., they actually acknowledged that they had made a major mistake and that the one regret she had was that they hadn't been much clearer on this issue of airborne transmission. And this was an important piece. Do you know how many millions of dollars we've spent on Plexiglas screens and so forth that were meaningless, that were not at all there? How many people walked around with their mask on their chin, a chin diaper, or they used a respiratory protection device that was like a bandana that was totally inadequate of protecting him? We didn't do a good job at putting that kind of risk activity into perspective, and then telling the story of why a respiratory transmitted virus like this was so important.

Mark Olshaker: I think, Chris, that Mike brings up a very good point, which is one of our major chapters is on crisis communication. And we really have to do a much better job of conveying what the science knows, what the science doesn't know, what Will be known eventually. But people thought of this as a completely binary black and white situation. Either the science says this, or it doesn't say that. Science, as we've learned, is not about truth. It's about the search for truth. And that's something that people didn't understand. And that's something, unfortunately, I don't think the current administration's health establishment understands. So, we have to make a much better effort. And yes, it was like building the airplane as we're, as we're flying it. But what we realized was and what Mike and I have been advocating for many, many years in various articles and op ed pieces in which we certainly say in the book is we have to think of disease, of infectious disease, of microbes in the same way that the military thinks of human adversaries. Arguably short of a worldwide thermonuclear war, a pandemic can cause much more damage to our way of life than any other possible human conflict. And so, we've got to prepare in the same way. You don't wait until the war starts to build the aircraft carrier or the fighter jet. You have to have it ready in advance. You have to plan in advance. You have to procure in advance, and you have to have a scenario or many scenarios that you can work with. And we think, unfortunately, the opposite is happening. So, I would say to a certain extent our book is kind of the opposite of what's going on. Now, if you want to know what's not being done and what needs to be done, I think we lay it out.

Dr. Osterholm: And let me just give you an example of that, because I think this is so important for the readers to understand, as Mark just detailed. In fact, we laid out a number of proposals that we thought were critical for future preparedness. And of course, I have a memory of having been involved with the 9/11 Commission when again, spending time at the Department of Health, Human Services, that overlap that commission, which was nonpartizan and headed up by a Democrat and Republican, was an ideal venue for actually vetting what went wrong, what could have been learned? How can we fix that in the future? And so, I kind of romantically have the sense of that's what we should have done with COVID. Well, we haven't we didn't. We haven't learned anything except the fact that we still are arguing about the virus come from a lab leak or a spillover in Wuhan. And I think that that's an important point. But one of the other areas that we cover is the fact that the one tool that we have that's very powerful against a pandemic is a safe and effective vaccine that's available on day one of the pandemic. Well, we're not there. For COVID, surely we have good vaccines, but they're not great. They don't always prevent infection. They don't prevent transmission. But they're pretty darn good at reducing serious illness, hospitalizations and deaths. When you look at influenza, which again, is going to cause pandemics in the future, here we have a situation where we have a vaccine, but it's an old vaccine with largely based on 1950s technology.

Dr. Osterholm: It's grown in chicken eggs, you know, something from the 1950s. And our global capacity to make an influenza vaccine is such that we can maybe make enough to vaccinate a quarter of the world in the first year after the pandemic begins. Well, we need a type of technology that could rapidly advance manufacturing. Doesn't have to be a perfect vaccine like influenza vaccine. Much like COVID, it reduces transmission and only in a limited way. It does not prevent you from getting sick necessarily, but it surely reduces serious illness, hospitalizations and deaths. Well, right now, with if we had mRNA technology applied to influenza, we believe that we could have good vaccines that could be manufactured in quantities enough to vaccinate the world in the first year of the pandemic. We're talking about two different scenarios that are difference between millions and millions of deaths. Well, what happened just now? The Trump administration just canceled $500 million worth of work on making an mRNA vaccine technology or reality for influenza. And so even the things that we had in place, which were not adequate to deal with the pandemic, are now gone. Now we're into nowhere land for preparedness. There isn't a single person right now in charge of pandemic preparedness, emergency public health response in the White House. This is the first time in literally decades that we've not had someone there. So, I think one of the things we tried to do is bring that kind of information from the pandemic also in the final pages of the book into that perspective, so people could see.

Mark Olshaker: Chris, I think one of the important points we have to get across is when we published Deadliest Enemy in 2017, we think we got it all pretty well right. We wouldn't take back any of the things we wrote. The one thing we got wrong, and it was a crime of omission rather than commission, was it never occurred to us that in a major public health emergency, a worldwide pandemic, that medicine, public health would become politicized, that there would be different responses between red states and blue states and anything like that. It never occurred to us that what we thought was protecting the public, or doing our best to protect the public would become a political issue. And this is something that we've had to deal with extensively now in this book. And we're seeing it playing out, as Mike says, in real life, right in front of us.

Chris Dall: But Mark, does that get back to, Ann mentioned this earlier, this idea that different areas of the country experienced the pandemic in, in different ways. People in, you know, Kansas didn't experience it the way the people in New York City experienced it.

Mark Olshaker: Well, that's true, but I think also Ann can speak to this and give her opinion. But I think part of it was confirmation bias going in. Preconceived notions about the establishment, about government, about freedom of individual choice. And if you look at how we responded compared to, say, how some of the Scandinavian countries responded, who have a much more cohesive social construct. I think you see a big difference. Ann, do you want to weigh in on that?

Ann Hennigan-Grace: Well, I think a challenge is and now I sound like Mike saying one of our challenges is is that when we were working on this book, we really didn't want to make it a political book, per se. We wanted to make it a call to action from a survival of the species standpoint. Mike called it, this is a love letter to my grandchildren because the focus really is on public health. How do we as humans prepare ourselves to stay alive? The microbes are going to continue to challenge us, and we need to present a united front. Whether you want to call it science based, fact based, however you want to classify it. The fact is that there are humans and there are microbial threats, and viral threats are something that we need to deal with as a species. I would hope that going forward, this book is written very much from that standpoint, not from the standpoint when we discuss things that were decisions that were politicized. Obviously, you can't avoid acknowledging that they were politicized, but we don't take action to promote political agenda in any way. As much as we try to establish a foundation for why the public health recommendations that Mike would make would be valid to consider going forward.

Chris Dall: I want to get back to that in a moment. But, Sydney, I want to ask you, as a person who is in the early stages of their public health career and maybe a future public health leader, I would put money on that. How is this shaped your view of public health and the kind of communication that will be needed for the next pandemic?

Dr. Redepenning: I mean, I think in general, this was a very valuable learning experience, working on something like this because it did shape my views in a lot of ways. Of course, a lot of what Mike and Mark and Ann all put into this book is very similar to the types of things that I've learned working with Mike every day at CIDRAP. But some of the things specific, I think, to the book that stood out to me is I honestly, when I first read the first few chapters of the manuscript, I thought, this feels like a horror movie. I mean, a very realistic one. But it was terrifying because it felt so real. It felt like something that could happen. So, I think being early in my career, it made me think of how important it is that we are building up our public health workforce, something that is a big part of my career that I'm very passionate about is undergraduate education. It's something I've been involved in throughout graduate school, and I'm still involved in and reading this book, I thought, this is more important now than ever because when the big one hits, we need public health workers. We need a strong workforce to be able to respond. I think from the communication perspective, being early in my career and seeing how COVID played out and how public health unfortunately lost a lot of our trust between public health and the public during the pandemic. I think that Mike and Mark do a really incredible job of explaining why that happened, how it happened, and what we can do differently.

Dr. Redepenning: I'm hoping this new generation of public health workers can really prioritize transparency in our communication and this acknowledgment of, and Mike has said this hundreds of times on the podcast before, so I'm sure this will be familiar to our listeners, but that it's okay to say what you know and that it's okay to say also what you don't know what you're doing to find out and what we might not be able to find out for some time because of the nature of evolving science. That being the case for things like lockdowns and mandates and all of these things that were rapidly changing. And as you said, Chris, kind of building the plane as we're flying it and being able to do a better job of acknowledging that as scientists was another really big takeaway that I had from working on the research for this, as well as reading it and being really involved, is that I hope it's something that younger public health professionals take the time to read and really learn from, because I think there's a lot of valuable lessons for us that come from this book that we can take with us. As much as we all want to think that there won't be a next pandemic for us to respond to. We know that that is unlikely to be the case, so I hope that we can learn from it.

Chris Dall: Mike, I want to pick up on that because this is something you talk a lot about on the podcast. This idea of acknowledging what we don't know. But do you think in a future pandemic, aren't people just going to be frustrated with that too? If public health officials are out there saying, well, we're not sure what's going to happen.

Dr. Osterholm: Well, Chris, I think that first of all, it's how you say it. You know, I said many times on the podcast and in my public appearances that this is what we know and this is what we don't know. So, it's not as you come in, as a blank slate. You basically say that, you know, once we saw the variants arrive, for example, we really started to see a very different epidemiology, for example, in children, early on in the first year of the pandemic, many people just wrote children off and said they don't get that sick. It's not that big of a deal. Well over 1500 kids ultimately died in the first three years of the pandemic. 87% of those deaths were in year two and three. It was coincided with the arrival of the Delta variant and then Omicron. And so, we needed to quickly pivot and change and say, well, wait a minute now, this isn't quite the same as we saw in the first year when all those papers were published that said it's not a problem. And so even there, they were right that first year. But they ended up not being right for year two and three. And we needed to correct that. So, I think our job was to tell that story of what we're learning. This is what we know right now, this is how we know it. And that, I think, was what people actually trusted. And you gave them the sense of what we're going to do to try to find out something if we don't know it. So, I never said to anyone, oh, we just don't know. You got to say, this is what we know. This is what we don't know. This is what we're doing to try to find out what we don't know. And this is what it means for you.

Mark Olshaker: The communication is so important. We have to say what we know. We have to say what we don't know how we're going to find it out. And I think people will believe that. And the other thing that's very important that I think Mike has struck throughout the COVID pandemic, and certainly we all want to when the big one hits is we're all in this together, we're going to work together. It's going to be very tough, but we're going to get through it. And if we work together, if we cooperate, if we take into consideration everyone's needs, then we're going to get through it. And I think, you know, we often look back to Churchill during World War Two. He didn't say it was going to be easy, and he didn't say it was going to be short. But he said, we're going to work together and we're going to get through it. And I think that's the same note that we have to put forth. As many of you all may know, I'm also a documentary filmmaker, and I've done a number of films on public health. The first one I used Mike in was right after 2001, after the 9/11 and the anthrax crisis, where we did a film for PBS called Bioterror Living with a New Reality, which Mike was on, and we said, look, we're not saying this is going to be easy, and we don't know everything yet. But, the people during the London Blitz living in the subway tunnels, they got through it and they got through it by cooperating with each other and, having a positive attitude. And that's what we're trying to convey.

Chris Dall: I want to go back to something that, Mike, you said earlier, and either Mike or Mark can take this one, but you mentioned the 9/11 commission, and you talk about in the book you call COVID-19 a microbial 9/11. Is that what you were going for, a 9/11 commission type look back at what went wrong and what we got right?

Dr. Osterholm: Absolutely. And I was part of a smaller group that was made up of some of the people who had worked on the 9/11 commission, but it was a privately funded effort and, you know, really didn't have, how should I say, the horsepower to address these challenges. They did a review on it, and I congratulate them on that. But what we should have done is actually got policymakers involved to understand what happened in a way that they could then bring forward the kind of changes that only policymakers elected officials can do. They didn't do that. They instead spent their time arguing about was Wuhan a lab leak or was it a spillover? And from that perspective, you know, I early on said, move on. We're never going to know. No one will be completely satisfied. So, what we need to do, though, is remember either one of these could happen in the future. So, what do you doing to prepare for a lab leak? What are you doing to prepare for the next spillover event that could occur tomorrow? And we just didn't resonate with the vast majority of policymakers who wanted to go to Partisan politics. And that was really unfortunate.

Mark Olshaker: And the other thing we have to realize is that this is a one world event. What happens overseas affects us. One of the reasons we started patterning our scenario after the severity of the 1918 Spanish influenza, which was the greatest public health disaster of modern times. And what we quickly realized was we were in no better shape now than with 100 years of science and technology than we were in 1919, because we've got four times the world population. We've got the airplane travel, which can get anywhere faster than the incubation of a virus. We've got a billion international crossings of borders every year. We've got megacities which are in terrible shape in terms of hygiene and overcrowding. We are eroding all of the natural habitats for these virus vectors. And unless we do the kind of things that Mike's been talking about in terms of virology, in terms of vaccine technology, in terms of planning for non-medical interventions to begin with, we're going to be no better off. And that's one of the things we're trying to warn about.

Chris Dall: Mark, as you know, in the polarized political landscape that we're in, there are going to be people who say, you know, well, who are these guys to be saying, you know, what went wrong and what we should be doing the next time around. How do you respond to that? And how would you want someone who might have different views on the pandemic to read your book?

Mark Olshaker: Well, we want to engage, obviously, in dialog, and we've made it very clear that the medical considerations are not the only ones that count. We also have to keep the society going. As Mike says, we've written several op ed pieces that say it's not just the medicine, it's not just the science. We have to do what we can to keep society open, to take care of the people who have to be out there. And what's very interesting is when you have a pandemic, the whole definition of essential workers changes completely. The essential workers become the truck drivers, the grocery clerks, the people who work in factories, delivery people, all kinds of things like that. Which means that we have to involve our economists in this, not only the scientists. We have to involve our public health leaders, our civic leaders, by presenting the entire picture. We hope we can convince people because we're not just saying one thing. We're saying you have to look at the totality and we're willing to engage in that dialog. And we hope that with the voluminous research that Ann and Sydney have collated for us and assembled, we hope we prove our points.

Dr. Osterholm: And one other piece that's really important here, Chris, that was missed is what happens over time. When something lasts for 3 or 4 years, we're not prepared for that. You know, we are a much more of what I would call the category five hurricane approach. It's going to be hell for about 12 hours, but then we can go into recovery. And what we were talking about is a as a situation would keep unfolding and surprises, and you had to help people prepare for that long term. And that's what we tried to do. Even in the pieces that we wrote in our op ed pieces. I mean, I can tell you that based on what I knew about the variant's emergence in the middle of the pandemic, I talked about the fact that the darkest days of the pandemic were still yet to come. And man, did I get panned by some of the quote unquote columnists out there for being a scaremonger. Well, it turned out we were right, and we needed to prepare for that. We needed to help people get the sense of what was going to happen and what they could do about it.

Mark Olshaker: Because of just what Mike's saying. The economic considerations, the communications considerations, the public management considerations all became really important. And so, in a long-term pandemic, they became just as important. Ann, I think you want to contribute something here?

Ann Hennigan-Grace: Well, one thing that crossed my mind during the pandemic and as we worked on the book and in this discussion now is, tying into the communications that you were talking about, managing expectations. We live in a very instantaneous society, between the internet giving us information that we want, assuming that we have access to it, people binge watch series rather than even having to wait a week for the next bit of information to unfold for them. Toddlers know that they can ask Alexa or Siri for a question, and they get the answer instantly. So, it's almost as though the modern society is primed for, we need the answers now. We need to get through it now. All we have to do is x, y, z, and we're done. And, even when there are wars, unless you are in the war itself, it's not really affecting many of the people at home. And I think part of our issue now is that many times we have a failure of patience. We have a failure of stamina. I'm guilty of it as well. But we need to step back and say there are some things that are not under our control to fix as quickly as we want to get the answer as quickly as we want. And waiting is almost a lost art. And that's why the communication is not only so important up front, but the continuous updating and making sure that people know we are touching back. We are still on top of it. It is still unfolding. But this is just one of those things that isn't as quick as a show that you might want to binge.

Chris Dall: We've not been in the era of three networks and Walter Cronkite, you know, Roger Mudd and Peter Jennings for a long time, we have a multiplicity of voices through social media, through podcasts, through blogs, a lot of people expressing their opinions. I mean, doesn't that that makes communication, especially in an event like pandemic, so much harder.

Ann Hennigan-Grace: The thing that I brought up when we started working on the communications chapter was that we needed to have a section where people like Syd, and other public health folks coming up. You guys know modes of communication that those who have been in the industry, if you will, for decades, don't know. And just as you need to stay current with the science, public health needs to be current in the art and science of communication. And there are people who can make podcasts who have no background in science, but if they're produced well, they will get a lot of play and they will become popular and they will be forwarded to friends. Oh, check this out. So, I felt that in each outbreak, we learn new ways to communicate, and we need to be at the same time that we are building the science aircraft. We need to be building the communications aircraft so that we're not playing catch up when something big hits, but we're able to leverage whatever is popular at the time.

Chris Dall: Syd let me turn that to you. And how are you thinking about that, that communication element in an era where we have so many voices?

Dr. Redepenning: Yeah, I want to second everything that Ann just said because I couldn't agree more. But to add to that, the thing that terrifies me about the way that we're approaching communication, or I should shouldn't even say the way that we're approaching it, but just sort of a fact of communication in this era is the way that social media algorithms operate, and how much of a challenge that creates for public health or really any truth telling organization that is trying to get out fact based messaging, because any social media site that you use quickly learns what type of content you like to look at and what type of things you don't agree with, and then it continues to show you what you want to see and what it thinks that you'll agree with, because that's what's going to keep you spending the most amount of time on that site. And so, if for many people, that is not necessarily true information and has more to do with not necessarily which podcasts are putting out correct information, but which have the best production and which have the most engaging voices to listen to and the most interesting stories, whether those stories are true or not, that's what's going to keep pulling people in. And then the same is true for social media. The way that my Twitter or Instagram pages look looks completely different from someone who is anti-vaccine or anti public health. And I think the biggest challenge isn't just going to be how we're messaging and evolving, which channels we're using to communicate, but really figuring out how to sort of break into the online spaces that are designed to keep public health out.

Dr. Osterholm: And if I could just add that the United States response to the next pandemic, whether it be influenza, coronavirus, whatever, obviously has to fit within the global response in terms of what happened. I want to just remind people that what we're seeing globally, in some cases, is even more concerning that we're seeing in the United States with regard to public health. Take Canada, for example. We've been very concerned about measles in the United States. We have well over 1200 cases right now this year. We have a population of 240 million people. Canada, which has a population of 40 million people, has over 3500 cases this year. And that's an indication of what's happening there in terms of people following the recommendations to be vaccinated for measles, just as it is in the US. Europe is even a higher rate of infections right now occurring in some of the countries there. So, this is an international phenomenon. This is not just something in the United States. And I think it's really important to recognize we have some very heavy lifting to do in public health to understand how do we communicate with the citizens of our respective countries and how does it vary by age? How does it vary by experience with social media, etc.? And this is not going to be a simple response. This is going to take some really very, very important research work to understand what's happening and why.

Chris Dall: Mark, was there anything you wanted to add?

Mark Olshaker: Well, Chris, I would just add that we really break communications down into several of its components. And a lot of it has to do with Mike's concept of humility. You have to have a certain amount of humility to admit what you know and what you don't know. But again, a plug for reading our book we really do go into the various ways in which people get things right and wrong, both from a public health and from a government policy standpoint in communicating in a pandemic. And if, as Mike says, if public health doesn't have trust, it has nothing, which is why communications is as vital as any other component of this struggle.

Chris Dall: So Mike and Mark, what I found interesting was that in your future pandemic scenario, the response of U.S. and world leaders is hampered by some of the very same problems we saw during COVID. Is that because we are really unlikely to see, ever see any kind of thorough review of what happened during COVID?

Mark Olshaker: Well, I think we wanted to make it realistic. We didn't want to make it pie in the sky, and we wanted to make it such that people could learn from it, and that the nonfiction parts of each chapter would be able to explain how it should happen. So, in some cases, they got things right. Some are characters. In some cases, they got things wrong and we wanted our scenarios to be a counterpoint. In some cases, to the information and the takeaways that we were trying to convey.

Dr. Osterholm: I think one of the other things that was very important here. Pandemics happen. The pandemic clock is ticking right now we just don't know what time it is. And given the information, Mark provided several questions ago as it relates to how the world is different today with population interface with wild animals in distant jungles, we never did before. The increasing agricultural production in terms of livestock and poultry. We really do have a much greater chance today for a virus to emerge as a pandemic virus. And so, he wanted also for people to understand this is not optional. This is not maybe it'll happen. It's going to happen. The question is, we don't know what time it is. As I said, the pandemic clock is ticking.

Mark Olshaker: Here's one perspective. We as a species reproduce on average every 25 to 30 years. I would say that's kind of one human generation. What I learned is that microbes reproduce anywhere from a number of minutes to a number of hours, to a number of days for a generation. So, at worst, they have a 40 million to 1 advantage over us in terms of evolution. So, we've got to have other things at our disposal, because as far as evolution, we're on the wrong end.

Chris Dall: I want to wrap this up with a final question, and it kind of goes back to what Mike was saying about the challenges that public health faces, not just here in America, but around the world. And some of that has to do with how the COVID-19 pandemic was handled. And some of those messages. The distrust is coming from bad actors and people with ulterior motives. But all that being said, are we better prepared for the big one given what we saw during COVID-19? Or are we less prepared?

Dr. Osterholm: We are absolutely less prepared. I've already laid out the challenges we have in this country, where we've basically continuing to tear down what public health system we had. We are continuing to watch the challenges to local medical care, particularly in rural areas, due to financing challenges. We already have laid out the fact that the very kinds of programs we need to develop much more effective and available vaccines has basically been gutted. That all says we're in worse shape, but I think that in addition, this is not just a US phenomenon. For example, the European Union has been a major supporter of various public health activities over recent years. There's a group called CEPI, the Coalition for Epidemic Preparedness Innovations, which came out of the 2015-16 Ebola era to actually provide a place for investment in new vaccine research. Well, that was supported largely by these European countries that have now cut way back their donations because of the fact that they're now spending 2 to 4% more on their GDP for defense. And so, there's almost like a perfect storm of events happening in terms of support for this kind of preparedness. And again, you know, as I've said many times, reflecting on the old oil commercial of my youth, you can pay me now or you'll pay me later. And I know that unfortunately, that's going to happen. We just need to be able to try to do whatever we can to convince the public that preparedness is worth something you want to do.

Mark Olshaker: And we've had economists tell us over and over again. Any money you spend on pandemic preparedness or public health is tiny in comparison to what it would cost if you don't. Once the pandemic hits.

Dr. Redepenning: I would also say, in addition to everything that Mike and Mark just said, I think and we talk about this a bit in the book, we are significantly less prepared from the perspective of our workforce. The pandemic contributed to an incredible amount of health care worker burnout, and not just among physicians, but also nurses and other essential healthcare workers that have since left the field. And we don't know when or if they will choose to come back. And then on top of that, on the public health side of things, a lot of the positions for younger researchers or younger epidemiologists that used to exist from groups like the CDC and other federal agencies and state health departments. Those positions have been eliminated because of some of the cuts in funding. So, our next generation of public health workers that could be coming in to help alleviate some of this burnout is now left without career opportunities. And because of that, what I'm seeing down to the undergraduate level, in my work is undergraduates that previously had told me that they were thinking of going into public health and making that their career, they no longer see it as a stable field where they feel like there would be any job security for them. And so even though it's something they're really passionate about, they're choosing to put their efforts and their education elsewhere. And I think when that big one hits, we'll see this mass exodus of healthcare and public health workers. And also, on top of that, be suffering a lower rate of people entering the field, which will make it a lot more difficult to respond. And I think, Ann, you also wanted to add something.

Ann Hennigan-Grace: Well, just in case the message that all three of you, the points that you've all eloquently made, in case those were not depressing enough, my concern is also from a society standpoint, we are, we're so divided right now, and I think many people are prepped for the next pandemic from a place of already ready to dig their heels in with preconceived notions of how this is going to go. And I just would hope that people would open their minds and open their hearts a little bit. And instead of deciding ahead of time what's going to be wrong, let's just look at what can we do not only to stay alive, but to keep our neighbors alive? This is a book that uses COVID-19. It's not necessarily a book about COVID-19 per se. It uses COVID-19 the same way that we use the fictional virus that we have in our tabletop exercise and the scenarios that weave through the book. Use these to give yourself an idea of the things that can go wrong, and the things that we might be able to do to make it better from not only the standpoint of public policy, but also at the individual level. What can we do? What can we as individuals take responsibility for? Can we think critically about things instead of just knee jerk reacting to things? Can we open our minds to what might be going on that we hear about from public health leaders? Can we be critical thinkers when we identify who we accept as a public health leader, versus who may just be the shiny toy on a particular program? And so, I think that we I would hope that as a society and that as individuals, we could step up a little bit better.

Chris Dall: Mark and Mike, I'm going to give you the last words. Mark, I'll start with you.

Mark Olshaker: I think Ann just articulated it very well, which is we've got to open our minds, open our hearts, and be open to each other, both here and around the world. And there are lessons to be learned if we're only willing to listen to them.

Dr. Osterholm: And I would just conclude by, first of all, thanking you, Chris, for moderating this podcast today. This is obviously something out of our quote unquote comfort zone and how we've done podcasts in the past. I also want to acknowledge what a privilege it's been to work with these three individuals. You know, it's been a real joy. I've learned so much from them as we've put this all together. And I just hope that this book can serve as a way for others, who are thinking about what can we do to be better prepared for a public health crisis, and that this book may serve as a bit of a roadmap for that.

Chris Dall: The Big One: How We must prepare for Future Deadly Pandemics is now available online or at your local bookseller. Thanks for listening to the latest episode of The Osterholm Update. If you enjoyed the podcast, please subscribe, rate, and review wherever you get your podcasts, and be sure to keep up with the latest infectious disease news by visiting our website, CIDRAP.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to CIDRAP.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning and Elise Holmes. Our researchers are Cory Anderson, Meredith Arpey, Leah Moat, Emily Smith, Clare Stoddart, Angela Ulrich, and Mary VanBeusekom