Mike Osterholm on Covid’s Next Act
“Anything beyond a 30-day prediction from a statistical model is pixie dust,” says epidemiologist Mike Osterholm. Photo by Ackerman + Gruber

Mike Osterholm on Covid’s Next Act

Amid another surge in Covid-19 cases in the Midwest, we check in with Minnesota’s high priest of pandemics to talk masking, boosters, and politics.

Michael Osterholm directs the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota. We used to know him for annual public radio appearances that reminded us how lucky we were to have never lived through a major global pandemic. So much for that. You may think you’ve heard all you need to from the now ubiquitous epidemiologist. Yet it’s undeniable most of his calls on Covid have been prescient, give or take a tsunami. Most valuable have been his nuanced critique of public health interventions. We interviewed him in mid-November, as the Delta wave peaked anew, but tried to focus on the big picture, asking questions that should have been asked months ago by a press corps that is mostly set on proving a point rather than getting to insight.

TCB: Are you still in the predictions business on this virus?

Mike Osterholm: Anything beyond a 30-day prediction from a statistical model is pixie dust. On the other hand, the general sense of where the pandemic is going, we can surely predict that, and I think my weekly podcasts are track record of that. Last April and early May, I thought some of the darkest days were still ahead of us and that has been borne out.

There is no herd immunity with this virus. It will continue to flare up around the world at unpredictable times and without a given cause and effect, and what I mean by that is these surges start and stop at will, not because of something people are or aren’t doing.

Why are the far northern New England states—Maine, Vermont, and New Hampshire—on fire right now, with some of the highest immunization rates in the country? Why are New York and L.A., with a great deal of [population] mixing, having very limited increases in transmission, even though we know they have major undervaccinated populations?

TCB: Is the politicization of the pandemic global, or is it a uniquely American phenomenon? And has it really mattered in our outcomes?

Osterholm: Politicization of the pandemic is surely as severe in the U.S. as it is anywhere in the world. But it has shown up around the world. We just saw it recently in pushback [over community restrictions] in Australia and New Zealand.

It has had a tremendous impact on the course of this pandemic. If you just look at what’s happened since the Delta surge in late June, with the vaccine rich resources we have, yet over 110,000 Americans have died. Technically, all of those, or at least most of them, could have been prevented if they’d been vaccinated.

I think that one of the things that made this pandemic so challenging relative to influenza pandemics of the past is it just goes on and on and on. [With] other pandemics, you had waves of illness that were six to eight weeks.

TCB: Sort of moot right now, but where do you come down on the virus’ origin story?

Osterholm: First, there is no evidence it was man-made.

As to the lab leak theory, it’s a real concern. In 1976, the Russians were doing research on H1N1 and it leaked in Siberia and we had a pandemic. In 2005, there was a National Science Advisory Board for Biosecurity created to monitor these really dangerous bio-research projects, the so-called gain-of-function. I was on it until 2014, so I take this issue very seriously.

That said, the Wuhan lab is one of the best in the world. Could it have leaked? Usually there would be an outbreak at the lab, then. We have no evidence of that. We now understand this virus jumps through animal populations quickly [see below], making an animal hypothesis more credible. I don’t think we can say it didn’t come out of that lab, but I’ve seen nothing to support that.

TCB: Let’s talk about masks, one of the most controversial interventions. You’ve been willing to parse this question with some nuance. How and when are masks impactful with this specific virus?

Osterholm: It’s become a political symbol as opposed to a meaningful public health intervention.

We just did a two-part series on our website that I would urge you to go look at. We detail the evidence for what works and doesn’t work. And then we critique a number of studies that have recently been done, which, generally speaking, held an inherent bias to find that masking worked.

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I have not changed my position since March 2020: When I say “masking works,” I put that in quotes, because merely putting a piece of cloth in front of your face is not effective masking. I was out there early saying that this was an aerosolized pandemic, not a respiratory droplet issue. It was and is hygiene theater to put up plexiglass, which makes no difference even though you see it everywhere now.

I think we have done ourselves a major disservice in the public health community by not adding rigor to the science around transmission. I fault CDC, WHO right up front. They, for over a year, refused to accept the now-accepted idea that aerosols were important. Meaning, you have to use quality respiratory protection that will deal with an aerosol.

I think we had a really stark lesson in the summer when people complained the [cloth] mask they wore did not keep out smoke from forest fires [hundreds of miles away]. If you smell the smoke, you are inhaling virus.

TCB: What is the masking you favor?

Osterholm: N95 and KN95. There is no shortage, even for the general public. The warehouses are full of them.

TCB: Should government agencies state what benchmarks they will rely on to end masking rules and other interventions?

Osterholm: I’m part of a paper coming out shortly from members of the former [Biden] transition team advisory group, of which that’s the whole thesis. What is our end game? You know, we don’t have one.

The world’s is: “Make sure that the health care system doesn’t break.” You can bend, you can bend it a lot, but don’t let it break. And to me that is a very vague standard. The collateral damage that occurs with that is huge. We in public health have not done the work of pegging to a goal. The CDC changed masking recommendations with no explanation why. With influenza we accept 12,000 to 50,000 deaths [per year], but we don’t shut down.

The end game [that] China has is unsustainable and represents a risk to the global economy. China is insisting on zero-Covid, and they’re willing to do anything and everything to achieve it. Six cases can shut down a multimillion population city. They are shutting ports over two cases, and the interruption to the global supply chain has been massive.

This virus is only going to keep transmitting, and one of the challenges [China] has is their vaccines are clearly inferior, so their outbreaks will not end.

TCB: What’s your take on the vaccine situation right now? You questioned the wisdom of a three-week gap between doses.

Osterholm: The vaccines are remarkable. You have a six-fold lower risk of getting infected, you have a 12-fold lower risk of dying. But the breakthroughs tell us we still have a lot more to learn. We brought [dose spacing] up [with CDC], but we got shut down and told “this is the way we have to do it ‘cause this is what [Pfizer’s] study tested for.”

A year ago this week, Pfizer announced the first data showing this 90 to 95 percent protection against severe illness and hospitalizations and deaths. And we went from a mindset hoping for 50 percent to this infection will be done in no time. And no one really asked what’s going to happen with this thing 10 months down the road or five months, because we know that seasonal coronaviruses are notorious for being hard to vaccinate. Meaning that [our bodies] don’t make long-term durable immunity against them.

As we get further out from the doses, we’re seeing all these breakthrough infections. Israel was a month ahead of us on vaccination and they have a health system where they can immediately link up vaccine and patient outcome. Their data showed waning immunity hitting all ages. I think the booster dose is not a booster dose. It’s really a three-dose vaccine.

TCB: Are you saying it could end up being a four- or five- or six-dose vax?

Osterholm: I don’t know. No one knows. I come back to this concept of evolving science. We have done a very poor job of explaining to the public that we don’t have all the answers right now. But what you want is an environment where we implement, we study, we learn. In each iteration we keep getting better and better. What is the ideal dosing? What is the ideal spacing between doses? That’s what we’re learning. I think if we get to a point where we have to give doses every six months, we’re in big trouble because the world is not gonna be able to manage that.

I think where we’re going to get some relief and potentially a path forward is small molecule drugs are going to play a huge role. As soon as you’re diagnosed with Covid in its earliest hours, you take these drugs and they’re going to be quite effective. So your first line of defense is vaccine. Second line is drugs.

The final thing I would just say is already people are beginning to work on vaccine 2.0 that could be better at inducing durable immunity.

TCB: What is your position on vaccine mandates?

Osterholm: I do favor compulsory vaccination, because getting 75 to 80 [percent] vaccinated in Europe has not stopped the propagation of this virus, but it’s made it eminently more manageable. It’s about our health care system, having people and facilities available to treat cancers and the normal health emergencies. It’s about not putting your neighbors at risk. If I had drug-resistant TB you would not want me out on the streets.

TCB: Natural immunity, the immunity that is derived from having the virus—is there any reason to believe that it’s any better or worse than vaccine-derived immunity?

Osterholm: Well, I can’t say it’s better or worse, but we have a growing number of studies now that look at those who are infected and get reinfected. And when you look at people who have been previously infected, but who get at least one dose of vaccine, there is at least a four-fold lower risk of having a reinfection. So while there is clearly protection that occurs with having been infected, the durability is still a question.

TCB: Are the current waves emerging in Europe and North America evidence of limited vaccine efficacy, or are they in the unvaxed?

Osterholm: It’s both, but it’s primarily the unvaccinated. Since with a breakthrough infection you’re just as likely to transmit the virus as if you weren’t vaccinated, people take that to say, Why get vaccinated? Well, you have a much, much lower risk of getting infected at all. If you’re not ever infected, you can’t transmit it, so you have reduced transmission in the community. The second thing that were seeing is even among those who do have breakthrough infections, the overall percentage of those that have severe illness and die is much lower than [the unvaccinated], and so you help relieve some of the pressure on our health care system.

TCB: Going down a bit of a rabbit hole here, but what’s the significance of the study that says white-tailed deer are major reservoirs of Covid?

Osterholm: We don’t know. Because of chronic wasting disease, CIDRAP is very in tune with the cervid world. The study that was done [in Iowa] looked at roadkill deer and farmed deer. And what was remarkable is if you look from April, May, June, July [2021—before Iowa had its big surge this summer—the incidence of Covid in the deer parallel, to the week, increases in incidents of human illness.

So why is this important? When we worry about variant development, this virus, in the first instance, came from an animal. So there are 25 million deer in this country. Last year six million were harvested. Those deer had close contact with the hunters who got them. And if a new virus or a mutated virus evolve in deer [the risk is very great].

No one I know understands how these deer are getting infected.

TCB: We have a lot of asymptomatic people getting tests. Repeatedly. It’s stressing our testing capacity. What is the value of testing asymptomatic vaccinated people with exposure to a person with Covid?

Osterholm: The testing situation is a challenge right now. For example, the FDA just recalled 2 million over-the-counter tests because of false positives. Still, if you have a reasonable degree of exposure to someone, some of the most dynamic transmission probably occurs in the 48 hours before you become symptomatic yourself. So what you’re trying to do is identify those people so that they can limit their transmission.

By day five-to-six, your level of virus goes down dramatically. This is why the Wuhan experience was so illuminating. When I put out my statement on January 20, 2020, saying this is going to cause the next pandemic, it was based on evidence that people were transmitting substantially in the one-to-two-day period before they had a symptom.

TCB: What have we learned about our nation’s health care infrastructure in this pandemic?

Osterholm: Well, I think if anything, we’ve come to challenge the notion that we even have a system. I think we have a lot of bits and pieces that have all been kind of thrown together in a bucket and said, here’s your system. The fact that, for example, the major limiting factor in providing care is not intensive care beds, not ventilators, not drugs or supplies, but people. We have a system that is stretched so thin, how do we keep it together?

We rely on Israel and U.K. for so much of the data around vaccines and how they are working because they actually have public health systems and were able to quickly bring together population-based data, but we couldn’t. We are so disjointed.

TCB: And is that because of the lack of a nationalized system of some sort?

Osterholm: Well, that, or even one that is standardized in a way that you can link individual records back to outcomes wherever they are.

TCB: We have been told that the societies that managed Covid with the least deaths and disease did so through extreme measures. China, New Zealand, etc. But when you look at North America, Europe, those regions with more draconian interventions often saw infection waves and death counts indistinguishable from places with few. Why have we not seen worse outcomes in those places if interventions work?

Osterholm: I said in 2020 that lockdowns should be applied where you have rampant transmission to slow it down. And that if you apply it in locations with little to no activity, you create a movement against using it when you need it. The challenge we’ve had is demonstrating when community-based interventions make a difference versus ascribing far too much cause and effect to interventions that may only be associations.

TCB: Early on, you used the phrase “we’re gonna have to learn to live with this.” Have we, yet?

Osterholm: Nobody has gotten that far. Denmark is 78 percent vaccinated. They dropped all interventions. Life was normal. But now their cases are going up fast. They’re going to reinstitute restrictions. I just talked to a friend and colleague there yesterday and the amount of anger and wait a minute, you told us this was done, is enormous.

Go three years and if you don’t have any major Covid activity, you’ve probably learned to live with it, but until then you may just be buying a virus holiday. India, 25 percent of its population is vaccinated. They think they’ve won the lottery because they’ve seen little activity since the surge early last summer. [But] they’re going to get hit again.

TCB: Are you back out in the world, or are you still locked down?

Osterholm: I’m not back out in the world.

TCB: What will it take?

Osterholm: I don’t know yet. You know, I got my booster, I feel confident, but at the same time, I don’t.

This interview will appear in the upcoming December 2021/January 2022 issue of Twin Cities Business.