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Andy talks to epidemiologist Michael Osterholm, one of his most trusted sources. He was one of the first to see the pandemic coming in January and has been a step ahead ever since. Andy and Mike talk about what has happened since the pandemic came to the US, what we’ve learned from past pandemics, what the major surprises are, and what is happening next. Plus, hear an appreciation of Andy’s co-host and son Zach, who is leaving the show to focus on his first semester of college.

Website Notes

Check out these resources from today’s episode: 

• Here is the Remdesivir study Mike and Andy discuss in today’s episode: https://jamanetwork.com/journals/jama/fullarticle/2769871. 
• Listen to Mike’s podcast, The Osterholm Update: COVID-19, here: https://podcasts.apple.com/us/podcast/the-osterholm-update-covid-19/id1504360345. 
• Check out Mike’s latest opinion piece for The New York Times, written with Neel Kashkari, president of the Federal Reserve Bank of Minneapolis: https://www.nytimes.com/2020/08/07/opinion/coronavirus-lockdown-unemployment-death.html. 
• Learn more about the first documented case of COVID-19 reinfection here: https://www.sciencemag.org/news/2020/08/some-people-can-get-pandemic-virus-twice-study-suggests-no-reason-panic. 

In the Bubble is supported in part by listeners like you. You can become a member, get exclusive bonus content, ask Andy questions, and get discounted merch at https://lemonadamedia.com/inthebubble 

Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt, and find Michael Osterholm @mtosterholm on Twitter.

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Transcript

[04:53] Andy Slavitt: So a bit of a melancholy episode, because last episode was Zach’s last episode, at least for now, as he gets prepared for school. And so I wanted to — instead of my normal introduction — just talk a little bit about Zach and a little bit of a dedication. And I don’t actually know, Zach, if you’re gonna listen to this now, but I hope you do someday. Maybe you’ll listen long after I’m gone with your kids or your grandkids. So here goes. I’ve got 10 things to say to you. First, this was your idea, this podcast. Thank you for thinking about it. It’s been great fun. Second, I learned so much from you, and I do learn so much from you all the time. Dads don’t say that enough, but I really enjoyed how much I got to learn from you presenting your facts. Third, thanks for sharing with this audience who you are. I know you don’t love doing that necessarily. May not be easy for any 18 year olds, but I think people loved it. Fourth, I love being your dad and your brother’s dad. Mom and I, we would trade everything else we had for that. Five, I watched you grow on this show. I hope you had fun doing it. I hope you’ll look back and be proud of it. Six, sometimes when we were doing the show, I would just look over at you and feel very proud. Seven, there were times on the show as we were setting up, as we were recording, where I talked to you more sharply without tenderness in my voice as we were working. I hope you don’t take that as a sign of what adulthood should mean. Adulthood should mean every bit of love and nurturing and caring that you’ve experienced in your life. And the good days. Number eight, I will miss you on the show. Number nine, thank you. Thank you for everything you contributed. I’m excited for the next steps in your life. I know it’s not an easy time, but I hope you get to be 18 and what it feels like to be 18. I know being on this show may have had its moments, but it’s no substitute for being a kid. So go be a college kid even if it happens to be from our basement for some time. And we’ll make that work. And then number 10, come back any time you just say the word. You can have your old spot back even if we have the best co-host in the world. There’s only one you. And we’ll kick them out for you.

 

[07:55] Andy Slavitt: OK, onto the show. Really happy to have Mike Osterholm here on the show today. Mike is a friend. He is the director of something called CIDRAP, which is the Center for Infectious Disease Research and Policy. It really is as much fun as all that. At the University of Minnesota. He is like the guy of pandemics. He’s written about pandemics before it happened. He has been calling this, he has advised presidents. He is somebody who has an incredibly strong voice on this podcast. I think this episode you’ll find to be very much like the Larry Brilliant episode. And there are some really great and interesting parts of this interview, and I learned a lot. So let’s chat with Mike. 

 

[08:47] Andy Slavitt: How you doing? 

 

[08:55] Mike Osterholm: I have no idea. What year is it? 

 

[08:59] Andy Slavitt: Are we doing better or worse than you thought we’d be doing in March? 

 

[09:04] Mike Osterholm: I think we’re doing differently than I thought we’d do in March. I can’t say that it’s worse or better, but I’ve been surprised by how it’s unfolded. The partisan nature that divides down into ideology as opposed to public health practice and the implementation of that. I think that’s really been unfortunate.

 

[09:33] Andy Slavitt: It didn’t start that way, though, right? I mean, at the beginning, going back to March and April, it felt like people were relatively together trying to figure out what’s going on. 

 

[09:44] Mike Osterholm: Yeah, well, you know, even back then, I felt something that wasn’t as partisan, but it was nonetheless preconceived notions. You know, I published an email on January 20th saying that this was going to be a pandemic. We published this on our website. In fact, one of the more, I think, wonderful things that our group was able to contribute — I actually met with leadership of 3M on January 20th. And in doing that, I shared with them what we had concluded. The next day they fired up every N95 manufacturing machine they had in the world and ran 24/7. Long before the U.S. government ever got a hold of them and asked for more. But during that time period from January 20th — and I wrote an op-ed piece on February 20th in the New York Times saying, come on, let’s get on with it. This is going to be a pandemic and we need to be preparing that way. And you know where I got a lot of resistance was a lot of the public health community. There were people saying, here goes Mike again. You know, he’s just scaring the hell out of everybody needlessly. You know, bad news, Mike. And, you know, no matter how we tried to lay out the data, people didn’t want to believe it. And, you know, remember, we still had our U.S. government largely saying that everything was OK. We had WHO saying it was OK.

 

[11:06] Andy Slavitt: It’s not like you’d said that every day of your life. I mean, you’d said it was coming. You’d said we need to prepare for it. But it sounds like it’s not like you were raising these alarms. I should step back and ask one thing. This is really for the audience’s benefit. People who hear me talk and they think I am smart, most of the stuff I get, I get from Mike Osterholm. From the start of this thing. And not just Mike. There’s a few other people that you’ve had a chance to meet in the show. But I think Mike primarily is one of those people that when I’m confused or want to understand something, you know, you’ve been the guy that explains it to me. So if we were agreeing here, if you hear things from Mike that sound like things you’ve heard before, it’s not because Mike’s copying me. It’s actually because I copied Mike. Now you’re finally hearing the source. 

 

[11:48] Mike Osterholm: Well, you know, I think that we’ve thought a lot about this. I mean, you know, I come back to it and I’m not trying to promote here. But, you know, in the book I wrote that was published in 2017, Deadliest Enemies, Chapter 13 is on coronaviruses. And the title was SARS and MERS, A Harbinger of Things to Come. And Chapter 19 was on what an influenza pandemic would look like originated out of China. And it almost unfolded exactly as this coronavirus pandemic. So we thought a lot about this. You know, we’ve thought about it beforehand.

 

[12:21] Andy Slavitt: And did you kind of tabletop at CIDRAP like how it would go? And did you kind of, you know, red team kind of scenarios? Were you that detailed?

[12:33] Mike Osterholm: Yes. And in fact, right after 9/11, we were asked by the U.S. government to develop a whole series of tabletops that we did for the government on bioterrorism, but then also it melded into influenza. And, of course, what everyone was preparing for was an influenza pandemic, which obviously didn’t happen. And it’s not what we see here, but there are a tremendous number of similarities. And so we have done a lot of work on influenza pandemic preparedness and how that might look. We’ve done a number of different tabletops, you know, policy discussions on what to do, how to consider it. And there are some differences than this happening here. But on a whole, how society would be impacted was exactly what we’d predicted. 

 

[13:19] Andy Slavitt: Did you think when you wrote that in January, that we still had a chance to contain it, like happened in South Korea. Or did you feel like no, we were going to have community spread.

 

[13:30] Mike Osterholm: On January 20th, I really felt that it was gone. It was like the fire that got away. I did believe that China would probably do as well as anybody to contain it, because they could take the draconian measures to really bring it to a halt. They could keep people in their homes for 12 weeks or more. What I wasn’t sure is how much transmission occurred in China, because, as you may recall, this whole thing unfolded right at the time of the Lunar New Year. And Wuhan, which most people don’t realize, is the transportation hub for all of China. All the major fast trains between Beijing, Shanghai and Hong Kong go through Wuhan. All the major airports, they’re kind of like the O’Hare for the U.S. Right in the center of the country. And so we were concerned about how much movement would actually occur within China. But we also knew that there would be a lot of case activity outside of China because of that. And so a week after I wrote the January 20th memo, I did another one in which I said, you know, it’s probably going to take four to six weeks before the rest of the world sees this. Because we have one or two and then four and six and eight and 10 cases and nobody will pick it up. And by the time we do pick it up, it’ll largely be in heavily populated areas around the world. And it’ll flash quickly because then the numbers, when they start, the big ones start to double. And so that’s exactly we saw in New York. We saw in Lombardy, you know, we saw in other cities around the world. 

 

[19:28] Andy Slavitt: How quickly did you know that there was going to be asymptomatic spread? Because one of the things that others missed — and a lot of political leaders didn’t understand for a long, long time. But even I will tell you — I don’t know if you know this, you probably do — but the first model the CDC used was an influenza model for a spread. And so the reason they kept coming up with answers that this is not going to be so bad is because they kept using an influenza model, which, of course, people are sick and they stay home because they know they’re sick. 

 

[20:02] Mike Osterholm: Yeah. Well, you know, it’s interesting because I had the good fortune — or you might say the unfortunate situation — to have worked on both SARS and MERS. In 2003 when SARS hit, I was still splitting my time between the secretary’s office at HHS and the university. And so I was involved with the 2003 SARS outbreak response. And we realized at that time that the individuals were really not very infectious until day five or six of their illness, which allowed us then to, if once we got rid of the animal reservoir out of the markets, if we could just basically isolate these cases soon enough, we could stop transmission, which then happened. Well, the repeat of that happened in 2012 with MERS, and I happened to be very involved with that. I served as an advisor for the royal family of Abu Dhabi and have spent time in the Middle East working on this issue. I was in Samsung Medical Center in 2015 when that outbreak occurred from someone bringing back the virus from the Arabian Peninsula. And there the same thing happened, in this case the animal reservoir was camels, which we never got rid of and weren’t going to. And so people keep getting pinged with this virus over there. But we understood that humans didn’t become highly infectious again until day five or six. So initially, I, too, thought that was the case. I just assumed that this was going to sound like a coronavirus. The Chinese will clean this up quickly and they’ll figure out who is infected, they’ll get them isolated. And by January 10th, it was very clear to us, because we’ve been following this since December, that that wasn’t the case. That there was clearly asymptomatic or at least very mildly-ill symptomatic transmission in the community that was not occurring just in the hospital. So that’s how we knew on January 20th, when I made the statement, which I published, that this was gonna be a pandemic because this now did involve exactly what you just said, asymptomatic transmission, or at least mildly-ill people transmitting, which we hadn’t seen in the same way with MERS and SARS, and that truly distinguished it from them. 

 

[22:10] Andy Slavitt: When we were having dinner that night at the University of Minnesota annual dinner that I came as a speaker, we sat together, which was a fun night. That was back in December, I believe. Were you following what was going on even then? 

 

[22:23] Mike Osterholm: That was actually just before this happened. Yes, it was in December. And it was a fun night. You gave a great talk that night. And I love talking to your wife. It was really happening at that time. I mean it was happening in Wuhan at the very night we were there together. Just nobody knew it yet really. 

 

[22:43] Andy Slavitt: And by the way, if people don’t listen to Mike’s podcast, which we’ll have a link for, you have to listen to it. It’s great. I advise people to have two or three sources of information. And, you know, the criteria by which I advise people is pick people who will say what they know and what they don’t know, will state their biases and will adapt their views as things move along. And you’re also willing to, I think, infer things and be clear about what you’re referring and what you know. But you’re willing to kind of help people understand applications. You were one of the first people that was talking about aerosolization and people were talking about surfaces. And I remember running into you and you’re like, Andy, don’t worry about the surfaces. It’s not the surfaces. 

 

[23:32] Mike Osterholm: But, you know you know what you didn’t do, though? You didn’t allow me to hear my disclosure tonight. And that disclosure is I know less about this disease tonight than I did six weeks ago, because the more I learn, the less I know.

[23:43] Andy Slavitt: Oh, that’s funny, because that’s the kind of where I was going to go, Mike. Let’s just take a quick recap of what do we know and what don’t we know. If there’s three columns, what’s the stuff we’re absolutely positive about, that we really understand about this virus.

 

[23:59] Mike Osterholm: I think we have a pretty good handle on the fact that the transmission of this virus is primarily swapping air with someone else. Number two is that for reasons we still don’t understand, there is kind of a modified SARS/MERS impact of this disease, in the sense that there is a super shedding kind of environment, where it’s the right person in the right environment, meaning indoor air, where you see lots of transmission. And it’s been stated, and I think the numbers are probably very close to that, that 20 percent of the cases account for 80 percent of the transmission. And, you know, it’s amazing when you see some of these outbreaks that occur in very distinct things, like one wedding or one funeral or one evening at a bar. And it’s remarkable the kind of transmission you see with that. So I think that’s something we do know.

 

[24:52] Andy Slavitt: Do we know if that’s something about the individual or is that something about the type of location, purely just the type of location, or is it both?

 

[25:00] Mike Osterholm: I think it’s both. In other words, indoor air itself won’t do it. You know, we have a lot of households where people would say, well, it has to be droplet because only 15 or 18 percent of all the household contacts get infected. It’s not that infectious. And they’re right. But then you have those where somebody can transmit to 80 of 92 people that were in that room that night, and they’re shedding virus that is just remarkable. And we don’t understand why. You know, we’ve been looking at things called sticky mucus and so forth, is there a way that in what we breathe and when it comes out that would actually enhance the amount of virus? And I think we’re learning a lot about aerosols. Aerosols being these very tiny bb-like drops as opposed to the big bowling ball-like drops and while they contain much, much less virus, there’s so much more of it that if you inhale that and that’s what flowed. So I think that, too, we now have a much better handle on than we did before.

 

[25:58] Andy Slavitt: So if we could identify the super spreaders, we could, like, make them wear like orange t-shirts or something.

 

[26:05] Mike Osterholm: Better yet, those are the ones I’d love to put in isolation, you know, for themselves and for others. If we could isolate them like we did, you know, with MERS and SARS patients, you know, you could stop transmission. This is where this whole issue about R-naught and R-T all these things that people cite all the time about what the risk of transmission is, remember someone who might be highly infectious for measles, as an example, get them into a room with negative air pressure and the right filters and they should transmit to nobody. So it’s always a combination of the individual and how infectious they are, but it’s also the environment they’re in. And that’s what I think we often miss with this disease, is it’s the combination thereof. 

 

[26:44] Andy Slavitt; So we’re trying to control the environmental piece. We’re trying to, you know, at least identify that there are certain places — bars, church choirs, old buildings, places of poor ventilation, etc. I think most people understand that to have that message and they understand that if they’re in a setting like that, they’re better off wearing a mask and so forth. But how are we on the people themselves at saying, you know, Andy’s got the virus, Mike’s got the virus, one may have a little more symptoms than the other, but one of them’s a super-spreader. And the other one is not. How close are we to being able to figure that out? 

 

[27:17] Mike Osterholm: We’ve got a long ways to go. But what’s interesting, let me just point out the environment issue, because I think this is another important point. You know, right after the protests occurred, in fact, while they were going on, I was interviewed a lot and people would say, oh, boy, this is just going to blow this thing up. And I said, you know, I don’t know if it is. And the reason for that is outdoor air. The virus dissipates quickly. It’s not even sunlight, because most of the protests occurred at night. And I said, be careful. Don’t jump to that conclusion. And lo and behold, sure enough, it didn’t turn out to be a major enhancing factor at all in transmission. At the same time, I warned everybody about Sturgis. I said Sturgis is gonna be a heck of a problem. So wait a minute. You’re not consistent here. And that’s outdoor. And I said, no, no. I’ve never been to Sturgis, but I’ve heard a lot of stories. The number of indoor bars, the number of tattoo parlors, the number of all the places that people go to, they’re indoors. And so it’s not the riding of the bike. It’s not basically walking down the street nearly as much as it is being indoors. And that’s the distinguishing feature between Sturgis and the protests. They weren’t indoors during the protest. They are at Sturgis. And now we’re beginning to see. We just had a big boost in new cases in Minnesota today. And we’re just at the beginning. It’s going to be a big number of cases.

 

[28:38] Andy Slavitt: So it sounds like we understand much better about how the virus spreads, and we don’t quite understand who those people are, so there’s not a lot we can do. Are scientists looking at that, epidemiologists looking at that question. Do you think there will be an answer to that question? Because, God, it would be helpful. 

 

[28:58] Mike Osterholm: I don’t think so. I think, you know, maybe our animal models will get us closer to that. I mean, the answer to this is gonna be a vaccine that would ultimately make sure none of us got infected with it in a meaningful way. But I think the question you’re asking is really important, because this is not the last coronavirus that is going to happen. So, you know, we’re going to see more. So I think that it is a really important question that we need to answer. I don’t know how to do it right now. And even the people who are doing the animal studies, where they’re actually, you know, intentionally infecting macaque monkeys, using different routes and so forth, trying to understand why certain ones get much higher in their infectiousness. By the way, you see the same thing in the animal models. You infect a group of monkeys, a number of them will get sick. Mildly sick. Not that much virus production. And there’ll be a couple of them all same age, same gender, that will just have sky-high virus levels coming out of them. And they’re not any sicker than the animals that don’t have much. We don’t understand why. 

 

[29:58] Andy Slavitt: Interesting. All right. Let’s evaluate how we’re doing on the science. So I think there’s probably a few different areas of science that are important to us here. One is clearly the vaccine and how we do it and on the path there. The second and a very topical conversation this week is around therapies. And the third one I”ll go back to, it’s a bit of a different category that you and I love to talk about, which is testing. If you go back again to, say, January 20th, when you wrote that paper, how impressed should we be? How do you feel about how we’ve done from a scientific standpoint? What can we do better? Where’s the most promise? 

 

[30:33] Mike Osterholm: I think, first of all, on the vaccines, I want to contrast the therapy. I think it’s been remarkable what’s been done so far, you know, not just in the United States, but in Europe. And of course, we have the Russian and Chinese vaccines, that we don’t understand yet very well. It has been nothing short of a game-changer kind of approach. I give everyone credit for that. The problem with it is, however, that we want this vaccine yesterday, and even to do it correctly — I liken this to the Iowa farmer that decides he wants to take the end of the summer off, so he is going to plant twice as many acres in April so he can harvest in July as opposed to September. Doesn’t work that way. There you go. That’s it. So I think the bottom line message is on the vaccines, we still have a lot of work to do before we will be satisfied we have an effective vaccine. Now on the therapy side, we haven’t done it like that. I mean, the Brits have done a much better job organizing and moving out the kind of clinical trials that have given us meaningful data. That’s the challenge. I mean, the paper that just came out — in fact, I just happened to have it here. This was published today. You mind if I read you the summary of the remdesivir study that everybody, you know, is so high on, that was the one got the emergency use authorization for. But let me just read you the conclusions. OK, because this was what got all the news, how important this was.

 

[32:04] Mike Osterholm: “Among patients with moderate COVID-19, those randomized to a 10-day course of remdesivir did not have a statistically significant difference in clinical status compared with standard care 11 days after initiation of treatment. Patients randomized to a five-day course of remdesivir had a statistically significant difference in clinical status compared with standard care. But the difference was of uncertain clinical importance.” This was the main study. What is this telling you? So the fact that we don’t even know more about that than we do just with that, I think we underpowered and we didn’t really appreciate the challenges of wanting to save someone’s life, which any physician wants to do, so we’re going to throw everything at them that we have. But then it eliminates the ability to really study it in a systematic manner to make sure we don’t have bias, we don’t have all kinds of selection issues that come into play. And so the same thing is true right now with the whole issue of plasma therapy. You know, the data just are really unclear. So I think we’ve not done so well in the therapy side. We need to change it. 

 

[33:15] Andy Slavitt: And there’s only so many patients. I mean, there’s a lot of people being infected, but you can’t have a patient in every single trial. And so we put these people in these trials for these very marginal drugs, which, by the way, they can be prescribed off-label anyway. Meanwhile, in England, we’ve got these clinical trials going on with actual patients. So the fact that the FDA spends all this effort and energy around this, it goes back to your first point, it looks political. One of the most disappointing things for me is that our institutions, which are supposed to be protected from politics and where we’re supposed to see the clearest views of the best information we have at the time, whether it’s the FDA or the CDC, none of them have really covered themselves in glory. Fine. People make mistakes, this is a complex novel virus. But the political interference has been really disturbing to me. 

 

[34:21] Mike Osterholm: It’s unprecedented. And I think one of the challenges we’re gonna have here is we already have a public that’s skeptical of science. And, you know, we’ve already heard these surveys, which I’m not sure how much credence I put in them, that people wouldn’t take a vaccine for COVID-19. I think if you’re in the middle of a house-on-fire event, and you had a license to provide a vaccine, and public health is saying take it, they probably would. But I think right now, my very worst thought could be is that if we have an inadequately researched vaccine, we haven’t done the data analysis because we don’t have the data to analyze relative to effectiveness and safety, and public health leaders stood up and said, this is not — no, we can’t do this right now. That would create such a confusion in the public, such a backlash, that I worry desperately about that we can’t have that happen. Because we not only jeopardize this vaccine, I think we jeopardize vaccines across the board for which we’re fighting desperately right now to get the American public to understand why they’re so important. 

 

[35:28] Andy Slavitt: Right. This sort of knowledge of the collective good, which is something that seems more foreign to us in this country than I would have — it’s disappointing. But this idea that, you know, that we all have to value and benefit and that the trust in the FDA is an asset we can’t squander for the very reason you describe. And it’s quite possible that we could have a very valid vaccine candidate, that there ends up being very low trust in. And that would be, as you said, a really unfortunate situation because of the great work that science would have done. So that has got to be reestablished somehow. 

 

[36:03] Mike Osterholm: It does. And, you know, and I think it’s very clear, I believe this is true about public health in general: if we had an effective and safe vaccine right now, we would celebrate its approval in its use. And it would have no partisan issues. I’m more than happy to have what some called an October surprise if the data are there to support it. So this isn’t about, you know, trying to inject politics into this at all. We just have to have the science that backs up our data. If we’re wrong and this is not a safe vaccine, it doesn’t work, we’ll pay for that for generations to come. We’re still paying, as you so well know, from 1976 and swine flu with Guillain-Barre syndrome. I mean, there are still people who remember that and say, well, I don’t trust the government. 

 

[36:50] Andy Slavitt: So the White House called me before the convalescent plasma announcement and asked if I would publicly support it. And I said the following. I said, I’ll tell you what, if the president doesn’t overstate the value, if the data is presented clearly and cleanly. If the FDA scientists can speak clearly about the reservations, then I’ll analyze that and I’ll support it if I agree with that. But that’s not what happened. And I told them specifically, I said if on the other hand, the president uses this in a way where the value is overstated, it’s going to be a big mistake. And I said it’s a mistake that I think all of us are going to pay for, in my view. That seems like it’s what’s happened.

 

[37:32] Mike Osterholm: Yeah, I think, you know, let the science just be the science. If we can carve out one area right now we all want to be successful, there shouldn’t be one who wants to be successful and one who doesn’t. We want to do whatever we can to reduce the pain and suffering, the death and economic destruction that this virus is causing. I would celebrate right now any finding from this administration, or any other government of the world, if the data were there to validate the findings and the safety was clear and compelling, boy, what a great day to celebrate.

 

[38:07] Andy Slavitt: Absolutely. Absolutely. I mean, the only thing that can catch up to invisibly spreading viruses is science.

 

[40:07] Andy Slavitt: I want to make sure that we clarify for the people listening when you say vaccine, what exactly it is you mean, because I think people have in their minds when they hear vaccine, sometimes they think, oh, MMR vaccine. One little dose and I’m good for life and it’s 97 percent. Other people might have in their mind an influenza vaccine. I’ve got to get it annually. And it got an even chance of working. But if it works, it’s going to save a lot of lives. And even that’s good incrementally. What should people expect when they hear the word vaccine? 

 

[40:41] Mike Osterholm: Well, I think you raise a really good point. An important point. We need to help define the future now for the public so that they don’t appear to be surprised by whatever information comes out. I think you’ve seen that kind of telegraphing already from people like Tony Fauci and others who have been saying, you know, this vaccine may only be 50 or 60 percent effective, but that’s a heck of a lot better than zero. And so, you know, don’t expect this to be perfect, but it doesn’t have to be perfect to still have a big impact. I think the challenge we have right now is twofold. One is in terms of who is protected, even 50 or 60 percent are protected, if it’s primarily the same people who have mild disease, younger, healthier people, then the vaccine is going to have less impact than if we can find a way to protect those who are at higher risk of serious outcomes, people who are older. And as you know from influenza vaccines, that’s a challenge. Influenza vaccines tend to work better on those who tend to typically do better once they get infected. But still the impact is substantial from getting your flu shot. I think that’s going to be the same situation here as we have that. The second situation, though, is one that came to light today, which we knew is coming, is we’ve been concerned for some time that with both SARS and MERS, we have evidence of waning immunity. This isn’t like even an influenza virus, like a pandemic strain, you do develop immunity probably last many, many, many years for that specific strain. But this morning, it was reported that the first case of well-documented second infection occurred. This was an individual from Hong Kong who had been infected last March, at the time was identified, the virus isolated, obtained culture positive, and then he recovered. He was on a trip to Europe, came back to Hong Kong months later and coming through customs he was tested, found positive. They actually cultured him again. They got another virus out. It was a different one than the first one. So it wasn’t a chronic infection. And it was the same strain that we saw in Europe. So he did bring it home with him. That clearly pointed to the fact that at one point he had been infected, likely developed some immunity, and then it waned. That’s not a surprise. We actually should expect to see that more. So what we’re trying to figure out is how does that fit in then to how often we are vaccinated. If we get infected and we lose our immunity, if we get infected a second time will it be a milder illness? Surely it could be possible. And so this is an area that we still have a lot of work to do, but it’s not going to be like, as you pointed out, the MMR, the childhood immunization that may have a long, long longevity in terms of protection. This one likely is going to have a much shorter term protection level and require booster doses, if anything.

 

[43:34] Andy Slavitt: You must get a chuckle, Mike, about how many armchair epidemiologists exist in the world now. I mean, there are people that are positive about things that no expert I know even has an opinion about, relative to herd immunity can be achieved at 30 percent level, and it levels off because of this cross immunization from T-cells. And these are people who haven’t heard of the word — no offense to them — they haven’t heard the word T-cell before a week ago. We’re naturally clutching at straws here. We want to know more. We want more certainty. It makes us all feel better. But I also think that what this show is about and yours is people can handle the truth better than they can handle the ups and downs being disappointed in. It’s good to know what we know and what we don’t know. So if we’re going to take stock of what we know about immunity and herd immunity levels, start with herd immunity levels. Do you feel there’s any possibility that the virus slows down at 20, 30 percent? Is New York just as at-risk today at 25 percent as it was before? Put us putting aside how long it lasts for a second. 

 

[44:45] Mike Osterholm: Yeah. You know, this is a really important question. And thank you for asking because I think it is one that really deserves a conversation. And again, I’ll just say that I’ll take you as far as my knowledge will let me go. And when I hit the edge of the cliff, I’ll tell you, OK? If you want to keep going that you’re at your deal, OK? Number one is, just so everyone understands what herd immunity is, it’s really just a statistical probability in the sense of if I’m infectious with a certain virus, there’s a level of infectiousness that comes with each one. Now, I’ve already talked about the fact that with COVID-19, we kind of have a different approach where some people may be highly infectious and others not. It’s kind of like saying your head’s in the freezer, your feet are in the oven and your average temperature is just right. But let’s just take the people who are of a certain level infectiousness. So if I’m out there, how many people in the community have to have protection already, much like a rod in a virus reaction, meaning that there are control rods. So if suddenly I’m in front of three people or four people and three out of the four are already protected, I can at most transmit to one. And once you get that below one person per person infected, then the number of cases start to go down. So herd immunity isn’t even about transmission stops, it’s just that that’s when the speed at which it is occurring begins to slow down. The theory had been, well, you know, maybe if people who already had these coronavirus infections and that they have some residual T-cell functionality — and I’m not a coronavirus virologist, but I hang around a bunch that have taught me a lot. And, you know, they’ve been a little skeptical about, yeah, would that happen? Because with MERS and SARS, we actually saw waning immunity over time with those infections. So I liken it this way: you know, I have been studying certain populations that have had unique opportunity for us to understand how infectious these are and what happens. Look at the prison population. Look at San Quentin. San Quentin went from nobody infected to fairly quickly over 60 percent infected. And then it slowed down but it kept transmitting until there was 80 percent infected. I could go through populations like that where there was no evidence of residual immunity that somehow protected, you know, after it hit 20 or 30 percent, where a very high percentage of the people all get infected, which says if there was some kind of earlier herd immunity, that wouldn’t have happened.

 

[47:19] Andy Slavitt: Right. And so I think the worst formula in the world is to try to do math on a podcast. But if you tried taking out your phone and multiplying one point two times, one point two times, one point two, eventually the numbers get pretty big. If you’d use one point seven, the numbers get really big. But if you use a number less than one, Mike is saying that if you use point seven or point five, those numbers, do things really go down. You wrote a piece recently with the head of the Federal Reserve here where you talked about the fact that we can sort of simulate that effect. And I’m putting words in your mouth a little bit. But by taking a bunch of different actions, even before we have a vaccine — because as you said, if we don’t share each other’s air, the virus has no place to go or fewer places to go. So talk a little bit about what you said in that paper.

 

[48:18] Mike Osterholm: Well, you know, I think that part of it is, is what is the best of the bad alternatives? You know, if nothing’s working. And right now we’re in a bad situation. I’ll make a projection here tonight. I hope I’m wrong. But, you know, when we saw case numbers increased to 32,000 new cases a day in March and April, in particular on April 12th, you know, New York was on fire. We thought, oh, my God, this can’t get any worse than this. And then, you know, kind of flatten the curve, things started to improve, and we got down to about 22,000 cases a day by Memorial Day. And at that point, we were done. Pandemic fatigue set in. And then look what happened. Towards the end of July, we were up at 65,000 cases a day and we thought, boy, 32,000 cases a day doesn’t sound so bad, does it? Well, now we’re down. We’re gonna get into the 40s, maybe occasionally high 50s for a few weeks. And then all the university and college campus cases are going to explode. They’re starting to now. We’re gonna see more transmission spill over to the community, and we’re going to go right back up again. So it’s almost like we’ve had this peak, come down a little bit, and level. Another peak higher than the first, come down a little bit, level. And now we’re on this climb. 

 

[49:41] Mike Osterholm: The reason I bring this all up is because our best guess is — and it’s more than a guess, we actually have data — that while there are some spots in the United States, particularly New York City, some places in Florida, Arizona, where we have higher levels, but on a whole, only about eight to 10 percent of the U.S. population has been infected by this virus so far. Which is still a lot, when you think about, you know, 30 million people have been infected. That’s a lot. But we got a lot left to go. So for us to get to herd immunity, the thing we’re just talking about, of 50 to 70 percent, and we’re at eight to 10 percent now, the question is, well, how are we going to get there? Well, you can get there through natural disease, which will just keep occurring until you get there, or you’re going to get there by a vaccine and hope again you have some durable immunity. So what we wrote about was what is the lesser of two evils? And we’ve learned from around the world that you can lock this thing down and you can drive the case numbers to such a low level. Imagine it like a forest fire, containing 60 percent of it, you go home and say, well, we’re done. How fast it comes right back. But if you only have the embers left, the brush fires, then, you know, the county fire department can handle that. They don’t need the big national crews to come in. And so what we’re saying is, if we could drive it down, then we can keep it down, like New York has done. I mean, New York to me is an amazing comment about this issue. We all know that New York has not come back to its full self. It’s not. It’s the same city it was. But you know what? They’re now in their 13th week of flatness. They’ve had days where they haven’t had any deaths at all. And I think that that’s an example of what can be done. Now, what we proposed was you need to lock down in selected areas, not all across the board. For example, you don’t need to lock again down in New York. But you do need to lock down some hotspots. Minnesota right now is one that I’m really concerned about. But what you do is you pay for it. You don’t leave anybody behind. And Neil, who is a brilliant, brilliant leader, you know, the Federal Reserve has looked at our savings. We’ve gone from eight percent savings to 20 percent saving from this pandemic. I mean, we can finance supporting individuals left out of work, small businesses, city and state governments buy just the savings that we have and we can pay ourselves the dollars back as opposed to some foreign country. 

 

[52:08] Mike Osterholm: And we hold people whole. You know, it’s where people are hurting that they’ve been financially hard hit is what’s wrong. So I think that’s the point that we’ve raised is get it down. And the modeling that the Federal Reserve Bank has says, look, we’re going to bleed a lot more. We’re going to spend a lot more money between now and the time a vaccine might get here, let’s say if it is early next year, than we’re going to do if we do a lockdown for four to six weeks in selected areas to get the case numbers down. And then hold them down through testing and tracing and the kind of approaches we can do that these other countries are doing. And I worry that, you know, we didn’t learn the lessons of these other countries. And I also worry that, unfortunately, other countries of the world learned too much from us. Because they then in some cases just let up completely, like Germany, France, places like that where now we’re seeing the increases again. You know, how do they do like New York did? Just keep the foot on the brake enough to hold it down, but not to smother the community. 

 

[53:09] Andy Slavitt: You’ve been pretty judicious — you were the first person to explain to me that asking everybody to sacrifice all at the same time in a very large country like this is a colossal mistake and unnecessary. And it really seems to me that the logical sense in what you’re saying is it’s the big events, both personal and family events, arenas, churches, bars, and you can be smarter this time. I mean, I think in April, you threw everything at it. Now, maybe you could say, look, there’s a lot of stuff we can continue to do. Maybe there’s a don’t list, there’s a be careful list, and there’s a do list.

 

[53:47] Mike Osterholm: You’re absolutely right. And here’s an example. You know, I really miss going out to eat and just enjoying time at a bar. You know, I miss that. But at the same time, right here in our state, just this summer, we’ve had over 47 bar-associated outbreaks that have occurred. And we have had almost 50 other event-related outbreaks, just like you talked about. And that is really helping to fuel this whole situation. The same thing is going to happen with colleges, universities. You know, I don’t care what you do, we have colleges that tested everybody when they first got there and they’ve already had outbreaks. Because all it takes is one person that was tested at the wrong time, or multiple people, and it starts from there. It doesn’t mean testing isn’t important. But you’re right. What we want to do is minimize the big outbreaks and to hold those down. And accept the fact that we’re gonna have cases. I would never tell anyone that there’s a single college campus in this country that’s not going of cases. They are. But we don’t want the big outbreaks. 

 

[54:52] Mike Osterholm: On testing, which again, I’m no expert in, but it seems to me that if you wanted to do something like open schools, you’d have a very specific strategy for testing for schools. So I spent time with the NBA and you may have as well, and with Steve Kerr on the podcast last week talking about the bubble, the number one thing that they say about testing isn’t the accuracy level. It isn’t anything else. It’s actually the cadence. Because the test is only as good as a point in time. And so getting a test that’s easy to do and cheap, is actually more important than getting a test that’s two or three points more accurate than another one, but takes six or seven days and costs $150.

 

[55:34] Mike Osterholm: Yeah. You know, the challenge that we have today is not even as much the test. Current testing availability is important. We’re now seeing in a number of the college campuses — and this is something we knew already. Up to 50 percent of the students refused to do any contact tracing, refused to give any names, refused to get tested themselves. We have a number of people in this country who do not believe that this pandemic exists. It’s a hoax. They will not get tested and followed up. And when you start adding these all up, you get a pretty sizable number pretty soon of those that refuse to participate. 

 

[56:12] Andy Slavitt: The question I get asked very frequently is will we learn our lessons from this virus, and my answer is it depends if this ends up going down like the crack epidemic or the opioid epidemic. You know, the crack epidemic happened to “other people,” and our policy response was cold. We criminalized the whole thing/ With opioids, it felt like it happened to all of us. And while I don’t think we’ve done a great job, you know, we talk about it differently. People think about it differently. For right now, I think there’s a lot of the country that still looks at this like the crack epidemic. And the more it happens to older people, prison populations, you know, farm labor communities, meatpacking plants, and the more that younger people kind of get it, but they’re just carriers, the more that deepens my sense that this red/blue thing could be more pervasive than we’d like it to be. 

 

[57:05] Mike Osterholm: You’re absolutely right. But I think one of the things that may also start to influence this is we’re beginning to see this long-haul phenomenon, these people who are initially ill but mildly ill, at two and three months are still really quite ill in the sense they’re very fatigued. It’s a chronic fatigue like syndrome. And this is actually occurring at fairly high incidence among young, healthy adults. That begins to leave a real mark, because they just can’t get out of bed. They can’t go to work. And, you know, they’re not at risk of dying in an intensive care unit, but their quality of life is really substandard. If that message can get out that, you know, this is something you don’t want to get, not just because you’re not going to be in an intensive care unit, but look what the potential is here for you over the months ahead. And we don’t know where this is going to go yet because many people are still sick months later. 

 

[57:58] Andy Slavitt: Can’t you hear them now, though? Mike, your fear mongering again. I put a tweet out about long-haulers because I interviewed a bunch of them. And I got a whole response of now you’re moving the needle. This is just about people dying.

 

[58:11] Mike Osterholm: You know what it is? You know, this is just about telling the truth. It’s about, you know, we didn’t know about this three months ago. And now it is learning and sharing what we know. And long-haulers are absolutely a very real and legitimate piece of this. And so, I mean, when you put things out like that, you’re right on the mark.

 

[58:32] Andy Slavitt: The demands on your time are 24 by seven. I know you’re doing a great service to all of us. One of the principled people who is not willing to being knocked off message. And in a week like today, you know, if you want to ask yourself, are there still people out there who will not be knocked off message and say what they believe and say what’s right? You’re listening to one of the very best in Mike.

 

[58:59] Mike Osterholm: Well, thank you. You’re very, very kind. And as Ben Franklin once said, we must hang together, or we shall hang separately. So I like hanging with you. Thanks, Andy. 

 

[59:16] Andy Slavitt: I really hope you liked that conversation with Mike. As you noticed, we’ve substituted Mike in it because I’d want to get him on the show for a long time. We still have a couple of great ones coming up. We’re going to talk about a toolkit episode about getting back to school coming up on Monday. On Wednesday, we very, very, very likely have for you Mike Birbiglia, the reason I say very, very, very likely is because there is so much news happening all the time that we are pulling other pieces together. We have a tool kit episode coming up the following week on long-haulers, as you heard Mike and I talk about what those are, people who are really sick for quite a long time with COVID-19. Anyway, I should let you go. Thanks for sticking with me.

 

[01:10] Andy Slavitt: Thanks for listening In the Bubble. Hope you rate us highly. We are a production of Lemonada Media. Kryssy Pease is our producer. Ivan Kuraev is our editor. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produce the show and run our lives. My son Zach Slavitt is my cool co-host and onsite producer. Music is by Dan Molad and Oliver Hill. You can find out more about our show on social media @LemonadaMedia. And you can find me at a @ASlavitt on Twitter or @AndySlavitt on Instagram. If you liked what you heard today, please, please, please tell your friends to come listen, but from a distance. And for now, stay safe. Share some joy. And we will get through this together. And #StayHome.