Updated: Jun 15, 2020
Blue Zones published this insightful interview with Michael Osterholm, PhD, MPH, an acclaimed expert in epidemiology of infectious disease who has advised administrations from both political parties, and wrote a book in 2017 Deadliest Enemy that foretold a global pandemic was coming and recommended how to fight it.
This interview is simultaneously insightful and scary, providing a balanced and pragmatic perspective on how to think about the virus, and what to expect. Some of his points agree with what seem to have become predominantly held views, while others deviate from the common narratives we see emphasized in the media and commentary. I really think it highlights some key concepts that characterize our situation in fighting this virus that are lost on the media and most of society, and lead to unhelpful narratives in our fight against the virus.
I will summarize some of his key points in bold and introduce some of my own commentary on his points.
The long game: This virus is a "leaky bucket" virus meaning that, if there is one little crack somewhere, it will get out and infect people. Because of this, it will continue to spread through the world until herd immunity is reached or an effective vaccine is developed.There is no reason to think the virus will just mysteriously disappear after a first or second wave.
The idea that this will inevitably spread around the world until herd immunity is achieved or an effective vaccine developed is the scariest aspect of his viewpoint.
I think this has key implications for how we manage this. Strategies that presume we can fully control it, or make it go away, are bound to fail -- even if tamped down in a local area, it will tend to come back and reinfect. I believe this means we need to prepare to have this virus with us for a long time, and focus on sustainability when constructing mitigation strategies.
Points about vaccinations: He conveys hopeful optimism, highlighting how remarkable it is that the international scientific community has moved so rapidly on developing a vaccine, with >120 current candidates under evaluation. However, there is no guarantee that any of them will be successful. Coronaviruses present specific challenges as highlighted by difficulties with SARS and MERS. Two concerns are (1) that vaccines may only produce short-term immunity, but not durable immunity, in which case people would have to be re-vaccinated, and (2) there is a risk of antibody-dependent enhancement, in which antibodies are made but not enough for protection.
That last point is a particularly tricky risk with COVID-19. It is clear that the most severe cases of COVID-19 are accompanies by an out-of-whack immune response that is not effectively controlling the virus, but causes potentially deadly complications. It is these complications that seem to most often lead to death. That means, we had better be SURE that a vaccine is producing an effectively protective immune response before giving it widely, since there is some chance that a vaccine's stimulation of the immune system, if insufficient to confer protection, would lead to a higher risk of these severe complications and more advanced disease.
This also means we can't assume that we will definitely have an effective virus by January 2021; or summer 2021; or January 2022. We need to be prepared for a long battle with this virus and need to devise our mitigation strategies with this long game in mind.
Who is most at risk, and what they should do: We know those most at risk for severe disease if infected with this virus are older individuals, risk greatly increasing for every decade after 50, people with preexisting heart, lung, or kidney conditions, those with compromised immune system including certain types of cancers, or individuals with metabolic disorder, especially with diabetes and obesity.
The highest risk factor for those under 55 is obesity, so working on healthy lifestyles is the best thing that younger people can do.
For older people at risk, protection is tricky -- he mentions that locking people up in a bubble until an effective vaccine is ready, 18 months or more, is tricky since long-term isolation will induce mental health issues. He recommends minimizing contacts with large groups and mask-wearing, and to focus on "physical distancing" not "social distancing" -- trying to find ways to be socially connected and active without being in large crowds and physically close to many people.
What I hear here is an emphasis on balance. Trying to take basic targeted mitigation steps to reduce settings with the highest risk of exposure, but acknowledging that it is not health for people to quarantine for long periods of time. Finding creative ways to be socially connected while minimizing exposure seems a key strategy.
Accurately assessing what situations produce high risk of infection: The virus does not just "magically" jump between people -- it is about time and dose. Indoors much higher risk than outdoors. Outside respiratory particles and aerosols dissipate very very quickly, and in cases where infections were tracked nearly all were inside. Time near infected person affects risk of infection so passing by them unlikely to lead to enough viral exposure to cause infection. Masks help a bit by limiting the volume of virus to which one is exposed. Singing or shouting expels more respiratory and aerosol particles and thus more viral volume so increases risk. Being together in large groups in tight, indoor spaces is the setting that has led to most super-spread events. He emphasizes that it has been tricky during this pandemic to raise awareness of how to prevent viral spread without scaring people needlessly.
To me, one of the key issues for a sustainable long-term viral mitigation strategy is identifying and communicating a tiered list of factors raising risk of infection. This will help individuals recognize the first-order mitigation strategies -- the few steps that are most important, and the secondary strategies -- that also help reduce viral transmission but are less important than the first-order effects.
Community compliance is also a tricky issue here, and clear messaging is key. They key to compliance is raising enough healthy fear of the virus to get people to comply with the basic mitigation strategies that will reduce viral spread without causing irrational fear that can do more harm than good.
When people don't take the risk serious enough, they won't even practice basic guidelines like avoiding large, indoor crowds or wearing masks. These factors are key to keeping viral spread low, so if too many people do not comply the virus can spread out of control.
If people have too much irrational fear, they may neglect important aspects of life to their detriment with extreme steps that might not be necessary to reduce risk of infection. People may neglect medical care or screening for other issues, leading to undiagnosed and advancing disease that could have been prevented, while failing to understand that doctors offices and hospitals have taken extreme steps to make the environment safe. People may neglect mental health by isolating themselves from people more than is necessary, given that with basic precautions they could safely visit with people, e.g. outside, at a safe distance, and with a mask. People may neglect exercise, healthy sun exposure, and the mental health benefits of outside activities for fear of exposure to other people, when all indications are that outdoor viral spread seems to be a much lower risk than inside.
The messaging from leaders and the media needs to be clear, consistent, and transparent -- acknowledging past guidelines and recommendations that have changed and explaining why they have changed with growing knowledge.
Necessary Leadership: He emphasized the darkest days are still ahead of us. We need optimistic, moral, and commanding leadership that doesn't minimize what we are facing but can inspire confidence we can get through it OK.
I fully agree. I mourn our lack of this type of leadership that could be making all of the difference in the world to our country and the broader international community. Why is there such a dearth of good leadership in the world?
What our priorities should be: Push vaccine and treatment development forward and improve production of personal protective equipment for healthcare workers. Develop better protocols and information sources for the public to understand what is going on, to overcome the confusion caused by hearing so many different things from so many different sources.
I fully agree that it is key to provide better protocols and information to the public, and provide sufficient explanation and transparency to overcome any lack of trust or confusion resulting from contradictory advice.
Worst case scenario: That it suddenly seems to disappear, perhaps because of weather, leading people to let their guard down. And then it comes back quickly and severely in the fall, with people not practicing basic mitigation strategies, and overwhelms the healthcare system and the rest of society.
I can see that -- the key is for us to be vigilant and not let our guard down, to realize that this war vs. this virus is an extended conflict, not a quick battle.
This resurgence we see in some states might be a mixed blessing -- it reminds us the long term nature of this war vs. the virus, and hopefully will keep us on our toes, and inspire us to do a better job of constructing effective but sustainable mitigation strategies.
Best case scenario: "that this just continues to burn on - -it's with us, but it doesn't ever overtake us. We learn to with the virus, and we and are able to suppress it without destroying society as we know it." And then that we get a safe and effective vaccine within 12 months and be able to effectively distribute it.
Amen and amen and amen. I can't emphasize how strongly I agree with this take, and don't think that many people realize this. From the responses and commentary I see, it seems to me most people seem to think that with lockdowns or testing or contact tracing we can completely control this virus or make it go away, but given its nature and its global reach, it seems that is not possible (I have believed that for a while, and Mike seemingly has this viewpoint as well). We have to realize that we are going to have to live with this virus for a while, so need SUSTAINABLE strategies to limit its spread that do not "destroy society as we know it." Lockdowns DO NOT satisfy these criteria. They are not sustainable and cause a great deal of collateral damage to society that has the potential to do irreparable harm to it. We need to accept that a certain degree of viral spread is inevitable, and not jump to suggest lockdowns be reintroduced as soon as a few places have some increase of cases.
On herd immunity, future deaths and the Swedish model: He estimates that 5% of the population has been exposed, so we are only 1/12 of the way to herd immunity most places. However, he expects the death rate per case to decrease since the first wave "burned through" long-term care communities "in a really terribly, terribly" tragic way. But we still could see 800,000 to 1.6 million die in USA before this is over. He argues the so-called "Swedish model" trying to speed up herd immunity no longer exists, but that no place has an answer to how to manage this. Even places that tamped down the initial outbreak are experiencing resurgence, so according to the "leaky bucket" concept there is no one way to manage the virus.
The thought of this many cases and deaths is horrifying. Hopefully we can find a way to protect people better until hopefully a vaccine is ready.
He highlights how there are lawsuits pending in Sweden given their mishandling of the crisis at nursing homes which led to 1/2 of their deaths. I note that this has also led to nearly half the USA deaths, and there could be lawsuits in the USA forthcoming because of reckless policies that led to increased infections and deaths at nursing home facilities
On lockdowns: He argues that long term lockdowns are not feasible, but at the same time we can't just "let things go". He describes these as two "guardrails", and that we must find a middle-ground solution between these extremes. We have to learn to live with this virus.
Again, amen and amen. I think this is the KEY principle we all need to understand right now. Accept that lockdowns are NOT the solution, are not feasible long term, are not going to make the virus go away or stay under control. They may need to be used in certain locations for certain periods of time, but I think should be used rarely, cautiously, and for as short a time as possible taking into FULL ACCOUNT the havoc they wreak all over society (not just the economy, but that too). But also not fail to be vigilant, or to let our guard down and let the virus spread out of control.
This "middle ground" he mentions is what I mean when I mention "targeted mitigation strategies" that involve taking key steps to reduce viral spread in a way that limits collateral damage to society, constructed to be sustainable while acknowledging we are playing a long game with this virus and have to learn to live with it around us.
What a great interview, and what an insightful perspective Michael Osterholm brings! I hope his insights and messaging is disseminated and grasped by the broader society!