Three Years Into the Pandemic: What to Expect?

Friday, March 10, 2023

Senior Fellow for Global Health, Council on Foreign Relations; @llborio

Senior Fellow for Global Health, Council on Foreign Relations; @YanzhongHuang

Regents Professor, McKnight Presidential Endowed Chair in Public Health, and Director, Center for Infectious Disease Research and Policy, ​University of Minnesota; CFR Member


Professor and Dean of the Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego; CFR Member

Panelists discuss the current state of the COVID-19 pandemic, the evolution of the virus, vaccinations around the world, and lessons learned for future pandemic preparedness.

ANDERSON: Hello, everyone, and welcome. I’m Cheryl Anderson. I’m a professor and dean of the Herbert Wertheim School of Public Health and Human Longevity Science at the University of California, San Diego.

I’m joined this morning by our distinguished speakers. We have Dr. Luciana Borio, who’s a senior fellow for global health at the Council on Foreign Relations. We’re also joined by Dr. Yanzhong Huang, who’s also senior fellow for global health at the Council on Foreign Relations; and by Dr. Michael Osterholm, who’s the regents professor, McKnight presidential endowed chair in public health, and director of the Center for Infectious disease research and policy at the University of Minnesota, and a member of the Council on Foreign Relations.

We have a really exciting discussion planned with you today around three years into the pandemic, what do we expect? So we’re going to kick things off and start with a question for you, Dr. Osterholm. What’s the current state of affairs with regards to pandemic COVID-19? What do the current statistics look like? How are we doing as a nation and how are we doing as a world?

OSTERHOLM: (Off mic)—two-and-a-half hours scraping the hard mud off my crystal ball this morning, and I will proceed from there. And I do this with a great deal of humility because I don’t think anybody can really tell you.

Let me just take a very, very quick run back through where we started from. Remember in 2020 we saw peak activity in a number of locations around the world that resulted in surges of case in selected, particularly metropolitan areas, in different countries in the early part of 2020. Then we saw a summertime reduction in case, a kind of a mountain peak, a mountain valley. And then, of course, we saw the big fall peak, big at that time not so much relative to later peaks, in late 2020. And then we saw Alpha arrive, even with the advent of vaccination, in late 2020-early 2021. It was very, very challenging in Europe in particular. At the same time, we saw Beta and Gamma variants arise in South America, South Africa. Similar challenges.

When Alpha made it to the United States in January of 2021, the states of Minnesota and Michigan got pounded really very badly, the worst we’d seen. And for reasons we can’t explain, most of the rest of the country saw very little action with Alpha. But then along came Delta, and then we saw this big peak in cases again in the summer of 2021. And then of course, as you know, that resided. Again, the mountain peak went down to a mountain valley. And then along comes Omicron in November-December from South Africa, spreading around the world. We saw the largest peaks of both cases and deaths associated with Omicron.

But what was notable is after those numbers of cases begin to come down from that very high peak, we hit largely in the United States what I would call the high plains plateau, where we basically have seen case numbers somewhat consistent, and we’ve also seen the number of deaths—largely between 350 to 550 deaths a day. Today, we reported out 401 deaths. And the high plains plateau we thought was starting to come down some, meaning kind of a soft glide landing after ten to twelve months. But over the recent weeks we’ve seen those numbers of deaths go back up again. And that is with XBB.1.5 now throughout the country. It’s not as if there’s big surges. It just is a different epidemiology today.

Now, let me just put this in a global context. This week the WHO is reporting out 131,000 cases a day of about 1,000 deaths. Yet, in the United States, we make 401 of those deaths today. And if you look at the U.K., Austria, and Germany, they have very similar death rates as we do right now. So four countries are contributing largely the number of deaths reported. What this really tell us is our numbers really mean little. I think that there is a very, very, very big data gap right now through much of the world of what’s actually happening and what basically these numbers mean.

And let me just conclude by saying, if anybody thinks they can predict where this is going, good luck, OK? I look back, and if I had a nickel for every time somebody said: We should do it this way this country does it or that way that country does it. And if you look back at August and September, Japan, which had done really quite well throughout most of the pandemic, got hit very hard with BA.5. There were days where they were actually at the highest mortality rate seen in the world. And then that August, September, and early October peak subsided substantially, and came down, and everybody thought they were done. Well, then in December a second BA.5 wave hit in Japan, peaking in early January, and actually seeing some of the highest mortality rates reported at any time in any country in the entire world. Now, what was that about? A second BA.5 wave like that?

So I think one of the things that we have to say today when we talk about where we’re at or where we’re going, is we have to say we have great humility. We do not yet understand what it means for immunity, whether it be from infection or from vaccines. How long does it last? What happens? Does it protect you against serious illness, hospitalizations, and deaths, but not necessarily infection or the ability to transmit. We don’t understand that. And so that’s important. We don’t know what new variants are going to come. You know, we had this prediction that in fact we were going to see major activity with XBB.1.5. Didn’t happen.

And I would also point out that we have to be very careful about assuming we know this is a seasonal virus, as the FDA has asserted, in terms of its vaccine approach. We have been following very carefully through the period of December in through February activity in the New South Wales area of Australia and the northeastern part of the United States, and it was identical for twelve weeks—identical! Now, that’s not seasonal, when you have a situation like that. So I think we still have a lot to learn about this. We are still really at the whims of the virus. Our immunity surely is playing some role in this, and that’s good news. But I don’t know that we can tie to what’s going to happen in the future.

ANDERSON: Well, thank you, Dr. Osterholm, for that really nice review of where we’ve been. And appreciate, really, the humility in trying to describe anything about where we might be going. Dr. Borio, I’d like to ask you to pick up a little bit on where Dr. Osterholm left off with regards to what we learned. Can you talk about the lessons that we’ve learned over the past three years, and the implications of those?

BORIO: Sure. Thank you so much for having me today. It’s great to see everybody. You know, I think, to state the obvious, that we were not prepared and we are not prepared. And I think it was, to me at least, very shocking to see the dramatic inequalities with respect to access and lifesaving vaccines that emerged—and medicines—that emerged globally. And we haven’t really done enough to be able to find—you know, to remediate these issues for the next crisis. I think it was surprising too that, you know, having good preparedness on paper, as is the case with the United States, doesn’t amount to much. We suffered incredibly from this pandemic, even though everybody expected us to do much better given how we had been evaluated on paper, you know, in recent years.

You know, it was great to see that science and the private sector saved the day. And these vaccines are incredible. And they’re not perfect, but they continue to provide durable protection against severe disease, death, and hospitalization to most healthy individuals. They don’t protect—they’re very imperfect in protecting against, you know, infections and the variants. But they continue to give us a tremendous amount of, you know, benefit. And we need to do more for people that have underlying medical conditions, and are immunocompromised, and are extremes of ages, for sure. But again, I think science and the private sector saved the day. And that was really boosted and enabled by proper leadership and coordination in the form of, you know, a very seasoned vaccine executive, which was Moncef Slaoui and General Perna, seasonal—you know, a U.S. government leader, because they were able to muster these capabilities in a coordinated fashion. And I’m talking about, of course, Operation Warp Speed.

We also have not used science always to guide us. And that’s been frustrating to us scientists. A great example is that there was a really interesting study done at Heathrow and other airports in the U.K. as well in March of

2022, where they did wastewater surveillance of the terminal, as well as the inbound flights during a period of COVID restrictions and in the aftermath when they were lifted. And by that, they mean, like, testing people before they came, making sure they were vaccinated before they arrived in the U.K. And guess what? There was no difference. So the travel measures seem to have had no impact on the activity of viral—the virus in the wastewater at these terminals. This research, I think, is fascinating because it didn’t get much publicity, but is just one of hundreds of datapoints that we have that could have helped us make smarter decisions. And we haven’t.

I think, just to—you know, to end here, two things. One is that we have become complacent a lot quicker than we had expected. And the pandemic isn’t over yet. And we see governments around the world already cutting funding to the initiatives that would allow us to prepare for the next one. And of course, we know that there are many brewing around the world, because this—you know, emerging infections never really stop. And I would say, lastly, that we have no idea how to handle disinformation, which is rampant. And we do need the best minds to kind of figure this out, because it’s been a major problem for our ability globally, actually, to mitigate the consequences of this horrible pandemic.

ANDERSON: Well, you’re hitting on a really important point there about how do we manage information and how do we think about the importance of the scientific contribution to the scenario like this? In addition to science, we know that other things impact health, right? Policies, ideology. And like no other time before, we saw that really come to bear on what we’ve experienced over the last three years.

Dr. Huang, would you please provide some perspective on how politics and ideology shaped the pandemic COVID-19 response?

HUANG: Absolutely. Thank you, Cheryl.

Yeah, I actually just want to follow Lu’s comments on this. When you are making the public health-related decision-making, when you’re supposed to follow the logic of science, right, not the realpolitik, but you know, very often it’s the opposite we saw, right, in this current pandemic response. You know, there’s a lack of respect for expert advice, right, against the recommendations of top experts. For example, chloroquine was used to treat COVID-19. There’s this theory that—(inaudible)—products, you know, and the international mail, you know, could, you know, spread, you know, COVID-19. That was effectively promoted, you know, by, you know, official, the government—(inaudible)—right? Vaccine use became polarizing, politicized the issue. There’s widespread vaccine hesitancy and skepticism, right? Top public health experts were slandered or silenced.

And in some countries, COVID response essentially, you know, was more about the rulers staying in power, right? That’s why we saw they initially played down the threat and covered up the crisis. The numbers, as Michael just said, means little to them, or maybe means too much to the power holders. So you know, but the— you know, the layer that we also—the same, you know, rulers, you know, policymakers overresponded, overreacted to the pandemic by turning to prolonged, you know, draconian measures, for example, in some countries, to contain the spread of the virus.

This is at the national level. But when you look at international level, right, we know that effective COVID response requires global collective action, you know, but in reality it’s often, right, many countries follow the realist approach that’s just the—you know, the competitive and the zero-sum aspect of international relations, right? Vaccine nationalism is a good example, right? And that’s also why the use of COVID response to achieve geopolitical goals—like we saw, for example, some countries practice, you know, mask diplomacy, vaccine diplomacy, right, to achieve geopolitical gains.

And but this is certainly what China’s very good at playing that, but you know, when you look at the U.S. response, right, there was concern about China’s efforts to capitalize on the pandemic to seek geopolitical

advantages. The United States moved to counter China’s influence by launching its own vaccine diplomacy, right?

And I think the problem is that when pandemic response is viewed through the lens of geopolitics, right, we encourage the framing of the crisis as a national security problem, right? And that securitization not only led to a reliance on drastic and sometimes draconian measures in pandemic response, but also it hurt international health cooperation by discouraging sample and sequence sharing; you know, making it difficult, you know, to hold serious dialogues among major powers, especially those between United States and China. It also encouraged disinformation and the spread of conspiracy theory over the issue of the origins of the pandemic, the use of foreign vaccines, you know, the nature of the U.S. overseas labs, for example, right?

And finally, I think let’s talk about ideology. I think it’s important at this time because for the first time ideology now entered a pandemic response, right? But when the pandemic response is framed as a competition between democracy and authoritarianism, you know, we saw, right, that the—some countries started to use their early success to highlight the superiority of its political system, right? And then you saw also, right, that the Trump administration, right, tried to counterbalance that by highlighting China as the cause of the pandemic. You know, that further polarizing, you know, the origins, the probe issue, you know. That, you know, essentially is where we are now in, right, the impasse of the origins probe. You know, we are very likely never going to find the cause of the pandemic because of that polarization/politicalization, because of the entry of ideology.

ANDERSON: Well, OK. (Laughs.) So those are some really important points that are being raised. And it turns out, you know, that all three of you have talked about things that we didn’t do well, right? And the state of affairs being maybe suboptimal to where we could have been or should be. Let’s think about, you know, what to expect next. What could we have done better? And I’d like for you to respond in thinking about what could we have done better during the earliest phases, where we really relied on public health measures, right? Before the science was mature enough to deliver a vaccine for us, we had to use just some really core things that are important for public health.

We had guidance on gatherings. We had mask usage policies, et cetera. And then think about also the phase where we had a vaccine on hand. And many of the issues that Yanzhong just brought to bear. And then now, as we need to prepare ourselves for all of the emerging infectious disease threats that are moving forward. So I throw that question out to you, right? We’ve laid out some of the challenges and the problems, but what are some of the things that we should be doing to solve toward more preparedness for the future?

Mike, you want to start with you?

OSTERHOLM: Sure. Well, I think the—one of the most important challenges that we’ve faced throughout this pandemic, and it has only deteriorated with time, is trust in public health. And I think that that, by itself, is a critical issue, because so much of what we would do about this pandemic was empowering the public to take, in a sense, what they could into their own hands and protect themselves. Clearly, how we communicated about vaccines, what we communicated about vaccines was challenging. I agree with Lu, I think there were amazing miracles in the pandemic, saving millions of lives. But how did we describe these to the public, and what was their ultimate acceptance of these?

I look today, you know, where we have been very clear about the fact that we believe that the booster dose surely can reduce serious illness, hospitalizations, and deaths, particularly in older people and in compromised individuals. And yet, we look at—it’s almost 20 percent higher vaccination rates for flu this year in that same age group than for COVID. What was the difference? Why? Why did we not have that happen? And so I think trust in public health was key. I think also at the beginning, we didn’t really think through, in a way that made sense to the public, what we were doing.

When we did these lockdowns, which if you think about it lockdowns were never meant to be permanent ways of holding back this virus. It was basically meant to flatten the curve, meaning that if we were going to have 1,000 cases in your community, you didn’t want those all in one week. You wanted them, if you’re going to have to have them for hospitalization purposes, et cetera, what if you could do it in ten weeks, OK, and still have the same number of cases? And we never really explained that to the public. And as such, we saw in many instances what mom and pop hardware stores and grocery stores closed in many places in the country, but large, big store operations continued, because they were deemed essential. That created its own social, political, and cultural issues right there.

We were never really clear on respiratory protection. We blew it. WHO and CDC, frankly, blew it, because they missed the importance of airborne transmission, what that means for making recommendations and how to use appropriate respiratory protection. And so from that standpoint, we also lost the public, as we had all these divisive kinds of debates about what we should or shouldn’t be doing. It was notable that the chief science officer of the WHO, upon her retirement recently from WHO, said the one regret she had is how poorly WHO handled the issue around respiratory protection and airborne transmission for the first two years of the pandemic. And so we didn’t have our act together in many ways, in terms of trying to deal with this issue.

And then finally, I don’t think anyone really thought this in a policy manner, but, you know, when you think of a long-term crisis, you don’t think of a train derailing in the same location for three years. It derails once, it creates a major crisis. We kept derailing every day for three years. And as such, how does the public handle that? How do policymakers handle that? And I think that that by itself was something we weren’t prepared for. If you go back and look, and my dear friend John Barry, one of the real authorities of the 1918 pandemic, would tell you that they experienced the same kind of fatigue among the public in 1919, 1920, and 1921, per what happened in 1918, as cases continued. So this is not a new phenomenon that people get fatigued, they decide this is it, no matter what’s happening. We weren’t prepared to deal with that. You know, we kept on somehow hoping that every day was going to be the last day of the pandemic.

And here, as we’re sitting here talking about it this morning, you know, 400-plus deaths a day may not seem like a lot when we were at one point 3,300. But let me just point out that the number-one cause of death due to cancer in this country every day is lung cancer. And we average about 350 deaths a day. Now, I don’t think anyone would say, well, you know, that’s the old people. You know, well, we’re saying that here now. And yet, we are done. The public’s done. Policymakers are done. And even the Congress is done, as we look at appropriations. So I think one of the other lessons we have to learn is this is not going to be a one and out. This is a long, long, drawn-out process that a pandemic like this represents. And to help people understand that is going to be very important in how we respond in the future.

BORIO: Now, Mike is right. I mean, it’s incredible. Such a wonderful summary of, you know, the current state of affairs. I just I think it’s helpful to go back to—you know, you asked, Cheryl, like, early, you know, after vaccines, and now. And, you know, I worked in the Trump administration. I was at the NSC working on biodefense. And I had left government by the time this emerged, but what I can say is that sometimes we fail to appreciate that government was very fractured at the early parts of the pandemic, and especially the health components.

There was a true—a lot of tension and fighting. And that was actually very unusual. And I had been a civil servant for a long time, and the positions of key responsibility—you know, people with key responsibility for managing it did not necessarily see eye-to-eye on things, even before the pandemic. And I’m talking about the ASPR and the secretary of health and director of the CDC. And we can’t really, you know, explain the challenges without really taking a deep look at what was happening in government in these important positions beforehand.

I think that for the vaccines, you know, it was such a wonderful, incredible, life-saving, you know, thing to have. And I think we, you know, in a way became a little complacent, and that that became the most important

tool, the backbone of everything. You know, it’s the backbone, but it’s not the only bone. And we just basically relied on vaccines to this day as going to save all the problems. And we’re ignoring other things that are important, like indoor air quality, and, you know, the data use and sharing agreements, and strengthening public health. And we just forgot about all this other stuff.

And, you know, to my worry too, we end up, you know, extending the mandates for a duration that was much longer than what they should have, in my opinion, remained for a lot of mandates. For, you know, healthy college kids, and this and that. And now we’re seeing this backfiring, where—you know, you’ve noted the vaccine is not preventing transmission effectively, and that a lot of people had already been, you know, infected and protected. And, you know, you’re imposing mandates on a fairly healthy population. Now a lot of state legislators are actually restricting the use of mandates for vaccines that we know are—you know, there should be mandates for, like we’re talking about measles, and chicken pox, and others, because they do prevent transmission and they do save lives to other people. There’s a community benefit with these vaccines. So I think we kind of overstated this welcome.

And now, you know, I think that we still sadly, you know, it’s a little bit like the failure to realize that we do need to have a strong coordinator at the White House. We need to have somebody who has extensive management experience and/or extensive government experience, because things are not going to happen with Congress, with the public, among the interagency, without a strong leadership. Reminds me of one of the Truman quotes about Eisenhower, where, you know, you’re going to—he’ll become president, he’ll sit there. He'll say, you know, do this, do that, and nothing will happen. And, you know, it’s not like being a general in those positions. You really need to know the art of management, and you need to be able to leverage that experience to make the U.S. government, the interagency work, you know, in synergy, productively, effectively, efficiently, to use all the capabilities so that we can have a better tomorrow.

ANDERSON: Yeah, Lu, that’s interesting—

OSTERHOLM: Cheryl, can I just add one thing to that very thoughtful comment? Lu, I agree with her 100 percent. I think one of the other challenges we have right now, this is not a pandemic that’s equal among all. If you look at it right now, and if you look at the last six months up through the end of December, so that we actually have more complete data, almost 86 percent of the deaths have occurred in people sixty-five years of age and older. If you add in the fifty to sixty-four year old age group over this point, almost 97 percent of the deaths are in that group. And so for the younger age population, they’re feeling like it’s over with, it’s done. They don’t see severe illness. In fact, the rate of severe injury and/or illness and deaths is substantially lower for COVID right now than for kids dying in automobile accidents of the same age. And so people don’t tell kids they can’t go get in a car.

And so one of the problems we’re having is how do we parse that out? How do we protect the older population, where we’re still having this very high unacceptable level of deaths, or the immune compromised population? And I think that this has been a big challenge. This is not an equal-opportunity disease anymore, relative to, at least, what we’re seeing in severe outcomes. And we haven’t really figured out how to talk about that yet, and how we respond to it.

ANDERSON: Yeah, I want to maybe come back to that later on when we have questions and answer period with our audience. However, I would like to have Yanzhong comment on the origins of COVID-19 because, as Lu’s just mentioned, you know, we’ve been talking through our governments and our political scene about this now for three years, you know, with various other things. Can you comment on the origins and what we know about that?

HUANG: Well, again, this is becoming increasingly politically sensitive issue. But in a way it is also complicated by the WHO-China joint study in early 2021 because we know that the study essentially legitimized the theory, right, that touching could spread the virus, which we know is not true, right? But this is

from a(n) authoritative WHO study, right? It also says that lab leak, extremely unlikely, right? And you know, essentially what it says, the natural theory is the only, you know, possibility, right, that led to the pandemic. So that report was used basically by China to argue—(inaudible)—right—this is done, right? This is over. There’s no need to have a second stage, right, of the pandemic probe. So in a way, the WHO went to China. They said, well, we want to do a second stage probe. But China says, well, your report already said this is done, right, that this is the finding, right; why don’t you go to other countries, you know, to conduct the similar study?

So, you know, I think this is politicized, and certainly it does not help, you know, when I think the U.S., you know, started to highlight the lab leak, you know, as the cause of the pandemic, you know. So we know, right, that now the—just recently the Energy Department joined FBI to support the theory about the lab leak. You know, so there’s two to four in the U.S. intelligence community, you know, as far as the origins of the pandemic’s concerned. But you know, we don’t know, you know, what has happened, right? But the Congress now is asking the U.S. to declassify this information, right, about the origins.

And certainly, right, the—China was just provided another reason for China to argue this is, you know, political intrigue, right. That’s, you know, the—but without China’s cooperation, there’s no way we can define the actual cause of the pandemic. So you know, eventually, you know, the bottom-line here is that, you know, there’s— unilateral investigation of the pandemic origin is not going to lead us to have a definite answer to the cause, but will only make the U.S.-China relations even worse. That, you know, make it even more difficult for us to continue the probe, right, to get cooperation from China.

ANDERSON: Yeah. Thank you so much for those perspectives.

Well, we’ve, I think, laid a really reasonable foundation for discussion now with our audience. And so we’re ready to open up for questions. Please be reminded that this meeting is on the record.

OPERATOR: (Gives queuing instructions.) We’ll take our first question from Sonya Stokes.

Q: Good morning. I’m Sonya Stokes. I’m an emergency physician and term member at the Council. Thank you to the panel for this excellent discussion.

My question is a follow-up to Dr. Huang’s comments on misinformation during the beginning of the pandemic. How is misinformation continuing to influence pandemic preparedness and response, specifically misinformation coming from institutions of medicine that are directed against health care workers, public health practitioners, and scientists? I’ll give one brief example. Dr. Lisa Brosseau responded to a study on masks versus N95s for preventing the spread of COVID. This was published in the Annals of Internal Medicine December 2022. Annals then published a commentary accusing Dr. Brosseau of a financial conflict of interest. What is the effect of these types of inflammatory misinformation directed at scientists and health workers, especially when it comes from major medical journals or high-level medical experts in medical institutions? And what has been done or is being done to address this? Thank you.

OSTERHOLM: Cheryl, can I take that one. Thank you, because that actually directly relates to our center. Lisa is an employee at the Center for Infectious Disease Research and Policy. And actually, I was on that same document for which that response occurred. And what I think is really unfortunate, as you pointed out, is this is a way to defer or deflect what is really the challenge being laid out for those studies. And in fact, our center does receive unrestricted support from 3M company through the University of Minnesota Foundation. They have no impact on anything we do. They have no review.

More importantly, they sell more procedure masks than they well N95 masks. And the whole point of it was, is that somehow we were being influenced by them to actually have some—you know, our statement related to

their business model. And it was actually just the opposite if, in fact, there were to have been any at all. But I think the point you raise is a very important one. And we get accused of that very, very often—you know, somehow having a conflict of interest when there’s none at all. It’s a smoke screen.

And I think this whole issue around respiratory protection—there’s an article today in the New York Times that’s trying to address a previous article in the New York Times. Both have major problems. And they were written by non-scientists, but they appear to be scientific-oriented pieces. And so I think this is one of the challenges that we have right now is the issue of how do we put forward information that is vetted, that is vetted by experts and not by people who suddenly waded into the game of pandemic response. And I think that that’s a huge challenge.

I don’t have any answer for you, but thank you for raising that because Lisa was not conflicted, doesn’t take any personal money from 3M, and our center doesn’t. And the irony of it is that our conclusions actually worked against their sales.

HUANG: Well, just to follow up what Mike just said, I think maybe to address this issue of misinformation, I think it is important for government to invest in improving the information literacy of the ordinary people. And in the meantime, I think in terms of global governance, I think it’s important, I think, for the international society, maybe through WHO, to develop, right, the certain rules and norms, right, that—to dispel, right, disinformation/misinformation, you know, allow, for example, authoritative agencies, you know, like WHO but maybe also a third party, to just come out and say: Well, this is a lie. Or: This is not true. But unfortunately, we are not seeing that over the past three years during the pandemic response.

ANDERSON: Yeah. Thank you very much. We’ll take our next question at this time, please. OPERATOR: We’ll take our next question from Craig Charney.
Q: Hi.

You know, the conversation so far, like many policy discussions, has focused on the failings and difficulties of the effort. But I’d like to take a step back and compare it to the flu epidemic of 1919, 1918, 1920. That killed seventy million people by many estimates. This one has killed seven million, ten times less. At the same time, the world’s population is four times larger. We were two billion in 1920, we are eight billion now. In other words, fatalities, proportionally, have been forty times lower this time around. So, yes, there have been mistakes. Many things went wrong. But let me ask you, what went right? Why did we do forty times better than a hundred years ago?

HUANG: Well, a quick—to question, Craig, and maybe Michael and Lu could weigh in on this. I want to point out in 1918-1920, that was before, right, ICU beds become available. That is before antibiotics become available. Actually, I was—I think half of the deaths, according to—(inaudible)—that happened during 1918, right, and 1919 could be saved, you know, if antibiotics become available. You know, so certainly advancement of the biotechnology, you know, played a(n) important, you know, role, right, in terms of explaining why there’s these differences.

BORIO: Right. I’ll agree with that. I mean, I think we are in the era of modern medicine, and it’s been incredible to see the use of therapeutics. You know, the U.K. did a very important study early on that showed that steroids were very important in managing the severe disease. But, you know, I think part of the frustration, Craig, is that we know that they could have done it even faster. You know, we could do things even better. And that—so it’s a relative, you know, sense of failure. Of course, if you compare back to before the era of modern medicine it’s been, you know, really dramatic.

Like I said, you know, science saved the day. The private sector that, you know, works pharmaceuticals and small biotechs saved the day. And really saw the critical, you know, synergies that exist between small biotech and big pharma, with BioNTech and Pfizer, as well as Moderna with this Canadian company that was working on the nanoparticles that was very important to allow the delivery of the vaccine. So this is, like, science at its best.

OSTERHOLM: Yeah. I would just add, I agree with both comments, that I don’t think we have yet fully understood just how many lives were saved with vaccine, even though—you know, and the fact that it arrived as quickly as it did relative to a pandemic, particularly with the new platform technology that had been largely untested in a general population vaccine, I think that this was really remarkable. The other thing I would say though, to support your point, is that this one was not the big one. This is not. And I think people don’t really yet fully understand that. As bad as this is, think about the following: What if this were a virus that had the potential for transmission that we see with SARS-CoV-2, but it had the case fatality rate of SARS or MERS, with 15 to 35 percent? You know, would it continue at that rate with transmission through the population? I don’t know.

But if that were the case, we surely could have a 1918-like event all over again in terms of number of severe illness, hospitalizations, and deaths. And so I think this is all the more reason why preparedness is critical right now. I worry desperately we’re going to think: Well, we’re done. We got this one over with. We’re done. You know, it won’t happen again on my watch, or my kids’ watch, so don’t worry about that. And we can’t say that. And I think that that’s a challenge we have going forward. So that does support your point that, you know, in a sense we did better here with this one, but this wasn’t the worst one.

ANDERSON: Thank you, panelists. Reason to definitely stay vigilant. We’ll take our next question at this time. OPERATOR: We’ll take our next question from Shannon Kellman.

Q: Good morning. Thank you so much for doing this. I am the senior policy director at Friends of the Global Fight.

And I’d like to ask a little bit about forward thinking and how we address what comes next. The Biden administration has proposed a new combination bureau, moving PEPFAR is part of this, and a broader assistant secretary to oversee a bureau of global health security and pandemic preparedness to address efforts to combat future pandemics. And I will note that with the Biden’s budget—Biden administration’s budget release yesterday, it did not include any funding for this new bureau. So an unfunded priority from the State Department.

I’d like to get a sense from you all what we think this bureau could do, how it could be effective in addressing future pandemics, and how we can build on the expertise of something like PEPFAR to be included in that to address future pandemics, and then how to make that political case to members of Congress for either the need for the funding or to the administration for how to prioritize these efforts going forward. Thank you.

ANDERSON: Thanks, Shannon. Luc, would you like to start with that one?

BORIO: Well, I know that President Biden himself is famous for a quote where he says, don’t tell me what you value show me your budget. And I think that this is a great example where, you know, there are significant, you know, uncertainties about where is it that we’re going to put our resources to address the multiple demands that we have, specifically in this area of emerging infections?

OSTERHOLM: Can I just add, and share a sense of the, I think, what is the thrust of your question. Lu was a participant in an activity that our center held over the last year and a half, where we brought together over fifty of the world’s leading experts on coronavirus, the virology, vaccinology, immunology, public policy, financing,

et cetera, to develop a coronavirus vaccine roadmap that says: Yep, the vaccines we’ve got right now are good. They’ve done a lot of good. But we need great vaccines. And what will that take? And we put together this very comprehensive, detailed roadmap in each of these areas with measurable outcomes by date and time.

And this is going to take a major investment for the world to recognize and then have these new vaccines, if they’re ever to be had at all. And I think the fact that there was an absence of any support for this new vaccine work in this budget was very concerning. Now, I do believe the administration is trying to identify current funds that might be moved towards this that they may be announcing in the near future, but the world is going to have to understand what this takes. We’re in the same boat with influenza. We did a roadmap three years ago, with the support of the Wellcome Trust, a comprehensive influenza vaccine roadmap. And we’re surely making inroads, but it’s a slow, slugging process. And we need to invest more there.

You know, when you look at the world’s economy right now and you realize what has happened because of the pandemic—as much as Ukraine has added to that, yes, it has—what we’re seeing is global inflation, what we’re seeing is economic havoc, what we’re seeing are the challenges that many countries have had. You know, we talk about our country and inflation, you know, we’re lucky to be at the levels of inflation we are compared to many countries in the world that were put into that place by the pandemic.

And so, to me, it’s a very simple one. As a kid there was an old commercial on old black and white TV from the oil FRAM company that once said: You can pay me now or you’ll pay me later. And I think that this is such an important concept right now. We need to be investing in both influence and coronavirus vaccine work because, in fact, the payoff would be immense. And I—you know, if there’s any legacy we can leave our kids and our grandkids, it’s people like me need to be constantly reminding the world that this was not the big one.

HUANG: May I add? In terms of function, commissioning of the new bureau, I hope—and just my wishful thinking—that it could become a focal point for international health cooperation and collaboration. Because now if you look at all these agencies involved, right, in dealing with global health, you know, we have, you know, the HHS; you know, the U.S. CDC; we have the State Department; we have the National Security Council. In fact, now the National Security Council seems to be, like, the agency with the veto power on the international health cooperation because the—but the problem here is now that geopolitics now become a dominant concern very often for, you know, the actor like National Security Council.

You know, that actually make it—you know, sort of international health cooperation even more difficult, you know, than in the Cold War era, right? One of my favorite example is our relationship with China, right? We know that China is one of the biggest, right, the risk factor, right, in preparing for the next pandemic. But because of the geopolitical concerns/considerations, we don’t want to talk to the Chinese because we’re basically saying, well, they are doing that for the propaganda, you know, and they are not sincere. But if you don’t even want to talk to the Chinese, then how come you can talk about cooperation?

ANDERSON: Yeah. Really important point. And, you know, the establishment of agencies, authoritative or not, without clear funding for them is not going to get us there either.

We’ll take our next question at this time.
OPERATOR: We’ll take our next question from Tom Mahoney. Q: Hi. Tom Mahoney from Harvard.

Back to the last point about the big one that Dr. Osterholm and any of the other scientific participants. If we are, for the moment at least, in an endemicity phase of the pandemic, albeit at an unacceptably high level of case fatality rate—for some context, you mentioned the 400 deaths a day. I believe that’s about 2X the nadir of pre-

Delta in 2021. But in any event, how do you judge—this is a very open-ended question—how do you judge the risk of another Omicron event, a variant with a jump discontinuity in transmissivity and/or new innovation?

OSTERHOLM: Well, you know, let me just add that I think that sometimes we take more comfort than we could or should in our previous virus experience to say, well, we’re protected. And what I mean by that is just look at 2009. And there, we had an H1N1 virus that emerged out of Mexico that was very different than the H1N1 we had been dealing with for decades, and caused an influenza pandemic. And actually, many people said, well, that wasn’t such a bad pandemic. But if you actually look at years of potentially life lost, it did disproportionately hit, for example, young pregnant women, people as such. And so that the actual number of deaths, in terms of years of potential life lost, was really quite significant. And here was a virus that said, well, we can’t have an H1N1 pandemic; we already got an H1N1 virus circulating, OK? That mindset, it had to be a different one.

So I think we always have to come back to what is the immunologic crossover between a virus yesterday and a virus tomorrow? Now, you raise a very good point. And many of us would hope that we could have more sustained immunity against coronaviruses. But as we know, look at the common cold. Coronavirus has offered little to no protection against this particular one. Would we see that in the future? We just don’t know. So I surely think your point’s an important one. We have to try to understand that. I think it’s true both for coronaviruses and influenza. And this, again, is an area that we just need a lot more work in.

And then I also I think—and Lu mentioned this before too, which is important—is immunity is relevant to the time of that day. What does it mean six months later? What does it mean, you know, a year later? And what is B-cell versus T-cell immunity, something more likely to be durable if it protects you against serious illness, hospitalization, death, but not against infection. And we know that for influenza, for certain. You know, one of the reasons I’ve been an outspoken critic about making a coronavirus vaccine right now a seasonable vaccine, there’s no season. There isn’t. We just haven’t seen it.

Why do we have seasonal vaccines? Because if you looked at influenza, in particular, we know we can count on a new influenza season somewhere between November and February, OK? We vaccine just before that, because our studies have clearly shown you may lose up to 15 percent protection for your influenza vaccine per month after vaccination. And so you want to vaccinate close to the season, OK? But if you have that kind of wane in immunity, what does that mean for these future viruses we might encounter? So could we have a population- based protection of some kind with the coronavirus activity we’ve already experienced? Absolutely yes. But how much and how long and what does it mean? I don’t think any of us can say at all what that means. And Lu may have a comment on that, since this is an area she thought about too.

BORIO: You know, I think you’re right, Mike. And I just think that it’s very—you know, we should not be—as tempting as it is, we shouldn’t not be comparing SARS-CoV-2 with influenza virus, because you’re just so different. Even though they cause very much misery to humans in the form of fevers and body aches and risks for infections and sometimes pneumonia and all that, they are very different viruses. And, you know, the flu vaccine, for example, does not induce a robust cellular immune response. So it’s really—you know, it really requires a neutralization component to be—to be there, to protect you. And it’s different for the SARS-CoV virus vaccines.

And ultimately, I think we just have to follow the science. We have to continue to monitor, continue to do the studies that—you know, to inform the best strategies. It can’t be because we want to simplify the message. It can’t be because we want to simplify the schedule. You know, the public is not going to buy into that. We need solid science. And we also have the realize that there’s uncertainty, and the data is still incomplete. We need to go—keep after that. I think, you know, we have good reason to celebrate right now. We’re in a good spot. Again, the vaccines continue to show durable protection with respect to the cellular immune response, but things could change. And we just have to be on top of it.

ANDERSON: OK. Thank you. We’ll take our next question. OPERATOR: We’ll take our next question from Lynne Novack.

Q: Hello. I’m actually calling from Patagonia, Chile. And I got COVID on the way here. (Laughs.) So I’m still recuperating from it, but thank God for the vaccines and I’m doing OK>

ANDERSON: We’re glad to hear you’re doing OK, Lynne.

Q: OK.

The question I have is—well, actually, there’s a couple of them. There was a book that came out in January 2021 by Michael Lewis called The Premonition. And he had a lot of really interesting things in there about the way the government did not do things they should have been doing, and the few people either in the government or out of the government who were trying to do good things. Do you have any comments on that?

OSTERHOLM: Well, I think—first of all, let me just say, there were a number of different people that were stepping up early on and putting out the kind of information that should have alerted us to the pandemic. I published a document from our center on January 20th of 2020 saying: Get on with it. This is the next pandemic. We need to be prepared. I went to the Journal of American Medical Association to say we should do a commentary on this, and instead they not only rejected it but the following week they did an entire full-page cartoon demonstrating why flu was so much more important than COVID and that we should be concentrating on flu. You know, I was on Joe Rogan shortly thereafter that, and I said I thought there could be eighteen—or, over the course of the next eighteen months we could easily see over 800,000 deaths. Not based on some big fancy model, but just some very common statistics of this, this, and this. Eighteen months later, we had 800,000 cases.

And I have to say, it wasn’t just the government. The reason I’m telling you this, I got more pushback from my colleagues. I got pushback from people saying: You’re scaring the hell out of people needlessly. This is irresponsible. And less so than government. So as much as government was a problem, and I don’t want to minimize that. And I think, you know, Michael Lewis captured that in Premonition. But I think it was out public health and medical communities who were also stunned by this, and not believing it was going to happen. And that too is a—I think a challenge as to why then we were delayed in many of the things we did. And then when we did, we went from, you know, ten miles an hour to 200 miles an hour. All the lockdowns happened. We didn’t have clear messaging about what you should do or not do. And I think that then we went far too far on the other side, without bringing the public along with us. So I think it was—there’s enough blame to go around for everybody, everybody. And government surely wasn’t spared, but I think my own colleagues shouldn’t be spared either.

HUANG: Just follow up on Michael, I could provide another example, right, that, you know, I think it’s just— you know, it takes time even for the leading public health experts, you know, to, you know, gain a better understanding of what this virus is. Remember, you know, when that—even before the pandemic started—it was in February 2020—you know, I was in a leading university to start talk about COVID. There was, you know, very famous public health experts there. You know, when he was asked a question whether we should wear masks, and he was basically saying: Well, if you are healthy, there is no need for you to wear masks, right? This is from the beginning. This is very top universities, top public health schools, you know, that leading expert who was, you know, saying this kind of thing, right? So, again, it takes time for us, you know, to understand what that virus indeed is.

ANDERSON: All right. Thank you. We’ll take our next question. OPERATOR: We’ll take the next question from Anne Romatowski.

Q: Hi. Thank you so much to the panel for this really wonderful and excellent discussion.

My question is about long COVID. For many years, researchers, physicians, and patients familiar with post- viral illnesses have been raising the alarm about the woeful inadequacy of research and funding for such diseases. And now, three years after the start of the pandemic, the CDC has, in fact, acknowledged that COVID can, and I quote, “have lasting effects on nearly every organ and organ system of the body for weeks, months, and potentially years after infection.” That’s the end of the quote from the CDC.

We’ve seen labor force implications of long COVID across the United States, health care implications. As we, you know, think about the path forward with this pandemic and potentially future pandemics, could you all comment on sort of what the needs are, related to long COVID, and if you could offer, you know, any glimmers of hope, would be interested in that too, if you see any existing. Thank you.

BARIO: Mike, you’ve thought a lot about this, I know from our conversations, so. (Laughs.)

OSTERHOLM: Well, you know, first of all, I come at this from a long history of having been very involved with chronic Lyme disease, chronic fatigue syndrome, post-infectious kinds of conditions that have surely been challenging. And I think the one thing that has been very clear and compelling in those is that in many instances it’s likely not an infectious agent that is doing the damage anymore, it’s sort of cascade of immunologic responses in the human that is actually causing the problem. And, you know, I think that if you look at long COVID it is a very substantial issue. And we’re trying to figure that out.

If there’s any good news that I see with long COVID right now is, number one, we are seeing people recover a year later, getting back largely to wellbeing. Although, there are surely some who are still not. But the other thing is, is that it appears to really vary by the variant that you got infected with. And we’re seeing a substantially reduced amount of long COVID associated with the post-Omicron period. That is not the same as we saw during the pre-Delta—you know, the Alpha, Delta, early Omicron days. So that may be a cohort in time that are going to have their own unique challenges that are seeing different kinds of long COVID.

But I think to me, this is an opportunity which has not yet really been realized in any way, shape, or form to do for immunology what HIV did. If you look at what happened in the mid-1980s, HIV set off an entire cascade of research, from an immunologic standpoint, that brought us a lot of findings that weren’t directly applicable to HIV, but they had tremendous implication in understanding human immunology. And, I mean, I think there’s a lot of that opportunity here right now, and we need to do that. And I agree with you, if you look at the workforce issues that have come up, you know, estimates as high as 2 percent of the current workforce is unable to be in the workforce, who want to be in the workforce, because of long COVID.

And so, again, this is another one of those investments. You know, pay me now or pay me later. We need to invest much more in this area. And I do believe the implications are really very positive, that we can not only address post-infectious issues related to COVID, but what are the post-infectious implications for other diseases that we’re seeing similar kind of long illnesses following their initial insult.

ANDERSON: Yeah. Well, you know, Mike, I think that is probably a perfect place to close our discussion this morning and thank our audience for joining us today. You know, it’s been an enlightening and informative conversation around where we currently are, what happened as we evolved with this virus and the vaccinations, as well as the need for a road map and investment in future pandemic preparedness. Mike, Yanzhong, Luciana, thank you so much for being with us today. And we look forward to hearing more from you in your respective spaces that you work in around pandemic preparedness. Thanks, everybody.


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