How ready are we for the next pandemic?

Osterholm says it is not a question of if. He compares it to arguing about whether there will be another hurricane: we will see more pandemics, we just do not know when, where, and how bad. He says the pandemic clock is ticking and we do not know what time it is, and that another major one could start tomorrow.

Osterholm walks through the recent coronaviruses: SARS in 2003 killed up to 15 to 20 percent of the people it infected but did not spread easily, MERS in 2012 killed up to 30 to 35 percent and also did not spread easily, and COVID-19 spread widely but killed about 1 to 1.5 percent. He says researchers have identified viruses in bats that combine both traits, able to transmit like SARS-CoV-2 while carrying the genetic makeup to kill at 20 to 35 percent. He is describing viruses that already exist in nature, not a hypothetical.

Osterholm puts it at about the resources one aircraft carrier would provide. He says that with that kind of funding he is convinced the next five to seven years could produce highly effective vaccines that are manufactured in advance and held ready to deploy worldwide. He notes that microbes have killed far more people in the last century than all the wars, and that almost nothing goes into defending against them by comparison.

It is a question of speed, according to Osterholm. Growing influenza virus in chicken eggs and cell culture would cover roughly a quarter of the world's population in the first 12 to 15 months of a pandemic, with the rest waiting until years two and three. He says mRNA could likely cover the world in 9 to 12 months, and that the difference between those two timelines is millions of deaths. The United States had $500 million going toward making that real and the investment was ended.

Osterholm's answer is no, and he says he wrote as much in the Washington Post in early March 2020. His reasoning was that the virus would be around for years and you cannot lock down for years, so whatever you chose had to be sustainable. He notes 41 states began lockdowns in late March 2020 and all but one had ended them by early June. He also points to China, where areas stayed locked down for two years and then saw large numbers of deaths once restrictions relaxed, because the virus was still there.

It is the alternative Osterholm proposed instead of lockdowns. Every hospital already knows its daily census, so when capacity reaches 90 to 95 percent you ask that region to slow down for about two weeks, avoid large public gatherings, and possibly close schools, then bring the numbers back down and ride out the next wave. The goal is protecting medical care, which he calls the most important thing you have before a vaccine exists. He says the idea never got much traction, and he still stands by it.

Osterholm says aerosol spread was most of what COVID transmission was, and that he still meets people who do not believe it. He explains that speaking produces both droplets, which fall within six to eight feet, and aerosols, the fine particles that travel like smoke or perfume across a room. He says millions of dollars went to measures like plexiglass that made no difference. He does not offer a single explanation for the delay, but the episode notes a World Health Organization post stating COVID-19 was not airborne.

Osterholm says the country got this one wrong by freezing its thinking at year one. In the first year of the pandemic 199 children in the United States died of COVID and studies supported keeping schools open. Across the first three years almost 1,600 children died, with 87 percent of those deaths in years two and three as the Delta and Omicron variants changed the picture. He cites a Boston study finding more than 80 percent of documented household cases in those later years started with kids bringing it home. Snow days, he says, would have worked well in schools.

Osterholm calls the evidence absolutely unequivocal. He says the vaccines saved millions of lives around the world and likely at least 1.2 to 1.8 million lives in the United States. He is also direct about what they did not do, describing a vaccine that did not stop transmission or prevent illness but was powerful at preventing serious illness and death. That, he says, is why he got his and keeps getting them.

Osterholm says that when it comes to what happened in Wuhan, there is no doubt in his mind that we will never know. Asked to guess, he says the data tend to favor a real spillover a bit more, but that he cannot say. He served on the National Science Advisory Board for Biosecurity from 2005 to 2012 and says he is hardly agnostic about lab risks. His conclusion is to prepare for both a lab leak and a spillover and stop spending time on a debate that will not be settled.

Osterholm defines it simply as doing something to a microbe that enhances its ability to spread or to cause serious illness and death. He says the answer is not yes or no but depends entirely on the conditions. His example is Ebola: The Hot Zone described an outbreak among monkeys in Reston, Virginia that spread through a facility, and there have been lab outbreaks where infected animals were 30 to 40 feet apart. He led a group of 16 senior Ebola researchers who published on respiratory transmission, and says learning whether these viruses can be made airborne would be worth it only inside BSL-4 containment with multiple barriers.

Osterholm says that for the first time in decades, nobody in the White House has bio preparedness as their job, and there is no node for it on the security council. If a major biological event happened today, he says, he would not have a clue who would be in charge. He adds that CDC has lost more than 20 percent of its workforce and that no one in its senior leadership is a scientific professional. He calls this the darkest days he believes public health has seen in the last 100 years.