Epidemiologist: This may get worse

‘ My job is not to scare people out of their wits, it’s to scare them into their wits’

As the number of U. S. deaths attributed to COVID- 19 approached 82,000, the USA TODAY Editorial Board spoke with Dr. Michael Osterholm, one of the nation’s leading epidemiologists. Osterholm, 67, is director of the Center for Infectious Disease Research and Policy ( CIDRAP) at the University of Minnesota and co- author of “Deadliest Enemy: Our War Against Killer Germs.” Questions and answers have been edited for length, clarity and flow:

Q. How bad is this outbreak? A. Sixty days ago, COVID- 19 was not even in the top 100 causes of death in this country. Within six weeks it was the No. 1 cause of death. That hasn’t happened since ( the) 1918 ( influenza epidemic).

Q. The United States has 4% of the world's population but has 28% of the recorded deaths from the coronavirus. Why is that?

A. Any number like that is artificial at best. If you had to add it up globally, we still play a very prominent role in the number of deaths that have occurred. But at the same time, I would say that we’re not any different than many areas of the world where lots of cases are going uncounted, both deaths and regular cases.

Q. Where are some of the biggest hot spots in America?

A. Nursing homes, long- term care, prisons, homeless shelters, meatpacking plants — these are all areas where, once that virus gets into those locations, it's like a gas can. Suddenly 50% or 60% of the people are infected in those locations. I think we’re going to burn through those populations quickly over the course of the next three to four months at most.

Q. Does that mean the worst will be over then?

A. I think you’re going to start seeing it move into the rest of the U. S. population. When you look at adults 18 years of age and older, up to 40% of us have some co- morbidity that would put us at increased risk of having a severe infection or dying. We are still going to have lots of deaths. … While the rate of deaths will be much lower in younger individuals, the obesity epidemic in our country is going to take a hell of a toll.

Q. If the epidemic dies down during the summer, can we rest easier?

A. Right now the thing that scares the hell out of me more than anything is that suddenly, in the next two months, cases in the U. S. suddenly drop off dramatically. That would tell me, this may be acting like a flu virus. And if that were the case, you might very well expect to see a late summer/ early fall peak that could be much, much more severe than anything we’ve seen already and much more universal in terms of where it hits and how it hits. If we have a big fall peak, it’ll redefine us as we are as a modern society. We’re in uncharted territory. We don’t know.

Q. Why are you so concerned about another peak?

A. As much pain, suffering, death and economic disruption as we’ve had, it’s been with 5% to 20% of the people infected, and most of those areas of the country have been in the 5% to 10% range. That’s a long ways to get to 60% to 70% to even begin to see herd immunity. Think what we have to go through. This damn virus is going to keep going until it affects everybody that it possibly can.

Q. Why are some areas, even within the same country such as Italy, hit so much harder than others?

A. We don’t know, and it can’t be explained by any sociologic, population density, transportation issue. We don’t know. That’s the random nature of these viruses.

Q. In a recent report, CIDRAP said it's important for leaders to “proclaim uncertainty.” So what else don't we know?

A. One question is ( whether we will have a safe vaccine before we get to) that 60% to 70% level or higher, or will we have to achieve it through illness and hopefully durable immunity? A second question is, what does immunity mean? If we don’t have durable immunity, we can expect these ( waves) to happen over and over and over, and that’s a scary proposition.

Q. How would you rate the government's response?

A. I have a major, major concern about leadership right now. We’re not where we need to be, either from an execution standpoint or understanding the problem. We’re just in the second inning of a nine- inning game. ( Leadership means) admitting when you’re wrong. Don’t sugarcoat things. Just tell the truth. I think we have some real challenges ahead, because this may get a lot worse, not better. I don’t think people really get a sense of that yet.

Q. How can officials communicate better with the public?

A. Just tell the truth. What do we know, and what don’t we know. I’ve already acknowledged a number of things that I don’t know. And I think I know this virus pretty well. Don’t minimize issues. My job is not to scare people out of their wits, it’s to scare them into their wits. Basically, you’ve got to be clear and compelling. To tell people that this is gonna be over with right now, I think, is absolutely an abdication of leadership.

Q. Where do we go from here? A. I’ve been saying from the get- go: We can’t lock down for 18 months or more to whatever it might take. And then even then, we don’t know what it will do. At the same time, we can’t let these cases go willy- nilly. I mean, they will bring down our health care system. The number of deaths will be remarkable. So how do we thread the rope through the needle? We need leadership there right now. This is not going to be easy.

Q. Isn't there a trade- off between the economy and health?

A. This shouldn’t be dollars or lives. This should be, how do we integrate both and bring them together? How do we make tough choices? That’s not happening. That’s leadership again. All those things are not happening. It’s not a partisan issue. It shouldn’t be.

Q. Will the economy bounce back quickly?

A. Six months from now, the economic picture in this country is going

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to look a lot worse than it looks now. There’ll be more unemployment. There’s gonna be a higher likelihood of this disease having much more impact on our communities. How are we preparing to get the American workers through that now? How are we preparing national and international supply chain issues now?

Q. Aren't other countries showing the way forward?

A. Please don’t tell me that I just have to do what they do in Korea. Or I have to do what they do in Singapore. Or I have to do what they do in New Zealand. Every one of those ( nations) is vulnerable to this virus tomorrow. We just all have to confront the fact that there’s not a magic bullet, short of a vaccine, that’s gonna make this go away. We’re going to be living with it, and we’re not having that discussion.

Q. How can leaders in this country improve the conversation about moving forward?

A. Using my baseball analogy, where I said we’re only on the second inning of a nine- inning game, we’ve got to figure out: How do you declare balls and strikes? Four weeks ago, we had everybody agreeing that we’re going to reopen ( once we) have 14 days of reduced occurrence of illness. Then, when it got another couple of weeks along and that wasn’t happening, we just threw all that out the window without ever saying we did.

Q. How does that affect public perceptions?

A. We’re setting the precedents for making decisions by press conference or by tweet. And this is where the public is getting confused and more angry, because all they want is the truth. Just tell us what it is and why we’re gonna do it. The first step is basically saying there are no easy answers here. There aren’t any. … People are going to die. Don’t deny that. People are going to die no matter what we do.

Q. What do you think about the protesters who want a faster reopening?

A. If people at these rallies want to infect themselves, that’s their choice. It’s like smoking. If you smoke, the health care system will take care of you. But if you come in with your lung cancer, you don’t put three other health care workers at risk of getting lung cancer. ( If you come in with COVID- 19), you put a lot of health care workers at risk. The numbers are clear and compelling. Health care workers are taking a heavy hit.

Q. Are we sufficiently protecting other essential employees who can't work from home?

A. I would never have believed this possible, in this day and age in public health, where you could have people at high risk of transmission at meat processing plants, where a president just determines by the Defense Production Act that this is an essential area of work. And that basically, if you don’t go to work, the governors have decided you don’t get unemployment, and yet we don’t provide them protection. These people aren’t getting N95 ( masks). That’s just wrong. That’s morally, ethically wrong.

Q. How much control do we have? A. I’ve been saying all along, we’re not driving this tiger, we’re riding it. We are not going to determine the course of this pandemic beyond potentially flattening some of the peaks or in some ways limiting high- risk people from potentially getting infected and having bad outcomes.

Q. Is widespread testing part of the answer?

A. Test numbers surely are important, but how well can you basically maintain testing? Let’s just start at the front end. We are seeing equipment that has not ever been meant for the purposes it’s being used for right now: 24/ 7 testing, 365 days a year. We’re starting to see a breakdown, because these machines were never meant to run like this.

Q. How about tracing the contacts of infected people?

A. Early on, if you had a small number ( of infections), you can get in and you can control it to the extent that you can’t get rid of it, but you can surely minimize it. Once it hits a level like it is in most countries right now, contact tracing plays almost no role, I believe. Once you see a big escalation in cases, you’ll be having contacts by the many thousand, and it’s just not going to work. It’s going to come back to the individual and following up and trying to limit it that way.

Q. Do you think that we'll have a vaccine before we get to the 60% to 70% herd immunity?

A. We have 100- plus vaccines ( in development) right now. The question is, will any of them work? What happens if you have a vaccine that’s only 20% effective? Are you going to use that? Are you going to put it out there? And when I say effective, what if it’s for six months that it’s protective and then the data shows that it wears off after six months and you need a booster? I think that we have real challenges yet there. Knowing what I know about coronavirus immunology, it’s not a slam dunk. I hope, more than I can put into words, that we have one. But hope’s not a strategy.

‘ There are no easy answers here,’ Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy, tells the Editorial Board on Monday.