The Pandemic Prophecy

He doesn’t know when it’s coming, or how bad it will be. But Dr. Michael Osterholm, one of the world’s foremost infectious disease experts, believes a flu pandemic is inevitable. And to hear him tell it, we’re nowhere near ready.

Photo by Eric Moore

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So we can build a missile defense system, but we’re just as vulnerable to a flu pandemic as we were in the Model T era? “I think we were better prepared in 1918,” argues Osterholm. And he has a point: America was more self-sufficient then, growing its food closer to home and producing a much larger share of its medical supplies and other essentials. Travel was slow, limiting the spread of diseases. During his lectures on pandemic flu, Osterholm always shows what he calls his most important slide: a graph of the number of days it took a person to circumnavigate the earth 150 years ago and today (365 versus 3), juxtaposed with a graph of the world’s population then and now (just under a billion versus more than 6 billion). His point is clear: since today there are many more people (read: potential virus hosts) in the world, and they get around much more quickly, we may be more susceptible to a pandemic than ever before.

“It’s obviously a big, big public policy issue,” Osterholm says of pandemic flu preparedness. He notes that HIV/AIDS has killed 28 million people over the past 30 years. Bad as that is, he says, pandemic flu “could easily kill 180 million people in one year…. [Pandemic flu] is the biggest thing I know I’ll ever be a part of in terms of a public health problem.” In fact, Osterholm says this is the first such threat that’s kept him awake at night. “In terms of how it’s transmitted, in terms of how it kills,” he says, “this is everything that you could ever dream up in your worst nightmares of what an infectious agent could be.”

The Center for Infectious Disease Research and Policy is Osterholm’s command center. It comprises several offices tucked within the health center complex on the University of Minnesota’s Minneapolis campus, employs 14 people, and has an annual budget of about $1.5 million. But it’s not the sort of place that will save you when the flu hits the fan. There are no labs here, no microscopes, no test tubes. CIDRAP deals with information. Its staff analyzes the latest developments in bioterrorism, food safety, infectious disease outbreaks such as SARS, and, of course, influenza. They disseminate this news in staff-written reports on their website (www.cidrap.umn.edu), a leading source of information for public health officials around the world. CIDRAP also sponsors seminars on infectious disease issues and has several government contracts, mostly with the Department of Homeland Security and largely related to improving the nation’s bioterrorism surveillance program. To the general public, however, CIDRAP is Osterholm. And for Osterholm, the center is not just an information clearinghouse, but a nonpartisan stump from which he can organize, advocate, and critique without censure.

Osterholm’s myriad media appearances and colorful style have fueled suspicion that he’s promoting himself along with his concerns. But while he allows that his provocative words sometimes draw attention to himself, Osterholm insists that’s not his intention. He has no ambition, he says, beyond the walls of this office. “I’m where I want to be and should be,” he declares.

Of course, immediately following 9/11, he was often in Washington. And in 2002, when the Centers for Disease Control (CDC) was searching for a new director, Osterholm’s name came up. At Tommy Thompson’s behest, Osterholm was then serving as one of four people on the CDC’s transition team, helping to run the health agency until a director could be found. According to the Atlanta Journal-Constitution, Osterholm’s name fell somewhere between the wish list of potential new directors and the list of those who provoked anxiety among the CDC rank and file. “Someone whom CDC employees both respect and are unnerved by,” the newspaper called him. Osterholm says he was never a candidate and, in any case, he values his freedom of speech too much to embed himself within a government institution. “I’m seen as a neutral broker,” he says.

This self-professed neutrality, however, hasn’t inoculated Osterholm against charges of bad science. In a September 2005 New Republic article titled “Chicken Little,” science journalist Wendy Orent (author of the 2004 book Plague: The Mysterious Past and Terrifying Future of the World’s Most Dangerous Disease), argues that a future bird flu pandemic of 1918 proportions is unlikely and that the officials suggesting such horrors are needlessly inciting panic. “Among these doomsayers,” she writes, “none has been more strident than former Minnesota Department of Health epidemiologist Michael T. Osterholm.” Orent suggests that Osterholm has promoted inaccurate assumptions before, citing public statements he made after 9/11 about King Hussein having evidence of illegal smallpox stashes in Iraq. (These stockpiles, putatively created for use in germ warfare, were famously never found.) Orent even quotes an anonymous government official as saying that these statements by Osterholm “had a significant impact in high places” on the decision to invade Iraq. Osterholm says the idea that his remarks would have had such an influence on the Bush administration is
“far-fetched” and “crazy.”

But the main reason Orent and other naysayers discount Osterholm’s pandemic scenario is that they believe the key to knowing whether a flu bug will spawn a pandemic is an understanding of how the virus evolves—and that Osterholm, not being an evolution expert, may not be in a position to know. These critics have aligned themselves instead with the theories of Dr. Paul Ewald, a University of Louisville–based expert on the evolution of infectious disease. Ewald believes a typical flu virus maintains itself at a low to moderate level of virulence, or infectiousness, because it needs its hosts alive and walking to propagate. The reason the 1918 flu evolved such exceptionally high virulence at the Western Front in Europe, he says, is that the trenches from which World War I was largely fought offered such an exceptional context in which to evolve—a place so crowded with bodies that transmission of the flu virus didn’t depend on a walking, talking person. The virus could kill with impunity. Such virulence, Ewald’s theory goes, won’t be seen again unless those exact conditions are duplicated.

“It’s BS,” Osterholm says of Ewald’s model, “plain BS.” He counters that the first country to be devastated by the 1918 flu was Switzerland, far from the front. Also, if unusually high crowding was a requirement of high virulence, he says, then the squalid, nearly trench-like conditions in developing nations today should provide even more reason for concern.

Other pandemic pooh-poohers, such as Time magazine’s medical columnist, Dr. Andrew Weil, suggest we could contain avian flu when it’s still localized. That would be nice, Osterholm observes, but he believes containment would be difficult, if not impossible. “We have as much chance of stopping a pandemic as we would of putting a curtain around Minnesota and keeping out winter,” he says.

This isn’t the first time Osterholm has been criticized for his predictions. In the mid-1980s, he was “royally panned,” as he puts it, in a series of Star Tribune articles on AIDS. The series offered an analysis of the threat in which Osterholm came off as a fringe figure for suggesting two things he’s so far been proven right about: that an AIDS vaccine wouldn’t be created in his lifetime and that heterosexual transmission of AIDS would become a major issue in developing nations.

On the wall of his office, Osterholm keeps a plaque he received for giving a flu-preparedness talk at the CDC in 2003. Then, too, few people took the threat as seriously as he did; he beat the drum for two years before pandemic flu suddenly became the talk of the nation. “That’s what’s hard sometimes,” he says, staring at the plaque. “Think how much progress we could have made.”

A few weeks later, Osterholm calls me to say that he’s taped an appearance on Oprah. New York Times columnist Thomas Friedman also has talked to him about a flu story, he says. Momentum is building on the issue. Two days after that, he e-mails a Nature magazine article regarding the H5N1 virus in Turkey. “The naysayers,” he writes, “can’t deny the virus is doing exactly what we worry about most…mutating.”

In early February, sure enough, there he is on Oprah—for the full hour. Generally, only Tom Cruise gets the hour treatment. Pandemic flu has arrived.

On Oprah, Osterholm is asked how regular folks can prepare for the flu. Stockpile food? Certainly, he says. How about masks? Maybe, if they’re the right kind of masks. Think about what you’ll do, where you’ll go, how you’ll work under pandemic conditions, Osterholm counsels. And beyond that, push, as he is, for a more robust public health system. The one thing you can’t do, he says, is hope it won’t happen.

And yet…what if it doesn’t? That is, what if it doesn’t happen the way Osterholm is suggesting it could. Or it doesn’t happen soon enough and the public, feeling duped, begins a backlash. Osterholm is prepared: “You gotta stay the course,” he says. “The risk isn’t going to change.” Pandemics happen. In fact, Osterholm’s supporters say that even if we somehow end up overprepared, a buildup of social services and health-care infrastructure is greatly needed anyway. Thompson, for one, commends Osterholm for all his preparedness work. “This country owes him a debt,” he says.

America has been dangerously unprepared before—9/11, Katrina—with the result that localized disasters became crises of national identity. When Osterholm calls for the country to unite against pandemic flu, he is hoping to preserve not just the health of the United States, but the union itself. When discussing pandemic flu, Osterholm frequently quotes Ben Franklin’s observation, “If we don’t hang together, we’ll all hang separately.”

Last November, Osterholm spoke at a pandemic flu preparedness seminar sponsored by the Minnesota Chamber of Commerce and aimed at local businesses. Osterholm was asked his opinion of the federal government’s commitment to preparedness. He mulled the question so long it seemed he might not answer. Finally, he did. “I don’t give a damn about not being liked anymore—this is too important an issue,” he said. And then he laid into politicians who’ve paid lip service to pandemic preparedness but done nothing.

“I’m afraid we’re going to have a commission like [the one convened after] 9/11,” he said. In other words, a sweeping, klieg-lighted investigation into everything that went wrong during the Great Influenza Pandemic of 200–. “And this time,” he says, “we’re all going to be held accountable.”