Episode 170: What Happens Now? Public Health in Uncertain Times

Chris Dall: Hello and welcome to the Osterholm update, a podcast on COVID-19 and other infectious diseases with Doctor Michael Osterholm. Doctor Osterholm is an internationally recognized medical detective and director of the center for Infectious Disease Research and Policy, or CIDRAP, at the University of Minnesota. In this podcast, Doctor Osterholm draws on nearly 50 years of experience investigating infectious disease outbreaks to provide straight talk on the latest infectious disease and public health threats. I'm Chris Dall, reporter for CIDRAP news, and I'm your host for these conversations. Welcome back, everyone, to another episode of the Osterholm Update podcast. Two weeks ago, the US Department of Agriculture announced the first H5N1 avian flu detection in pigs. The infected pig, which was on a backyard farm in Oregon where an outbreak was recently reported in poultry, showed no signs of illness, nor did the four other pigs on the farm. But public health officials had long worried about the spread of H5N1 in pigs, which are known to be a mixing vessel for zoonotic and human influenza viruses. This is just one of several new developments in the H5N1 outbreak, which in just a few months will be in the hands of a new presidential administration that appears to have very different views on public health. The H5N1 outbreak is among the topics we'll be discussing on this November 14th episode of The Osterholm Update, after we bring you up to speed on COVID-19. We'll also provide an update on flu and other respiratory viral activity and answer an ID query about pertussis. And we'll bring you the latest installment of This Week in Public health history. But we're also going to discuss what the policies of the incoming Trump administration could mean for public health and infectious disease response in this country, and how they will shape this podcast going forward. But before we get started, we'll begin with Doctor Ostrom's opening comments and dedication.

Dr. Michael Osterholm: Thanks, Chris. Welcome back to all of you in the podcast, family and anyone who may be joining us for the first time, or if you're an infrequent visitor and you're with us today, I hope you all will find what you're looking for. A lot has happened since our last podcast episode aired. The 2024 US presidential election is now history, and the impact of the results are sending shockwaves through the country and the world. As a nation, it feels like we're bracing ourselves, some with eager anticipation and others with sobering fear for what comes next. Political campaigns always feel divisive, but I think most would agree that this presidential election, as well as all the down ballot elections, felt particularly polarizing for all. You may recall from the last episode, I did something I've never done before in my 50 year career in public health and government service. I spoke candidly about my fear for the future of public health. Under a second Trump administration. After the episode aired, I spoke with many in the field of public health and medicine who shared my concerns. Now, as we sit here with these results, I think we're all asking what comes next? What does come next for public health? Under the leadership that has a track record of opposing evidence based public health practice? What comes next for institutions like the CDC, the NIH, the FDA, the EPA that provide guidance and leadership for public health research and policy? What comes next for reproductive health care? What comes next for global health initiatives? What comes next for Medicare and Medicaid? For prescription drug prices? For public health support for vaccines and easy, affordable access? What comes next? The dissatisfying answer is we don't know.

Dr. Michael Osterholm: There are campaign promises and a project 2025 policy wish list that fuels some of my fears about public health under the next administration. Until the Trump administration takes office and begins to craft the actual agenda. We can't anticipate exactly what we're dealing with. I urge what we do not conclude what will happen until we see what the new administration actually brings forward for policy and program changes. We must stay focused on what is actually happening, not what speculation causes us to worry about. The unknown is very difficult. I know that, and I recognize that many of you may be struggling in this post-election waiting period. I'm dedicating this podcast episode to anyone dealing with the anxiety of what is to come. Maybe you, like me, are worried about what's at stake with our health systems. Or maybe more of your concerns lie with what election results mean for our economy, your child or grandchild's future, or the safety of your neighbors.

Dr. Michael Osterholm: The dread, even potential fear that comes with not knowing what happens next is so difficult to overcome. But I encourage you to take care of yourselves, to stay connected to your communities, and to look for actions big and small, that you can take to advocate for the safety and well-being of yourselves and others. And please never forget the healing power of kindness. At the end of this episode, I'll be sharing how this podcast and the entire team at CIDRAP plan to stay vigilant and responsive to the challenges that the field of public health will undoubtedly face in the years to come. We will make every effort to call balls and strikes, just as we did in the three-plus years of the COVID pandemic. I promise I will stand with you, the podcast, family and others looking for the same kind of information for the next four years. I will be there in times of uncertainty and anxiety, offering my best assessment of what is happening and what we can do to improve our public health world. I ask you all to stand with us in the other trusted leaders who will continue to share important and credible public health practice, public policy and medical information. No matter what comes next. I promise we will keep showing up and I hope you can join us.

Dr. Michael Osterholm: Now let me move to that part of the podcast that is nails on a chalkboard for a few of you. Thank you for your patience. But for someone like me to get down there right now in terms of the big events, what am I talking about? Well, today in Minneapolis, November 14th, sunrises at 710, sunsets at 744, nine hours, 34 minutes and 26 seconds of sunlight. We're losing about two minutes and 22 seconds a day. We're not far off from December 4th, which is the day that we have the earliest sunset. Not December 21st. December 4th. Between that date and December 14th, the sun will set at 431, 13 minutes shorter than it is today. Hold on. We're going to get there. It won't be many more weeks and we can actually see the upside of the sun coming. Now, our dear friends and colleagues at the Occidental Belgian Beer House in Auckland, New Zealand, Vulcan Lane, that is, they get to see the sunrise at 603 and sunset at 807. 14 hours, three minutes and 56 seconds. They're gaining about one minute and 49 seconds a day. They're on the upside. They'll have a lot of light for a while. Please share it with us. We're on the downside, but we're getting there and we're going to turn the corner soon.

Chris Dall: Mike, we've seen declining COVID activity across the country in recent months. Is that trend continuing?

Dr. Michael Osterholm: Chris good news. Good news. COVID activity remains low. It's about as low as it's been all year. So I'd say that we're still in the good but not great place. And what I mean by that is that I'd like to see it even go lower. National wastewater concentrations are still considered low and decreasing in every region other than the Midwest, which has seen a very slight increase over the past two weeks. Hospitalizations, emergency department visits and deaths all continue to decrease as the XEC variant rises in prevalence, making up 28% of US cases in the past week. So far, it does not appear that XEC is going to be responsible for a substantial increase in case numbers. Quite a bit has happened since our last episode, but the most notable regarding COVID-19 is an update to the Hospital Respiratory Data Reporting System here in the United States as of November 1st. Healthcare organizations across the country are now again required to report the following metrics first hospital inpatient and ICU bed capacity and occupancy data overall and by bed type. In other words, pediatric versus adults. Number two. Number of hospitalized patients with lab-confirmed COVID-19 influenza and RSV by age group. And finally, third, numbers of new hospital admissions of patients with lab-confirmed COVID-19 influenza and RSV by age group. Because of this transition, there is a slight delay in reporting and we expect the first update since the new reporting requirements to come tomorrow, Friday, November 15th.

Dr. Michael Osterholm: So for now, we only have hospitalization data for the last week of October, when there were over 2300 Americans reported to be hospitalized with COVID-19. In the 35% of the hospitals that reported their data last week. This would mean around 6500 cases actually occurred. If we assume that the 35% of the hospitals that are reporting are representative of all hospitals, we don't know that approximately 14% of those hospitalized were in the ICU. This is nearing the lowest weekly hospitalization rates we've seen since the start of the pandemic, which we saw just a few months ago in July of 2024. But I think we'll have a much clearer picture of where we are truly at in our next episode when we have complete hospitalization data, weekly deaths continued to decline for the most recent week of complete data. There were 760 deaths reported. This marks the 18th straight week with more than 500 American lives lost to COVID per week. We had a listener write in and offer some perspective about these totals, and I wanted to share this because I think it is a powerful message when we take a look at the bigger picture. In the past year, we have lost 58,200 Americans to COVID-19, which would be an average of about 1120 weekly deaths over the entire year.

Dr. Michael Osterholm: During the Vietnam War, the US lost 58,220 American soldiers, almost an identical number. Let me repeat that. We lost 200 more American soldiers during the Vietnam War from 1954 to 1975, than we lost in just the past 365 days to COVID-19. You can see why deaths are still a very critical issue. We've moved past the darkest days of this pandemic, but that doesn't mean it's faded entirely from our lives. To give you a perspective again on the 58,200 Americans who have died from COVID in 2022, the last year we have complete data for we had 42,514 individuals who died in motor vehicle accidents in the United States. Think of that 42,514 in COVID. When we consider ourselves on the back side of the pandemic, still lost 58,200. Now, to even put this into more perspective, if you look at the entire year of 2021, which was by far the hardest hitting year in the pandemic, we lost 460,000 lives in this country from COVID, substantially more than the 58,000 that we're talking about. But as you and I both know, these deaths are our loved ones. They're our fathers, our mothers, our grandparents, our children, our friends. And death is still a challenge. So let me just say the good news is we are in a better place by far. We're getting better. Let's hope that we can continue on this track and bring our COVID deaths down even further.

Dr. Michael Osterholm: Let me give a quick vaccine update because that's key to bringing down the number of deaths. Unfortunately, uptake is very low. Why? I'm somewhat pessimistic. We're going to see major gains in the number of deaths prevented. As of October 26th, only 14.8% of U.S. adults reported receiving the 2024 2025 COVID vaccine and 13.8% reported they planned to get a vaccine. This is slightly higher than what we saw in 2023, but is still very low, 42% reporting they will definitely or probably not get a vaccine in 2024. Now, looking at child vaccination rates, only 6.1% of kids six months to 17 years have received the 2024 24 vaccine. Let me repeat that. Only 6.1% of the kids, and only 13.4% had a parent say they plan to get their child vaccinated. This is slightly higher than last year, but it's very concerning, especially considering that 50% of parents reported they will definitely not, or probably not get their child vaccinated. As I have stated so many times on this podcast and other venues. These are good vaccines, but they're not great. Yes, we do need to get these boosters. And as you know, the CDC, per the recommendations of the ACIP, have now made it clear that all of us are eligible for two doses of vaccine a year. In fact, for those who have underlying immune conditions older, they actually are allowed three doses a year.

Dr. Michael Osterholm: Why do we keep talking about more doses? Because we see good protection against serious illness, hospitalizations and deaths for those first 4 to 6 months after vaccination. But then it wanes. That's when you need to get your booster. But let me also share with you a quick summary of a recent study from California that emphasizes the benefits of the vaccine in kids. Because if we can reduce the 50% of parents, even by a little, it'd be a step in the right direction. This study, which looked at multisystem inflammatory response syndrome in children or, as you know, MIS-C, MIS hyphen C following COVID-19 infection between January 2021 and June 2022, found that unvaccinated children were at a significantly higher risk of developing MIS-C than children who had received two doses of the Pfizer-BioNTech vaccine at least 14 days prior to the infection. This was a large study that included children ages 5 to 17 reported to the California Department of Public Health and who met the CDC criteria for MIS-C. Researchers ultimately identified 133 cases of MIS-C to include in the study 60 aged 5 to 11 and 73 aged 12 to 17. There were also five cases of MIS-C in children who were partially vaccinated during this time period. MIS-C is a post-COVID condition that presents similar to Kawasaki disease or toxic shock syndrome. 2 to 8 weeks after infection symptoms include fever, inflammation and multisystem organ involvement.

Dr. Michael Osterholm: All 133 cases in the study required hospitalization, half required ICU care, and up to 2% died. This incidence of MIS-C was significantly higher in the unvaccinated population compared to the vaccinated population. Now, looking at the age breakdown of these cases in the 5 to 11-year-old age group, 85% of the MIS-C cases were unvaccinated and the incidence ratio in unvaccinated children was 3.3 times higher than in unvaccinated children. Interestingly, in the 12 to 17-year-olds, 90% of the MIS-C cases were unvaccinated, and the incidence ratio in the unvaccinated was 22.9 times higher. Let me repeat that 22.9 times higher. Even when adding the partially vaccinated kids who received one dose cases into the analysis, the impact of vaccination still cannot be ignored. The incidence rate ratio of MIS-C among unvaccinated children 5 to 11 was 3.4, and the incidence of MIS-C in unvaccinated 12 to 17-year-olds was 16 times higher than in fully vaccinated kids. This means that kids who were fully vaccinated with two doses of the vaccine had a significantly lower likelihood of developing MIS-C after a COVID-19 infection. It is evidence that these vaccines provide a benefit, especially to kids. It's hopefully enough evidence to encourage at least some of the 50% of vaccine-hesitant patients to rethink their decision and protect their children from this really severe post-COVID condition.

Chris Dall: And what are we seeing with influenza and other respiratory viral activity right now?

Dr. Michael Osterholm: Well, again, Chris, good news. We're beginning to see early signs of influenza activity picking up in the US, but it is still minimal. During the week ending in November, second levels of outpatient respiratory illness did begin to increase, though they are still below the national baseline level we expect to see during an influenza season. All states are still reporting minimal or low levels of influenza activity, though Washington, D.C. did report high levels of activity early last week. RSV activity has been slowly increasing over the past few weeks, but similar to influenza, it is still well below what we expect to see later in the season. If you haven't gotten your influenza vaccine yet this year. Now is the time to do so. Similarly, if you are in the 70% of eligible pregnant individuals or 63% of the adults over 75 who have not received your RSV vaccine. Please don't delay your vaccine any further. As always, we will continue to keep you updated as the respiratory season progresses. Just remember right now these vaccinations can do a lot. Both influenza and RSV to keep you from becoming seriously ill, requiring hospitalization, and even from dying. Boy, what a cheap, cheap investment the vaccine is to prevent that.

Chris Dall: As a quick follow up mike, there have been a few media reports about an increase in walking pneumonia. Can you explain for our listeners what that is and what we're seeing?

Dr. Michael Osterholm: Well, Chris, let me start out by saying I hate the term walking pneumonia. It  sounds like somehow it should be out of a horror movie. Okay. But it's a term that I've heard ever since I've been in public health, and we're not going to change it. Let me answer your first part of the question you raised. What is walking pneumonia? At least as defined from a medical standpoint. It describes most usually relatively mild cases of a bacterial pneumonia, typically caused by the bacteria Mycoplasma pneumoniae. This bacteria can cause flu like symptoms, including dry cough, headache, fatigue, and fever. Because the pneumonia caused by mycoplasma pneumonia tends to be more mild, hence the name walking pneumonia, and only occurs in about 10% of cases. People with infection often continue to attend work or school, resulting in further transmission. Now to the second part of your question. What's going on with walking pneumonia or mycoplasma pneumonia infections right now? The CDC released an alert on October 18th, indicating that the increase over the past six months in the proportion of patients in emergency departments being diagnosed with mycoplasma pneumonia, associated pneumonia, or bronchiolitis.

Dr. Michael Osterholm: This increase has been particularly significant among children ages 2 to 4 months, which is actually close to the prime age group. We expect to see illness 5 to 17 year olds, so it's nothing at this point. That is really a unusual occurrence of infection. And the good news about mycoplasma pneumonia not besides being usually mild, it's treatable using macrolide antibiotics. Fortunately, we aren't seeing much resistance to macrolides here in the United States for Mycoplasma pneumoniae, though it is a problem in other parts of the world, particularly Asia. This is yet another example of a disease that, while not a significant threat to the US today, could become a major challenge in the years to come. Antimicrobial resistance worsens. This truly is a slow motion tsunami, and one that the public health community needs to act on. Now, for those interested in antimicrobial resistance, I highly recommend you listen to CIDRAP's other podcast, Superbugs in You, which we will link in the show notes so that you can go and hear more about what the current and future challenges of antimicrobial resistance are to us as a society.

Chris Dall: So now let's turn to the H5N1 influenza outbreak. In addition to the detection of H5N1 in the pig in Oregon, a recent CDC serology study found a 7% infection rate among farm workers in Colorado and Michigan who had been exposed to infected cows. Mike, how concerning are these developments?

Dr. Michael Osterholm: Chris I'm not sure anything can surprise me anymore after witnessing the H5N1 outbreak unfold over the past several months. As you noted, on October 30th, the USDA announced that a noncommercial backyard farm in Oregon with a mix of livestock and poultry tested positive for the virus, notably including one of five pigs on the farm. It is notable that the first animal cases on the farm were in poultry, and again likely exposed as a result of migratory birds passing through the farm. The animals on the property shared water sources, housing and equipment, which likely led to the spillover incident. As we've discussed on this podcast, pigs are a very concerning mixing vessel because they do, in fact, have the ability to grow influenza viruses in their respiratory tract, similar to the ones that would infect humans. Genomic testing of the virus from the pig did not reveal any sequence changes that would suggest the viral strain is more transmissible to humans. However, it was a different sequence than we've seen with the 2344B clade, which has been causing so much concern in the dairy industry. So, in short, seeing that transmission to this pig was possible. It is concerning to me. We should not underestimate H5N1 ability to make this jump. Although, as I've said time and time again with you, we've been watching literally since 2003 and have yet to see any evidence that really this virus is able to go multiple generations in a human population.

Dr. Michael Osterholm: My main takeaway from the CDC serology study is that agencies and the public are underestimating the sheer number of animals and humans implicated in the ongoing H5N1 situation with the 2344B clade. What I'm talking about is really focused also on those individuals who are working closely with dairy cattle or with poultry that are infected with this virus. To summarize the CDC study's findings, researchers tested blood samples from dairy farm workers who had been exposed between 15 and 90 days prior and found that eight of 115, or about 7%, had detectable levels of antibodies, suggesting a previous H5N1 infection. Of the eight with antibodies, four subjects remember having symptoms consistent with what we've been seeing in cases across the country, primarily eye infections resulting in conjunctivitis. However, 26 of the 107 seronegative subjects reported read draining or itchy eyes as well. In short, we don't know if these individuals actually had H5N1 infection, particularly as conjunctivitis or virus in the eye. Let me just remind you again that influenza viruses that are of the avian origin are the two three receptor binding viruses, meaning they bind to receptor sites in a human's eye. Given the fact that we have two three receptors there, but not deep in our lungs, so it's unclear yet what that means to get an eye infection and the likelihood that, in fact, it'll turn into the classic influenza.

Dr. Michael Osterholm: One of the issues that is front and center in trying to protect farm workers, those who deal with the poultry or the dairy cattle from getting infected. It's clear that there's low adherence to personal protective equipment, in conjunction with the seemingly nonstop H5N1 detections in livestock and birds. First, less than half of all the subjects, 42 of 115 wore eye protection, and only 1 in 5 reported using a respirator mask while working. This virus takes every opportunity to infect when it can, and workers cannot mitigate the risk of infection without the necessary protective equipment. Having said that, it's very clear that it's hard to use this kind of protective equipment in this kind of setting, either dealing with poultry or the cattle. It's not like a health care setting. And even there we see challenges in getting people to adequately use it. So as I laid out in the last episode, it's clear to me that the USDA's current actions cannot control H5N1 spreading to more dairy operations as well as those of poultry operations, as long as the number of infected herds or flocks keep growing, we can expect more human cases among those who work in close contact with the positive animals. But again, so far these cases have been conjunctivitis, not that indicating a respiratory transmitted influenza causing a pneumonia-like condition. The authors of the study that I just noted listed recommendation based on their findings, including the need for improved active monitoring of exposed individuals and farm worker education on infection risk and prevention measures.

Dr. Michael Osterholm: While these interventions sound reasonable, there are clearly major logistical challenges on the farm side and practitioner side that may hinder implementation. Let me just also remind you that we are undergoing what may be potentially a major change in immigrant workers on these farms. For those who listen to the last podcast may recall, I noted, for example, a state like Wisconsin, the number two dairy state in the country, there are approximately 13,000 individuals who work milking cows every day on those farms. They are being milked, in many cases 24 over seven, twice a day. Now, of those, 10,000 are considered to be undocumented immigrants. Now imagine if they are rounded up and in fact are deported. What will happen to the dairy industry in Wisconsin? Well, it will literally have to shut down. What will happen with the potential for transmission of H5N1 in these people who we lose track of? What will that mean? We don't know. This is a truly complicated area right now, when we need to bring the best of public health to the game, and I worry that we're not doing that. And I also worry about the deportation issue is going to be a real challenge going forward, trying to both protect humans and animals from age five and one.

Chris Dall: It's time now for our ID query. This week we heard from Annette, who wrote. I'm hoping for an update about the current pertussis outbreak that seems to be happening all over the country. What's going on?

Dr. Michael Osterholm: Well, thank you Annette. Actually, your sense of what's happening is right on the mark. This is a very timely question that I'll take in two parts. First, the trends in pertussis cases and then the complexity of the vaccine landscape. Regarding current trends, pertussis is on the rise in the US. We have five times as many pertussis cases this year compared to 2023, and Minnesota's experiencing an eight year high. However, this is a return to typical trends after an atypical drop from the last three years of the COVID pandemic. In the years leading up to 2020, the US averaged around 18,000 cases per year. That dropped significantly during the acute years of the pandemic to less than 4000 cases per year, on average. So far for 2024, we have almost 21,000 cases, so it's certainly returned to the pre-pandemic levels. But I don't want it to imply that this is an acceptable amount of cases given the highly effective vaccines we have and the devastating impact that the disease can have. Now, pertussis can infect people of all ages, and it's been a challenge on college campuses this year. But the disease is especially deadly in infants. Before a pertussis vaccine was available in the 1940s. Almost 10,000 children in the US died of pertussis each year.

Dr. Michael Osterholm: Let me repeat that. Before a pertussis vaccine was available in the 1940s, almost 10,000 children in the US died of pertussis each year. For context, approximately 200 children died from influenza each year, so pertussis vaccines are really critical for this population. This brings me to our second point, which is the complexity of today's vaccine landscape. The vaccines, known as DTaP or Tdap, two different ones, offer protection against pertussis as well as diphtheria and tetanus. We will link information on the exact CDC recommendations, but five doses are given during the routine childhood series and then an adolescent dose at 11 to 12 years of age. Tdap is also recommended in the early third trimester of every pregnancy to help protect newborns against pertussis. It is also recommended that anyone coming in contact with babies, including fathers, grandparents, or other caregivers, make sure they receive a dose of Tdap in the last ten years. So yes, we continue to see pertussis, but we can do so much to control it. We can prevent these severe cases, particularly in young children, the newborns, if we just all follow the childhood and adult recommendations for the use of the pertussis vaccines.

Chris Dall: And that brings us to this week in public health history. Mike, who are we celebrating this week?

Dr. Michael Osterholm: Well, let me just say this is unconventional, but it's one of my most favorite ones, reflecting back on public health history. And I think for some of the listener audience here, this choice will not be lost on them. Chris, we've spent quite a bit of time covering this election in the past few episodes, and if it's not clear yet, policy and public health are entirely intertwined. The executive branch is one important piece of the policy landscape, so I've decided to draw upon another president in American history and their role in impact of public health. By late 1776, the US was facing a two front war, one against the English army and another against infectious diseases. Researchers estimate that nine of ten deaths in those early months of fighting came not from British bullets, but from microbes. The deadliest and most debilitating disease in this era was smallpox, which killed as many as a third of all those infected. Many, if not most, of the British troops had already been infected with smallpox and recovered, whereas the vast majority of US soldiers were still susceptible. In this context, General George Washington made the weighty decision to inoculate his army against the disease beginning January 6th, 1777. Ironically, an interesting date in recent history. All soldiers coming through Philadelphia and Morristown, new Jersey, received the smallpox inoculation. Washington explained his decision in a letter to Doctor William Shippen, a chief physician of the Continental Army. Quote, necessity not only authorizes, but seems to require the measure for should the disorder infect the army in the natural way and rage with its usual virulence, we have more to dread from it than from the sword of the enemy, unquote.

Dr. Michael Osterholm: The order for inoculation was difficult and controversial, as the method at the time was primitive and potentially lethal. It involved making a small incision in the recipient's skin and rubbing it with a thread or a piece of cloth contaminated with the virus. The theory was that this route of exposure would invoke an immune response without the high risk of serious illness associated with inhaling the virus. But if this theory proved deadly for soldiers, it would not only decimate his army, it would also present a major obstacle for further military recruitment. By the end of February, the entire army was inoculated. Fortunately for Washington, the Continental Army and the new nation. The plan worked. According to the National Park Service history. Though it was a controversial action, many historians credit George Washington's medical mandate. With the colonists’ victory in the Revolutionary War and the creation of the United States of America. There are numerous takeaways from General Washington's leadership in this scenario. Presidential actions are consequential not just in the moment, but potentially for decades or even centuries to come. Making public health decisions can be controversial, but we should never shy away from doing the right thing, even when it's difficult. And finally, vaccines and other measures to prevent infectious diseases are absolutely critical in a functioning society. I think many of us recognize that now more than ever.

Chris Dall: Mike, let's turn back now to something you mentioned in your dedication. And I know that it's something you've been thinking a lot about since the election. Given some of the names that have been floated as potential leaders of centers for Disease Control, National Institutes of Health, Department of Health and Human Services and the Food and Drug Administration, the next four years could potentially have a profound impact on public health in this country, and that's going to mean expanding our mission as a podcast. So what is your vision for this podcast going forward and what can listeners expect?

Dr. Michael Osterholm: Well, Chris, as you know, we have put a great deal of thought into this issue. It's one that I don't have a clear answer for you, but let me just share with you what we have come upon and how we've gotten there. We've gotten lots of emails from listeners over the past week asking us what is next, following the results of last week's election, let me just be very clear. The podcast family got through a pandemic together. We will get through the next four years together. It likely won't be easy, but we will still be here and we want you to be with us. The content you know and find useful isn't going anywhere. We're still going to cover issues pertaining to public health and infectious diseases, especially those issues surrounding COVID. We will clearly cover any new emerging infectious diseases of public health importance, but we're also going to be increasing our focus on policy issues that impact public health and watching closely what this new administration is doing. As a reminder to our listeners, until now, I've had a nonpartisan career. I've had a role in every presidential administration since the Reagan administration. And when I was at the Minnesota Department of Health, I worked for two Republican governors, two different Democratic governors. And I say with affection one independent wrestler, Jesse Ventura. And I never endorse political candidates, nor did I provide more or less help to someone because of their political standing. But we're in a new time for public health and a new time for public health policy.

Dr. Michael Osterholm: Never before have we had a president elect state an intention to involve someone as anti-science and anti-public health as Robert F Kennedy, Jr. In the leadership and management of agencies like the FDA, the CDC, the NIH, the EPA, or the USDA. Never before has a document as concerning for public Health as project 2025 been created by those embedded in the Presidential Administration. Please understand this isn't about Partisan politics. I would be just as critical of a Democrat or independent president elect. If the incoming administrations were doing and saying the things that the incoming Trump administration are saying. I will congratulate successes throughout this next four years. I will also point out unfortunate public health failures. I will call balls and strikes without fear or favor. The truth is, we don't know what things will look like at the FDA, CDC, NIH, EPA, or USDA in the months ahead. They could be significantly defunded and experienced reorganization. We intend to use this podcast to inform you on the changes that are being made in these organizations in the months ahead, as well as any policies that could impact public health. We will continue to primarily focus on infectious diseases, but there may be times where we cover policies that expand to other areas of public health, assuming we feel that they are still within our area of expertise. Just know I'm up for four more years. I'm making that commitment to you. Now, let me share with you some of the critical issues that we're closely following.

Dr. Michael Osterholm: If one looks at domestic-level issues, most are focused on what RFK Jr has been saying. Now, it's important to note that although president-elect Trump said that he let RFK go wild, it's unclear what this means, and I would be a little bit cautious in assuming how much actual impact that he can have. Surely there will be a lot, but I'm not sure that it might be as far reaching as some think. The president has no power to ban vaccines or fluoride because these are states’ rights issues, meaning that in the Constitution, from a public health perspective, not having been part of the federal mandate, these are up to the states. Now, as we already know, that can still be a problem depending on the political makeup of the state. But it's really important to understand that we will probably see a lot of these issues come to the Supreme Court, which by itself we aren't sure how they will react. One of the examples I want to share with you is I've seen a lot written about declassifying federal government positions. There are over 2 million civil servants, of which 4000 are currently considered political appointments. Some would say, well, if they in fact do this thing called schedule F, where they're going to basically take and move everyone from a government-appointed position to one where the president or the administration at least can decide at will to fire or hire. It could be a mass exodus of individuals.

Dr. Michael Osterholm: It's not quite that simple. There's actually a rule 42 in place, which is an important rule in federal government where certain employees, because of their expertise, their stature, their policy involvement, they can supersede the pay scale of what they would normally get. Are these are the doctors often people with scientific expertise, people who are more difficult to recruit into government because of the salaries they are vulnerable to. The president saying you're gone, but not most of the employees. So if you look at the rank and file of many of these organizations, I don't think that they really are. In fact, at risk. But we'll have to wait and see. Do I think those who came in under rule 42. Uh, this higher pay. But now vulnerability to appointment removal? Yes. We'll have to see also what will happen to the various agencies. How about reorganizing those federal agencies? I noted NIH, CDC, EPA, FDA, etc.. Well, with executive order, there is a lot that a president can do, but how much we don't yet quite understand. So from that perspective, I too am still waiting to see just what the breadth of any changes might be. Don't get me wrong, I anticipate potential situations where they make an attempt to change your organizational structure, but at this point, I don't think that we can say that that's going to happen. This is going to be one of those ones where we're going to have to keep following it very closely. There are clearly issues around Medicare and Medicaid, reproductive health, drug availability, vaccine availability, all things that are very important.

Dr. Michael Osterholm: And as I pointed out before, even with vaccines, the president does not have the power to ban or to stop using vaccines. But what they can do is make from a reimbursement standpoint, a policy standpoint much more difficult for vaccines to be used. We're going to have to wait and see how that goes. So at this point, I can tell you there's a lot on the table that could happen, but we just don't know what will happen. And that's what we're going to provide you with. We'll keep a scorecard every day and keep you informed of what's going on. Now, where I do think that there are some immediate issues that can happen that are real concern to me are on the international level. You may recall that President Trump withdrew the United States from the W.H.O. in his last year in office. Now, membership in the W.H.O. actually requires a one year time period before you can drop out. So from the time you notify that you're leaving. And in this case, the Biden administration came into office before the year was up and rescinded the removal of the US from the W.H.O.. Now, if that were to happen where they were removed, this would be a huge issue. The US provides roughly $110 million of support to the W.H.O. every year. Now, should other countries be providing more? I could argue yes, but the point is, if the US drops out of the W.H.O., this is going to be a huge, huge hit for which we're going to have to try to figure out how to fill that in.

Dr. Michael Osterholm: There are other agencies, USAID, the Agency for International Development, which has done so much in terms of helping in the low- and middle-income countries with health programs, of which, unfortunately, far too often get carried over into reproductive health, which means that somehow people believe they have something to do with abortions, which in turn can freeze funding. This is going to be a challenge. The Fogarty International Center at the NIH has been a center that has done so much on a global basis to help support vaccines. There are potentially on the chopping block, and one of the programs that, for me, is just actually so important is the Global Fund to Fight Aids, TB and Malaria. The US is the largest contributor to this program. 6 billion out of the $15.7 billion of budget came from the United States in 2022. The administration clearly could pull that money and make it impossible to help support that. We know that the UN Population Fund, which again involves reproductive health, is going to automatically be on the chopping block. It was on the chopping block in the previous Trump administration. One other area that I just want to note that I think is such an important issue is PEPFAR, the President's Emergency Plan for Aids relief. This was a program started by President George Bush after the 9/11 event.

Dr. Michael Osterholm: Basically, this program providing support to HIV prevention in Africa has been nothing short of miraculous. The ability to keep an entire generation from becoming infected by getting antiretroviral drugs to pregnant women just before they deliver, literally did so much to prevent transmission in the birthing process to the uninfected child. The number of adults who are living long, productive lives today in Africa because of these drugs has been nothing short of remarkable. That's a $6 billion program that we understand is on the chopping block. Hopefully, you can see from this that there are a number of different programs, a number of different issues, which we will keep you informed about. So let me just say, based on the feedback we received from our previous episode, I think this addition to our podcast will largely be appreciated by the podcast family. Let us know. Please continue to send us your feedback, both positive and negative, so we can continue to make this podcast as useful as possible. But it's our impression from reading the many, many emails and comments of the past few weeks, this is something that you'll all find useful. We intend to report the facts about what this administration is doing, and discuss the impacts of the policy decisions in an unbiased way. Just calling balls and strikes, just as we did during the early and uncertain days of the pandemic. You'll start to see these additions to our podcast, beginning with another episode next week, and then we'll be back to the other every other week.

Dr. Michael Osterholm: Release schedule until we take a two-week break for the holidays in December. As I said earlier, we and I'm talking about you and us, got through some very dark times of the pandemic together as a podcast family. The results of this election are setting us up for another public health crisis, and I believe we can get through this one together just as well. Chris, let me just close this discussion with a quote from someone who I have long admired and appreciated. Edward Everett Hale. Born in 1822, died in 1909, was an American author, historian, Unitarian minister. He was best known for his writings such as The Man Without a Country, published in The Atlantic Monthly in support of the Union during the Civil War. He was the person who spoke out encouraging Irish immigration to the United States in the 1880s because of the fact we had needs for workforce, and at the time there was great pushback on this immigration. Everett Hale has a very famous quote that, for me, means everything, and it is about my commitment to you, my commitment to this podcast. Here it is. I am only one, but still I am one. I cannot do everything, but still I can do something. And because I cannot do to everything. I will not refuse to do the something that I can do. I'm here for you. We're here for you. I'm committed to this because we can do something. And we will.

Chris Dall: And now I just want to clarify those upcoming schedule changes that Doctor Osterholm mentioned. So after this week's episode, we're going to have an episode next week that will be released on November 21st. That will allow us to take off the Thanksgiving week. Then we'll be back with episodes on December 5th and December 19th, and then we'll have two weeks off during the holidays back on January 9th. And we will remind listeners of those changes in the upcoming episodes. And one other bit of housekeeping, CIDRAP and The Osterholm Update are now on the social media site Bluesky. So if you want to follow us there, you can follow the links that are posted on the episode page. Mike, what are your take-home messages for today?

Dr. Michael Osterholm: Well, Chris, I really have two messages I want to share. The first one is the fact that we can't be distracted with what's happening in our world from the political perspective. Because we in public health have issues in front and center right now. Whether we're talking about H5N1, we're still talking about respiratory viruses and the potential for resurgence of activity with the winter season. We're talking about international issues, everything from Marburg to mpox. I go through the laundry list. We're talking about antibiotic resistance. So we have to keep focused on that. And just remember to do our job because it is our job and that's important. But the second thing is, is that we have to also understand that we do know that the issues and challenges of improving public health has been changed. The framework has changed a lot. But just remember, the issues haven't changed. It's just the environment we have to operate in. And now it's our job to figure out how to work within that environment to accomplish what we otherwise were trying to do in a different environment. So it's going to be complicated. But I think the main focus here is just know that the environment has changed. But that doesn't mean that the problems have changed.

Chris Dall: And what's your closing song for us today, Mike?

Dr. Michael Osterholm: Well, Chris, I did pick one after some really long and thoughtful deliberations with several of you trying to find one with the right tone, the right, the right message, and one that for me is an anthem of who and what we are all about. So I picked one we've used before I was written and sung by Stan Rogers, who was born in 1949, died tragically in 1983, in a fire aboard an Air Canada Flight 797 that was grounded at the Greater Cincinnati Airport. He died at the age of 33. Stan was known for his traditional sounding songs, frequently inspired by Canadian history and the working people's daily lives, especially from the fishing villages of the maritime Provinces and later the farms of the Canadian Prairies and Great Lakes. Stan wrote what I think is still one of the most meaningful songs to me, the Mary Ellen Carter. We've used this song twice before. On episode 94, on March 10th of 2022, and then we use it again in episode 132, June 1st, 2023. Today we bring it back as one that I think is very relevant to where we're at, what we're doing, and what we must accomplish. The Mary Ellen Carter. She went down last October in a pouring, driving rain. The skipper he'd been drinking and the mate, he felt no pain to close to Three Mile Rock, and she was dealt her mortal blow and the Mary Ellen Carter settled low. There was just us five aboard her when she finally was awash. We worked like hell to save her all heedless of the cost and the groans she gave as she went down.

Dr. Michael Osterholm: It caused us to proclaim that the Mary Ellen Carter would rise again. While the owners wrote her off, not a nook would they spend. She gave 20 years of service. Boys then met her sorry end, but insurance paid the loss to us. So let her rest below. Then they laughed at us and said we had to go. But we talked of her all winter. Some days around the clock, for she's worth a quarter million. Afloat and at the dock. And with every jar that hit the bar. We swore we would remain. And make the Mary Ellen Carter rise again. Rise again, rise again. Let her name not be lost. To the knowledge of men. Those who loved her best and were with her to the end. Will make the Mary Ellen Carter rise again. All spring now we've been with her on a barge. Lent by a friend. Three dives a day. In a hard hat suit. And twice I've had the bends. Thank God it's only 60ft. And the currents here are slow. Or I'd never have the strength to go below, but we've patched her rinse, stopped her vents and dog hatch and porthole down, put cables to her fore and aft and girded her around. Tomorrow, noon we hit the air and then take up the strain and make the Mary Ellen Carter rise again. Rise again, rise again. Let her name not be lost to the knowledge of men. Those who loved her best. And were with her till the end. Will make the Mary Ellen Carter rise again. For we couldn't leave her there, you see. To crumble into scale.

Dr. Michael Osterholm: She saved our lives so many times. Living through the gale. And the laughing drunken rats who left her to a sorry grave. They won't be laughing in another day. And to you to whom adversity has dealt the final blow. With smiling bastards lying to you everywhere you go. Turn to and put out all your strength of arm and heart and brain. And like the Mary Ellen Carter. Rise again, rise again, rise again. Though your heart it may be broken and life about to end. No matter what you've lost. Be it a home, a love, a friend. Then like the Mary Ellen Carter. Rise again. Rise again, rise again. Though your heart it be broken. Or life about to end. No matter what you've lost. Be it a home, a love, a friend. Like the Mary Ellen Carter. Rise again. Well, thank you all for being with us again this week. We look forward to your feedback on our plans for the future podcast episodes, the content that we'll cover, how we'll do it, and just know how much we appreciate your feedback and input. If there's anything that I'm feeling right now, it's the support. It's the camaraderie. It's the closeness that we all have together on this podcast. Thank you for that. It means everything to us at CIDRAP. As I said to you before, I just signed up for another four years. I'll be here that entire time. I plan on it. Thank you again. Be safe and be kind in this time when things are so tough. Be kind. We need it more now than ever. Thank you.

Chris Dall: Thanks for listening to the latest episode of the Osterholm Update. If you enjoy the podcast, please subscribe, rate and review wherever you get your podcasts, and be sure to keep up with the latest infectious disease news by visiting our website CIDRAP.umn.edu. This podcast is supported in part by you, our listeners. If you would like to donate, please go to CIDRAP.umn.edu/support. The Osterholm Update is produced by Sydney Redepenning and Elise Holmes. Our researchers are Cory Anderson, Angela Ulrich, Meredith Arpey, Clare Stoddard, and Leah Moat.