The Book to Buy in Bulk for Public Health Officials

The Big One: How We Must Prepare for Future Deadly Pandemics
Michael T. Osterholm and Mark Olshaker
Little, Brown Spark (2025)

Note that Dr. Michael T. Osterholm, an epidemiologist, and his co-author Mark Olshaker, a journalist, use the plural “pandemics” in the title of their new book, The Big One: How We Must Prepare for Future Deadly Pandemics.

They know we have endured many pandemics in the past, and will endure many more in the future. This is a safe prediction, but their own U.S. government will be unable to plan for pandemics. That’s because on the night of Oct. 10, the Donald Trump regime dismantled U.S. public health by firing hundreds of senior experts in the Department of Health and Human Services, and then hiring some of them back. On Oct. 16, U.S. District Judge Susan Illston ordered a pause on the layoffs, an order the Trump administration is expected to appeal.

Osterholm describes the COVID-19 pandemic as “the most momentous, as well as the most painful, experience of my career in epidemiology so far, one that included both triumph and tragedy.” The triumphs included the rapid development of vaccines that saved millions of lives; the tragedies included the failure of millions to accept them.

And as bad as COVID-19 was, bad enough to shorten life expectancies even in advanced countries, Osterholm thinks we got off lightly.

“The virus killed 3.4 per cent of those infected,” he writes. “Imagine, for example, if the next pandemic had the ability to kill on an order of magnitude closer to those of the previous two serious coronavirus outbreaks: the 15 per cent rate of SARS (severe acute respiratory syndrome), first seen in 2002, or around 35 per cent for MERS (Middle East respiratory syndrome), experienced 10 years later.”

Most of us don’t want to think about COVID-19 ever again, let alone think about something even deadlier. But Osterholm and his Center for Infectious Disease Research and Policy, which he founded at the University of Minnesota in 2001, are in the business of watching for disease outbreaks and alerting other health scientists and health-care workers.

Osterholm and Olshaker know they’re writing this book for more than their health-care colleagues. They take pains to write simply and clearly — and sometimes bluntly.

“Humanity has become an extraordinarily efficient biological mixing bowl as well as a highly productive viral mutation factory,” they write. “And on top of all these factors, the reality is that health-care systems around the world are so broken — or, in some places, non-existent — that we cannot adequately care for our populations in the best of times.”

The authors also know that mere predictions of doom will have little effect on readers, except perhaps to make them stop reading. So they imagine the emergence of a new coronavirus, SARS 3, in Somalia. It infects a struggling farmer named Warsame Amir Osman and his family, and spreads to others. Some cross the border into Kenya and seek help in the giant Dadaab refugee camp. Some die.

By the time the disease is confirmed as a new coronavirus, it has spread to France, Indonesia and the United States, carried by people who have names and families and plausible reasons for being in East Africa and for leaving it.

The authors know they’re writing this book for more than their health-care colleagues. They take pains to write simply and clearly — and sometimes bluntly.

Start with the precautionary principle

The SARS 3 narrative runs through the whole book, in parts that precede each chapter. It’s a fiction technique, and so well done that it reads like an excellent medical thriller. The rapidly spreading pandemic is a lot like COVID-19, but the doctors dealing with it at once apply the precautionary principle: “Until you have evidence to the contrary, act as though every new infectious agent is easily spread through the air.”

When the evidence does come in, the virus is indeed airborne — but health-care workers are using N95 respirators, which, unlike ordinary surgical masks, can effectively block viruses.

That in turn lends weight to Osterholm’s argument when he says, “This was one of the greatest failures from the pandemic. It is a lesson we must learn now so we can do better next time. We should have educated everyone that the most effective way to avoid breathing in SARS-CoV-2 — an aerosol- and droplet-spread virus — was to use an N95 respirator (officially called an N95 filtering facepiece respirator) correctly and consistently.”

Ordinary blue “surgical” masks, Osterholm says, are like installing a screen door on a submarine and expecting it to keep the water out.

But masking in any form is now politically suspect, putting both health-care workers and the immunocompromised in dangerous positions. Osterholm and Olshaker argue, “We believe public leaders often focus on hygiene theatre because at least it seems as if they are addressing the issue.”

The authors point out that surgical masks are designed to keep health-care workers from sneezing, coughing or dripping on their patients, and they’re useless against viruses.

N95s, they tell us, “were mostly used to protect workers from inhaling dangerous aerosolized chemicals from paints, solvents and other substances.... With the advent of COVID and use of respirators for non-industrial applications, it became clear that, even though less comfortable, the hospital type of respirator — without the valve — was the one to protect wearers from the particles around them and protect others from their potentially infectious exhalations.”

After almost half a century in public health, Osterholm is tough on his colleagues, and not just about their failure to treat COVID-19 as airborne right from the start. He also criticizes the mandated responses: border closings, lockdowns, masking, vaccination and school closings. He notes that all received serious pushback and weakened public trust in public health.

“Studies,” the authors write, “show some effectiveness for some of these approaches under very specific conditions.” Closing schools, for example, might be acceptable for a month or so, but “what happens if we’re talking about 18 or 36 months?”

So if mandates must be imposed, they should be solidly based in science and they should have limited goals such as easing the burden on hospitals or nursing homes.

They also need to change as new information comes in. For example, a vaccine mandate should last only as long as a new vaccine is shown to have long-lasting effects in protecting people and keeping them from transmitting the disease to others.

Medical countermeasures should be fast

Osterholm and Olshaker also discuss medical countermeasures — vaccines, antibodies and drugs that are antimicrobial, antiviral or anti-inflammatory. They also include diagnostic tests and personal protective equipment.

Normally, medical countermeasures go through extensive testing and assessment, which can take years. In the case of Operation Warp Speed, the authors tell us, all the federal agencies involved agreed to scrap the red tape, and the first COVID-19 vaccine was therefore available very early in the pandemic.

“But now we are back to the pre-pandemic vaccine approval mindset,” they write. “We must never compromise safety and demonstrated vaccine effectiveness but at the same time, we need a revolution in how we support vaccine development and licensure.”

They also argue for military-style planning and preparation. Just as we don’t wait until war breaks out before we start building aircraft carriers, vaccines against future influenza and coronavirus outbreaks should be in development now, not when the World Health Organization decides to declare a pandemic. Better to have such vaccines and not need them than to need them and not have them.

Osterholm and Olshaker’s chapter on risk communication is especially good. In public health, risk communication is the exchange of information between experts and the public about a likely threat to their survival, health or well-being. If accurate and trusted, risk communication should enable any population to reduce the odds of falling ill or dying by following expert advice.

But in the COVID-19 pandemic, risk communication in most advanced countries was a disaster. The use of masks, for example, became politically charged behaviour; mis- and disinformation about “cures” like ivermectin was more trusted than expert advice.

And the experts themselves, the authors argue, made a fatal assumption early on: they assumed that the SARS-CoV-2 virus would behave like influenza, so messaging didn’t change as the virus mutated into new strains.

“Before the Big One,” Osterholm and Olshaker say, “we must establish a communication network that flows from the highest levels in global and national public health, scientific research and medicine, all the way to the community level, identifying and co-ordinating with trusted messengers on a regular basis. This communication should be two-way, as these messengers are best able to understand the concerns of those in their community, enabling them to serve as spokespeople both up and down the chain and to be proactive.”

Fighting the infodemic

In the current COVID-19 pandemic, we are enduring a second pandemic — an infodemic — in which our electronic devices deliver a baffling mix of “fact, rumour, interpretation and propaganda.”

To mitigate the infodemic, Osterholm and Olshaker “propose the creation of an international epidemic and pandemic information intelligence crisis command operation — a ‘validation bureau’ with the personnel, expertise and resources to evaluate mainstream and social media statements, preprints, publications and other preliminary finding and announcements, and sufficient capacity and funding.” It would be a kind of public health Snopes to confirm reliable information and identify misinformation and outright lies.

The Big One concludes with an admission that trust goes both ways: if a government agency misleads us about, say, the value of surgical masks, then we won’t believe that agency and will likely reject its advice on vaccines or isolation. If that agency admits from the start that the news is not only bad but incomplete, we will trust its changing advice over time.

But the book is intended for U.S. readers, whose trust is unlikely to improve when the Department of Health and Human Services, or HHS, recently lost an estimated 1,100 senior experts and administrators in a single day on Oct. 10.

Dr. Angela Rasmussen, a U.S. virologist working at the University of Saskatchewan, took to her Substack and called it “The Death of Public Health.” Some 700 HHS workers were then rehired while the Trump government said a “coding error” was at fault.

Regardless, some key health agencies and people in the HHS are likely gone for good, and the survivors have no assurance that they will even be listened to. No one is likely to establish an actionable pandemic plan, much less an epidemiological Snopes to quash misinformation.

But state health departments should buy The Big One in bulk for their own people and for their political masters. Both the Public Health Agency of Canada and all provincial health ministries should do the same. Osterholm and Olshaker offer a dauntingly detailed list of actions needed, many of them expensive and politically dangerous. But they are clearly actions we need to take.

If the Trump regime and Health and Human Services Secretary Robert F. Kennedy Jr. have no interest in preventing the deaths of millions of Americans, then the Americans themselves — and we Canadians — will have to do it.

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