CRISIS AVERTED: Caitlin Rivers on the Hidden Science of Fighting Outbreaks

Writer's Voice

In this episode, we speak with epidemiologist Caitlin Rivers about her book Crisis Averted. From the successful eradication of smallpox to navigating the COVID-19 pandemic, Rivers delves into public health challenges, funding gaps, and the “panic and neglect” cycle that threatens our preparedness for future outbreaks.

Host’s Note

We are less than a week away from the most consequential election in US history. A lot is at stake, including the fate of basic freedoms and democratic rights. But one huge matter life and death matter has gone largely ignored: the fate of our public health system.

Everything from access to clean water, life-saving vaccines, reproductive and maternal health, and so much more, is on the ballot — but few voters know that. That’s because public health — the infrastructure that keeps us safe and healthy — is the invisible half of our health care system. We only think about it when we are in danger, like during a pandemic, not when we are well.

The choices made for President and Congress in this election will determine whether we can meet challenges by strengthening our public health system — or whether we will fail because that public health system has been utterly dismantled.

The American Public Health Association has published a terrifying description of what would happen if Donald Trump is able to put Project 2025 into action — It was created by the most extreme members of his previous administration and widely considered to be the plans for his next, whatever he may deny. The report says, “while Project 2025 is aimed at the executive branch and intended as guidance for the next administration, many members of the U.S. House and Senate and those in state government support many of the policies proposed in Project 2025,” and are looking for ways to enact them.

Here’s just some of what the APHA warns about Project 2025:

• It would politicize the Centers for Disease Control, replacing scientific experts with political loyalists to Donald Trump and MAGA ideology. Project 2025 would cripple the use of data collection on disease outbreaks and prohibit it from issuing health guidance on vaccines and masks.
• Project 2025 would nationalize strict anti-abortion measures, including requiring states to report abortion data — meaning states would have to monitor women’s pregnancies. It also would limit or ban access to reproductive health care drugs like Mifepristone.
• Project 2025 would limit access to Medicaid: adding work requirements and capping benefits, which would disproportionately affect those with chronic conditions or disabilities, affecting the poor and disproportionately people of color.
• It would entirely privatize Medicare, skyrocketing costs — and profits to insurance companies — while limited access to seniors and people with disabilities
• Project 2025 would cripple our response to the climate crisis, ending government research on climate, stripping away environmental protections and encouraging the use of oil and fracked gas, putting the dangerous impacts of climate change on human health on steroids.
• And it would also privatize the weather service, so that Americans would have to pay to know if a hurricane or tornado was coming their way.

But we don’t have to speculate about the future impact of another Trump administration. Donald Trump already has a track record on public health, with his epic failures in responding to the Covid pandemic. He claimed the virus would go away “like magic.” He told Americans to drink bleach or take horse tranquilizers to cure it. He set governors of different states against each other competing for masks and medical supplies in a kind of Pandemic Hunger Games. He favored Red states over Blue states in providing funds.

If re-elected, Trump promises to put a purveyor of anti-vaccine lies—RFK Jr— in charge of the Health and Human Services and let him “go wild.” These are the stakes. Vote accordingly.

Episode Topics Covered

• Personal story and the challenges of twin-to-twin transfusion syndrome
• The eradication of smallpox and lessons learned
• Underfunding of public health and its consequences
• The “panic and neglect” cycle in public health
• New threats: Mpox and H5N1
• Public trust, transparency, and public health communication
• The balance between public health mandates and individual autonomy
• Advocacy for the creation of the CDC’s Center for Forecasting and Outbreak Analytics

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Key words: public health, pandemic preparedness, Caitlin Rivers, Crisis Averted, infectious disease, smallpox eradication, public health funding, CDC, public trust in health, Mpox, H5N1, health policy, epidemiology

Summary

In this insightful interview, Caitlin Rivers, epidemiologist and author of Crisis Averted: The Hidden Science of Fighting Outbreaks, discusses the complexities and triumphs of public health. She explores critical themes, from the eradication of smallpox to the lingering risks of pandemics and epidemics.

Rivers highlights key concepts like the “panic and neglect” cycle and the importance of continuous investment in public health infrastructure. Additionally, she addresses ongoing concerns such as the persistence of smallpox in labs, new threats like H5N1, and the delicate balance between individual autonomy and public health mandates.

Key Quotes:

1. “Public health is something of an invisible shield. It protects our health but is woven into our everyday lives in a way that does not often surface.”
2. “We are in a cycle of panic and neglect, where investments in public health surge during crises but dissipate once threats seem distant.”
3. “The eradication of smallpox is one of humanity’s greatest achievements, and it’s a reminder of what public health can achieve.”

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Transcript

Caitlin Rivers, welcome to Writer’s Voice.

Thank you.

It’s great to be here.

This is a terrific book and such an important one because we really live in an era where public health is as important, if not more important than ever, because as you say in the book, some people call this a pandemic scene.

We are facing the possibility of more and more pandemics, epidemics.

And yet the public health system is so under threat.

But I want to begin by asking you about your own personal experience with which you begin your book, with a very difficult pregnancy with your twins.

Briefly tell us about that and then tell us what your story illustrates about public health.

Sure.

In 2018, I became pregnant with my identical twins, and many people don’t realize that identical twins are very risky, much more risky than fraternal twins because they share a placenta.

And this can lead to imbalances in the blood supply between one twin and the other, which is exactly what happened to us.

So I actually underwent two fetal surgeries, had multiple fetal blood transfusions and spent a long time on bedrest and in and out of the hospital trying to maintain the pregnancy and keep my twins as healthy as possible.

And thankfully, we did make it to 31 weeks, they were delivered at 31 weeks, which for our situation was probably better than we hoped.

But of course, left a long road ahead with about two months in the NICU and a lot of support from our medical providers to get my babies home and healthy.

And for me, this really illustrates the difference between the way that we experience health and well-being as individuals, and how it relates to public health.

So what happened to me with becoming pregnant with identical twins, which is not hereditary.

This is identical twins are completely spontaneous.

Becoming pregnant with identical twins, developing twin-to-twin transfusion syndrome, which is what we had, experiencing so many interventions and early delivery, the odds of this happening are so rare, astronomically rare.

And so when you see a statistic like one in a million or one in five million, you might think, oh, who cares?

You know, that’s never going to happen to me.

And statistically, that’s true.

But when it does happen to you, when you do experience something so traumatic and so engulfing, it really took up every second of my family’s lives and mental capacity.

When it happens to you, the statistics don’t mean quite as much, right?

Because you’re really in the thick of it.

And so I wanted to offer that story to my readers, because public health, when we’re thinking about millions of people and, you know, millions of lives saved, it can become abstract.

It can become a little bit difficult to really absorb what that means for families and communities.

And so I wanted to draw a line between my experience and how difficult it was for me and the way that public health can spare people from difficult experiences, maybe not identical to infrequency, but there are many afflictions and diseases that public health has really chased away from our daily lives.

And I think it’s really important to help people understand how meaningful that is.

And just to start with a huge success first, talk about smallpox and the eradication of it, the campaign to eradicate it.

How did it come about?

This really took a long time, but it is the only disease that has been completely eradicated.

What had to go right for that to happen?

The eradication of smallpox is really one of humanity’s greatest achievements.

It’s such an incredible success story.

Smallpox is a disease that listeners may not be familiar with because we no longer contend with it, but it is spread very easily from person to person.

It caused very large, painful, unsightly boils, basically, full-body rashes, and the mortality rate could stretch above 50%.

The average mortality rate was more like 10%, but you can imagine what a ferocious and fearsome foe that was to face a disease that had a very good chance of killing you.

After you survive, the survivors were likely to develop unsightly scarring, pocking, and eye problems and other sequelae were also very common.

One of the unique things about smallpox is that it didn’t circulate in animals.

It only circulated in humans, and there was also a very effective vaccine that could prevent it from spreading from person to person.

Now that characteristic is actually unlike, say, the flu vaccine or COVID vaccine, which can protect you from severe illness but will not likely stop transmission.

The smallpox vaccine was so effective that it did stop transmission.

Well, epidemiologists in the first half of the 20th century leveraged these two insights to set the intention to make the decision that they were going to pursue smallpox to the end of the earth.

They were going to set out to completely wipe it from humanity.

Now for the first several decades, actually, of the eradication campaign, they pursued this by maintaining at least 80% coverage of smallpox vaccination in every community in the world.

And you can imagine what an onerous undertaking that was.

That means vaccinating not just the vast majority of the world, but keeping those vaccination rates that high as new babies are constantly being born.

And so it was just an enormous undertaking to try to protect people and communities from this terrible virus.

Eventually, it became clear that although that strategy was effective in most places in the world, there were a few countries that it was just too difficult to maintain a level of coverage.

And so epidemiologists came up with an additional innovation, as if deciding to eradicate smallpox and getting so close was not amazing enough.

They realized that if they could visit smallpox cases quickly enough, if they could move quickly enough, they could vaccinate the people who had been in contact with that person and protect them from becoming infected.

This is called ring vaccination.

And this strategy required a lot of coordination, it required a lot of urgency, but it really was the key that allowed epidemiologists to travel that final mile and make that final push towards eradication.

And indeed, smallpox was declared eradicated in 1980, and there has not been a case since.

It’s an incredible story.

And you know, there were not a lot of people who thought it could be done until it was done.

But I have one question about smallpox, because the smallpox virus still does exist in two high-security labs, one in the United States, one in Russia.

Why is it being kept around, and could that pose an eventual risk?

This has been a continuous discussion in the public health community since eradication in 1980.

You’re exactly right.

There are two stores of smallpox remaining in the world, both in high-containment laboratories.

And the justification for keeping those viruses in those laboratories is so that scientists can continue to study the virus, and most importantly, try to develop new vaccines, treatments, collectively what we call medical countermeasures.

Now, this may seem like a low priority, given that there has been no cases of smallpox in nearly 50 years, but there are actually cousins of smallpox, including mpox, which you may have heard in the news over the last few years, which continue to circulate.

And actually, much of the research that has emerged from modern smallpox research has been leveraged into developing medical countermeasures, vaccines, and treatments against mpox.

And so there has been benefits from that over the years, and those benefits are what have kept alive the discussion or kept alive permissions that allow these labs to maintain smallpox stores.

I just worry that some unscrupulous regime will unleash it.

Is that really a realistic worry?

It’s realistic in the sense that the consequences, if that were to happen, would be very severe.

But I think the probability is very low.

And so you can see how difficult it becomes to weigh those two dimensions.

I will say there’s a WHO committee, World Health Organization committee, that oversees these two labs.

They conduct regular inspections to make sure that the proper security protocols and biosafety protocols are being adhered to.

And any experiments that either of these labs wish to conduct on the virus must first be approved by this WHO committee, which evaluates the risks and benefits.

So there are checks and balances in place to make sure that scientists are proceeding with appropriate caution and wisdom.

But there are and have been for decades calls by experts in the field to destroy those stocks.

And so I think it’s a very reasonable position to hold to feel that those should be destroyed.

Now Caitlin Rivers in Crisis Averted, you talk about many instances where competing needs, costs and benefits need to be balanced and weighed.

So let’s kind of move out for a minute, take a larger view of public health itself.

You write in the book that public health is the invisible other half of the health system.

You know, if you say one half of the health system is the medical infrastructure that we have, public health is the invisible part of our health system.

Because when it works, you don’t notice it.

We haven’t had smallpox, people forget what it’s like.

So we’re not necessarily thinking about that.

But there are many, many cases like that.

So it’s only when it fails that it becomes visible.

So first tell us, what is public health?

You talk about four major areas that comprise it.

That’s right.

Public health is something of an invisible shield.

It protects our health, but it’s woven into our everyday lives in a way that does not often surface or become visible in the same way that the medical system does.

So a few of the key areas of public health are infectious disease and epidemiology, which is my specialty, environmental health, which is really about protecting our environment and therefore human health from things like dangerous chemicals, pollution.

There is social and behavioral sciences, which really looks at the decisions people make.

If we’re thinking about how to encourage people to quit smoking or to reduce their alcohol intake, those are really behavioral changes that we need people to participate and buy into.

And so social and behavioral health examines how to partner with communities for that purpose.

And the fourth area is health policy and management, which really looks at the kind of legal and policy structures that we need to promote health.

If you’re wondering what all that means in terms of concrete implementation or concrete evidence of public health in the world around us, sanitation is perhaps one of the biggest changes to public health over the course of history.

When we turn on our faucets, clean water flows.

When we flush the toilet, waste is safely discarded.

And for a lot of human history, that was not the case.

And of course, sanitation is absolutely critical to prevent the spread of disease.

And it’s something that is now so common, so universal that we all take it for granted.

And yet this system that we depend on to protect the health of the public is severely under threat.

Just tell us what kind of resources go to public health and how do they compare to other things that we spend our public monies on?

Public health is perpetually underfunded, and it’s been a challenge for decades really to make the case for why it’s so important to continue to support public health and to provide it adequate funding.

The funding that goes to support public health is a teeny tiny fraction of what’s spent in the medical system.

But in my opinion, we have that entirely backwards because it’s public health that keeps people healthy.

We really only rely on the medical system in most cases when something has already gone wrong and you need to try to rebuild or restore health.

And so I think if we put a lot more attention and resources into public health, we would be able to really save money and improve the health of the population in a way that is a lot more cost effective.

Just to give you a sense, less money is spent on a per capita basis for public health than for things like parks and recreation, roads and transport, schools, nearly every line in a local community’s budget will be exceeded by every other priority compared to public health.

And I think there’s a lot of opportunity there to make some changes that could really benefit all of us.

Yeah, you, this is a shocking statistic is in your book, Caitlin Rivers, three out of every four Americans live in a state that spends less than $100 per person per year in public health.

That’s probably less than people spend on going out to the movies.

It really is incredible.

And when you think of the kinds of changes that public health has made, even in the last, say, 25 years, it’s clear that it’s very cost effective and we should be keen to invest in it more.

For example, the rate of people who smoke has declined precipitously since the 80s, and the diseases and the poor outcomes like lung cancer that have been averted from those changes is enormously beneficial and cost-saving, and I think we should promote that as much as possible.

Similarly, maternal and fetal health, close to in the same genre, if you will, of the health crisis that I experienced, although we’ve made enormous strides in protecting the health of pregnant women, fetuses, and babies in the last, say, 100 years, we still have one of the highest rates of maternal and fetal deaths compared to our peer countries.

Again, a lot of opportunity there to improve those statistics, which would not only improve the lives of those women and babies, but would also save a lot of money.

Yes, and these are issues that affect different groups of people differently.

Of course, we learned that in the COVID-19 pandemic when black and brown people and poor people were not able to isolate at home.

They had jobs where they had to go out into the community, were at much higher risk.

But these cases, these kinds of examples abound.

I mean, I just think of Flint, Michigan, and the crisis of lead in the water pipes, the contamination of lead in the water pipes there.

Talk about the determinants of health and give us some illustrations of things that people might not have thought about as being absolutely critical to boost the support for public health in order to prevent disease.

When we think about our individual health, we often think about things like our family history, our diet, our exercise, things that we have control over, at least in theory.

But one of the teachings of public health is that our ability to make decisions or the infrastructure context that influences those decisions are really influenced heavily by things that are outside of our control.

So things like our race and ethnicity, where in the world we were born, or even where in the United States we were born, our income levels, these are things that are actually enormously influential on our health.

So for example, I live just outside Baltimore City, and like Flint, Baltimore City has a persistent problem with homes, particularly low-income homes, being serviced by lead pipes.

There are also still, in the year 2024, efforts to remediate lead paint in homes, and lead paint has not been in use in the United States in decades.

The consequence of lead, particularly in homes that have young children, is it can cause permanent neurological damage, so it’s a very, very severe and troubling affliction, and the problem is really concentrated in low-income communities.

That is an example of how a determinant of health can really permanently influence the outcome and the health span of children who deserve every opportunity to survive and thrive in the world.

And we are talking with Caitlin Rivers about her very important book, Crisis Averted, The Hidden Science of Fighting Outbreaks.

You talk about a cycle that you call panic and neglect, or I believe it’s called panic and neglect in the field of epidemiology.

What is that cycle?

I specialize in outbreaks.

Panic and neglect is one of the strongest forces I have seen over my career in the way that we prepare for and respond to outbreaks.

The cycle of panic and neglect is what happens when something like the COVID-19 pandemic or like the 2001 anthrax attacks, which were deliberate, deliberate attacks in the United States.

These kinds of large events that shake us to the core, inspire a lot of action, a lot of investment, a lot of attention on public health, and that boost results in additional funding, additional support, new programs, it really drives a lot of energy in the field.

But what happens over time is those investments work.

We reduce risk, we avert poor outcomes, we really prevent bad things from happening.

And so, over time, the nothing, the all quiet calls start to draw down people’s attention and they think, what are we spending all this money for?

Nothing ever happens.

Why are we trying to prevent bad things from happening when of course there is nothing happening?

And the case starts to deteriorate.

It starts to really be difficult to justify.

But of course what happens when the funding and the attention recedes is the threat comes back exactly as you would expect.

And so the cycle begins again.

And we’ve seen this over and over again.

And every time it happens, what public health officials and public health professionals say is, if only we could maintain that level of funding and attention and not let it dry up, we could keep things in this state of relative improvement.

But of course that’s not what happens.

And so I think if there were one kind of structural or perspective change that I would want for the field, it would be to end the cycle of panic and neglect and really realize that continuous investment is what we need in order to prevent a huge number of the next threats.

Yeah.

And let’s talk a little bit about the COVID-19 epidemic because, well, it’s fresh in our mind and it is still not over, yet we don’t even have testing and tracing at any level that is free to the public anymore.

Why is that?

You know, it was terribly mismanaged under the former president, President Trump, but under the Biden administration, just about everything has gone away.

Why is that?

And what are your, what’s your judgment of that?

What is your comment?

It really does relate to this cycle of panic and neglect.

It really is in evidence everywhere all the time, unfortunately.

It’s true that during the pandemic, there were a lot of important investments made.

There were cash payments to families who were affected by the widespread closures.

There were programs to bring testing and vaccines for free, I might add, to really the whole country, but with a particular emphasis on low income or minority communities.

And several, I want to say two to three years into the pandemic, those programs just expired and they were allowed to end.

And so those really important investments that we made in reaching people and helping them to access the tools that they need to stay healthy just went away.

And of course, that leaves us enormously vulnerable, not only to the continuing effects of COVID-19, but to the next threat that is sure to roll through.

And that’s another point that I think is really important for readers to understand is the COVID-19 pandemic is widely understood as a once in a hundred year event, because the last major respiratory pandemic was in 1918.

From my perspective, as someone who specializes in outbreaks, epidemics, and pandemics, these kinds of events that really worry me and require attention and concerted effort to control happen about every two years.

And in fact, that is what we’ve seen.

COVID-19 started in 2020, and in 2022, we saw the Mpox epidemic.

And now here we are in 2024, and a variant of Mpox is again, really concerning me.

So right there, just a easy example that about every two years, there’s something quite serious that emerges.

A variant of Mpox?

That’s right.

The 2022 Mpox epidemic was caused by what’s known as clade 2, which describes the specifics of that virus.

And clade 2 spread around the world, primarily spread to men who have sex with men.

What we’re seeing now, two years later, is that a new type, clade 1b, again, just describing the characteristics of the virus, is really spreading very easily and quickly in parts of Africa, particularly the Democratic Republic of Congo.

And anytime we start to see an epidemic that’s really getting around very easily, it’s important to take notice because there’s a possibility that it could affect the United States.

And so that’s what I’m watching in my professional capacity as an epidemiologist right now.

And you haven’t yet mentioned bird flu, which, although by and large seems not to have the current variant of bird flu, H5N1, you know, largely seems to have been transmitted to the few human cases from animals.

However, there have been recently, because I read your newsletter, Caitlin Rivers, there have recently been some worrying transmission that doesn’t seem to have come from animals, although I’m not sure that’s been proven.

But that’s really the big epidemic.

So talk a little bit about bird flu and, you know, what’s in place to avert disaster or to warn us of it coming.

That’s right.

So H5N1, which is a particular type of influenza, has been circulating very widely in birds for years now, actually causing mass die-offs, occasionally spilling into animals like sea lions and causing mass die-offs.

And so I’ve had my eye on that situation in birds for a while now, but the situation really changed in an unexpected way this spring when H5N1 was found in dairy cows.

Now this is particularly striking because influenza is not known to infect cows.

That’s not its usual home.

And so this was a very unexpected and startling development.

And with influenza, my rule of thumb or my personal rule is never trust influenza because it loves to change, it loves to mutate, and it has long been identified as one of the candidates to cause the next pandemic.

And so this unexpected development really put me on edge.

Now as H5N1 has now been circulating not only in birds, but also in dairy cows, it’s had a lot of opportunities to interact, if you will, viruses don’t interact, but it’s found a lot of opportunities to find humans.

And so we’ve seen over the summer months and now into the fall, occasional cases of H5N1 in people who work with dairy cows.

But of course, the longer this is allowed to go on, the longer that the virus is allowed to circulate and try new things, the more opportunities it is to hit jackpot and find a way to spread easily between humans.

We have not seen that yet, but what we did see just recently is a H5N1 case in a Missouri person who was hospitalized, which right there makes me nervous because that suggests this person developed fairly severe illness.

But what was particularly striking is the person was not known to have contact with dairy cows.

Epidemiologists, even now, two weeks later, are not sure how this person got infected.

Even more unsettling is that several people who were in contact with this person, household members, healthcare workers, developed flu-like symptoms at the same time that they were sick.

Now, it’s a little bit of a puzzle, and this is one of the interesting things about epidemiology.

It’s very much detective work.

The close contacts were not tested.

We don’t know whether or not they had H5N1 because they did not get the test that could determine either way at the time.

And so epidemiologists are still puzzling together how did this person who was hospitalized become infected?

Did any close contacts also become sick, and what’s it all mean?

So definitely something that I’m watching closely and hoping that it kind of dies down and recedes, because that does happen sometimes, but of course a more concerning outcome would be if there’s evidence of human-to-human transmission.

Yeah, and it’s terrifying.

You write, Caitlin Rivers, in Crisis Averted, about the first SARS-CoV epidemic that was in 2003, where a pandemic did begin to happen, basically, but by and large was averted.

I mean, people died.

What did they do right there, and do we still have the capacity to do what they did?

In my mind, that was one of history’s near misses.

We came very close to experiencing a terrible pandemic in 2003 with the emergence of SARS.

SARS is actually a cousin of COVID-19.

They even have the name of the virus that causes each disease is even SARS-CoV and SARS-CoV-2, so that tells you how closely related they are.

But the original SARS caused much more severe illness, so you can imagine just how scary it would be if that had really made its way easily around the world.

But that’s not to say that it was a small event, because it was very serious, and we came very close to losing control.

It’s thought to have emerged in China, potentially in 2002, but it wasn’t identified until 2003.

And it was carried around the world, as viruses often are, by travelers, people who were traveling between countries, got to their destination, and a few days in, realized that they were actually quite ill.

Epidemiologists, fortunately, identified fairly quickly, I should say epidemiologists and astute clinicians, because doctors, nurses are very important partners in finding new diseases.

But they realized fairly quickly that there was a new disease afoot that was very dangerous, spread very easily between people, and they started coordinating with their counterparts around the world.

The first step, really, to getting this virus under control was case identification or finding people who were sick.

And so identifying exactly what the disease looked like in humans was one important component.

Now once epidemiologists and clinicians around the world were able to identify cases, and I should add there was not great diagnostic testing at the time, because this is more than 20 years ago, so a lot of it was just made based on signs.

A lot of the diagnoses were made based on signs and symptoms.

But that contact tracing that many people became familiar with during the pandemic became very important.

And so the people who were in contact with a case or with a person who were sick were very quickly, speed is important here, very quickly identified and quarantined or asked to stay home.

Another important distinction between SARS and COVID-19 is that during SARS, people were sickest, people were most infectious when they were sickest.

That’s an important, it sounds like a subtle thing, but it’s an important distinction, because with COVID-19, you can spread it without even knowing you’re sick, because you haven’t developed symptoms yet or because you have a very mild illness.

With SARS, it was mostly people who were hospitalized who were very infectious, and so infection control or really being cautious in hospital settings was also very important.

But there were hundreds of cases of SARS in something like 23 countries around the world, and so I really want to emphasize how close the world came to experiencing an absolutely devastating event.

And in the street there’s a virus, it’s affecting everyone, they ate a bat out in China, even people.

You know, there were differences, as you point out, I mean, this key one, that people could spread the disease without knowing that they were sick.

But let’s talk a little bit about the response.

Because you write a lot in the book, Caitlin Rivers, in Crisis Averted.

You write about the necessity of developing trust, of having people trust public health, public health officials.

Now we know that former President Trump tried to downplay the virus.

He famously said, yeah, it was going to magically disappear in a very short period of time.

But I kind of expected that from him.

It probably cost many, many lives.

But what I didn’t expect was, you know, some of the failings of the CDC in warning people, not just the CDC, but the World Health Organization, these are the people who are in charge of public health.

What did they get wrong?

One of the arguments that I make in my book is that the root of trust, you cannot move forward with trust without truth telling.

I think one of the biggest missteps with COVID-19, which I continue to see in responses today to MPOCS and H5N1, is a reluctance of public officials to be frank with the public about the severity of what is likely to come.

In the early days of the COVID-19 pandemic in the United States, we heard a lot of reassurances that the risk to the American public is low.

And again, as someone who specializes in epidemics and pandemics, I was looking very closely at the data coming out of China, for example, and it was clear to me that this virus was coming.

It was coming to our shores, and it would likely spread easily.

Because it did so, it had done so already in China and Italy, and then of course in New York City.

And so it was simply not true that the risk to the American public was low.

And I think that we really did a disservice to the American people by not telling them the truth about the difficulty of the situation that we were likely to face.

And those kinds of impulses to reassure or to obfuscate difficult truths is something that I think happens too often in public health.

And if there was one change to communication that I would like to see in my field, it’s really a move towards taking on those difficult truths and walking with people as we experience these kinds of tragedies together instead of saying, oh, it’ll be fine, don’t worry about it.

Or we don’t have any reason to believe anything is going to go bad when, in fact, it’s very likely that or at least there is some substantial risk worth acknowledging that things could be difficult.

And I was really disappointed in someone who otherwise, I think, deserves a lot of respect.

But I think this was emblematic of what you’re talking about, and that’s when Dr. Anthony Fauci went on television, and I watched it.

And he said at the time that not only should the general public not wear masks, that wearing masks could be counterproductive.

Now, before this interview began, I told you that I used to work in the field of occupational health.

I’m very well aware how effective masks can be if they’re worn properly.

And they can be worn properly.

It’s not that difficult a thing to do.

And I was really shocked that he would say that.

Now, why did Fauci say that?

And, you know, ultimately, he corrected himself, but I think there was a huge amount of damage to trust that happened as a result.

I think that’s a really important example.

And as you highlight, when Americans were originally told that not only did they not need a mask, but they should not wear a mask, there were a lot of spurious justifications that accompanied that.

You don’t know how to wear it if you haven’t been properly trained.

You’ll just touch your face and the risk of touching your face to adjust your mask will be worse than breathing contaminated air.

I think that all of these justifications were offered to back up the assertion that not only do you not need a mask, but you should actively avoid wearing masks.

In fact, I think there was a secret kind of secondary reason why people were told this, and that’s because there were not enough masks.

The supply chain was not designed to supply enough masks for 300-some million Americans to wear one every day, and so the masks that were in circulation were needed for healthcare workers who, of course, are at very high risk of becoming infected with COVID-19 or with any infection because they’re caring for people who were sick.

Now eventually, this did kind of come out, and the messaging was changed to say you can wear a mask if you want, but you should save the good ones for the healthcare workers.

And I think people, people being the public, really understood that justification, which was the true one.

We saw people choosing instead to wear cloth masks, even because many people, of course, were made to stay home from work and had a lot of free time, choosing to sew dozens or hundreds of cloth masks and distributing them.

I think once the ins and outs of the true situation were just shared, that the public really understood the need to save good masks for healthcare workers.

And again, this really points to the need to just always default to truth-telling.

Just lay out the uncertainties, the difficulties, the complexities, and trust that people are ready to listen and to be partners, I think, in keeping their communities safe and healthy.

Yes.

And I was one of those people who sewed masks in a project that we had here for local essential workers, yet they weren’t just cloth, because just cloth by itself doesn’t really do that much.

We actually sewed in medical-grade filters into the masks, and you know, I think they were quite effective.

But what that set up then was, I think it didn’t set it up, it allowed a huge politicization, it gave fuel to the fire of the right-wing culture war against public health measures that continues to today.

And you write about this, because this is always an issue, you know, public health versus individual autonomy.

You know, I remember people saying when I asked them to wear a mask that they would say, well, my body, my body, my right, you know, taking a page from the reproductive rights movement.

But there’s a difference between women’s power to control their own body, you know, the bodily autonomy and what you need in an epidemic.

So how do you negotiate that?

This is a really active legal area, actually, to really distinguish the line between where individual autonomy starts and where public health kind of picks up, obviously, in the case where your choices and actions can directly result in someone else being harmed through, for example, transmission of a virus, it becomes, that’s where the law does allow for public health officials with sufficient justification to impose, for example, mandatory quarantine or mandatory isolation, meaning you have to stay home.

But that is always a very last resort for public health because it’s contentious.

It can be difficult for the trusting relationship, obviously.

And so it really is a last resort.

But public health officials, particularly those at the local level, who spend a lot of time in their communities, are very skilled at building relationships with people, hearing their concerns, answering their concerns, and really making public health actions into a voluntary kind of whatever intervention is needed.

And actually, despite the highs and lows of mask wearing and later vaccination, what we saw in the early days of the pandemic was enormous compliance and enormous willingness to participate in things like voluntarily staying home, in creating cloth masks for the community, as you just described.

And so people really did pull together.

And I think that we should trust that people will rise to that occasion and really band together.

I’m not so sanguine, Caitlin Rivers, I have to say, because now this kind of distrust of public health is becoming institutionalized in laws in different states where public health measures have been, especially in Republican states, we have to say, I don’t think it’s happened in any states that are run by Democratic legislatures, but where public health measures are actually being criminalized or at least not allowed anymore.

And in Project 2025, which if Donald Trump does become president again, is likely to be the plan, actually seeks to prevent public health agencies from doing things like requiring vaccination in school children.

And this is at a time when we’re seeing outbreaks of measles and whooping coughs that get greater every year.

So talk about the road ahead.

And then I’m going to ask you to also talk about what can we do to change the political will to be able to fight against those restrictive measures?

I’m a perennial optimist.

It’s hard to do this job with any other perspective on life.

So I do tend to just hope, I guess.

I won’t say trust, but I tend to hope that this is a difficult moment in public health history, but that there is still enormous capacity for goodwill and wanting good things for our community and expecting that community members will participate in manifesting those good things.

But you’re exactly right that the pandemic created, and in some cases deepened, existing friction between public health and state legislatures, for example, because you’re exactly right that in many states there are efforts, some are already successful, in removing public health powers that have been granted to public health authorities, in some cases for a century or more, and are now being rolled back.

And I do think that that is a direct backlash of things like the stay-at-home orders and mandatory mask orders, mandatory vaccination, that the public really, some parts of the public, I don’t mean to imply that this was widely felt by everyone, but that some constituencies felt was overreach.

And it does worry me because it really degrades our ability to respond to and manage threats.

And what we’re talking about is the kind of institutionalism of this erosion of public health in one political party.

You say that politics is a part of public health.

And so, what can public health advocates do to do the politics right?

There’s been a refrain in public health over the last five or so years that we have to get politics out of public health.

And of course, this was a very reasonable reaction to things like the Trump White House involving itself in public health guidelines, for example, around school reopening, really interfering in the guidance-making process.

And so, that created an urgency or an imperative to separate political machinations from the creation of public health guidance.

But I argue in the book that I don’t think that’s entirely the right direction because politics and politicians are the ones who make and enforce laws.

They are the ones who hold the power of the purse, which is to say that they grant funding for things like public health priorities.

And so, I would actually like to see more engagement from my public health colleagues in political matters.

Because if we’re not out there making the case for why our work is important, why it deserves to be funded, then we’re not going to see the kinds of funding and authorities that we need to do our best work.

And so, I think that we should actually be leaning in more instead of endeavoring to separate the two worlds.

And Caitlin Rivers, finally, you are a good example of doing that kind of advocacy.

You advocated for the creation of the Center for Forecasting and Outbreak Analytics.

It was established under the first national security directive signed by President Biden.

What is that center?

What does it do?

The Center for Forecasting and Outbreak Analytics is the newest center at CDC, and it’s meant to be something like the National Weather Service, but for outbreaks.

It is meant to really create the kinds of advanced models and advanced analytics that decision makers, which could include federal leaders, state leaders, or even the public, rely upon to make decisions.

So examples of the kinds of products that this center creates are forecasts, what’s happening with outbreaks next, interventions, so you can test in the model different kinds of interventions.

What happens if we increase vaccination levels?

What happens if we encourage people to social distance?

You can really test those interventions in the model and see which is more effective.

And it is something that I’m really proud of.

My colleagues and I spent years advocating for the creation of this center.

And as you said, it was first established, or the directive was issued in 2021.

And it is now, I think, a really important piece of our pandemic preparedness capability.

Oh, it’s interesting you mentioned the National Weather Service, because another provision of Project 2025 is actually to shut down the weather service, to privatize weather forecasting, which would wreak havoc with preparing for tornadoes and hurricanes.

Are you concerned that that might happen to your newest Center for Forecasting and Outbreak Analytics?

Yes, the House budget for the last few budget cycles, and this is in Congress, has proposed very, very steep cuts to CDC and has zeroed out funding for the Center for Forecasting and Outbreak Analytics.

Now those budgets have not become law, they just remained in the House budget.

And those kinds of proposals to draw back public health funding is exactly what I was describing when I described the cycle of panic and neglect.

We create new capabilities, new investments, we create the Center for Forecasting and Outbreak Analytics, and then just a few short years later, it’s in danger of being defunded.

And I think that’s a real mistake.

Well, hopefully enough people will read your book so that they vote accordingly as well and they tell their representatives, their leaders, that they want public health to be supported.

The book is Crisis Averted, The Hidden Science of Fighting Outbreaks, and it has just been great to talk with you.

Thank you so much for coming on to Writers Voice.

Thank you for the opportunity.