During the first year of the COVID-19 pandemic, the public-health expert Ashish Jha posted hundreds of detailed Twitter threads, fielded thousands of interview requests, and was mentioned sixty thousand times on cable and network news. “I felt like part of my job was to help people not just understand the moment they were in but the kinds of decisions that would soften the impact of the pandemic,” he told me. He was particularly eager to speak to conservative audiences that were less likely to encounter his views, so he often appeared on Newsmax, which gained notoriety for supporting President Donald Trump’s false claims about the 2020 election. “One of the tenets of public health is that you don’t write people off,” he said. “If somebody has been harmed by poor-quality information, you don’t walk away from them.”
Jha attracted the attention of President Biden, and, in April, he succeeded Jeffrey Zients as the White House’s so-called coronavirus czar. (His official title is COVID-19-response coördinator.) He took over at a complicated moment when highly contagious Omicron subvariants were causing new surges of infections, but Americans were weary of restrictions and a pandemic-response package was stalled in Congress. The package is still stalled, forcing the White House to repurpose funds from other areas, such as COVID testing, to vaccines and antiviral pills, and the surges only recently started to recede; last week, when I was getting ready to meet Jha for coffee in New York, I tested positive for the coronavirus myself and went into quarantine. We had to speak via Zoom instead. “This happens a lot right now,” he told me. “We have to get out of this phase.”
Jha, who lives in Newton, Massachusetts, with his wife and three children, is not an epidemiologist or virologist and has no previous experience in the federal government. When he was a child, his family emigrated from eastern India; he went to high school in New Jersey and studied economics at Columbia. After medical school and public-health school, at Harvard, he became a leading health-policy researcher there, focussed on improving the quality and cost of health-care systems. (We collaborated on several papers when I was a medical resident.) In 2014, to the surprise of many experts, including himself, Jha was tapped to run Harvard’s Global Health Institute. At the time, he could barely keep track of all the global-health acronyms, he once told me. But he learned quickly, and after six years he was named dean of Brown’s School of Public Health. We spoke about his unlikely journey to the White House, his philosophy of public health, his Twitter account, and the future of the pandemic. Our conversation has been edited and condensed.
Many experts believe that this, more or less, is our new normal: new variants, intermittent surges, breakthrough infections, occasional boosters, offices emptying out when cases rise—COVID not as an emergency, but not something we can forget about, either. Is that the way that you see things? Are we condemned to repeat the recent past for the foreseeable future?
No, no, no. Might we have to deal with this for another six months or a year? Sure. But are we living like this three or five years from now? Absolutely not. We have hundreds of thousands of Americans getting infected every day. We still have a few hundred people dying of COVID every day. I don’t think any of this is an acceptable normal for the long run. First, it is very disruptive. Second, we don’t fully understand long COVID, but the idea of people getting infected over and over and over again—it’s just not great. Third is that this just continues to fuel more variants.
So, what’s going to change it?
What’s currently driving new variants is their ability to escape immunity. As we get more complex immunity—meaning that some people have immunity from the original vaccines, other people from newer vaccines, other people have immunity from infections with Delta and Omicron—you’re building a population immunity that gets harder and harder for the virus to break through. I do think there is a limit to how much the virus can keep evading.
There are things we can do to slow down the spread, like substantially improving indoor air quality and more widespread testing during surges. We have got to build a new generation of vaccines that block transmission, like oral or intranasal vaccines. If we get those—and I think the science is starting to come together—we can drive down transmission to the point where infection numbers are a tenth of what we have now and deaths are substantially lower, too. Then COVID really does begin to fade into the background. Is that going to be easy? Is that going to happen tomorrow? No. But I think we can get there over the next twelve or eighteen months.
How will we know that the pandemic has ended and COVID-19 is endemic?
There is no agreement on what it means for a virus to be endemic. We have this sense that with endemicity, there is some stability. You don’t have big surges. Some people have argued that an endemic virus is one where the R0 [the number of additional infections caused by each infection] is around one. For me, I think a virus is endemic when it is no longer hugely disruptive to our lives—you can live your life without walking into a packed restaurant and thinking, Oh, my God, am I going to get infected? Am I going to get sick? With COVID, we’re not anywhere near the endemic stage yet.
You’ve been one of the most prolific communicators during the pandemic. At one point, you were doing ten or twelve TV interviews a day and putting out dozens of Twitter threads a week. Why?
A lot of people think of communication as the icing on the cake. You have your policy, you have your recommendations, you get the science right, and the communication is kind of a nice-to-have. In a pandemic, that’s completely wrong. You need to engage the public, helping people understand, “Hey, the infection numbers are growing, and that means these are the three behavior changes you should make.”
Has Twitter been a net good or net bad for the COVID discourse?
Net good. Twitter has been phenomenal at bringing scientists together to share ideas and collaborate. But net good is not the same as all good. A lot of people have used it as a way of either minimizing COVID or spreading fear about it. Social media has made it easier for people to communicate. We can share these moving pictures and videos of tragedies and create a sense of shared experience. At the same time, people can exploit it to further their agenda.
As doctors and scientists, we often think we can fight misinformation with data. But sometimes I wonder if that’s true. People believe what they believe for all sorts of complex social and psychological reasons. How can we improve the chances that science, which is messy and nuanced, wins out?
Misinformation thrives in information vacuums, and those who show up first often get to define the terrain. This puts scientists at a disadvantage. By the time they show up with the right answer, the discourse has often moved on, and people have settled on strong views about what they think. Scientists can’t wait for certainty. You should lead with what you already know, even if you haven’t nailed everything down to the fifth decimal point. Just let everybody know it’s your first draft. Sometimes, it turns out that with more evidence and data, you learn that your initial assessment wasn’t quite right. That’s O.K.
You were born in Bihar, India, and didn’t speak English until the age of nine.
Bihar is one of the poorest states in India. My parents left for the reason that lots and lots and lots of people leave, which is to give their children more opportunities. First, we moved to Toronto. It was cold and I didn’t have any winter clothes. I also didn’t speak a word of English. I could say, like, “yes” and “no,” but I couldn’t put together a sentence. Then we moved to New Jersey. At some point, the primary language in which I think switched from Hindi to English. I remember going back to India when I was in college and realizing that I was thinking in English, and then translating my thoughts into Hindi.
How has being an immigrant influenced your work?
As an immigrant, you’re always negotiating across multiple cultures. I think there’s something that allows you to see other people’s perspectives and bridge divides more easily. It’s also true that, as an immigrant, you always feel a bit like an outsider. Before the pandemic, I would write a paper and some journalist would call my office and say, “We’d love to talk to him. How’s his English?” My assistant would be, like, “His English is fine.” They’d be, like, “Yeah, but could he do radio?”
Before the pandemic, you wrote about health policy at a blog titled “An Ounce of Evidence.” You didn’t complete the sentence, but I always imagined it to be something like “. . . beats a pound of opinion.”
In so much of health policy, people hold these strong views that are not based on data or evidence. As an academic researcher, my view was that you can have whatever opinions you want, but we should all be guided by the evidence. We may decide that we have different values. I, for instance, care deeply about making sure everybody in America has health coverage. Other people may not hold that view. That’s fine—those are values. But, if we agree on a goal, evidence is how we move the world forward.
I started writing the blog because I thought there were these really important questions, and if I tried to turn them into papers it would take six months for them to come out. But I could do an analysis and write it up within twenty-four hours. That could move policy forward more effectively.
You’ve described yourself as a “reluctant academic” and have said that you didn’t want to do research at all. Then you built a career as one of the most productive health-policy researchers in the country. What happened?
At first, I wasn’t convinced that research was right for me. I worried that too much academic work didn’t care about moving the needle on things that mattered in people’s lives. But I had a mentor who kept pushing me and said, “O.K. If that’s your concern, then do the kind of academic work that does change people’s lives. Don’t stop once you publish your paper—figure out how to translate it to policy.” So I spent an enormous amount of time in Washington over the last fifteen years, talking to policymakers, understanding how they think, understanding the challenges of turning data into action. I think it’s been very helpful in this role.
You haven’t worked in the federal government before. When you took your current position, Anthony Fauci said, “Probably his biggest challenge is that he doesn’t know government, he doesn’t have experience.” Beth Linas, an epidemiologist at R.T.I. International, said, “The only thing I wonder is how another academic with limited government experience will help the nation.” Were they right to worry?
No individual leader will ever have all the skills and capabilities you want. The job of a leader is to ask, What are my deficiencies? How do I fill them? How do I build a team around me? It wasn’t a mystery to me that I didn’t have deep federal experience, so it was clear to me from the beginning that I needed a team with great federal experience.
What does the conversation around pandemic mitigation get wrong?
Having spent twenty years in public health, I’ve learned that health is not just the absence of disease. Public health is a much broader sense of well-being that comes from spending time with family and friends and socializing and going to school and going to work.
In the early days of the pandemic—when things were really scary and we didn’t know what the virus was going to do—doubling down on a suppress-the-virus strategy, even if it had large social costs, made total sense. But, when people advocate for a similar approach now, when we have vaccines and therapeutics—that feels very anti-public health. I feel very strongly that we need to take a holistic view of health that takes into account mental health, and social well-being, and all of the other things that often get pitted against health. They shouldn’t be. They’re really part of the same thing.
Are we doing enough to protect vulnerable people?
When I came into this job, two months ago, I said we have to develop a strategy where we make immunocompromised individuals far safer. There are two things we can do. First, using more [of the monoclonal-antibody treatment] Evusheld—which is a very, very effective tool for people who are immunocompromised. Right now, we are substantially under-using Evusheld. Second is making sure that we have plenty of therapeutics available for immunocompromised people so that if they do have a breakthrough, we can treat them. That combination turns this virus, even for immunocompromised people, into something that is far more manageable and far less deadly.
Based on the current science, how worried should Americans be about long COVID?
You and I, as clinicians, know that post-viral syndromes have existed forever. If you take people who get influenza and survey them thirty days after the onset of symptoms, a lot of them will have lingering issues. When you see studies that say twenty, thirty per cent of people with a coronavirus infection get long COVID, a lot of that is post-viral symptoms that will resolve. That said, long COVID is a real problem. We don’t have precise assessments, but as I look at the data there’s clearly a proportion of people who get infected—probably in the single digits—who have substantial symptoms, often significant disability, well beyond thirty days. That’s a big number if you have a country where a lot of people have gotten infected.
What we call long COVID is probably a combination of multiple conditions. In some people, it might be a persistent viral reservoir causing problems. In other people, it could be autoimmune issues. In others, it may be tissue damage from the initial infection that continues to cause substantial symptoms. Do initial treatments with things like Paxlovid reduce your chances of long COVID? How much do vaccinations reduce the seriousness of long COVID? We need to understand all that stuff better.
The tricky part is that we have to do two things at once. On one hand, we can’t let long COVID become this thing that strikes fear in the hearts of everybody. And yet, at the same time, we can’t minimize long COVID.
One of the most comprehensive long-COVID studies was recently published in Annals of Internal Medicine. Researchers went looking for physical signs of long COVID that went beyond reported symptoms. But, when they followed COVID-positive and COVID-negative patients for months, they couldn’t find differences in things like inflammatory markers, autoimmune antibodies, lung-function tests, cardiovascular tests, or neurocognitive tests. What do you make of these findings?
I put that in the context of many other studies, including some that have found changes in neurologic signs and MRIs. I saw the study as an important data point, reminding us that for some people, the manifestations are discernible, and for others maybe not. I wasn’t convinced that this means there’s not a biological component here. There’s a long history in medicine of, if we can’t quantify it, we think it doesn’t exist. I want to make sure we’re not making that same mistake again.
Many parents have been waiting what feels like forever for vaccines to be authorized for children under five years old. The wait finally seems to be coming to an end. What took so long?
Kids under five are not just smaller versions of human adults. They have different physiology. There was a lot of work that went into making sure that you were getting dosing correct, and that these were really safe. Those two things slowed down getting the trials going, and getting enough kids into those trials. I have largely seen this as a taking-the-time-to-get-it-right process. Of course we all wish it had gone faster. There’s a lot of stuff we all wish had gone faster. But I don’t know what I would have cut out or done differently.
A recent poll from the Kaiser Family Foundation found that fewer than twenty per cent of parents say that they would immediately get their kids immunized, and around forty per cent are reluctant to do so. Why do you think that is, and what can we do to shift those numbers?
I go back to polling from December of 2020 that suggested that only about a third of adults were eager to get vaccinated right away. But here we are, a year and a half later, and eighty per cent of adults have gotten at least one shot. Vaccine confidence can build over time. First, we’ve got to make sure that vaccines are available for all the parents who want them right away. Second, we’re going to work really closely with people who parents trust—pediatricians, family practitioners—and arm them with information. Vaccine confidence is an extended ground game. That’s O.K. We’re in this for the long haul.
It’s also true that almost eight months after COVID vaccines became available for children aged five to eleven, less than a third are fully vaccinated. As a parent of three children, what would you say to a parent who’s on the fence? What about one who is adamantly opposed?
I begin by asking myself, Why did I get my kids vaccinated? It’s because I have a lot of confidence in these vaccines. You’ve got to get parents confident that this is the right thing for their kids. Part of that is countering misinformation. No pediatrician goes around thinking, How does this disease in kids compare to the disease in an elderly person? That’s a totally bizarre framework. And yet, people keep saying, “It’s not a big deal for kids, because it’s not as bad as it is in the elderly.”
The way pediatricians think about children’s health is, How does this risk compare to other risks that children face? In that light, COVID is actually a pretty serious thing. And then they ask a second question: Would the child be better off with the vaccine or without it? When I talk to parents, I remind them that the question is “What can you do to keep your kids healthy?” Not “What can you do to keep your kids healthier than your parents?”
What more should the U.S. be doing to insure the world is protected against COVID?
The Biden Administration has committed to sending a billion vaccine doses abroad. We’ve already donated over five hundred million doses. We are now at a point where pretty much any country that wants a vaccine can get it. The problem is that countries are not asking because they don’t know [if] they have the ability—financial and logistical—to turn those vaccines into vaccinations. Most countries have made investments in children’s vaccination campaigns, but don’t have any real adult-vaccination program. Figuring out how to vaccinate adults, how to vaccinate the elderly, is a substantial challenge.
Our job as the United States is to be working directly—and with partners like COVAX and the W.H.O.—to help countries build up vaccination programs. That’s what we’ve been trying to do. If you think about our recent emergency supplemental-funding request, there was five billion dollars to help make global vaccinations a reality. Unfortunately, so far, Congress has not been interested in supporting global vaccinations. That is a huge mistake.
In the future, we have to have enough vaccine-production capability around the world. So whenever we get a pathogen we can make so many doses so fast that this issue of who gets it first, who gets it second, becomes a non-issue. Before this pandemic, there wasn’t really a single good vaccine-manufacturing site on the continent of Africa. We’re beginning to make some changes there, but that needs to change faster. It’s also a reminder that it’s not just about having enough vaccines or therapeutics. It’s about figuring out how to help countries deploy them.
What gives you hope for the future of our fight against COVID?
We’re two years into this pandemic, and think about what science has already delivered: lots of effective treatments, multiple powerful vaccines that continue to prevent serious illness. In the coming years, we will have vaccines that are more durable, that prevent transmission, that need to be taken infrequently. We’re going to get more therapeutics. Our ability to manage this virus is going to get better and better. The real question in my mind is: What can we do to speed up that process? The hard part is turning all the great science into products that reach people in a timely and equitable way. That’s the job ahead. ♦
