Dr. Ashish Jha Anticipated a Pandemic. He Didn’t Think It Would Look Like This.

JHA: As with all things, it looks very different in retrospect than how it felt as it was happening. In the early days of the pandemic, I could see what was going on, both here in the U.S. and in Europe, and started talking openly about how we were far behind, we had been caught flat footed, that we had missed a window of opportunity to really get this virus under control. 

If that voice sounds familiar, it’s probably because you’ve heard it before — starting in the early spring of 2020, and basically ever since.

JHA: My name is Ashish Jha and I’m the Covid-19 response coordinator for the White House.

Dr. Ashish Jha didn’t intend to become a household name. When the pandemic began, he was head of the Harvard Global Health Institute. But as a public health expert who’d spent a long time researching pandemic preparedness, he was in high demand as the novel coronavirus hit, and kept on hitting.

 JHA: Oh, the first few months, March through June was just crazy. I probably was getting about two to 300 media requests a day. And basically, it would start at, 6:00 A.M. and go till 11:00 P.M. Initially, seven days a week until I just realized I can’t keep going. So I started taking Saturdays off, which was good. 

Ashish was on T.V., on the radio, on Twitter — basically everywhere you looked or listened. He was filling a void that, in his view, never should have existed.

 JHA: I really thought the primary source of information, good information would be coming from C.D.C. on a daily basis. In some ways that just never happened. And what initially was a couple of weeks of media just exploded into months and months and months. And at some point, three, four months in, I actually wondered, is this all useful? 

The public health response to an emergency, like the Covid-19 pandemic, is multifaceted. One aspect is communicating with the public, as Ashish found himself doing. Another, of course, is what to do about the emergency. And this is where things can get tricky for scientists, like Ashish and like myself, who rely heavily on data.

 JHA: There’s no question in my mind that there were a lot of missed opportunities for gathering more evidence. And it means two and a half years later, we’re still making certain policy decisions with less than ideal data.

From the Freakonomics Radio Network, this is Freakonomics, M.D. I’m Bapu Jena. Today on the show, my friend and former colleague Dr. Ashish Jha talks about making the transition from academics to politics:

 JHA: One of the things that you realize is you could have absolutely brilliant ideas that just cannot be implemented.

We’ll discuss why some of those ideas aren’t necessarily going as planned. And also: what can happen when you lean into the unknown.

 JHA: I think acknowledging uncertainty doesn’t create panic. I actually think it breeds trust.

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 JHA: Hey, how are you?

 JENA: How’s it going?

 JHA: Good, good. How are you?

 JENA: Good. You looking good.

 JHA: You know, I’m always looking good.

 JENA: I — that’s what I say about myself, but — 

Before he became the Covid-19 response coordinator at the White House, or the Covid “czar” as some people call it, Dr. Ashish Jha had an even more important job.

 JHA: You and I co-taught quality of healthcare in America, a super popular course. I’m assuming the popularity was because of me and not because of you.

 JENA: I just have to say that after you left, and I’m not saying this is causally related to you leaving, the evaluations, they just went through the roof. You’ve never seen them so high.

 JHA: I am deeply skeptical of this. 

Ashish was born in India, where he lived until he was nine. His family made their way to Toronto and then to New Jersey. He went to medical school at Harvard, where he also got a master’s degree in public health. After that, Ashish spent a lot of time thinking about American health policy, and eventually landed on two issues that he thought were interesting and weren’t getting enough attention.

 JHA: One was the public health effects of climate change, and the second was pandemics and pandemic preparedness — just became concerned, convinced that we were heading towards a pandemic and the world wasn’t ready. 

When the pandemic he was convinced was coming finally arrived, it didn’t exactly resemble what he’d anticipated.

 JHA: What I worried about, which I think many of us who were in the field of thinking about pandemics — what we worried about was a really deadly influenza pandemic. And the mental model I had of both how we would begin, how we would spread, and how we would respond to it, some of that mental model held true and some of it was just inadequate. 

As the pandemic unfolded, Ashish was compelled to communicate. He took to the airwaves and to social media, laying out what we knew and what we didn’t know about Covid. He did it calmly, and plainly, and people started not only to notice, but to rely on him.

 JHA: I started saying to friends, I think I’m gonna pull back on this. And got a response from people that made me realize what I was doing, what other people were doing, was useful — because in the term public health is the “public” and engaging the public, helping the public understand the moment we’re in and how to respond and how to keep themselves safe, is a really important public health intervention. It was odd to realize that this wasn’t a side thing that I was doing, that it was actually a really important part of a public health response was to communicate directly to the public.

Ashish left Harvard in 2020 and became Dean of the School of Public Health at Brown University, where he stayed until March of this year, when he went to the White House. It’s his most public role to date, and a detour from academia. But figuring out in which direction the country should go next with the pandemic requires reflecting on where we’ve been.

JHA: I wrote a piece at the end of January of 2020 about the novel Coronavirus. And there were parts of that piece that I go back and read and cringe at because there were really important issues that I, and I think many public health experts, got wrong. So most of us thought that the things that would be determinative for how well a country would do is your laboratory capacity, your healthcare system, your ability to manage the disease per se. What I think I did not appreciate, and I think a lot of people did not appreciate, was the importance of issues like social cohesion, of depoliticization, of a pandemic response. And I think in that context, yeah, this pandemic has turned out in many ways to be much more challenging than what I had envisioned might be something that America deals with, if you had asked me this question five years ago.

JENA: If you had that foresight, what do you think you would’ve done differently? Because what you’re referring to is not a scientific problem per se, or an operational problem — how do you ensure adequate I.C.U. beds, ventilators, start a process for developing and manufacturing a vaccine, ensuring a supply of masks. You’re almost talking about a social problem, which in part relies on trust.

JHA: It is about trust in my mind. There’s some empirical evidence that if you look at countries that have done well in the pandemic versus countries that have struggled more, by whatever metric you want to use, trust in institutions and trust in each other are two of the major factors that really differentiate high performing versus low performing countries. And thinking back to five, seven years ago when I started doing work on pandemic preparedness, we spent a lot of time thinking about laboratory capacity and healthcare workforce, which are important. I think I would’ve put a lot more emphasis on understanding what kind of trust do populations have in their institutions? How do you build up that trust? How do you, in the beginning of a pandemic, when there is so much uncertainty, communicate more effectively to people, both what you know and don’t know?

There’s no question about it. There was a lot of communication in the early days that conveyed way more certainty than people had from our public health officials. And I think sometimes that desire to offer assurance, which is a very good desire, can lead people to overstate what they actually know. And I think acknowledging uncertainty actually doesn’t create panic. I actually think it breeds trust. So there are a lot of lessons here that I hope we’re gonna be able to deploy for future pandemics,

JENA: I think it was Francis Collins made this point a while ago, which is that we spend so much time thinking about how to diagnose disease, treat disease, but there’s a fundamental behavioral problem that is hard to solve, which is: If you’ve got vaccines, if you’ve got treatments for a disease, how do you get people to take those medications? And, as doctors, we think about that a lot. And we know adherence to medications that are lifesaving is almost 50 to 60 percent in some diseases. And so we’re thinking about all the other things that had to be done, but didn’t really realize that one of the escape hatches, the biggest one, would be vaccines. And if we didn’t lay the framework, for people to say, all right, when this comes out, I’ve gotta be ready to go, that sort of seems to me like a huge loss. And I don’t really know what we could have done differently to prevent that.

JHA: When I look at countries, for instance, that are even more vaccinated than us and ask what’s different? You tend to see across a broad spectrum of political leaders, religious leaders, social leaders, everybody, fighting over all sorts of issues, but not fighting over vaccines, not fighting over whether vaccines are effective and safe. That has not been so consistent here, right? We have seen a lot of prominent people use their platform to undermine vaccines for whatever kind of reasons and gains, but ultimately ends up making it harder for our country to be as protected as it needs to be. And so something that we need to really spend more time thinking about is how do we build a broader coalition of people who can fight it out over all sorts of policy issues, but when it comes to key basic public health things like vaccines and treatments, maybe that’s a bit more of a neutral ground where we don’t always have to disagree and fight with each other.

JENA: I remember in the initial stage of the pandemic when we were talking about how your life had changed. you had entered into a public sphere that you hadn’t been in before.

JHA: The media stuff was public. I was also spending an enormous amount of time talking to governors, talking to state health officials, because the public health response really had become a state-by-state response, and a lot of leaders at the state level were struggling to get good advice from federal officials, weren’t getting the kind of data and the evidence. And so I would say, I spent almost as much time talking to policy makers as I did the media and that continued all through the fall of ’20. Things changed on the public policy side after President Biden came into office. The calls from governors, calls from states really slowed way down. That changed. But obviously, helping the public understand where things were going remained an important part of what I was doing.

JENA: Had you worked with policymakers before all this?

JHA: Yeah. I mean, but in a very different way. Right? It’s funny, I often describe myself as a skeptical academic. And what I meant by that was I felt like so much of academic work just didn’t make a big difference in the world. And I was not interested in a career where I built up my C.V. and had a great title. I was interested in having a career where I felt like I was moving real stuff in the world that made a difference in people’s lives. And so in the health policy work I did for a good chunk of my career, I spent a lot of time in Washington talking to policy makers, trying to understand what their pain points were, trying to understand where data would be useful for them, trying to anticipate what decisions they were gonna be having to make and figuring out can I use data to help them make better decisions? So that was always my mindset as I did my research. Policymakers have a different set of constraints. They often have to make a decision in days or weeks and not in months or years. And it meant: what data can I generate for them? Even if it’s not gonna be good enough to be published in a major journal, what’s good enough to help them make a bit of a better decision? 

JENA: I’m curious what’s it been like to try to implement strategy and think about the political implications for someone like you, who’s really, I would say, a scientist, at heart? What are the costs of going into public health in this sort of high-profile way?

JHA: I’ve been in this job for about seven months. And as you might imagine, it’s unlike anything I’ve done before. So in the past, when I thought about a policy issue, I could sort of pontificate and think out loud. I didn’t have to worry about constraints. I didn’t have to worry about tradeoffs. I didn’t have to think through the ways in which my ideas could go wrong. I didn’t have to think at all about implementation. One of the things that you realize is you could have absolutely brilliant ideas that just cannot be implemented because having a good idea is important, But the constraints are real.

After the break, Ashish will tell us about those constraints, how he’s tried to deal with them, and when he thinks he might be out of a job.

 JHA: I wake up every morning, and think there are three, 350 Americans dying every single day. And there is so much work to do to drive that number down

I’m Bapu Jena, and this is Freakonomics, MD.

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JHA: When you’re an academic, you can just say things like, “We should just do X.” Great. How? Now as I think about trying to move the needle on making sure more people are getting vaccinated or treated, we spend a lot of time thinking about “how?”

Since he became the Covid-19 response coordinator at the White House earlier this year, Dr. Ashish Jha has learned a little something about the way Washington works. Or, doesn’t.

JHA: Like sometimes you don’t have the funding because the administration doesn’t actually just get to spend money on whatever it wants. There are other times where you realize, you gotta bring people along — you have to bring agency leads along, you have to bring stakeholders along. So you begin to appreciate the complexity of the country we live in. You don’t always have to get to consensus, but you have to hear people out. It’s a very different set of perspectives than what I had a year ago where I could just think about what do I think is interesting and just tweet it and not have to worry about any of these issues, the biggest of which is how is this ever actually gonna get done?

One big, recent “how” that Ashish has grappled with is how to get people to take the bivalent Covid booster vaccine. This latest formulation includes two components, the Omicron BA4 and BA5 subvariants, as well as the original strain of the virus, which is where the term bi-valent comes from. As of early November, when I spoke with Ashish, just under ten percent of U.S. adults over age 18 had received the updated booster. And even among one of the most at risk groups, people over 65, uptake has struggled: just 23 percent have received the new booster, compared to more than 93 percent who completed their initial vaccine series.

Why has the U.S. struggled to get people to take this new vaccine? Is it a messaging problem? A data problem? Something else?

JHA: There’s several issues here. One is certainly that I think we need to continue to do a better job at explaining to people what the value of these vaccines are. This is a new vaccine and I’m always reminded whenever companies introduce a new product, it takes a while for that to take hold. And so that’s one issue. I think the second is we’ve gotta get people to see this differently. People often say, “Well, is this your third booster or second booster? What shot is this?” You know, when I went and got my flu shot this year, I didn’t think, “Oh my God, this is my 28th flu booster.” I thought, “This is my annual flu shot.” And I think that’s where we are for most people with Covid.

I think if we keep plugging away at those things, I think that’ll help. There’s no question, Bapu, that one of the main challenges has been, as a country, we don’t have an adult vaccination program. We’ve had to sort of stand that up in this administration. And then last but not least, one of the challenging things is how many people use their platforms to undermine confidence in vaccines. And I think in the long run, that ends up being a major part of the problem as well. So it’s a combination of helping people understand it’s a different vaccine, resources to run a real vaccination campaign, and then fighting against a tide of misinformation as well.

 JENA: If you had unlimited resources, would you generate different evidence about vaccines or masks or whatever public health intervention we’re talking about, than exists today?

JHA: People often ask the question, was there enough evidence for the current bivalent vaccines? And I actually wanna make two points on this. Point number one is the decision making on vaccines rests squarely inside the F.D.A. And there are things that we have like third rails around and one of them is us sitting at the White House getting involved in decision making at the F.D.A. Who is the F.D.A. doing this? It’s a whole bunch of career scientists. Their assessment was, we have enough evidence to authorize these vaccines. And in my mind, and you and I know this, like you don’t look at one piece of data to make a decision. You look at the totality of the evidence. And when you look at the totality of the evidence on bivalent vaccines, it’s hard not to conclude that it’s a good idea to move this forward and to authorize it. And if you’re gonna give people vaccines in the fall of 2022, that moving to a bivalent is the best strategy. People say, well, you know, wouldn’t it have been better if we had all this other additional data? And yeah, it would’ve taken an additional, you know, four, six months to run a large clinical trial. Do we need to run a clinical trial every single time we update our vaccine? I don’t think so. I’m not convinced that if we had run a large clinical trial that that would make a huge difference in the uptake.

 JENA: My sense is that this is not so much an evidence problem, but there’s more fundamental things at play here about human behavior and social cohesion and trust that are just gonna take time to solve. What’s the future hold for Covid? Is it becoming seasonal in your view? Is there a new normal that we’re approaching? What’s your take on what the next year to two years looks like?

 JHA: In my mind, the evidence suggests there is a seasonality. It’s not clearly as tightly seasonal as influenza is. We’ve seen surges in the spring and summer, but clearly the major surges have come in the fall and winter. It’s actually partly why I think most people will be getting an updated Covid vaccine once a year because even if there is some increase of infections in the spring and summer, for a majority of people, that fall shot will provide enough protection against serious illness that they’re not gonna need an additional shot. In terms of where the virus is going, I mean, the good news here is, 90, 95 percent of Americans have some immunity against this virus, either from a prior infection or from vaccines. That means that the risk of serious illness is much lower.

But we’re seeing a lot of very rapid viral evolution, and that evolution is driven by selective pressure on the virus to evolve away from our immunity. And that means in my mind that Covid continues to pose a substantial challenge. And, you know when people say, “Well, are we at a point where this is like the flu?” This is not like the flu. If you just look at the number of people dying every day, and right now we’re at a lull of 300, 350 a day. If you annualize that, it’s a hundred to 150,000 deaths a year. That’s four, five times worse than a bad flu season. My hope is we keep working on improving vaccines and treatment updates, we continue to defang this virus, make it less and less lethal. I think if we do the right things and manage it in the right way, we can really make this a much less serious source of morbidity and mortality for our population. But the work here is not done. I think if we let our foot off the gas and just kind of let it go, I think you’re gonna see a resurgence and you’re gonna see a lot more people getting infected and a lot more people getting sick.

 JENA: One of the initial issues, and it could be an issue this winter, is the health system strain. So if we have flu, R.S.V., Covid, all taking their toll this winter, that could be, enormously challenging for healthcare systems. So what is your view on pan vaccination versus just focusing on Covid?

 JHA: Yeah, it’s a great question and actually something we spent a lot of time thinking about. We pulled in leaders of major health systems and all the major medical societies into the White House in the last month to have very deep conversations about how we’re gonna get through this fall and winter for exactly the reason you outline. I mean, you know, people talk about the triple-demic of influenza, R.S.V., and SARS-COV-2 or Covid. And the fourth element I would add is a healthcare workforce that’s spent, that’s burnt out, that is not gonna be able to respond if you say, “Boy, we just need people to work extra shifts, work more hours.” I don’t know that the healthcare workforce is gonna be able to really do that. That combination really poses risks.

So in our messaging, in our work, we’ve been very clear that people need to get both Covid and flu shots cause we think that’s really important. In the future we might see RSV vaccines, actually just some data out from Pfizer suggesting that an R.S.V. vaccine may be effective. Again, we’ll see where that goes. But no question about it that preventing people getting significantly ill is our number one strategy for getting through this fall and winter because our healthcare system is gonna have a very, very hard time managing if all three of these viruses are raging and if people have not gotten vaccines. It’s gonna be very tough to get through this fall and winter without some serious strains on our healthcare system.

It’s impossible for Ashish Jha, or any of us, to know exactly what comes next with Covid. We’ve all been riding this wave together for nearly three years, and making predictions feels like a fool’s errand. Something I do know for sure is that we’ll never stop needing public health experts like Ashish. But eventually, and maybe soon, we’ll probably stop needing a White House Covid-19 response coordinator. When?

JHA: It’s a question people ask and I don’t have an answer because I actually haven’t spent that much time thinking about it. I wake up every morning, and think like there are three, 350 Americans dying every single day. And there is so much work to do to drive that number down. There’s a ton of work to do in thinking about transition, building a whole new generation of vaccines and treatments, making sure that we are, as a country, much better prepared to manage this virus over the long run. I would love to work myself out of a job. We should be doing things and institutionalizing things in a way that Covid becomes more and more into the background, and we as a country are just able to manage it more and more effectively with fewer and fewer deaths. And there will come a time when it’ll feel like, okay, the moment is right. That moment is not now.

That’s it for today’s show. I’d like to thank my friend and guest, Ashish Jha, for making time for us in his busy schedule. It’s been a while since we shared an audience and it was good to catch up. And thanks to you, as always, for listening.

Here’s an idea to leave you with. Sometimes, the questions that scientists are trying to answer are rooted in behaviors that people care about deeply. I’m thinking about things like masking, school closures, and lockdowns. There are scientific ways to study their effects, but people’s views can impact how they evaluate the science. Here’s an example. Let’s say a new study shows masking helps reduce spread of Covid-19 in schools. If you’ve supported masking in schools, would you be less critical of the study? Maybe even give it a free pass? Or instead, suppose, you believe that masks don’t help: Would you be more critical of the study? It’s an interesting idea to explore. How objective are scientists? How objective are the rest of us?

On a completely different note and speaking of research, we know that people typically take advice on which podcasts to listen to based on recommendations from people they know and trust. So, go find someone who knows you and trusts you — and tell them to subscribe to Freakonomics, M.D.

Coming up next week:

More than six million people in the U.S. currently live with Alzheimer’s disease, and that number is expected to more than double by 2050. A few months ago we told you why effective treatments that could address symptoms or slow disease progression have eluded researchers for over a century.

TARIOT: You know, the time to put out the fire is when it’s on the stove not when the whole house is on fire

We’ll revisit our discussion with Dr. Pierre Tariot, an Alzheimer’s disease expert who, like many of his colleagues, believes that intervening before symptoms even start could keep the disease at bay. Are they right? And after decades of disappointing results, is it time to consider new approaches?

TARIOT: There are lots of other shots on goal for the treatment or prevention of Alzheimer’s disease.

We’ll also tell you about some new developments in the field of Alzheimer’s research since this episode first aired. That’s all coming up next week on Freakonomics, M.D. Thanks again for listening.

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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter at @drbapupod. This episode was produced by Julie Kanfer and mixed by Eleanor Osborne, with help from Jasmin Klinger. Our staff also includes Neal Carruth, Gabriel Roth, Greg Rippin, Lyric Bowditch, Rebecca Lee Douglas, Morgan Levey, Zack Lapinski, Ryan Kelley, Katherine Moncure, Jeremy Johnston, Daria Klenert, Emma Tyrrell, Alina Kulman, Elsa Hernandez, and Stephen Dubner. Original music composed by Luis Guerra. If you like this show, or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.

 JHA: I don’t know how to turn my video off. 

 JENA: I should say, Ashish, you never used to be that guy who couldn’t turn the video off.

 JHA: Hey. Wow. Wow. It’s getting very uncomfortable in here.