Coronavirus Crisis Update: Ashish Jha “Equity is All About the Ground Game”

H. Andrew Schwartz: You're listening to the COVID-19 update a podcast from the CSIS Global Health Policy Center, focused on the science and policy implications of the outbreak. I'm Andrew Schwartz of the Center for Strategic and International Studies. And I'm joined by my colleague, Steve Morrison, to discuss the latest on COVID 19.

J. Stephen Morrison: We're thrilled today to be joined by Dr. Ashish Jha, a good friend and colleague, who recently became the Dean at the Brown University School of Public Health. We'll hear later in this podcast about some of the innovations he's introducing there. Ashish, it’s wonderful to have you with us here today. Thank you.

Dr. Ashish Jha: Steve, thank you so much for having me on. I'm really excited to speak with you.

J. Stephen Morrison: In your recent work, including some testimony before congressional audience on last Friday, February 26th, you dissected very carefully and fairly I felt the failures of the Trump administration, across a spectrum of areas. And you also gave us some early insights as to how you're tracking the first month of the Biden administration. And there's some reference to what's happening state by state. The Brown Microsoft Covid-19 vaccine tracker is bringing forward lots of very important and valuable data, particularly on the state by state outcomes.

Let's start with a big question, which is what grade would you give the Biden administration's performance thus far in building up in your own words, the federal end of the bargain as you put it. And as we think about what's happened in these last five weeks, you know, what are the areas that we need to be paying the greatest attention to the areas of greatest concern or uncertainty, looking ahead. So over to you.

Dr. Ashish Jha: Great. And when you ask, what grade would I give my first reaction as a, as a professor is, do you want me to be grading on a curve here? Or do you want me to just, and part of it is in contrast to the Trump administration–

H. Andrew Schwartz: –(laughs) I think you have to grade it on a curve.

Dr. Ashish Jha: Right. So let me start off by saying, if you're going to grade a student, if you can grade anybody, you first want to say, what are the criteria you're going to use for grading?

And that gets to that federal part of the, of the bargain. You know, public health has always been a state-led effort in the United States, but when we've had national crises, the federal government plays a large role. And there are a few areas that are particularly important, setting national strategy, pulling together resources, aiding states, because states–as much as they may be in the lead, don't have the resources don't have the technical capacity, just can't do it on their own. And so the federal government is supposed to play a really big, helpful hand, especially in bigger crises.

And overall, I would give the Biden team an A-minus. And I want to talk about why the ‘A’ and then why the minus.

So let’s talk about ‘A’–you know, on the communication front, they’ve been terrific. Much of what hampered our response–there were many things that have hampered our response in during the Trump year of this pandemic, but one of them was the constant misinformation and miss-messaging about how long this pandemic was going to last.

You know, it was very clear, I would say by April-May that we were going to be in the thick of it for at least another year, year and a half. Imagine if President Trump had come out and just said that it would have led businesses plan, accordingly individuals plan accordingly, we would have made the investments that were needed to get through this. But instead, we constantly heard it's going to end in four, six weeks or two months or the summer or the fall, or we're rounding the corner. And it undermined the ability of the American people, states, individuals, to really do the things they needed to get through this pandemic.

On the communication front, the Biden team has been dramatically better. They've been very clear that this is a real problem. If I have any quibble at all, I think they've been a little too negative too often. We hear things will be normal by Christmas. Sure. I think things will be much better, much earlier than that. And we can come back to why I'm so optimistic, but they certainly have been much better on that.

I've been talking to states throughout the whole pandemic. Most states tell me it feels like a light switch after January 20th, before January 20th, when they asked for help, mostly what they got was you're on your own. After joining January 20th, when they asked for help, what they got from the federal government was in which ways, what can we do? That's a huge difference. They've been, I think, extraordinary on ramping up vaccine supplies, better communication with states.

So where is the minus? A little bit on that communication–I feel like it’s a little negative. And then, to be perfectly honest, there's one area where I feel like they're not doing enough, much better than the Trump team did, but not doing enough. And that's in testing and building up testing capacity. There's this mental model people have that well, now we have vaccines. Just got to get vaccines out. The pandemic is going to be over. We don't need testing anymore. Testing is going to be a central part of how we keep our economy open and people safe for the next several years.

J. Stephen Morrison: But we're turning our attention away from testing as we move towards vaccination.

Dr. Ashish Jha: Exactly, exactly. And that's a problem and I wish the Biden team would be more forceful on that. So, uh, look huge change in the last month and a half. I want to start with that acknowledgement. Way, way better, but there are areas where they still got to plug away and do more.

J. Stephen Morrison: What else are you thinking about? What else are you concerned about? And testing–testing, I take that point. That's a, that's a hugely important point.

Dr. Ashish Jha: Yeah. I think developing strategies around variants, I think is one where they've been a bit slower than I would like for them to be. And I want to hear more of a clear plan for how they're going to deal with more variants coming online and how they're going to deal with variants that may actually escape our vaccine. And what do we about that? How do we plan for that now? So that's an area where I think it requires a little more.

And then the third area where I will say that the Biden team needs to do more is around the global stuff. Look, it's really easy when you grade yourself on global engagement against the Trump administration to look like a superstar. Rejoining the WHO, of course. Engaging with COVAX and putting in money, of course. And so, what I worry about is that the Biden administration is going to look at the situation at hand, compare themselves to Trump, think about what president Obama left with, and will shoot too low, will not rise to the moment that is in front of us. And it's a real risk because again, the previous folks were just so inadequate that it's easy to look good, and I worry that they won't be bold enough, big enough, aggressive enough.

J. Stephen Morrison: Thank you. We’ll turn back to the international strategy a little later. I want to ask Andrew jump in.

H. Andrew Schwartz: Yeah. Dr. Jha, I wanted to ask you, along those lines, we haven't heard a lot of the kind of, I wouldn't call it criticism what you just said, but you know, feedback about what's going on with the Biden administration coming out of the media. And do you think that because of, you know, what happened with the Trump administration, particularly in the last several months of the Trump administration, that the media, maybe aren't asking the tough questions to the Biden administration, and we're not really hearing enough about some of the issues you just raised.

Dr. Ashish Jha: My sense is, and again, you always compare yourself to the last guy, right. My sense is that after four years of being called the enemy of the people and being attacked very, very directly, there probably are people in the media who are feeling this huge sense of relief that they don't have that anymore.

And that while I'm–look, I'm all for relief and all for not being told, you know that you're the enemy of the people, but the media does have a responsibility to hold the Biden team accountable. And, you know, I bring up when people say, well, why are you criticizing the Bidens? I'm like, look, I'm not criticizing. And bottom line is that's my job as an academic, to point out things that I think are not perfect. You know, I don't think I'm soft balling them. I think they're doing a really good job, but it's our job in the media and in the academy elsewhere to say guys, good work, here are two things you could be doing more or better. That is very much our job. And, and I think that all of us need to do that. It's good for them too. Everybody needs somebody to push people to do better.

H. Andrew Schwartz: The thing that I keep coming back to is, you know, we've heard a lot about how some Americans are vaccine resistant. I keep thinking that Americans are vaccine-confused because they don't know which vaccine they're going to get, which is the better one, should they hold out for the best one. Is the Johnson and Johnson one that was just approved this weekend–is that going to be any good.

You know, some people are worried for instance, that if they had Covid and were given Regeneron, should they get one dose or two doses based on the monoclonal antibodies that they receive, there's a whole host of issues that come across. And I keep hearing about this vaccine confusion, and not a lot of answers.

Dr. Ashish Jha: Yeah, this is, I think this is really the job of the CDC. And you know, I know Rochelle Walensky well, she's terrific. Really a first-class scholar thinker, expert. She’s got a lot on her plate, but this is an area where we need to hear clearer communication from CDC on this. I get questions all the time, all the ones you just laid out, Andrew, and there are answers to every one of those questions, right. There are like, here's our best science-based answer. But as much as I'm happy to give those answers, it shouldn't be me. It should be the CDC or, or someone else. It should be Tony Fauci, but people need to hear that. And it's not one time, people need to hear that on an ongoing basis. What the right answers are on those questions, because those are the questions on everybody's minds. And people are asking basically, how do we navigate the next phase of this pandemic? There are some complicated questions.

J. Stephen Morrison: By definition, it's murky and confusing. The reopening of schools and the debate that's been triggered over the CDC guidance and interpretation of that. And the way it's been pulled. I mean, I think Andrew, that alone, I think is probably pushing a lot of the people that are saying to you I'm just confused here. And we were confused also because people are getting vaccinated. They don't know what that means. Right. They are heaving a huge collective sigh of relief. And then they're like, okay, but what about now?

What now? What's my B what are the parameters? What're the rules? And that's tough.

Ashish, can we come back to one big question about you personally, that I wanted to open with early in this conversation, which is, you know, you're a very conspicuously optimistic person and you've sort of staked out your ground and the optimist camp, and that's not new. And it's very pronounced in terms of the–looking at the course of the pandemic, the evolving response, what lies ahead for Americans 2021, when. Is that a fair characterization from me? And if so, I hope it is, what accounts for that?

Dr. Ashish Jha: So, of course my view is I'm–it's a very realistic assessment, not necessarily an overly optimistic when I, and you didn't say overly optimistic. And I think, yeah­–

J. Stephen Morrison: –No, I'm not saying you're veering into fantasy. I'm saying you're just, you argue your case. You argue the optimist case.

Dr. Ashish Jha: I have to say, I have spent a lot of time trying to think about ways in which I could be wrong because I, you know, in this pandemic, we've all been wrong. And so I try to look at the data. I look at a lot of data every night, I think about where things are heading. And I have in the last couple of months become decidedly optimistic. And I keep asking myself, what am I getting wrong? What am I missing? What the threats to my optimism. And there are some, right. It is not like there is no way things are not going to be completely terrific forever in two months. That's not what I'm saying. But I lay out the parameters and the chances that what I see as the summer and the fall are horribly wrong are just incredibly low. So let's talk about that.

I mean, number one thing of course is vaccines. And I've been doing a lot of talking to the manufacturers, folks at the White House, elsewhere. We just have more vaccines coming than we know–we will know what to do with. It feels funny to say that right now, when vaccines feel like they're in such short supply.

But in two months, maybe in as little as a month or six weeks, we're going to be like, wow, we have vaccines around and no one showing up to the appointments. So we're going to flip this very quickly.

When I look at the data on how much immunity there is from the infection, throw in the vaccination, all the data on reduction of transmission, you know, it's hard for me to see how we're having large outbreaks once we get into the summer. The one thing that could happen that is some new set of variants that really render our vaccines ineffective. I think that's extremely unlikely by the summertime. Anything is possible, but I, I really, it, every way I triangulate on this, Steve, I just, it makes me feel like we're going to have a really good summer, good fall. This is a seasonal virus late into the fall-winter we probably are going to see another spike in cases. It should be relatively small. And I think things will be meaningfully better

H. Andrew Schwartz: More vaccine than we know what to do with is a great problem to have–

Dr. Ashish Jha: It's a fabulous problem to have, and it will get into our conversation about international stuff, but it is a fabulous problem. And we've got to start planning for that problem. Yeah. I'd much rather have that problem than the opposite problem, but it's still a problem. And we have to have a strategy for dealing with that. And we should start working on that now.

H. Andrew Schwartz: What makes it so difficult to deal with when you have that volume of vaccine?

Dr. Ashish Jha: Yeah. So we've got to make sure that we have distribution sites set up that can handle it. Right now, we're doing, you know, last couple of days, we did 2 million a day. I mean, we should have enough vaccines to do three, three and a half million a day by mid-March. At which point I'd like to be doing three, three and a half million a day. I won't, I don't want distribution to be the problem. I want to make sure we have the sites, the vaccinators, the IT, the logistics all set up. So if a vaccine arrives and a person shows up saying, here's my left arm, that those–those two things can meet.

H. Andrew Schwartz: Then we're going to get into state by state and even county by county competency, right? Because you know, one state might be better than another one county might be better than another. I mean, we just saw even last night on 60 Minutes that, you know, the county where I live in Montgomery County, Maryland is despite being, you know, one of the most highly educated counties in the country we're really behind. And there's a variety of reasons for that, but it's hard to, hard to explain.

J. Stephen Morrison: Ashish, on your optimism. We see a lot of caution right now in President Biden and his team. And I think some of that caution is puzzling over what the proliferation of variants means in the bigger picture. If it's transforming this pandemic into something that's recurrent, that's endemic that we're not going to have a hard pivot through. We're not going to hit the herd immunity number and be able to loosen. We're going to have to deal with this evolving pandemic, which is going to put us into recurrent vaccinations, probably seasonal use of masks, behavioral requirements, looking forward, perhaps we hit more winter surge is smaller. But I'm assuming that some of your optimism is that we're taking out the death and extreme illness over in a fairly rapid amount of time. And you're not as frightened at this prospect of our morphing into an endemic, seasonally-based endemic outbreak. Can you say a few words?

Dr. Ashish Jha: That's exactly right, Steve. So, I, what I describe is we move from this kind of acute phase of the pandemic to the chronic phase. And look, the acute phase is this, right, is that everything is by Zoom. We're all kind of locked in to our homes that, uh, kids are largely in many places, not in school. That our lives have really been transformed in lots of not so good ways. And that Covid dominates our lives right now. Right? Covid is the number one issue in almost every single thing we think about in our society, in our lives right now. I think we get away from that probably by this summer. And by the fall we get into a Covid as a challenge, we are still dealing with it, but it becomes one of the challenges we deal with because hospitals are no longer overwhelmed. We don't have thousands of Americans dying.

And none of this is to say, no one will die of this. Of course, we'll have, we may have days where we have hundreds of Americans die again in the fall, and that would be really bad and we should try to come up with a strategy. But then we start getting into, and I hate using this analogy because it's been so misused, but we start then getting into how we deal with an influenza virus every year and flu outbreaks. We, we figured out how to manage it. And I guess I have a lot of faith in people's ability to deal with chronic problems and their ability to adjust and accommodate. And it will mean we may have periods of time where we put on a mask. It will mean that we may think about office space differently. It will mean that we may not have indoor concerts for a while, or that they'll look different. But all of that feels very different than this, which is Covid dominates our lives.

J. Stephen Morrison: Yes. And do you think that we're going to likely sail into a period where mandatory vaccination becomes the in many different sectors?

Dr. Ashish Jha: You know, I've been talking about this with universities across the country and what they can and can't do this fall. And the number one issue is whether they have mandatory vaccinations, and this is also true for businesses and certainly long-haul international flights, right. I mean, there is just a bunch of situations in which if I know everybody around me is vaccinated, I feel very differently than if a third of the people around me are not.

J. Stephen Morrison: And that shift to that kind of acceptance of that norm, right. That's a big shift, right? In our society in many other societies.

Dr. Ashish Jha: It is, I think given what we have been through, a lot of people will clamor for it. And a lot of people will accept it. You know, of course. I mean, I, the example I used was probably not a fair example, as I talk about how every year I have to get the flu vaccine. And if I don't, my hospital privileges get suspended. Like there's no question, like I'm not allowed to step on hospital grounds if I have not gotten my flu vaccine. Right. And I just, I mean, I would get it anyway, but the point is no one questions that if you work in a hospital and people just deal with it, my sense is you're going to have a lot of that. And when, especially when people are going to understand that, like the alternative is what we went through for the last year, I think you're going to see a fast majority of Americans get vaccinated.

H. Andrew Schwartz: You know, you had the Pentagon reported, the third of the military said they didn't want to get vaccinated. You know, you're going to have people clamoring in the fall to pack in the college football games, professional football games. Like you said, people want to go back and see concerts again. In Israel they're not letting people into things without proof that they've been vaccinated. Are we going to be able to do that in the United States?

Dr. Ashish Jha: It's going to be tricky. I don't see states doing much in the way of mandating of vaccines. This is where I think things like testing becomes super important. So if I want to go see a college football game in the fall, we can have our students all be vaccinated, but there are parents, cousins, aunts, and uncles would come to football games. And maybe that's a situation where everybody shows up and needs to get a 15-minute rapid antigen test before they're allowed into the stadium. And that just becomes a part of how we do some high-risk things–is that testing becomes that extra layer that manages the fact that we will have events without people being vaccinated. That's why I think testing becomes a, an important part of a hybrid model of activity, certainly through the first holiday season, first winter, where we just don't know how this is all going to play out. Over the years, I suspect things will change more and the virus may evolve. Our vaccines will get better, all of that, but I think the next year or two, there's going to be a lot of this is different.

J. Stephen Morrison: Let's talk a little bit about state-by-state comparisons. I mean, the work that you're doing at Brown and the way you laid out in your testimony, sort of how do we understand the divergence of performance by states. The variations. It was very helpful in terms of investment in infrastructure, quality, state, local community partnerships, quality messaging, and consistency and messaging, streamlining of the rules of the road for access to vaccines.

So you give a good framework and understanding who's–who are the good performers and who are the laggards in this case, but I wanted to step back for a moment. What do you see out into the future? Do you see our country across states and territories and major urban centers, I mean, those add up to about 64 jurisdictions.

Do you see a pattern emerging that has kind of geographic clustering or fragmentation of high performers, poor performers, or do you see something different from that? Or do you see a convergence where over time there's a leveling out and those that are behind catch up and we're at a more uniform moment in time. What's your outlook?

Dr. Ashish Jha: Yeah, it's a really good question. I guess we saw incredible divergence across states on testing, on PPE, on a whole bunch of social distancing policies throughout the entire last year of the Trump administration. Right. And that was because they really wanted to let states figure this all out on their own. It's easy to say, well, under President Biden we'll see much greater uniformity. I think that's only partly right. So I do think we'll see a little bit more, the lagging states will get more support if they want it, right. That's the key part, if they want it. And these vast disparities across states, I don't think we'll quite see, but we will absolutely see variations across states. We will absolutely see some states really drive forward with a whole bunch of policies and implementations. And that's because these decisions are made ultimately at the state level and the federal government can't really push them too hard.

The federal government can offer help, can offer assistance. There are plenty of states who are going to want to do it in a certain way, based on their own local political interests, and that are not going to necessarily land them in great spaces. So I think I expect a moderate degree of variation, not the huge gaps that we saw during the Trump year of this pandemic. But it's not going to be fully uniformed work. We're not going to have like a national strategy on almost any of these things because it's not how our country works. Like–public health really is a state led effort.

J. Stephen Morrison: Which states would you say in a year's time are going to be problematic where there are tourist industries or people are not going to be so inclined to travel there because the safety factors a risk factor? Can you speak to that?

Dr. Ashish Jha: Yeah, it's a good question. I mean, so far, where we've seen real trouble, we've seen trouble in two types of states or two sets of strategies let's say. One is like a bunch of traditional southern states that have just not, they've not put in the resources and the effort and places like Georgia, Alabama, Tennessee, others that have not done a very good job of ramping up vaccinations, putting the kind of resources needed. Then you have a bunch of states like, and actually Massachusetts until recently was in this, California until recently was in this. But there were other states that tend to have much more focus on public health, have plenty of resources, but they made their rules super complex, difficult to execute. And they got caught up on the complexity set of issues. My sense is those states will figure that out because their focus at the end of the day on getting it right there, I've got the resources in.

And so, then we may have states like Alabama–and I'm picking on them just cause I think they're like near the bottom, if not the bottom, in terms of vaccinations. Who, unless they really ramp up resources and going into building up these distribution sites, also dealing with hesitancy? There's a lot of hesitancy among traditional conservatives or Republicans. This has been a surprise to me. We have not seen, at least I have not seen vaccine hesitancy data so broken down by political affiliation, but we see that. Unless those states really address that, we're going to have a real problem with some states being much, much worse off than others

J. Stephen Morrison: Well, what do you expect we're going to see in Texas and Florida? I mean the, in Texas, you've got the four big urban centers that account for, I don't know, 60% of the state's populations, which are Democratic-controlled and that's one set of geographies. And then you've got the rest of the state and in Florida, you've got a similar kind of urban¬–a couple of urban centers. And then you've got the rest of the state and you've got leadership that is all over the map in terms of the response.

Dr. Ashish Jha: Yeah. So Texas, I worry about. The problem with Texas so far has been because of the weather issues they've had, et cetera. It's hard to know how much of their, like they're among the worst in the country right now, but I really am going to give them a little bit more slack because they had about a week, 10 days where things got incredibly disrupted. And I worry the States like Texas and Florida become in some ways microcosms of the country where you're going to have pockets of really high vaccination. Like I expect places like Orlando and the greater Orlando area to be in reasonably good shape. Because they're going to want to draw in tourists, like tourism is their industry. And if they're having large Covid outbreaks, like it's not going to be that exciting to go to Walt Disney World. And so they're going to have a very specific set of motivations to deal with this. I think things are going to be in the more rural areas, especially in Texas. I worry along the Mexican border Rio Grande Valley. I worry a lot about vaccine availability, vaccine, hesitancy, distribution, communication with the communities. And that's what we're going to have to really pay close attention, to see what's happening there and how do we help make sure they don't end up falling way behind.

H. Andrew Schwartz: Let's talk for a minute about equity. You know, it remains a central concern, something you've talked about a lot. You argue we have to do better in targeting communities, grassroots education and publication of data, but the top line goal should always be improved access. Can you explain why?

Dr. Ashish Jha: So, the equity agenda on vaccinations is not going very well, um, right now and what data you look at about 7% of people who've been vaccinated are African-American, probably a little more than that Latino, vast, vast majority, 75 plus percent are white. And if you begin with who was really hit hard by this pandemic, that's a really sharp contrast, right? Because it was a Latino community and particularly African-American community.

And so everybody was worried about this and the way we dealt with it initially was to try to make some complex rules about eligibility and trying to get essential workers in. Very, very hard to execute. And some of the states that really try to push a lot on that actually, where someone was some of the slowest in getting out of the gate in terms of vaccination. And I have come to believe looking at the structural nature of our country. I'll give some specific examples–that equity's all about. The ground game equity is all about making sure there's plenty of access and that we're going into those communities. Working with community-based organizations, working with trusted people to make sure vaccines are getting delivered.

You know, I remember having a pretty robust conversation with a state health secretary about whether they should allow for people with chronic diseases in early to have access to vaccines. And he was making a very cogent set of arguments about how this is an equity issue and that chronic diseases, a 55-year-old African-American much more likely to have high blood pressure diabetes than a 55 year old white person. And that, and those are people who have high risk of complications and deaths. And so if you just go on age, you don't get the equity benefit and you want to put in chronic disease. I said, I'm totally with you, but let's talk about how this would actually work.

So how are you going to require documentation? You require a doctor which chronic diseases count. Oh, and by the way, I can get a doctor's note probably in 30 minutes saying not exactly whatever I want it to, but certainly a generously written one about what kind of chronic conditions I have.

African Americans and Latinos much less likely to be insured, less likely, even if they're in short to have access to general primary care. You think the 55-year-old bus driver is going to be able to pick up the phone, call his doctor and say, Hey, I need a note for my vaccination?

So, on surface, absolutely right. Put chronic disease in. But let me assure you that when you get implemented, what you're going to see is a very different group of people at the front of the line. And I don't think that using rules to, to get equity is going to get us where we want. So forget that strategy and set up sites in communities of color. But that alone won't be enough because people can drive to those sites. Make sure you have a strategy for reaching out to people, for getting people booked, brought in and, or, or go to people's homes and vaccinate them. There are ways of dealing with equity.

J. Stephen Morrison: You have to make that investment at a local level in order to open the access and get people there.

Dr. Ashish Jha: Correct. So the problem is, and I don't mean to dig on anybody and this is not meant to be criticism, but people sort of want equity a bit on the cheap. You know, it's, it's easy to say, well, we've got the right rules and that's going to have equity. We've got a lot of structural problems, a lot of structural inequity, structural racism we’ve got to overcome and that's not going to happen, uh, by setting up the right rules.

J. Stephen Morrison: Now, there is obviously a tension of–between the impulse now to go faster and scale faster and bigger on this vaccine because we got the variants, we got the expectations, we got the president out there committed. So there's all this pressure, pressure, pressure, move faster, move bigger that can shave the edge off of equity concerns pretty fast. How do you, how do you mediate those two things?

Dr. Ashish Jha: Yeah. I really think that we can find a way to do both. That we can move fast and be equitable. Look. So what's holding us back? One issue certainly has been, we haven't set up the like super smooth distribution centers that are necessary. I guess my take on this is, you know, some of what I've described and we've talked about with, with cities that actually are doing a better job is set up those distribution sites, those mega sites in communities where access becomes much easier for people, right? That's one way to do it.

J. Stephen Morrison: Pick the right places for your big mass vaccine–

Dr. Ashish Jha: And block off a chunk of appointments and give it to a community-based organization and say, you've got a hundred appointments for next week. Go get them filled with people that you guys interact with and work with. So there are ways of doing this that keep the lines moving, but still gets you a lot more of an equitable distribution of who gets vaccinated.

H. Andrew Schwartz: Yeah. I mean, one of the biggest problems is, is that, you know, a lot of the people who need it the most don't have a computer, or if they do have a, a phone that they could do this with, they might be hourly workers and they don't have time all day to try to search for an appointment, to try to book an appointment. And they're getting, you know, they're getting outflanked by somebody who, you know, is on the hunt all day for vaccine.

Dr. Ashish Jha: Absolutely. And then the appointment becomes available at 9:30 tomorrow morning and the essential workers like, uh, no, that's really not a choice for me.

H. Andrew Schwartz: Right, I’ve got to go drive the bus, whatever I’ve got to do–

Dr. Ashish Jha: Exactly. So we've really, we're not doing, we're not doing the implementation in a way that understands the structural challenges that people are facing. What we did was we basically, I think we spent way too much time debating the rules of the road and not enough on the ground game of how it was going to get implemented.

H. Andrew Schwartz: How do you reverse course now and try to make this something–that, you know, especially given the fact that we're going to have a lot of vaccine on our hands pretty soon.

Dr. Ashish Jha: Yeah. So my, my strategy has been to say, make the rule super simple, because I don't want rules to become a barrier to equity. I mean, the rules were designed to promote equity, but I think they've actually become a bit of a barrier. So make the rule super simple. I have argued for basically at this point, or certainly soon make it to everybody over 55, lowering that age from 65 to 55 picks up a lot of higher risk African Americans and Latinos who are in their late fifties and sixties, but with chronic conditions. So, open up to everybody over 55. And then second is collect data systematically on race and ethnicity. But about half the states collected with a decent amount of fidelity, about 12 states on collected at all, and then the other 12 or so collect kind of crappy data, we should be collecting data on race, ethnicity of everybody who's vaccinated.

You know, I was, I got vaccinated in my hospital where I work and I had to fill out a form like which included like myself, identified race, ethnicity. Everybody should have to do that. And that data should be given to the CDC. And, and so then you can look, states can look and say, well, is my implementation game actually work? If I claim that I'm trying to implement it in an equitable way, am I actually achieving it? Lots of states don't even know. Right? So it's like when Kaiser Family Foundation shows up and says, here's your data? They're like, Oh my god, I had no idea. I'm like, what do you mean? You had no idea? How could you not have any idea?

So there's a, there's a bunch of that kind of stuff. And this is a place where the Biden administration can absolutely do something, right. They can hold states accountable and they can say, look like you're doing a terrible job on reaching out and vaccinating communities of color. And then there's a whole bunch of specific tactics you need like work with churches and set up sites at the historically Black churches where people have a lot of confidence in that institution. So work with church leaders, work with community leaders. There's a bunch of that kind of stuff, but at a higher level, to me, it's about data, accountability, transparency and simplicity.

J. Stephen Morrison: Thanks. Let's turn to the international dimension. Let's talk a bit about the, the vaccine gap and U.S. diplomacy go back. So, you know, COVAX as a vaccine facility, it's making some progress. The recent U.S. pledge of $4 billion, very significant rise in commitments from the EU, the German government prior to that, the Canadians, but COVAX is not going to be the sole answer to the tension between nationalist tendencies to hoard supplies and the need for solidarity.

If we're going to address this looming gap between low and middle income countries, who are likely to be left with, to wait a long time for ample access to safe and effective vaccines. This is a delicate issue diplomatically for the United States and other big powers that have secured access to these doses. But as you've pointed out–in fairly rapid order, they're going to be sitting on big stocks. And it raises the question of when to really get engaged, to lead internationally.

When are we going to see some form which has been absent of sustained high level leadership to grow the manufacturing capacity, to bring transparency and an order and accountability to a marketplace that's very un-transparent and very chaotic. And increasingly driven by either the vaccine developers and or the Chinese, Russians, Indians. When are we going to bring our influence to bear? And we have significant influence to bear in shaping that environment to get the best outcomes versus the worst outcomes. What's your thoughts on how the us, as it reengages internationally?

We a very promising start with Munich security conference, President Biden's address. There has his address at the G7. Very promising opening, but stop short of really sort of talking about the big, the big issues that I've just laid down, including use of surpluses, getting that manufacturing up and running and trying to clean up a very un-transparent and chaotic marketplace. What are your thoughts?

Dr. Ashish Jha: Yeah, Steve, great set of questions to which I was going to say–I want to know your answers to all of that. But since you're asking me, I'll give you mine first couple of thoughts.

First of all, I guess I am. I understand that for the Biden administration, making sure that Americans have enough vaccines has got to be job number one. Because given what we have been through 500,000 Americans, that if President Biden came out today and said, I have decided to divert half the vaccines, we're getting in March to a global audience, it's just not going to work. I mean, it's just politically too costly. And I understand that and I think it is what it is. And I certainly would not advise necessarily like that's wrong. We've got to deal with the American issue.

I think the challenge is couple of things. I mean, first of all, I remind people that the two countries that really are, before they vaccinated their populations, giving out vaccines to others are Russia and China–as the two main ones we're doing it.

We can talk about India and the Serum Institute in a second, but certainly Russia and China have taken that strategy. And that ought to at least raise some alarm bells in people's minds of like what's going on here. And what is this whole vaccine diplomacy thing, and how is this going to play out? America does not want to be the country that gave the $4 billion to COVAX and said, again, kind of good luck, Godspeed by whatever vaccines you want. Because as you alluded to Steve, the problem right now is not money.

The problem right now is vaccines and America could have committed $10 billion. I'm not sure it would make much of a difference. Money is going to be, you know, it's always a little bit of a problem, but the big problem is that the wealthy countries have bought up all the vaccines. And if we're thinking about our long-term engagement with countries, if we're thinking about our developing our soft power. But also if we're thinking about just from a pure selfish point of view of making sure there aren't large outbreaks happening around the world, which can give rise to more variants, we've got to take a totally different strategy.

We've seen a rise of a bunch of variants of concern in less than a year. If this pandemic goes on globally for another one or two or three years, because the world has not been vaccinated, I feel like we're pushing our luck and really probably assuming unfairly that we won't see a variant that will really render our vaccines ineffective. So if I were advising the Biden administration, which I am not, but if I were, what I would say is you got to lean in heavily on this. You got to use your political and diplomatic power to help countries control outbreaks. I don't, you know, like I don't know what kind of leverage we have on Brazil, but we should really be engaged with Brazil. Brazil has been a place that has had really bad outbreaks and has continued to. And President Bolsonaro has not been super amenable to taking standard public health approaches.

Again, I don't mean to single out Brazil, but I, but I think we need a kind of a, all government, not just a vaccine strategy.

Second is we should start planning on what we're going to do with our excess vaccines. By the time we get into May-June. Like again, I don't see in may somebody walking around and saying, I really, really want a vaccine, but I can't get one. And like, I think we can plan that, plot that out now and start thinking about what are we going to do with our vaccines in may and how do we begin to get it out to out to folks? Do we just donate all of it to COVAX and let COVAX do it do, to what extent do we do the more bilateral stuff that the Chinese and the Russians have been doing? That's a strategic question that I think is really important.

And then the third, which you brought up around manufacturing capacity, you know, I–I kind of use it a bit of a tired cliche of in a, in a Washington Post op-ed I had where I said, you know, we have to sort of think about vaccine manufacturing as kind of a Manhattan project of, we've got to figure out how to substantially ramp up vaccine production for the world. It's a huge issue right now. And I don't see any other country being able to bring manufacturers together and using the power that really only President Biden has to say, guys, we need a totally different strategy. MRNA and vaccines may be a challenge to ramp up a lot more because there's a bunch of technical issues. There's a bunch of supply chain issues, but I think vaccines like the Johnson and Johnson vaccine, the AstraZeneca, a Novavax protein-based vaccine. Again, we don't, haven't seen the data on Novavax fully, but the little we've seen makes me very optimistic.

I think this is going to sound aggressive, but I think the president should set a goal of having enough vaccines to vaccinate everybody in the world by the end of 2021. Is that going to be easy? No, but I think it's doable.

H. Andrew Schwartz: You heard it first here. That's it. Well, Dr. Jha, in terms of innovation, you recently became Dean of the Brown University School of Public Health. Steve knows you really well. I know you from TV, but I assume you're charged there is to innovate. So tell us a little bit about what you're doing at Brown.

Dr. Ashish Jha: Brown School of Public Health is very new. It's about seven years old and university's old, but the school public health is new. And you know, when, when Chris Paxton and the president of the university reached out to me a year ago, a little over a year ago to ask me to be Dean, which was not like I hadn't had aspirations of being a dean of a public health school. But what she basically said was it's an opportunity to build a public health school for the 21st century. And I said, what does that mean? And she said, well, that's your job to figure out what should that mean. She had a set of ideas and we talked about them and we were very aligned in them. But what I was saying, and this is going to now sound so incredibly obvious, but 12, 13 months ago, 14 months ago when we were first talking, what we discussed was that public health has to be interdisciplinary and multidisciplinary in its, in its heart. Because public health is not just the epidemiological sciences or biostatistics, or it also incorporates things like behavior and economics and policy.

I mean, if we have learned anything about the biggest public health crisis in a century in the last year, is that policy, the political economy, political space for action have huge effects on what you can do. Most public health schools tend to circumscribe themselves into a box of kind of traditional public health problems. And what I have wanted–we've got some of that great work happening and opioids, and great work happening on care for aging and great work happening in a bunch of areas that are very traditional public health. But for me, the exciting part was to build on that, but also tackle some challenges that I saw as inherently outside of the box of traditional public health, but will have a profound effect on public health. And so, you know, 15 months ago I said, I brought up pandemics and I said, this is a really huge issue that we're not paying enough attention to as a global community.

That's based on some of the work that Steve and I had done. And Steve has been talking about this for–for years. And that struck me as a truly multidisciplinary problem, that, that isn't just a, you know, infectious diseases problem. Because it gets into everything from surveillance and governance of data to multinational cooperation and you know, all the stuff that we have seen play out. So that was one area where I was pushing.

Second was climate change struck me as the most important public health issue of our time. And one that we don't talk about as a public health issue. And I have to tell you that part of what makes it difficult for people to engage on climate change is, I mean, a lot of people obviously care deeply and everybody says they want to act on it or almost everybody. But when push comes to shove, a two degree temperature rise in 30 years, it doesn't sound great. But if we're going to be honest, it doesn't sound like the biggest catastrophe ever. I mean, you know, it's 24 degrees Celsius yesterday, it'll be 26 instead. That sounds fine. Of course, we all know that's not what this is at all, right, but it has these very profound destabilizing effects. But the way most people will feel it is on health issues. That's how it's going to get felt by a majority of people in my mind.

And so public health really is the face of climate change, and that's an area of work that requires a lot of sorting out. So that, maybe one more I'll throw in around data, you know, in this pandemic. Yes, I look at data from CDC and states. I also spend a ton of time looking at data from Google mobility, open table restaurant reservations. Like there's this incredible flow of new data that is happening that have these profound public health effects and most public health schools have not even begun to think about how to deal with that, but much of our society is kind of cooking along.

And that raises all sorts of issues of what kind of society do we want to live in? What are we going to deal with issues around surveillance states? So I think there are these big challenges of the 21st century that schools of public health need to begin to really own and tackle. They don't–may not have all the expertise in doors. So they got to collaborate with people around the university and across the country and outside of academia. That's the task for me, I feel like at the Brown School of Public Health is to build a public health school that can do that.

J. Stephen Morrison: We're getting close to the end here. And I know you've got some other pressing things you already told us why you were such an optimist, which is normally how we close these conversations. So I'm going to turn things around and say, what–what are you most worried about?

Dr. Ashish Jha: I'm most worried about what's going to happen globally with this, with this virus. And our inability to really engage in a global way that will continue to cause huge devastation in other parts of the world. May give rise to variants that then bring us back into the fold of having to deal more outbreaks, and that we will have missed an opportunity to lead in a way that I think only America can on pulling the world out of a horrible crisis. And if all of that plays out, it leaves a lot more people sick and dead. It leaves a very different world order. And I think it leaves America in worse shape and the world in worse shape. And I think that is the, the risk that I worry about most. Is we will pay too much attention to–not too much attention–we will pay attention to the domestic stuff, but we will not pay enough attention to the complex global landscape that we have to manage right now.

J. Stephen Morrison: Thanks so much. Thanks for spending so much time with us today. And we covered the waterfront. It's really been valuable and rich, and thanks for all the great work you do Ashish.

Dr. Ashish Jha: Thank you to you both for having me on. It was a lot of fun and really appreciate the opportunity to chat

H. Andrew Schwartz: We really appreciate you. Thank you, Dr. Jha.

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