The U.S. Is Missing Key Opportunities to End the COVID-19 Pandemic

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. This is our first episode of the new year, but unfortunately the subject dominating health care news is not new. We still have a raging pandemic on our hands, and even though we have a vaccine, there’s a long way to go before it’s over. So on today’s episode, I want to take stock of where we are in the pandemic. My guest is Ashish Jha, dean of Brown University School of Public Health.

Ashish, welcome to the show.

ASHISH JHA: Thank you for having me on.

SHANOOR SEERVAI: So we’re recording this episode the day after the official death toll from coronavirus is nearly 4,000 and it’s also almost a year into the pandemic. How are we going to get out of this colossal mess?

ASHISH JHA: Yeah, so colossal mess feels like a very technical and appropriate term. It is a colossal mess, there is no better way to capture it. We are going to get out of it. I think that’s the biggest thing for people to understand is we are going to get out of it. And 2021 will be the year that America and much of Western Europe and many other countries get out of it. For other countries who will slip into 2022, and we can talk more about that. So the question is how? Primarily we’re going to get out of it by vaccinating a large majority of Americans, and I do believe that is going to happen.

The question is how quickly? How many people will die between now and at a point when the virus is under reasonable control, and that will depend a lot on vaccination schedule. It will depend a lot on whether we can continue to do testing and mask-wearing. And then even when we hit a high proportion of people with immunity, the virus won’t go away. And so, we still will need a long-term strategy. So in that way, we’re not going to be completely out of it for a very long time, but I still am very confident that we’re on track for maybe in about six months, life beginning to start feeling like normal.

SHANOOR SEERVAI: Well, to that point of life beginning to feel like normal, you have said that you would like to host a barbecue on the Fourth of July.

ASHISH JHA: I did.

SHANOOR SEERVAI: Are you still optimistic about that?

ASHISH JHA: I am, but maybe there’s a little more hesitation in my voice. I felt really confident that I’d be able to host a barbecue in my house outside in my backyard, not a huge backyard, but thought I could have 20 people. And I guess, I got it wrong. I assume that when Operation Warp Speed said, “We will have 20 million people vaccinated by December and 50 million by January,” I thought they meant it. And then when I started doing the mental calculation, even though I said July 4th, I was saying I could even do it over Memorial Day. Well, Memorial Day is not going to happen at this point, we are way behind.

And so, I have overestimated the execution of this vaccine rollout. But I still feel like July 4th is a reasonable guess, partly because we are going to have a different team and the federal government starting very, very soon. And while it may take them a few weeks to ramp up and get really moving, I think the pressure that they are going to feel — and they already have been very clear they want to move quickly — I think will drive high levels of vaccinations as we get into the winter and spring.

SHANOOR SEERVAI: Right. And so, the problem right now is that the vaccine rollout so far isn’t going well. How do we make it better?

ASHISH JHA: Yeah. The vaccine rollout is going very, very poorly, I think. And it depends a little bit on people, some people have pushed back and said, “Well, these things are always complicated.” Sure. If these were under normal circumstances and there was no urgency and we didn’t really feel like we needed to move quickly, then you could say 5, 6 million people vaccinated a month after a vaccine has been authorized doesn’t seem so bad. If you believe that we are in an emergency, which we are, then it’s a disaster, the level of what we have managed to pull off in the last month. Look, so first let’s very quickly talk about what should have happened. I don’t want to spend too much time talking about that because I want to talk about what we should do now, moving forward.

SHANOOR SEERVAI: Sure.

ASHISH JHA: But under normal circumstances, if you had a competent team in the White House overseeing this, first of all, you wouldn’t have relied completely on states because states are really overburdened. I still think states have a really important role to play, just that they couldn’t do it all by themselves. Second is you would’ve gotten resources. I mean, the fact that no money was passed to support states doing vaccination distribution until essentially Christmas is insane. And it’s not like no one knew vaccines were coming. I mean, this is, to me, the most frustrating part is in September it was very clear we were going to have one or two vaccines, a high likelihood of having one or two vaccines by late November to December. There was no question about that by that point. On November 9th, Pfizer released its data.

And I remember that morning saying to all sorts of media outlets that basically around December 10th we were going to have an authorization. And my hope was that December 11th, 12th, we would start doing mass vaccinations. It just seems like no one bothered doing any of the planning, at least on the federal side and just said to states, “Figure this all out.” So here we are now into January, we’re at 5 and a half, 6 million, maybe a little higher for the number of Americans vaccinated, and states are slowly beginning to put their plans in place. They’re slowly starting to get some resources from the federal government that Congress has passed. I think two or three things are needed. One is you need an active partnership between states and the federal government. One of the things I hear from states is they’re going to get money, they can hire vaccinators.

And I was talking to a state health secretary, not that long ago, a couple of days ago. And he said, “I need to hire 5,000 vaccinators in the next couple of weeks. I will now have the money to do it, but it’s going to take me three months to hire that many people.” We have ability to get people. Let’s recruit former physicians, part-time or off-duty physicians, nurses, firefighters, lots of people can vaccinate. It’s actually not that hard, but let’s not go through a standard procurement process and standard laws and rules about how to hire people and you have to advertise. This is not the time for that. And he doesn’t have the ability to just do all this stuff by himself, he really needs the federal government.

So this is the kind of help that states need, and the federal government just has to become an effective partner. If I were running this out of the White House, I would be sitting with or having phone calls with every single state lead every day and saying, “What do you need? And whatever you need, we’ll use the power of the federal government to get it to you.” So if somebody said, “Look, I need vaccination sites set up.” Great. We’ll send in folks who will set up a vaccination site. If you need people, we’ll send in people. Walgreens, CVS, and Walmart combined can probably be vaccinating 2 to 3 million people a day. They have the capacity to do so.

SHANOOR SEERVAI: Right.

ASHISH JHA: But they’re sitting around waiting for instructions from somebody to activate them. Let’s activate them. Let’s just go.

SHANOOR SEERVAI: So, so far, no instructions. Hopefully when President Biden takes office in around two weeks, there will be instructions, but we still also have a problem with not enough vaccine doses, right? And you have been active in the debate on whether or not we can wait between the first and the second dose longer than the three weeks prescribed or four weeks prescribed.

ASHISH JHA: Yep. Right now we have at least 40 million doses made, maybe more between Pfizer and Moderna. And about 55 percent of them are sitting not even at the state. So right now, 80 to 90 percent of those vaccines have still not been given out, but we’re saving 55 percent for second doses. And this is a problem given how much spread there is and as you began this conversation with we’re hitting almost 4,000 deaths a day, it’s a problem that we’re basically saving all these vaccines. And so, what I have argued is let’s just get them all out. Let’s get them all into people’s arms. Let’s get all the high-risk people, people who are older, vaccinated more or less right away. And then as the vaccines come off the production shelf, the production lines, then start doing second doses.

So first of all, just being very clear, everybody needs a second dose. Second, I’m not arguing for a six-month delay between the first and second dose. But I am saying that all of the scientists, the immunologists, and vaccinologists I speak with, I say to them right now, let’s say the Moderna vaccine is supposed to go in on day 28, four weeks. Six weeks? No one thinks that’s a problem. Eight weeks? Everybody’s very comfortable. It’s really after that, that people start saying, “Well, I don’t know,” because now we’re getting away from the data. And my take is let’s get everybody round 1 vaccinated and then start doing round 2 as quickly as we can.

And if that means a few people, instead of getting it at four weeks, get it at six or even eight, it’s probably okay, it’s probably not that big a deal. But we will be able to do a lot more people very quickly instead of having to save 50 percent of all vaccines and move that way. Don’t be such a stickler on 28 days. If you slip by a few weeks, it’s totally fine. But instead of saving my vaccine dose for me, for my second dose, give it to an 80-year-old and get them that 80, 90 percent protection. And then when more doses become available, give me my second shot.

SHANOOR SEERVAI: Right. So you’re advocating for obviously the 80-year-olds, everyone above 55. How do we distribute after that? How do we decide who gets to be next in line?

ASHISH JHA: Yeah, after 55 there’s all sorts of intricate formulas people are coming up with. And Bob Wachter and I are going to have another piece out in the Times today where we basically say after that, do a lottery. And lottery I think of as the old — and we have this in our op-ed in the Times — where we say it’s like the old Winston Churchill line on democracy, which is “the worst form of government, save all else.” And lottery, nobody likes a lottery. People think, “Well, that sounds random,” because it is.

SHANOOR SEERVAI: Mm-hmm.

ASHISH JHA: The issue is that it’s already clear even from the distribution we’re having so far, that when you think about who’s going to get vaccinated, you have to think about two things and we’ve only been thinking about one. The two things you need to think about are what’s your plan for distribution? And then the second is what’s your ability to execute on that plan?

SHANOOR SEERVAI: Right.

ASHISH JHA: Or when you execute on your plan, how is it actually going to work out? And people are not thinking about that second group or that second part. And what we’re seeing already is that all of the privileges of being wealthier, of being white, of being well connected are already starting to show up. I am hearing over and over again from hospital boards. Hospital boards are not doing frontline care, but hospital boards are made up of wealthy donors and they’re all getting vaccinated. They’re all getting vaccinated. Whereas, I can promise you the 72-year-old janitorial staff person has not gotten the vaccine.

SHANOOR SEERVAI: Right.

ASHISH JHA: And so, the 45-year-old young guy who’s donated to the local private hospital has gotten his vaccines and that is the reality of how this is going to play out. So people have said, “Well, we should focus on comorbidities.” Completely agree we should focus on comorbidities. So the question is, how are you going to verify comorbidities?

SHANOOR SEERVAI: Right.

ASHISH JHA: Are you going to require a letter from a doctor? What do you do with the uninsured? What do you do with people who don’t have a regular doctor? A lot of work has been done shows that people who don’t have regular doctors tend to be poorer, they tend to be more likely to be minorities. Certainly the uninsured are. And so, are we basically saying all those people with comorbidities will go to the back of the line. I guess that’s what we’re saying. I don’t like that. And so, I think that from an equity point of view, it’s actually far more equitable to have a simple system that people can’t game than a complex system, that whatever its intention, will end up helping the privileged and the well-connected.

SHANOOR SEERVAI: And in so many ways, what you’re saying about this inequity of distribution is the same inequity we’ve been seeing throughout the pandemic. It’s poor people of color who are our essential workers, bagging groceries, they didn’t have the option to work from home in March when everything shut down. And so, so many more people of color and people with low incomes have gotten COVID and died.

ASHISH JHA: Correct. Correct. And what has happened, so there are two or three parts of this that, I think, on the disparities, on the inequity front that are worth teasing apart. I mean, one is a lot of the deaths in communities of color have happened in older people who are not essential workers themselves, but they live in multigenerational households, right? So the 28-year-old who bags groceries gets infected, may have mild symptoms, but gives it unfortunately to their 60-year-old mother who then gets sick and dies. And so, multigenerational households is one part of it. Lots of features of systemic racism and long-standing inequities feed into this. Obviously, when you think about testing, for instance. Where were the testing sites set up? They weren’t set up in neighborhoods with a lot of people of color in them, right?

They were set up in the wealthier, suburban, whiter neighborhoods. So now, not only are you more likely to get infected, you were less likely to be able to get that picked up because the testing wasn’t available. So at every step along the way, there has been this consistent set of policy decisions that have widened the gaps. And so, it’s interesting because on the issue of essential frontline workers, people say, “Well, if you’re going to argue that those people should not be at the front of the line, aren’t you then not addressing the equity problem?”

SHANOOR SEERVAI: Mm-hmm.

ASHISH JHA: And my take is absolutely concerned about that. There are two parts. I mean, one is, if you use age as your cutoff, as your criteria and go down to 55, more than 90 percent of all deaths that have happened in this pandemic among Black Americans have been in people over 55.

SHANOOR SEERVAI: Right.

ASHISH JHA: So even if you don’t protect that 28-year-old grocery store worker, you protect their 60-year-old mother and that’s where a lot of the deaths are happening, right? So there is still that part of it that’s very important. But the second part of all of this is that the truth is a 28-year-old grocery store worker, he or she probably doesn’t have a regular doctor that they can reach out to if they have comorbidities.

Or on the job verification, this has been a really interesting issue where I’ve been talking to states who are thinking about these frontline essential workers and two things are going on. States are getting lobbied by companies, powerful companies to say, “Hey, make my company available.” And when I’ve talked to CVS and Walgreens and say, “How are you going to do employment verification to know if somebody who’s a frontline central worker?” They say, “Well, we can’t, but large companies can give us their HR list.” So guess who’s going to give the HR list to CVS or Walgreens? It’s Fortune 500 companies and they’re going to get their employees all vaccinated. And the neighborhood grocery store, they’re not going to generate an HR list and send it to CVS and Walgreens in the same way.

So again, everything that we do that looks like it’s for equity, I have come to conclude is going to make things more inequitable in how it gets executed, because we’re not executing these plans in a society that’s equitable, we’re executing it in a society that’s deeply inequitable and that has been what I’ve been worried about.

SHANOOR SEERVAI: Right. I mean, we also have an issue, I live in New York and I know they’re setting up 24-hour sites this weekend, but there aren’t any 24-hour sites yet in New York City. So I don’t imagine there are many in the country. And again, that means that people who are going to work every day have no chance of being able to get in line because if 6:00 P.M. is the last time you can get your shot, well, sorry, you’re still bagging groceries at 6:00 P.M.

ASHISH JHA: Exactly. Exactly. This has happened in a couple of hospital systems where they decided that when they made vaccines available, they set up a sign up first come first serve, and how do they let people know? They’ll let people know by email at 10 in the morning. So guess which staff do not check their emails at 10 in the morning? Janitorial staff, other administrative staff, overnight workers because they’re sleeping.

SHANOOR SEERVAI: Right.

ASHISH JHA: And all of a sudden, essentially what they found was that the people who signed up were all the senior attending radiologists who were on their email at 10 in the morning, they signed up immediately. And this is the stuff that will happen. And almost no one, and none of the food workers, none of the janitorial staff, none of them signed up anytime early and many of them end up getting blocked out.

SHANOOR SEERVAI: So Ashish, I want to shift gears a little bit and come back to something you’ve said right at the beginning, which is that the U.S. and most of Western Europe will get out of this mess in 2021 and then in other parts of the world that might take longer. And when we think about other countries, even Western Europe, the pandemic has been devastating, but it’s been uniquely bad in the U.S.

ASHISH JHA: Yes.

SHANOOR SEERVAI: Why?

ASHISH JHA: Ah, yes. So I have two different sets of views that I think are both worth articulating. I’ll tell you where I lean, but I’ll tell you what I think really smart people disagree with me a little bit on this and it’s worth articulating their view, too. So part of it is the structure of our country and part of it is our leadership. So I believe that if we had had almost any other president or any major party nominee of the last 20 years — if we had had a President George W. Bush, a Mitt Romney, a John McCain, obviously Barack Obama, Hillary Clinton — our response would have just gone much, much better. We happened to have in the White House a person particularly ill-suited to manage a complex crisis, and he undermined the entire federal response.

And so, you had a president who both undermined the science, refused to do the things that were necessary, became a misinformation spreader, and ultimately decided to take a strategy based on his political team’s advice, that it was better to blame the states than to take responsibility and have a federal response. And I think all of that has been well documented and is very, very clear. And to me, I personally think the story stops there. That that is so clearly the explanation and the dominant explanation, that I don’t need much more. Now I’m going to give you where a few of my colleagues, who I respect immensely, where they say, “Ashish, that’s part of it, but that’s not all of it.” So let me just flat flesh out that other part because I think it’s worth hearing.

SHANOOR SEERVAI: Okay.

ASHISH JHA: They will argue that all of that of course is true, but that it goes beyond that. That our federalism as a structure makes it particularly hard for us to solve these issues because states have so much authority over public health issues. They would argue that our long-standing view of rugged individualism makes collective action more difficult. And I mean, again, I’m giving you views of people I respect immensely, so those are not bad arguments. I disagree with them and I’ll finish by giving you my disagreement. I think the right federal leadership under a crisis situation, we’ve had lots of instances where rugged individualism, yes, but people pull together and push in the same direction.

I think you saw incredible collective unity after 9/11, certainly the major wars, World War II et cetera, you didn’t have states saying, “I’m not doing it. We’re going to go build our own planes. We’re going to go build our own army.” There was a sense of national purpose, people did it. I think that could have been developed. It was never going to happen with this president. And so, I believe that America can respond to a crisis like this. I don’t think it’s about our people or our government structure. I think we happened to have had particularly ineffective leadership.

SHANOOR SEERVAI: And so, if we look at countries that have done better, I mean, they’ve still been devastated by the death toll, but give me a few examples of places where maybe you would have rather been than the U.S. for this pandemic.

ASHISH JHA: Yeah. Lots of countries, I think, have done meaningfully better. The classic ones of course are all across East Asia. And so, Japan has done dramatically better, but often people started with places like Singapore and then the pushback is, well, Singapore is a city-state and small. True, but Singapore has done great, Taiwan has done great. But Japan’s not a city-state. Japan is a large country with a lot of people. Japan has had far, far fewer deaths per capita than we have. South Korea, another relatively large country, has done very well, and then New Zealand, Australia, so that whole set of nations. Vietnam has done dramatically better than us. And you certainly can’t argue resources are the issue because Vietnam is a meaningfully poorer country.

In Europe, Germany’s had a hard time in the last six weeks or so, but overall in the pandemic, I think they’ve done a much, much better job than us. U.K., France, not so much. A lot of the Scandinavian countries like Denmark and Norway have done very well. Sweden, of course, has a very unusual response that overall has not worked out, but Denmark and Norway again are very small. They’re each smaller than Massachusetts. So I try to look at the bigger European countries like a Germany, which also has a federalist structure, and say, “I would have much preferred to have been in Germany during this pandemic,” from a pure health and safety point of view.

SHANOOR SEERVAI: If I push back a little bit on that: Germany is a large country, diverse federal structure, but certainly not as large as the U.S. And also Vietnam, how much faith do we put in the counting of the death toll in Vietnam relative to a country like the U.S. or a country like Denmark or Sweden?

ASHISH JHA: Yep. So certainly I feel perfectly comfortable with the death toll numbers of Germany, so that’s fun.

SHANOOR SEERVAI: Right.

ASHISH JHA: So that question and the idea underlying it is really important. And I would have pointed to a place like India, which has also done much better than America certainly, but I worry about India’s numbers. I worry about India, the validity of India’s death numbers, its surveillance system. How many people did it miss? I still think India will emerge from this having done much better than the United States on a per capita basis, but it’s a little bit more fuzzy. Vietnam doesn’t have a great data infrastructure, but it’s not terrible. And I don’t think that you’ve had tens of thousands of Vietnamese dying of this disease, and nobody knew about it.

SHANOOR SEERVAI: Mm-hmm.

ASHISH JHA: Because they’ve actually done a pretty aggressive job on testing and tracing and isolation, and they would have identified most of those. So I think the Vietnam numbers may be a little understated, but there are probably not way off and still way, way better than the United States.

SHANOOR SEERVAI: Mm-hmm. Well, if we do come to places like India, where they’re working on generic vaccines, the AstraZeneca vaccine has been authorized, but it’s also 1.2 billion people who live in small villages needing to get vaccinated. When the U.S. and Western Europe look better, hopefully towards the end of 2021, what are these developing countries going to look like?

ASHISH JHA: A lot depends on how America and other countries behave in the next few months in terms of vaccine nationalism. India and China are interesting places because they both have a lot of internal local manufacturing capacity. A lot. And so, even though you’re not going to see large numbers of people getting vaccinated with Moderna and Pfizer vaccines in India, you are going to see a lot of people get vaccinated with the AstraZeneca vaccine, one of their indigenous vaccines that they are making. And one of the reasons why I’ve been so hopeful that the AstraZeneca vaccine ended up being, the Oxford AstraZeneca vaccine ended up being safe and effective because literally hundreds of millions of Indians are going to get vaccinated by it. So I think India may end up doing okay in terms of vaccinations and numbers just because of its capacity.

There are really important questions about the African continent. There are really important questions about much of Latin America. Not the same level of manufacturing capacity as India and China, they have not bought up the vaccines the way America and other countries have. So I’m really worried about how much we’re going to be able to do. And that’s why you have these global programs like COVAX that should be able to move the ball forward, but it is not. America and Russia are the two major countries that have not participated. I have every reason to believe that under President Biden, America will be engaged in a much more meaningful way. We just have to wait to see what happens.

SHANOOR SEERVAI: Right, because we can’t continue this way with essentially closed borders for perpetuity. There has to be a point at which people can move freely again, right?

ASHISH JHA: Yeah, and the truth is that America is not going to get to 95 percent vaccination. So if we get to, let’s say 70 or 80, hopefully a little north of that, we’re going to have pockets of America that are relatively unvaccinated. And as we continue global travel, those places are going to get constantly seeded with infections from around the world. So we’re going to constantly be seeing spread within the United States. Some of it homegrown, some of it imported, and we can’t close the world off. It just doesn’t work. Our economy won’t work, business won’t work, culture won’t work, science won’t work. So we need to make sure that we understand that vaccinating the world is a good thing from a moral point of view, but it’s also an important thing for our own personal well-being.

SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. Our sound engineer is Joshua Tallman. We produce this show for the Commonwealth Fund, with editorial support from Barry Scholl and design support from Jen Wilson. Special thanks to our team at the Commonwealth Fund. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.