PROVIDENCE – The “check engine” warning light on our national disease dashboard is dark red and growing more intense each day as the coronavirus pandemic explodes exponentially across Rhode Island and the nation.

No amount of denial or wishful thinking will make it go away. People are getting sick and dying at alarming numbers. Last week, on Friday, Nov. 13, the daily rate of infections surged to more than 184,000 new cases. Hospitals are becoming overwhelmed, and doctors and nurses and caretakers are reaching their breaking points. The death rate is soaring, reaching more than 1,000 a day. The entire health care delivery system appears to be on the verge of collapse, despite the “promise” of a potential vaccine in the not-too distant future.

President Trump’s belief that we “have turned the corner” on COVID – that there is a light at the end of the tunnel – is, in fact, more like a runaway locomotive hurtling at us down the tracks.

Dr. Ashish Jha, the dean of the School of Public Health at Brown University, has become one of the top go-to public health experts, along with Dr. Megan Ranney, an emergency room physician with Lifespan. They often provide what seems like a daily running commentary on the contagious spread of the virus, appearing on the national news media.

The forecast for the next two months is terrible, Jha warned, speaking at the Rhode Island Public Health Association annual meeting, held virtually on Thursday afternoon, Nov. 11. [Ranney was one of the award winners honored by the Association.] But, Jha believes, we are in the top half of the sixth inning in our battle against the coronavirus pandemic, and he expressed hope that by July 1, 2021, things will be “meaningfully better.”

“We all won’t wake up on July 1 and say: ‘Thank God it’s over. Let’s move on.’ We will be dealing with this virus for many, many years if not for the rest of our lives,” Jha said. But July 1, 2021, Jha predicted, will look more like July 1, 2019, than July 1 of 2020.

“Not completely better,” Jha continued. “There will still be important issues because things will have to be done differently. But I am optimistic that come July 4, 2021, it will really feel like Independence Day. Things will feel meaningfully better.”

Straddling optimism and dread
In his 45-minute talk, Dr. Jha laid out his definitive analysis of the virus – where we have been, what we did wrong, what we did right, and the future challenges we face in attempting to control the contagion. Sharing what Jha had to say affords the reader an opportunity to participate in a master class in public health, in order to be able to better understand the full dimensions of the public health crisis we are confronting.

Unlike a Twitter thread or a three-minute brief on a national TV network, Jha’s presentation provided an in-depth, comprehensive, expert analysis from a public health and an infectious disease perspective – filled with context, nuance, insight, and even his own admissions of mistakes he has made.

In publishing a transcription of Jha’s talk, ConvergenceRI seeks to shine a bright light on the convergence that needs to occur between policies, practice and future investments as Rhode Island grapples with what promises to be a very dark few months. It is, by definition, a big read.

The world according to Jha
Here we are, in the middle of a global pandemic; all the things that created the risks for this pandemic, none of them are going away. In fact, they are going to get worse. A really key issue as we go beyond this pandemic is to ask: how do we prepare ourselves for the future ones? And, what is the role of public health?

I think there are some really critical issues there that we are going to want to sort out. That’s my goal, over the next 25-30 minutes, to try and cover all of that and then get into a discussion with all of you about these issues.

Let me spend 5-10 minutes laying out where we are.

Top of the sixth inning
I often like to use a baseball analogy to mark time in this pandemic. I believe we are in the top of the sixth inning of a nine-inning baseball game.

Let me lay out why I say top of the sixth inning; it may feel very specific, like wow, why not the bottom of the sixth? What about the seventh?

I’ll explain to you why the top of the sixth. Part of what I’m going tot try to argue with you is that while a large part of the pandemic is behind us, we still have some very tough months ahead.

And, I believe that the next couple of months will be particularly difficult. First, let’s talk about timeline.

Pandemic began Jan. 1, 2020
There are lots of ways of marking time with this pandemic. I believe that the beginning of this pandemic is really around Jan. 1, 2020.

Our best guess is that the virus probably started circulating sometime in September-October in Wuhan in China.

Probably, by November, I would suspect, it had spread to many parts of China. And, by December, it was out of China and probably into parts of Europe. By late December, [it was] probably in parts of the western United States.

But Jan. 1 is an important date, because Dec. 31, 2019, is when the WHO [World Health Organization] was informed by China of a pneumonia that was being caused by an unknown pathogen, and that it was happening in Wuhan.

And so Jan. 1 was when WHO set up an office to start investigating this. And, that is when the world really becomes aware of this.

An end date?
So, if that’s the start date, I’m going to claim to you that “June 30, 2021,” will be the end date.

I put that in quotes, because I can promise you that this pandemic does not go away on June 30.

We all won’t wake up on July 1 and say: “Thank God it’s over. Let’s move on.” We will be dealing with this virus for many, many years if not for the rest of our lives.

But by July 1, I expect things to be meaningfully better. In a way that July 1, 2021, will look more like July 1, 2019, than the July 1 of 2020. Not completely better. There will still be important issues because things will have to be done differently.

By the way, if we look at that [timeline] as 18 months, we’re in month 11. And so if you do the math on the baseball analogy, it’s the top of the sixth inning. And this is a baseball game that we do not want to have to go into extra innings.

We are now in a very bad situation
Let’s take a look at where we are today.

Right now, in this pandemic, we are in what people are calling the third surge, or the third wave; we are in a very bad situation right now, with the number of infections, the number of hospitalizations, and the number of deaths [soaring]. We all expected a fall surge, but none of us expected it to be this bad, this early.

I think the next two months of the pandemic are easily going to be the two worst months of the pandemic.

What’s going to happen over the next two months is going to make March, April and May [of this year] look relatively easy. This is going to be a very bad couple of months.

The good news, the bright light at the end of this tunnel, is the vaccine situation.

The vaccine is such that with the Pfizer vaccine being announced, along with other vaccines, I think Moderna is going to get an emergency use authorization as well, in the next few weeks, Pfizer will, and probably Johnson & Johnson.

I would not be surprised if we have two or three vaccines authorized by Jan. 1, 2020, and we are going to be able to start vaccinating 10-20 million people a month, starting in January, maybe even in December, and by February-March, things will start turning around.

And, I really do think that by April/May/June we will have the opportunity, if we get our act together and we do things well, that we will have the opportunity to have widespread vaccinations, with a large chunk of American people being vaccinated by May or June.

And, if we get to 40-50 percent, ideally 60 percent of Americans vaccinated, if we have a vaccine that is 90 percent effective, if you throw in the fact that by then, 20 percent of Americans will have already been infected, that is a lot of population immunity.

And, the virus really does act very differently in a population with that much immunity.

We are trying to hit a high degree of population immunity. We want to do it through a vaccine. And, I really think that it going to be possible.

Battling against incompetence
I am more optimistic that we will be able to execute on all this, because one of the many problems with the Trump administration, and I don’t mean to turn this into a deeply partisan talk, but one of the many problems with the Trump administration was their sheer incompetence with being able to get anything done.

Their ability to get hundreds of millions of doses of vaccines out to the American people I think was very suspect.

And, I think the Biden team is going to be more effective in that. That’s a guess; I don’t know for sure. That’s why I think that by the end of June, life will start to look better.

How we got here
Let’s talk a little bit about how we got here – why this pandemic has gone as badly as it has. Then, I want to talk about the disparate impact on racial and ethnic minorities in America, and why we should have completely predicted that, yet we didn’t.

There are many reasons why things have gone as badly as they have. We can certainly blame a lot of this on political leadership, but let’s avoid that part of the conversation, and [instead] talk about things in public health that have not gone well.

We have really struggled on data. It is really striking how hard it has been for public health agencies to collect data on this virus, to collect data on infections, and to report data in a [consistent] way. We have not had consistent data collection; we have not had consistent data on contact tracing, we have not been able to do contact tracing in most places.

The reasons why our public health agencies have not done what they needed to do is not because our public health leaders are not terrific.

In fact, we have seen pretty consistently in this pandemic a whole set of Department of Health leaders, chief public health officers become stars, because they have risen to the occasion in a context where things are very, very bad. We’ve seen that in Ohio, we’ve seen that in California. I would argue that we have certainly seen that here in Rhode Island with Dr. Alexander-Scott and her leadership.

It is not a “blame them” [situation]. It is that we have so chronically underinvested in data infrastructure, we have so chronically underinvested in having a public health workforce., that we have found ourselves flatfooted.

Critical data elements missing
The critical data elements that we need to make smart decisions about how we shut the virus down, how we control the pandemic, have been missing.

When I think these days about what data do I look at when I am analyzing what’s happening, I spend a lot of [my time] every day staring at data from every state in the country. Some of it comes from departments of health, some of it comes from Google mobility data, some of it comes from Open Table reservations data; there are all of these interesting sources of data that are telling us what is happening, what people are thinking, and what people are feeling.

One of the things that you see is when virus levels start rising and when people start getting concerned is that they stop going out for indoor dining, and you see Open Table reservations starting to fall. That’s great, we can use that kind of data. But I want more of that kind of data; I don’t want to have to rely on Open Table only.

So, there are a real set of data challenges. I think we in public health have to think about how to make different types of investments as we think about the future. I certainly think that has been a major source of why things have gone badly.

Misinformation gone wild
Another major source of why things have gone badly has been misinformation and disinformation. There has been a concerted effort by people, for political reasons, to try to create confusion in the marketplace about what is causing the pandemic and how bad the virus is. You’ve all heard it, [such as] “It’s nothing worse than the flu.” There was all this misinformation about how everyone was already naturally immune.

One of the things that has been interesting to me is that I have been very visible and I have been very public. And, often, I will talk about, like, a new study comes out in the New England Journal of Medicine about population level immunity in Spain, let’s say, based on serologic surveillance data, and let’s say I write a Twitter thread about it, and try to explain it to people about what does this mean.

What I find really interesting is that it’s not just that there are random people who are tweeting back at me with a kind of junky information. I get very concerted, well-organized, disinformation pushing back. All of a sudden, I’ll get like a hundred tweets of people writing back, talking about cellular immunity. And when I look at who these people are, and it’s like some finance dude in Laredo, Texas, I’m like: What do you know about cellular immunity? The answer is that he doesn’t know anything about cellular immunity.

These are concerted well-designed misinformation attacks to try to discredit public health officials. They have been pretty well organized, and they have been pretty consistent.

Most of us who have been [in the] public [limelight] have felt it and faced it. Some of it is disinformation about science; some are personal attacks. We have seen large numbers of public health leaders resign over [the last six months] because of the sustained personal attacks on them. We really have no strategy in public health for how to deal with this kind of [disinformation] – again, it is not just about misinformation, it is about these very individualized attacks on public health professionals and public health leaders.

I think that has been a major source of what has made things hard [with this pandemic]. We’ve certainly seen that with mask wearing.

One of the most effective spreaders of misinformation is a guy named Scott Atlas, who has been spreading misinformation since March. And now he’s in the White House, actually driving White House policy, with a stream of junk information. And, it’s pretty hard to counter.

Ill-equippped
Our entire community of public health folks [seem] totally ill-equipped to handle this.
We haven’t been trained in it. The mental model that we have had is: you do work, you come up with the science, you identify the evidence, and then you tell people what the evidence is. And people will follow it.

I think we have learned from this pandemic that that doesn’t work. It does, in my mind, lay out a set of specific issues that we have to start addressing in public health schools, that we have to start addressing as a public health community.

This pandemic has not been the great equalizer
There are many, many things that I have gotten wrong in this pandemic. If I just gave a talk on things I’ve gotten wrong in this pandemic it would take up well more than an hour. I won’t bore you with that.

But one of them is that I once made a statement, back in late February/early March. I’ll admit it. I was horribly wrong. Maybe all of you had more clairvoyance on this than I did: I made the statement that the pandemic was going to be the great equalizer, that it was going to affect everybody, and we weren’t going to be able to hide behind who we were, and that it would affect some people over others.

This pandemic has not been the great equalizer; it has been the great “exposer” of all the long-standing structural and deep issues we’ve had with inequities in our society. It has taken every one of those inequities and exploited them to make things much, much worse.

We have seen much higher rates of infections among African Americans, among Latinos, among Native Americans. We’ve seen not just higher infections, but even among people who have infections, much higher rates of death in each of these communities.

In retrospect, I should have seen that coming. And, in retrospect, I feel naïve thinking that this was going to be the great equalizer. I really did think that as a pandemic, it was going to play out a bit differently. I got that part wrong.

But, more important than my mea culpa on this is the fact that none of us noticed it for months. That it really took well into mid- to late-April into May before we began to recognize it. And, to me, that is a real travesty. And, the reason it took so long is that we didn’t have the data. We weren’t collecting data by race and ethnicity. We weren’t looking at these questions.

When people were setting up testing sites, they were being set in neighborhoods and communities that were relatively well-to-do. When we were saying to people: only essential places can be open, back in April, essential places being grocery stores, it meant that we needed essential workers.

Essential workers were much more likely to be poor, they were much more likely to be minority, and those individuals were getting infected at much higher rates. But did we set up our testing sites in communities of color where that was happening? The policy makers set up testing sites in neighborhoods where people were generally better off.

And so, people were not only getting infected at higher rates, but having a much harder time getting tested, and a much harder time getting identified.

If you are not getting tested, and you don’t know that you are positive, you’re spreading it to your family. People of color are more likely to live in multi-generational households, and so you saw the spread of the virus in multi-generational households, and you saw a lot of older people getting very sick.

There are a lot of lessons to be learned around how these long-standing issues of structural racism played out in this pandemic. Certainly one of them is that our horrible data infrastructure left us relatively “blind” to this for a long time.

Back to the future
What I’m trying to do is go back and discuss what are some of the major lessons learned. I would like to [take] the next five minutes to look to the future and to say: How can we do things differently?

We have gotten some things right. I think that our biomedical response has been really quite impressive. Doctors and nurses have been extraordinary. We’ve made huge gains in reducing mortality. We’ve gotten vaccines together in unprecedented timelines. We’ve got some therapeutics. The biomedical part of the response to this pandemic has been awesome.

But we are here [today] as public health professionals, and I want to talk about the public health part. It’s not been for a lack of effort on the part of public health people, but for a whole set of reasons – prior under-investment, a lack of enough data, real struggles with miscommunication – that we have found ourselves not being as effective.

I will just say, because it has to be said, that our political leadership in Washington has ignored and undermined public health advice pretty consistently.

Entering an age of pandemics
So, let’s think a little bit about the future before I wrap up. We are entering an age of pandemics. That’s where I began. Many of us, for years, have been saying that a global pandemic is coming. Well, a global pandemic is here. And, let me assure you that all the things that created the risk for a global pandemic five years ago, none of them have gone away. And, having one pandemic doesn’t make you immune to the next.

If we were having this conversation two years ago, and you had invited me and asked me what our biggest short-term threat was, I would have said: Our biggest short-term threat is a global pandemic. And, and if you had said to me: Tell me about what that looks like? I would have said, what I am really worried about is a respiratory virus coming from China, becoming global within weeks to months, and causing havoc throughout the entire planet. And, last but not least, it is probably an influenza virus.

It didn’t turn out to be an influenza virus; it turned out to be a coronavirus. And you could ask: Why did you say China? [Because] all of us where worried about China. But, in the future, we [should be] not just worried about China; we [need to be] worried about India, about the African continent. Also, Latin America, and increasingly, America as the source.

What we have to do is get away from the kind of jingoistic, anti-Chinese stance that has gotten infiltrated into our body politic. What we really have to do is to talk about what is it that puts certain places and countries at risk.

Why are we entering into an age of pandemics? The number of disease outbreaks is increasing. Why are the numbers of new novel disease outbreaks increasing? Because novel diseases in humans are mostly zoological in origin. They come from animals. And, the human-animal interaction and relationship has really been changing over the last 20-30 years.

Basically, deforestation, encroachment into animal habitats, and climate change are major, major drivers of why we are starting to see many more disease outbreaks. The reason [we need to worry about] China is not about any Chinese practice; it’s because China has gone through this massive economic growth, and that massive economic growth has meant lots of deforestation, it’s meant lots of encroachment into animal habitats.

The second related issue around economic growth and economic change is that one of the things we see in economic growth – we’ve seen it in China, we’re seeing it in India, we’re seeing it in Africa and elsewhere – is that when countries become wealthier, they eat more meat. And that means more animal production. More animal production is also a setup for more diseases. I really do think that climate change substantially increases the risk.

Last but not least is globalization. In 2003, there was a SARS outbreak in China. And, it was a different virus, not as infectious, but one of the reasons why it didn’t become a global pandemic is because China was a very different country [then]. The amount of internal travel within China was tiny compared to what it is now. And the amount of global travel out of China was tiny compared to what it is now.

And so, that’s why this virus was already out [of China] by December. That’s why when you hear our current President say things like: my China travel ban [made a big difference, he’s wrong]; the China travel ban, maybe marginally, made a difference by slowing the virus into our country by a few days.

The virus was already here. And, the virus [in the U.S.] mostly came from Europe. These travel bans just don’t do that much on the margins.

Well, globalized China is not about to become de-globalized. And we’re about to get a globalized India. And, we are going to get globalized countries around the world. Globalization, climate change, deforestation – all of these things, [tied to] economic growth, these are all things that are going to continue. We have to think about living in a world where pandemics are going to become much more commonplace.

Be prepared
What do we need to do to prepare? Well, we need to prepare by making much larger investments in our public health infrastructure – whether that’s in data, in people, in surveillance, in laboratories, all of that has to be done very, very differently.

Secondly, I really think we need to make big investments in information, in the information issues around [scientific] literacy, in how we communicate with people.

As public health officials, as academics, as professionals, we are just not trained in this stuff. And we have to start training people in how to communicate more effectively. I think that is an area where we need to make large investments.

I think we need to make large investments in the biomedical infrastructure around what are called counter-measures and therapies.

We got incredibly lucky with this pandemic; I know it doesn’t feel like we got lucky.

But we got lucky in the vaccine world. The reason why we are going have a vaccine so fast is the fact that we had done a lot of the basic science work on the vaccine with the original SARS virus, the SARS “classic” as we call it, the SARS COV-1.

We knew about the spike protein. We knew that the spike protein was really critical. We knew that if you could target that, you could make a vaccine.

So, we could take all of that knowledge and immediately apply it and make minor modifications and get going. We can’t assume that the next virus that is going to cause a global pandemic is one that we are going to know that much about and know how to counter it.

Let me finish up by saying: I think we have to think differently about pandemics.

I think we have to, through information, have to do a lot more work on building trust with people, communicating with people, building the kind of relationships with communities so that when pandemics hit, when disease outbreaks hit, we have those established relationships and we don’t have to try to establish them in the middle of a crisis.

We also need a totally different approach to data infrastructure. Over and over again in this pandemic, we’ve heard: “Well, we just didn’t have the public health workforce….”

You’ve got to have a public health workforce. And, in some ways, it can even look like the analogy that some people have used: we’ve got to have a standing workforce, and then you have to have [something] like a National Guard workforce. People who might be working in other sectors but have been trained in basics of public health that you can call on, and all of a sudden, get a much, much larger workforce, to do contact tracing, to do all this other stuff.

We can debate these approaches, but we can’t do it the way we’ve done it [in the past].

Last but not least, I really believe we really have to start addressing systemic issues in our society that cause large inequities. Because when disease outbreaks hit, just like any stress to the system, what we know is that those inequities really come sharply into [focus] and end up really harming certain populations disproportionately. We have to address the underlying issues.

[Editor’s Note: At this point, Fox Wetle, who was serving as facilitator, began to frame questions that had been sent by text by the audience for Jha to answer.]

WETLE: There are a set of questions that had to do with vaccines. One is vaccine hesitancy or skepticism, particularly with the speed of development. And, how does the public health profession respond. We’ve had vaccine hesitancy even before COVID, [driven] by a lot of misinformation. And also, about vaccine testing. Has it included enough of the minority populations, of the vulnerable populations? And I’ll add this: the elderly, too, who have been particularly impacted by the disease but were excluded for some of the testing.
JHA: Let me start by talking about what has happened with the vaccine development. The vaccine development has been done with an incredibly high degree of scientific integrity. People have not cut corners. This has gone very, very well.

I am not beyond being critical of things that I think have gone badly. A lot has gone badly with this administration. A lot has gone badly with our public health response. Vaccine development is not one of those.

I did not love the name, “Operation Warp Speed.” It creates a sense of speed that is not helpful in the hesitancy issue. But, if we can all look beyond that name, the science has been done well. One of the ways that they have sped up all of the timelines is that what used to have been done in sequence, we’ve now done them in parallel. So we did animal testing while we were doing the human testing.

We generally don’t do that. We would do the animal testing first, then we would go to humans. So, we have the data from both animal and human testing. They weren’t done sequentially; they were done in parallel. It does create risks, but we were willing to tolerate those.

We’re doing large randomized trials as Phase III. I look at the trials, with 40,000 and 60,000 people. So, there isn’t anything in the scientific process that worries me.

We’ve seen lots of pauses of these vaccines. The AstraZeneca trial, the Johnson & Johnson trial. All those pauses have given me assurances that the mechanisms we have for assuring safety when you have untoward events are all working. If we had not seen any pauses during the whole vaccine development, I would have been very worried.

All of that, to me, has gone well. We haven’t seen the data from Pfizer, even though I am very enthusiastic about where Pfizer data will land us. We’ve got to look at the data. But I think that what we will end up with is a vaccine that is pretty safe and pretty effective.

Show me the data
But there is a different set of question that it raises, which is: Who has been in the trials? What about young people? What about children? What about people of color? What about old people? People with chronic diseases?

This is something where the companies have been getting a lot of pressure, and I think rightly so, to make sure that they have a diverse population, so that they are not just taking 18-25 year-old healthy white men and women and testing it out.

I would say, overall, that part has gone OK. Moderna slowed down its trial because they were having a hard time recruiting people of color. They said, we’re going to take extra time to recruit them, and that was exactly the right thing to do.

Pfizer said that they initially cut it off at 65, and now they are saying they are going to expand the testing to people who are older. And, they are also going to go younger. Everybody’s cut it off at 18, but now people are going to start trying to test it in 15-17 year olds.

Testing it in kids is complicated. There’s a whole bunch of ethical, complex issues.

I think we’re going to have to watch what the data says. Everybody, all the vaccine manufacturers, are saying all the right things: we’re going to have a diverse group, we’re going to have elderly people. I say: show me the data.

In the next couple of months, we’ll see the data. And, if the data and the results are based only on relatively young, healthy people, then I think all of us are going to be skeptical that the vaccine can be widely deployed.

But I am cautiously optimistic that the data will show us that it has been tested in a relatively broad swath of the population. That opinion is based upon what I’m hearing and on faith, but not yet on evidence. But, let’s look at the data and then we can decide.

Meeting people where they are
Let me say one last thing about vaccine hesitancy. About a month ago, I started doing these “Dean’s Conversations,” and the first one was with Dr. Tony Fauci. The second one was with Heidi Larson. And Professor Larson is arguably the world’s leading expert on vaccine hesitancy. She runs The Vaccine Confidence Project. She has been working on these issues for well over a decade. There is no one in the world who I think is more impressive.

One of the things that I have learned from her over the years, and that I need to keep relearning over and over again, is you can’t take people with hesitancy and try to browbeat them and tell them they are dumb, and tell them they are anti-science. It’s not only wrong, it’s ineffective, it doesn’t land you where you want to be.

We should be different. The entire ethos of public health is we need to meet people where they are, and we need to help people move to a better place. It is the whole ethos of harm reduction.