Ashish Jha on Covid-19, pandemic fatigue, and when we’re getting back to normal

A very 2020 thing is that we now have a group of people who’ve become pandemic celebrities. They’d probably prefer not to have that moniker. But the fact is, public health experts are now well-known faces on TV news and well-known voices on your favorite podcasts.

Among them is Ashish Jha, who’s now dean of Brown University’s School of Public Health. He has more Twitter followers than STAT’s Adam Feuerstein and Damian Garde combined. And he’s particularly helpful at cutting through the noise and explaining what’s happening with Covid-19.

Jha recently called into STAT’s podcast, “The Readout LOUD,” to discuss the latest with Covid-19. This transcript has been lightly edited for clarity.

So we’ve been hearing for months that things could get really bad in the fall and now it’s the fall and things are really bad. We’re recording more than 70,000 new cases a day in the U.S. Hospitals have discussed rationing care because their ICUs are getting so full. And the number of deaths recorded each day is now rising again, though not as high as it was in the spring. What do you see is happening now that’s driving this new surge?

I do think we’re in a pretty tough spot as we kind of come to the end of October. I think all of us were expecting a surge in the fall — whether you want to call it a second or third wave — but I don’t think any of us expected that we’d be here already, that we’d be this bad.

I think a few things are driving this. One is it is starting to get a little bit colder; the virus is a little bit more efficient as a spreader in cold air. But more importantly, people are spending more time indoors. There’s a certain amount of pandemic fatigue that has set in because we’ve been at this for a long time. And I think people are getting tired of not seeing family and friends and so we’re letting our guard down. And, you know, this far into the pandemic, there’s still a lot of confusion and misinformation about what the right things to do are, whether to masks work or not. They do. And so that combination of things in a context of a policy environment that hasn’t built up the testing infrastructure we need, that hasn’t really done the things that we needed as a country, is why we find ourselves where we are.

So you did some research a few months back looking at how much testing we needed to be doing in the United States to actually control the pandemic. You found in June that for mitigation of the virus we need to do 1.2 million tests per day as a country and to actually suppress it we need 4.3 million. The Covid Tracking Project says we’re now at about 1.1 million tests per day in the U.S. on average. So how do you look now at the testing our country is doing in terms of what’s needed?

Yeah, so unfortunately, we’re still really far behind. When we did that [analysis] in June, it was under a very different environment. The number of cases in the country was much smaller and we didn’t have schools open. We didn’t have colleges open. And so at that moment, we were thinking, what do we need to suppress the virus at that time? As outbreaks get bigger and as needs for testing grow, we need a lot more. And so we’re now at a point where if we had ubiquitous testing — kind of imagine a life where you could do whatever testing you wanted — you’d want to make sure that everybody in nursing homes was getting tested. You want to make sure kids in schools are getting tested and teachers and colleges and critical workplaces. That would take many, many millions of tests a day. Of course, everybody who’s sick would also need to be able to get a test. We just haven’t built that kind of infrastructure.

So the messaging from the administration is often that we basically just need to get through this period of the pandemic until we have a vaccine and better drugs. So is that the right message? Is the vaccine going to be like a light switch and suddenly we’re done? Or is this a longer slog out than we’re really prepared for right now?

Part of leadership is communicating timelines effectively so people can plan and prepare, instead of saying this is going to go away, this summer it’s going to go away, it’ll go away in April, we’re rounding the turn. What that does is it says to people, you don’t have to make medium- and long-term investments because you’ve just got to get through the next few weeks. And then the next few weeks come and things are worse and people keep getting caught off guard.

We all wish that we have a vaccine that’s 98% effective, everybody takes it in America, and the pandemic essentially comes to a halt. That is not going to happen, as much as I wish it would. If we’re lucky, the vaccine will be 70%, 80% effective. If we’re super lucky, 60% of Americans will take it. And it will make a real difference — don’t get me wrong, it’ll make a real difference. It will not bring a pandemic to an end. We’re still going have to do certain things. We’re going to have this disease with us for a very long time. We should just level with the American people and tell them that.

So we hear the term pandemic fatigue a lot, and certainly we all feel it. And looking at the numbers, it’s easy to feel hopeless. But in your opinion, is it possible for the country to turn these numbers around? And if so, what would that entail?

Absolutely possible to turn things around. And I expect and hope that we’re going to see state leadership that’s going to help it turn around. So what would it look like? First of all, I think we’ve got to push more on mask-wearing. Even in states where there are mandates, it’s kind of unevenly enforced. I’m not a big enforcement guy, but I’m a big guy in like public communication and trying to get people to really cut through the disinformation and wear masks. I think that’ll help a lot. In most parts of the country, that alone won’t do it just because the outbreaks are so bad.

I think states could still be doing more on making testing widely available. States are struggling. Congress has got to get money to states to do this. But I think testing capacity — and I should say testing technology — has improved so much that we can make widespread testing much more widely available. And then I think we have to make some basic policy decisions. You know, in Massachusetts, where I live, casinos are open. Like, casinos maybe just shouldn’t be open during this pandemic. And I know their casino workers, and we should find a way to support them. But we should not have casinos open in the middle of a pandemic. We just can’t afford it. Not this one. So we’ve got to make some smarter policy decisions as well.

We mentioned pandemic fatigue, but there’s also a term that Dr. Mike Osterholm at the University of Minnesota calls pandemic anger. Up to a third of the country, in his estimation, believes the pandemic is a hoax or isn’t as serious as people like you are telling us it is. And at a recent rally, the president played into this, suggesting that doctors and hospitals are overcounting Covid-19 deaths because they get more money if they code for Covid versus people’s comorbidities, like diabetes or asthma. Can you walk us through this? Is there any chance hospitals are inflating the true numbers of deaths caused by Covid?

Yeah, so this frustrating because it has been around for a long time — this argument that somehow we’re either making up numbers or people are dying with Covid, but not of Covid and that there is this massive financial incentive. So let’s talk about what the financial incentive is and then let’s talk about what is actually happening. There is a 20% bump in payment for Medicare for hospitals if they have somebody with Covid pneumonia or Covid respiratory failure. And why did Congress do this? And why did the president sign that bill into law? Because we knew that taking care of Covid patients was going to be potentially more costly, more difficult, and that it was going require a lot more personal protective equipment. We knew hospitals will have to go out and buy those things because they weren’t gonna get it from the federal government. And so we, as a policy, decided to pay hospitals a little bit extra.

Now, hospitals are famous at maximizing revenue and finding everything they can possibly code legitimately. What hospitals largely don’t do is wide-scale fraud. They don’t take somebody who comes in with a pneumonia and say that person actually had a heart attack. They don’t do that because, well, first of all, I do think most hospital administrators have a certain sense of moral ethics. Doctors won’t do it because they would lose their license. It’s unethical. It’s immoral. And also, by the way, it’s super easy to get caught! Like literally hospitals get audited all the time. And if you get caught doing that kind of stuff, you go to jail. And most people would rather not go to jail for a couple of grand. So that’s not what’s happening.

What is happening, of course, is that if somebody does have Covid that people are incentivized to test and find those people and identify them. And that’s good. We want that. But then there are these like Facebook stories of the person who had a car accident and was Covid positive and got classified as death from a Covid pneumonia. Like, first of all, most random people don’t have Covid at any given moment. If you have a car accident and are Covid positive, you don’t get a bonus payment. And the idea that you would take somebody in a car accident and call them Covid pneumonia is absurd clinically. And so I’m not saying it’s never happened. I am absolutely certain it is not commonplace. It is not what explains why we are where we are. And we keep looking for these explanations when the explanation for 225,000 deaths and 8 million cases is pretty straightforward. We haven’t controlled the pandemic. We’ve got a lot of sick people. They’re dying. Instead of dealing with that, we keep coming up with, like, random theories of what’s going on.

Many countries in Europe this week are tightening restrictions amid surging cases. Both Germany and France, for instance, have closed businesses like bars and restaurants but are keeping schools open. That’s in contrast to some states in the U.S., which have done the opposite. So how do you think about those decisions from a public health standpoint?

This is another, I think, source of frustration for many of us in public health. You know, back in the summer when we were talking about schools, there was a lot of uncertainty about what to do with schools. And certainly when you looked across at Europe and places, you know, in Middle East and Israel and South Korea that had schools open, they largely were able to do it with much lower levels of virus in the community. And so I think many of us said suppress the virus, then open the schools, because opening schools is critically important from a public health and societal well-being point of view.

What has been interesting in the U.S. is lots of places have opened schools in places, I would not have recommended that they do so. Shockingly, despite all my Twitter followers, not everybody listens to me. And it turns out a lot of places opened up and they’re doing OK. Like, we’re not finding that schools are driving a lot of outbreaks. And what it says to me is I was probably being too cautious. And so here we are. And again, picking on Massachusetts: Boston public schools are close, but restaurants and casinos are open. And I think that’s completely the wrong set of priorities. I think Europe has mishandled this virus over the last couple of months. But on this one, they’re completely getting it right. If you’re going to start with closing things, close bars and restaurants, support those workers, but keep schools open. We’re not seeing much data that schools are a source of major spread in the community. They’re not driving the infections.

So I guess our last question for you is, is one that we all want to know, but we’re all sort of afraid to hear the answer to. When do you think life truly gets back to normal?

Ah, so truly is the key question. And normal, I guess, is the other part of it. I believe next summer is going to be much, much better than this summer. I suspect that a vast majority of Americans who want to get vaccinated will be vaccinated by, I don’t know, April, May, June. At least that’s my hope. I think there’s a good chance that that’s going to happen.

But then therefore, next summer, we should be able to do some amount of indoor dining much more comfortably. I haven’t been to a restaurant indoors since, you know, since late February. But I think that’ll be different next summer. The question is concert halls, movie theaters. I can imagine next fall going to a movie. But I’m gonna be wearing a mask — and it’ll be driven a little bit by how much virus there is in the community. But I’m hoping that there won’t be much. You know, kind of getting to a point where you can be indoors with large number of people and no mask-wearing, that maybe a couple of years away … because it probably will take a second or third generation of vaccines where you have 95 percent efficacy. But a lot of it comes back by next summer.