Dr. Ashish Jha is a globally renowned public health leader currently serving as the Dean of the Brown University School of Public Health. A respected physician, Dr. Jha is acclaimed for his expertise in addressing major health issues. Appointed by President Biden as White House Covid-19 Response Coordinator in March 2022, Dr. Jha led initiatives that enhanced treatment and vaccine accessibility, improved testing, and strengthened national stockpiles. His pragmatic approach to public health has garnered bipartisan praise for translating complex scientific challenges into actionable improvements. With over 300 publications in esteemed medical journals and a leadership role in pandemic preparedness, Dr. Jha’s impact extends globally. Prior to his current role, he held prominent positions at Harvard University, including K.T. Li Professor of Global Health and Director of the Harvard Global Health Institute.
Avital Strauss: Looking back on the Covid-19 pandemic, in what ways was the US response effective, and in what ways was it ineffective? Knowing what we know now, what public health strategies should have been adopted? How will these lessons be used to confront future public health crises?
Ashish Jha: In general, I think pandemic responses have three elements: First, there are the medical countermeasures such as tests, treatments, and vaccines. Second, there are the non-pharmaceutical interventions such as masking, distancing, and stay-at-home orders. And third, there is communication. I would say the US response was, overall, pretty mixed. One prime example of its failure was in how disastrous testing was in this country. We had no real surveillance system and no real testing infrastructure. For months, people couldn’t get tests. Importantly, that meant that we didn’t know where the virus was spreading. That led to what I believe was the major fault of the initial response, which was that we had to have these nationwide lockdowns because we didn’t know where the virus was spreading instead of having targeted lockdowns. There was a lot of virus in Rhode Island, Massachusetts, and New York, but there was probably close to none in Mississippi or Montana. Yet, because we didn’t know that, we had to do this very blunt response.
The second clear failure around that time was communication. Many important concepts at that time were never articulated or effectively communicated to the public. For example, why were we locking down? How long were we locking down for? What was the purpose of it? Usually, in pandemic responses, you want to have scientists leading the communication. Instead, we had the President of the United States leading the communication. To say that he was ineffective would be an understatement. Of course, you generally don’t want the president leading public health responses because presidents are inherently political figures. People who love the president will be very likely to listen, and people who hate the president will not. That’s true if it’s Donald Trump or Joe Biden. You want scientists leading in pandemics because they tend to be less partisan.
Where we did extraordinarily well during the pandemic was in building vaccines and treatments. Our medical countermeasure program, Operation Warp Speed, was incredibly successful. I also think we did pretty well in the pandemic in terms of innovation around health care delivery, telemedicine, and test to treat programs. While we saw our public health system really struggle, the health care delivery system stepped up in terms of how our doctors and nurses took care of patients.
A lot of the work I did when I was at the White House and a lot of the work that needs to be done is fixing those things that really didn’t work during the pandemic. I think we’ve made a lot of progress on surveillance. We have this national wastewater surveillance system now that allows us to track how viruses are spreading across the country. It needs to be better than it is, but it’s a lot better than it was four years ago. Our testing infrastructure is better, but it’s not where it needs to be. But, one place we’re probably worse off for future crises is around communication and polarization. We are way more polarized as a country than we were four years ago, especially on these issues. If we do have a bad outbreak, I worry a lot about people not listening to public health officials and the Centers for Disease Control and Prevention (CDC) and refusing to vaccinate.
AS: The US Covid-19 prolonged lockdown was effective in saving lives but is also associated with meaningful collateral damage, namely negative economic outcomes and growing economic disparities, a significant learning loss among school-aged children, a mental health crisis, an increase in suicide rates, a surge in deaths due to alcohol abuse and drug overdose, and anticipated excessive deaths in the coming years due to reduced access to support and treatment during the lockdown. Did we save lives in the long term? How are decisions about public health made when prioritizing immediate public health goals means greater mortality in the long run? In general in public health, how is the tension between short-term versus long-term benefits resolved?
AJ: Let’s start with the most obvious definition of lockdowns, which is stay-at-home orders. Those measures should be used as a last resort. There are lots of ways of controlling the virus without having to implement a stay-at-home order—the United States just couldn’t get any of those alternatives together in time. So, we had no choice but to call for full stay-at-home orders. In places like New York City, you really didn’t have a choice. If you hadn’t called for a full lockdown, the healthcare system would have just collapsed. You already had hospital beds in parking lots. However, the need to have full lockdowns across the nation was avoidable. The goal of lockdowns is that they should be targeted to places that are truly overwhelmed, and they should be as short-lived as possible. There’s really no justification for the fact that schools were closed for a year in many places. In my mind, that is unreasonable and unnecessary. To the extent that we were having lockdowns during the height of Covid-19, we needed to use that time to build up our testing infrastructure, to build up our surveillance infrastructure so we could stop the lockdowns, and to utilize testing and get people back to normal life. Unfortunately, we didn’t do that.
I think it’s important for people to understand that lockdowns are a bit like chemotherapy for cancer. No one says it’s a great thing you’re undergoing chemo, right? It has massive toxicity, and you use as little chemo as you need to. You understand that there are very large costs to it. But, it’s a sacrifice you make for your overall health. It’s unfortunate that, with Covid-19, we didn’t effectively balance the short-term and long-term needs of our nation.
AS: In some cases, countries tracked the spread of Covid-19 and were able to respond quickly and efficiently by using electronic surveillance (location data, video camera footage, credit card information, drones). What do you think about that in terms of a general public health tool, which can be very effective but contradicts a dominant mentality in the United States of a right to privacy? How can governments balance public health needs with individual freedoms? In the United States, is the American tendency to think individualistically rather than in community-oriented ways a barrier to public health?
AJ: Compared to doing nothing, the actions we took in response to Covid-19 undoubtedly saved lives both in the short and long term. But there is a lot we could do differently to reduce risk in the short term while also limiting potential long-term implications on health and mortality. I think the model for how to do this well that we really could have followed was South Korea during Covid-19. South Korea just basically used testing and tracing as their strategy, and it was extraordinarily effective. They largely kept their economy open, and even the night clubs were open, and they did not see a huge amount of spread. So, it is doable to respond effectively to public health threats with that sort of strategy that focuses on testing and surveillance.
With individualism, if you have a bad outbreak happening, some people will gatekeep their information, but most people are pretty open, and you don’t need everybody for this sort of a response to succeed. The biggest issue is how much do people trust the government to not misuse that information. People have a lot of mistrust of government, especially at the federal level. However, people tend to actually have much higher trust of government at local and state levels, and those levels of government are the ones who are actually running the test and trace programs. So, I have my doubts that there is truly deep-seated skepticism of and negativity toward local government that would prevent us from effectively implementing these testing and surveillance programs. We saw lots of places within the United States do it well.
Regarding broader individual versus community interests, I spent a lot of time during the pandemic thinking through these issues and talking to red state governors. Honestly, I’m not so convinced that this is as huge of a problem as it is made out to be. While many Americans may value individualism, they also care about their families and neighborhoods. If we remind people that the reason they should be doing certain things like wearing masks and isolating when infected is not for society but for people they love, that is powerful. You might still get a small minority of people who still refuse to listen to public health recommendations, but most people will be pretty responsive. I think that is true in conservative places and liberal places. I think that, regardless of political ideology, encouraging compliance with public health recommendations is about framing and reminding people that what you’re doing is going to affect people around you that you care about. My sense is it moves people.
AS: There’s discussion about Disease X, referring to a placeholder concept of an uncharacterized pathogen that could emerge as a public health crisis. Without knowing what Disease X might be, how do we know how to prepare for it? Relatedly, how do countries navigate the competing needs of investing in public health initiatives with benefits that won’t be realized for a while, like preparing for Disease X, versus investing in current healthcare needs and improvements to healthcare systems?
AJ: By definition, we don’t know what virus or pathogen will show up in Disease X. The general strategy that we have pushed for at the White House is that, while we don’t know exactly what Disease X will be, we have a sense of what families of viruses are more and less likely to become Disease X. On the more likely end, there are probably about 12 families of viruses to consider. In preparation for Disease X, we should start working on developing general vaccines against those diagnostic tests, but developing vaccines is really hard, in large part because you have to know what part of the virus to target. That requires a lot of scientific work to sort out, which we should be doing now. By the way, if we had done this kind of preparation 10 years ago, that would have included coronaviruses because that was one of the buckets of viruses that we worried would cause a global pandemic. Clearly, this targeted vaccine development will be very helpful because, more likely than not, the next pandemic will arise from one of the families of viruses that we would assess in this process.
But, what if it doesn’t? What if it’s totally different? Well, that’s harder. There’s some very good work being done at a variety of labs to essentially figure out if computer modeling can be used to see a new virus and quickly figure out what kind of vaccine that virus requires. This is scientifically very, very hard. There’s no easy answer, but we should continue investing and trying to come up with strategies.
Necessary preparations for Disease X extend beyond just vaccines, though. You also want to be able to do testing so that if we see a brand new virus tomorrow and can sequence it, we should be able to develop a diagnostic test within two or three weeks. I think we’re at a point where we can do that. The question is: Can we do it reliably? Can we scale it up? That’s where we struggled before, and I think we still have some work to do.
Lastly, the best way to prepare for future pandemics is to fight current pandemics better today.
For example, if you want to develop a vaccine against Lassa fever, why don’t you use some of that technology to try to figure out a vaccine against tuberculosis? It’s really all about getting good at developing diagnostic tests that are cheap and easy to scale. There are things we can do where we can learn how to prepare for Disease X by focusing on the viruses and mycobacteria that, in this case, are in front of us. Of course, there have to be additional investments, but the practice of running responses against various illnesses is ingrained in our public health system. Every winter, we know we’re going to have flu, RSV, and Covid-19. We should scale up testing and other means of fighting these common diseases as an exercise for how to deal with future pandemics. So, I think that you can address current public health issues and prepare for future pandemics simultaneously without one effort really taking away from the other but instead propelling it forward.
AS: From a public health perspective, should we be worrying about climate change? For example, with climate change rapidly worsening, scientists are warning that ancient viruses frozen in the Arctic permafrost could be released, bringing about other pandemics. Researchers have already isolated some of these zombie, or Methuselah, viruses, proving that they do exist. What is the public health response to such threats?
AJ: Climate change is the biggest threat to public health that humanity faces. I’ve been saying that for about 10 years. Part of it is difficult to see because people don’t know what you mean when you are talking about climate change in the context of public health. I see climate as the ultimate threat multiplier. Take every other threat, and climate just makes it much, much worse. For instance, we’ve always had heat waves, we’re just going to get many more heat waves, and they’re going to be much worse. We’ve always had pandemics—we’re going to have more pandemics. These permafrost threats might bring about a pandemic. Climate change is going to also cause migration, which brings about health impacts for migrants and the populations where people migrate to. Climate change is going to cause more droughts, which will bring about malnutrition and the negative health effects that come alongside that. The naysayers say that we have always had these climate disasters. Yes, just with climate change, they are becoming more severe. And climate change is going to tax healthcare and public health systems around the world. That is just the reality. We need to study these issues to understand not if climate change is real but how it is impacting our lives. And then we have to start building systems to try to mitigate it. So, we should absolutely be studying the viruses that we’re identifying with the melting of the permafrost. And then we should be thinking about if they are likely to be pathogenic to humans and if we need to start working on vaccines and treatments against them. Work just has to happen if we’re going to stay ahead of climate change.
AS: How can effective public health campaigns change the course of public health crises? What is the best way to make sure people heed public health warnings and mandates? How do we build trust in each other, in public health systems, and in science so that politicians and the population will listen?
AJ: Let’s talk more broadly about how you build trust in public health and how you build trust in science. In order to have people have trust in you, you have to earn people’s trust, and the way you earn trust is first by listening to people. I think one of the things that the public health community did not do very well in the Covid-19 pandemic was listen to what was on people’s minds. We were very good at telling them what to do but not so good at listening to what was happening and what their priorities were. The public health community needs to be much more trustworthy in that way. Additionally, during Covid-19, a lot of public health officials sort of saw this moment as an opportunity to revamp the entire healthcare or public health system. I don’t think they had built up the coalition that was really needed to do that. We needed to do a better job focusing on what the country gave us permission to do and not use the pandemic to further other goals. That’s part of being trustworthy. Of course, if you’re asking people to change their behavior, you’ve got to bring them along. That means building a coalition, particularly around trusted voices. We could have done more on partnering with religious and community-based organizations and making sure that people who already were trusted in those communities were partners. It’s very hard in the middle of a crisis to show up and say, “You’ve got to trust me,” but it’s easier if you can walk into a house of worship and talk to the leadership. If they come with you, it’s a very different ballgame. I think that’s going to be an important part of science communication in the future.
AS: Why is public health a political issue?
AJ: It’s always been political. Honestly, I’m not bothered by the fact that public health is political. In my view, public health being political is just another way of saying public health raises issues for which there are competing views, and politics is a process by which we resolve those things. Where I think public health has become a huge problem is that it has become partisan and gotten tied to certain types of political identity. For instance, if you decide that public health is a liberal ideal and you are a conservative, you’re going to be much less open to listening to public health. That’s a problem. The way you modernize public health is by reaching out to people across communities, listening to what their issues are, and helping everyone see how public health can be useful for what matters most to them.
AS: Is there a relationship between effective public health interventions and certain types of healthcare systems (e.g. universal, private)?
AJ: There isn’t a simple answer. In terms of public health’s effectiveness across different health systems, it’s really interesting if you look around the world at the response to the Covid-19 pandemic, where you had government-run health systems that did very well and very badly. You had largely privately run systems that did well or did badly. There are even some people who claim that authoritarian places did better than democracies, which may be true, but there are other upsides to being in a democracy that I really like. I think there were democracies that did very well. It is possible to have a democracy, to have a system like that of the United States, which is a mixed system of public and private, and respond well to public health threats. For instance, we were running a campaign to try to get elderly people vaccinated, and it was extremely difficult. We were working with fragmented health systems. At the same time, I talked to my counterpart in the UK, and for him, it was straightforward. The National Health Service (NHS) sent out an email to all the general practitioners, and they all sent out notes to every single person over 60, saying, “Here’s your appointment, come in for your vaccine.” We have no ability to do that in the United States. This is not to say that one health system did better than others. There are just some specific advantages that come with certain health systems that are very helpful at moments like this.
*This interview has been edited for length and clarity.