- When schools finished the academic year earlier the summer, they look forward to the fall with the first cautious optimism anyone had felt in a long time.

But today's guest has offered a level headed wisdom that the pandemic simply is not over.

He's Dr. Ashish Jha this week on Story in the Public Square.

(upbeat music) hello and welcome to Story in the Public Square, where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller with "The Providence Journal."

- Each week we talk about big issues with great guests, authors, journalists, scholars, and more to make sense of the stories that shape public life in the United States today.

To help us this week, we're joined by Dr. Ashish Jha, a calm voice of public health, knowledge and reason throughout this pandemic.

He's the Dean of the Brown University School of Public Health.

Ashish, thank you so much for being with us.

- Thank you so much for having me here.

- You know, we taped an episode with you in September of 2020, and I was looking through my notes about that last night.

And we had, at that point, lost just over 200,000 Americans to the pandemic, which seemed like an astronomical number at the time.

12 months later, I believe the number is approaching 640,000 Americans have perished.

Where are we in the course of this pandemic?

- So right now we're actually in a bit of a difficult spot in this pandemic.

And in some ways not where I thought we would be.

If we were talking a couple of months ago, let's say we were talking in early or mid-June.

I would have said we were in for a really good summer and that infection numbers were falling.

I expected them to continue to fall all through the summer and I expected the deaths to sort of peter out and just get to maybe a few a day, 100 a day at the most.

That's not what has happened.

What has happened of course is two major things.

One is we have the Delta variant, way more contagious than anything we've seen.

And then the part that really surprised me is that we hit a wall on vaccinations that after a year of horrendousness, we had these fabulous vaccines.

I thought everybody would rush out and get it.

A lot of people did, but about a third of Americans didn't.

And that combination means we're in a horrible surge, more than 100,000 infections a day.

Right now, more than 500 deaths a day.

But that number is going to go up a lot.

And I just think we are in for a pretty tough couple of months.

I don't know we can talk more about the future, but we're in a pretty tough spot in the United States.

And this Delta variant is really wreaking havoc across the world.

So it's not just, we're in a tough spot here.

Much of the world is struggling with this.

- You know, so I work at a university.

You work at a university.

We ended the last school year sort of hopeful in May, in June, that we would be getting back to normal.

And then when the president told us, we could all take our masks off, it was sort of this moment full of jubilation.

Did that guidance to take our masks off come too soon?

- No, a lot of people in public health think it did.

I'm in maybe the minority that thinks it didn't.

I thought it was a reasonable decision by the CDC to ask people or not to ask people, but just tell people that if you're fully vaccinated, you don't have to be masking.

That was what the best signs at that time was, that vaccinated people do not need to be masked up.

And I always say to public health folks who say, oh, they shouldn't have said anything is what would you have preferred?

Should they have not been honest?

Should they not have been open?

Should they have not shared that science?

I think CDC had to do what they did.

I get the frustration people feel about that change in policy, but I think it made sense at the time, but it's also a reminder that in a pandemic, when the virus changes, we have to change along with it.

We have to change our policy.

If we don't make the changes, we're going to get caught flat-footed.

So the virus has really changed over the last couple of months and the CDC's new recommendations have changed along with it.

- So with these new and alarming numbers, it seems that there is now beginning to be an uptick in people willing to be vaccinated.

And these were people who had the option before and decided not to for various reasons.

Is that in fact what has happened and we're seeing more and more people, and what is motivating people now to get vaccinated, months and months after Pfizer, Moderna, and J&J were available?

- So we are seeing an uptick and it's really good to see that uptick, Wayne.

There are two sets of issues in my mind.

One is, you know, is it enough?

And then the second of course is what's motivating it?

So let's talk about what's motivating it.

We don't know for sure, but it certainly looks like the places that are seeing biggest surge in vaccinations are the places that are seeing the biggest surges in hospitalizations and deaths.

And so what I suspect is happening is people are watching their family and friends get really, really sick.

Some of them get hospitalized, some of them die and realizing that all this nonsense they'd been hearing for a year about how this is nothing worse than the flu and it's a hoax, well, it's not a hoax when it hits your family.

And I think that is causing a lot of people to say they really want to do something to prevent that horrible outcome.

That's my guess of what's causing the surge.

The question is, in vaccinations, the question is, is it enough?

You know, we were about a month ago, we were vaccinating maybe 250-300,000 Americans a day.

Right now we're up to 6-700,000 new vaccinations a day.

It's a big increase, it's great.

At this point, it'll take us a year to get to where we need to get to in terms of getting all the folks vaccinated that need vaccination.

So it's too slow despite this uptick.

And so we need new approaches and new policies to really kick up vaccinations a lot more than what is happening so far.

- So what are some of those possibilities that you would recommend to bring those numbers up?

And then of course, you're right.

We need to get them way up to much higher than that.

- Yeah, and the reason we, by the way, we need to get them up so much higher than that is such a contagious variant that we need to have probably 90% of the population have immunity.

That means probably back to nation rates in the 80s for the whole population.

And right now we are just over 50% of Americans fully vaccinated.

So we have a long way to go.

We have a lot more people who need the shot.

So how are we going to get there?

There's gonna be any government mandate, the state isn't going to tell us, you have to get vaccinated.

The federal government isn't going to tell us, but you know who will are private businesses that say things like, if you want to work here you gotta be vaccinated.

And the reason I am getting more and more confident that will happen is when I talk to businesses across the country, they're coming to realize they'll never get their employees back in the office, unless everyone's vaccinated.

They'll never be able to run their business the way they want to.

Zoom land is okay for a short period of time, but not very few companies have decided, okay, we'll never bring our employees back, but the ones that decide they want their employees back, there's only one way to do it.

You've got to get everybody vaccinated.

That kind of stuff is going to move through.

So businesses, universities, I'm hoping schools will do this for their students, but also for the teachers and staff.

And all of a sudden you start realizing, oh yeah, that's a lot more people who will start getting the shot and it will make a big difference.

- Some of the other countries around the world, I'm thinking of France, Italy, Israel, I believe, have been experimenting with essentially vaccine passports.

And in France recently, I know they've deployed QR codes that you display on your phone if you want to go into a restaurant or a nightclub, and that proves that you're vaccinated, they can scan it, and you can be admitted at the door.

Will we ever see something comparable to that in the United States?

- I can imagine seeing it in places.

So New York City's trying a version of that.

San Francisco has a different version interestingly, it's not being done by the city, but it's being done by a coalition of bars and restaurants, because what San Francisco is seeing is that as Delta surge started going up, people stopped going to bars and restaurants.

And as you know, bars and restaurants are like usually really tough businesses anyway, they're right on the margin.

If 20% of customers that would come stop coming, a lot of those places can't make money and they can't sustain themselves.

So they're trying to figure out what to do.

I think you're going to see efforts like that often led by coalition of private businesses, but in some places by cities and towns.

I don't think again, we're going to see this at a national level.

We might see some states experiment with it.

I think it's a really good idea.

It certainly would build confidence in business.

Right now, given the state of the surge, I have stopped having indoor dining.

I just don't eat inside anymore.

Plus the weather is nice.

I will eat outdoors.

If there was such a system, I would eat indoors again, because if I knew everybody inside was vaccinated, it would make a big difference for me.

- So a question that I hear a lot, and actually I was driving today and heard it on a talk radio show.

And the question is, if you are vaccinated, can you contract the virus and spread it to other people?

In other words, is there protection against spreading to other people imparted by the shots?

- Yeah, there has been so much confusion about this, Wayne.

So let's set the record straight.

Vaccinations reduce transmission, period.

They really, really do.

So let's go through the data because there's a lot of confusion here and people say, well, you know, why am I hearing different things?

So one point to make is nothing in life is 100%.

These vaccines are not 100%.

Just because they're terrific, it doesn't mean they're 100%.

Can you still transmit?

You can.

It's way less likely than transmitting if you were not vaccinated.

So it doesn't prevent all transmission, but it does prevent a lot of transmission.

And there are two ways it does that.

First, it prevents you from just getting infected in the first place.

So the vaccines best evidence right now says they probably prevent about 80% of symptomatic infections.

If you're not infected, you can't pass it on.

So that's the best way to reduce transmission is to prevent the infection itself.

Second is even when people are infected, now they can transmit it, but the best evidence so far says they're much less likely to transmit it.

So my feeling is like, don't get confused.

If the goal is to protect other people around you, being vaccinated makes a big difference because you're much less likely to spread it to others around you.

- You know, there's another point about being vaccinated that you've made.

You've made it on a podcast and many other places as well.

And that is, you know, nothing is 100%.

You can get vaccinated and you can still contract the virus.

But if you do, chances are great that you will experience a relatively mild case of COVID.

Talk to that because, again, I think there's confusion about that as well out there.

- Yeah and I'll give you a little immunology lesson here of why that can happen.

So basically think of your immune system as having two arms, kind of your active forces and your reserves and your active forces are your antibodies.

And then your reserves are your T-cells and B-cells.

And you don't have to remember all of this and there's no quiz at the end of all this.

(Jim laughing) - [Wayne] Thank goodness.

- So look, with a super contagious variant like Delta, it can sometimes overwhelm your antibody levels and cause what's called a breakthrough infection.

So you get a massive viral load.

You're standing next to somebody who is, let's say, unvaccinated and infected.

They cough in your face.

You're vaccinated, you inhale a lot of virus.

It could overwhelm that initial response from your antibiotics and boom, you now have a breakthrough infection, ah, but you also have your B-cells and T-cells so that the vaccine has really gotten prepped and they show up and they say, not here people.

And they clear out the virus pretty quickly.

You may have a miserable day or two, but you're not going to go on to getting super sick, having COVID pneumonia and die.

The COVID pneumonia and death that we all fear becomes exceedingly rare, not zero 'cause nothing is zero, but exceedingly rare.

So that's what's awesome about these vaccines is yes, they prevent infections, but if you're unlucky enough to have an infection, they're going to prevent almost all severe illnesses and deaths.

- Thank you.

That's a good description.

And I think I could pass that test.

(men laughing) It's straightforward and understandable.

And that's one of the things we love about you wherever we see you, you speak in terms that people like us can understand.

- Ashish, we're three guys in the great Northeast and there's been a lot of local attention and I think increasingly some national attention to this cluster of cases in Provincetown, Massachusetts over the July 4th weekend, where upwards of 75% of the several hundred who became infected were vaccinated.

And I wonder if you could speak to what that tells us about whether it's the Delta variant or the vaccine and what should Americans take from those cases?

- Yeah, I will tell you my takeaway from the Provincetown outbreak and my takeaway was, my gosh, these vaccines did so incredibly well, better than I had expected.

So now that may seem counterintuitive because you're like, whoa, whoa, whoa.

All these vaccinated people, six, 700 of them got infected.

Not all six, 700 of them weren't vaccinated, but a lot of people got vaccinated.

I'm sorry, got infected.

75% of the infected people were vaccinated.

How can you say vaccines worked?

Let me tell you why I say that.

First of all, the P-town outbreak, the whole events of July 4th, was the ultimate stress test on these vaccines, right?

Because we're talking about a super contagious variant.

If you remember the July 4th weekend, it was pretty rainy.

I know, 'cause I was trying to have a backyard barbecue and all weekend, I was like, am I going to be able to do it?

Or is it going to rain out?

So it was raining most of the weekend.

And it was, you know, tens of thousands of people showed up to Provincetown for a celebration weekend.

And most of the celebration, partying, was happening indoors, bars were packed.

Restaurants were packed, nightclubs were packed.

It was kind of the virus' dream.

And what happened was yes, there were a bunch of breakthrough infections, but think of it this way.

Only a few hundred ended up ultimately getting infected, only seven got hospitalized, no one died.

And if people had not been vaccinated, this would have caused a massive regional outbreak.

In the unvaccinated version of this story, we would have seen tens of thousands, if not hundreds of thousands of infections that would have spread all throughout New England.

We would have seen a spike in hospitalizations from, you know, from Southern New England, all the way to Northern New England and beyond New York and New Jersey because of course people traveled from long distances and we would have seen a lot of people die.

None of that happened.

So we gave the vaccine the ultimate stress test and it worked, like nobody died.

Few people got hospitalized.

Some people had breakthrough infections.

The pandemic isn't over, we don't think these vaccines are 100%, but my God compared to the alternative, like I think, I think this went really well.

- So talk about durability or how long are these vaccines good for?

There's been all kinds of talk about so-called boosters or we're going to need six months later, eight months later.

And there're actually some countries, I think Israel is one of them, where they are giving a third shot of at least Pfizer.

Break that down for us.

Because again, here we're hearing a lot of different conflicting accounts.

- Yep, yep.

So if we go back to my story of the active forces and reserves, right, the active forces are your antibodies.

What we're seeing preliminary data from Israel is that your antibody levels are starting to wane after about six months.

Okay, not in everybody, but in older people and frail people, people who may not have had as good of an immune response initially.

So what that means is if your active forces are kind of declining, you're more susceptible to that sort of initial breakthrough infection, your B-cells and T-cells are still good.

They're still there.

And so what we're seeing in Israel is after six months, people are having more breakthrough infections, doesn't mean they're getting super sick and dying, but they're having more breakthrough infections.

And so Israel's decision is, hey, for people who are 60, who are more than six months out, let's give them that third shot, the booster.

And what that will do is it will give a huge bump to the antibodies and protect them from future breakthrough infections.

My feeling is that makes a lot of sense and it doesn't, it's not necessary for everybody.

People who are younger and healthier have relatively robust immune responses and they probably don't need a boost.

Or I haven't seen any data that they do.

But imagine the 80 year old frail elder living in a nursing home.

That person, if they have a breakthrough infection, it might actually kill them, right?

Because they're frail, they have kidney disease and heart disease and they may not survive it.

And so you actually want to probably be thinking about boosters for that population.

My best guess is what we're going to see over the next few months, and maybe even the next few weeks is FDA come out in support of that third shot for elderly people, for people who are immunocompromised, people with severe underlying health issues, and then say for everybody else, you're good.

Because even if you have a little waning of immunity, you're not going to have so much waning that you're going to see breakthroughs and you certainly aren't going to get particularly sick.

Next year, as we go further into this, you may see further waning in which case we may need a booster.

So my mental model has been, most people will probably need a booster at some point in 2022.

And maybe some people, the more high-risk people need it later part of 2021.

- So speaking of the FDA, by the time this airs, it seems likely that the FDA will give full approval to the Pfizer vaccine dropping the emergency use authorization, which some people have said is a reason not to get vaccinated.

It's not a good reason not to get vaccinated but that could happen.

So do you expect it will happen?

And what effect will that have do you think on people who have not been vaccinated and on the pandemic in general?

- Yeah.

I do expect it to happen some point sooner rather than later.

And so exactly when it's hard to predict, I've been puzzled at why the FDA has not moved faster.

They've got all the data, they've got the analysis, they should move faster.

I think they will.

Eventually, not eventually, they will get there.

It's just, it's gone slower than I had hoped.

The reason why I think it's going to be a big deal, Wayne, is, I mean, there's a small number of people who say I'm not getting it until the FDA does full approval.

Fine.

I think those people will be helped, but actually it's a psychological boost to companies that want to mandate vaccines.

I'm hearing from a lot of colleges and universities, a lot of companies, a lot of schools that they feel hesitant about mandating vaccines until there is full approval.

I think as soon as that full approval happens, you're going to see a rush of companies, rush of businesses saying to their employees, we want you to be fully vaccinated.

And that I think is going to drive up vaccinations in a very, very robust way.

So that's why I'm looking forward to it.

I think it will end up making a big difference primarily by increasing the number of people who are going to be willing to say, if you want to work here, if you want to study here, you need to be vaccinated.

- Ashish, it's late summer, which means that kids are beginning to return to grade school all over the United States.

There's a political fight about whether or not school districts should be able to mandate masks, particularly in the south, particularly in communities where political leaders have chosen to diminish the risk of the virus.

And to just tell people to sort of soldier on, where do you come down on the issue of masking in grade schools?

- It's a great question.

I look at this in a broader context, which is, I think, first of all, whether you're liberal or conservative, right or left, we all agree getting kids back to school full-time safely is gotta be one of our biggest social priorities, one of our biggest policy priorities.

Kids belong in school.

Kids need to be in school.

So I think we all agree there.

So then where do we start disagreeing?

We started disagreeing about how risky is it and what do you need to do to prevent that risk?

And I think the way to think about this is to take a much more comprehensive approach.

And so, you know, I recently just on one afternoon sitting down on Twitter, I just belted out what I think are the five major strategies that we have learned over the last year.

And it's just go through it because I think it provides a way to think about this.

First of all, I think it's very, very clear to me, but the number one strategy has got to be vaccinations that I believe teachers and all other staff should be fully vaccinated.

I believe in vaccine mandates for teachers and staff, by the way, I do it for doctors and nurses, I think there should be vaccine mandates for teachers.

And that's gonna be particularly important for preventing infection and spread for kids under 12 who can't get vaccinated yet.

The second beyond vaccines, and I would very strongly encourage them for kids over 12, beyond vaccines, ventilation.

I mean, this is an airborne disease, right?

So we know it spreads through the air.

We have had a year to improve ventilation.

If there is a school district out there that says we can't improve ventilation by September, the leadership of that school district needs to change because they've had a year to do this.

There've been billions of dollars given, there is no excuse for not having improved ventilation.

It literally begins by being able to open windows.

You can buy these portable HEPA filter things that cost like 200 bucks and work really, really well.

The bottom line is that's really critical.

Third is testing.

I think kids into schools should be getting tested, that by the way happened in the Providence schools, it's been happening across Rhode Island, testing once a week is a very, very good way of keeping kids and everybody else safe, particularly testing, we're talking of unvaccinated people.

Number four is mask wearing, which can make a difference, and especially if you have decent quality masks.

And then the last is avoiding kind of super crowded spaces, no packed assembly halls right now in the middle of the Delta surge and no indoor concerts while the Delta surge is going on.

So there it is.

Those are the five, right?

So where does masking fit it?

Well, it's one of them.

If you do all the other four, can you get away without masking?

Okay.

Sure.

But my big picture point is let's get kids back to school.

Let's not have these fights.

Let's not overemphasize the importance of masking.

I don't think it's the single most important thing we can be doing, but let's not undercut it either.

And it's totally reasonable in high transmission areas to have masking and overall you should have a comprehensive strategy for keeping kids safe, right?

So this is kind of like, you know, if you want to have a safe car, yeah, airbags are helpful, seatbelts are helpful.

Brakes are helpful and let's not fight about all of them.

I want a car that has it all, so I can use all of them.

- So we are seeing more reports of children and adolescents getting sick from COVID this summer.

Another one of the terrible trends.

Break that down for us, if you would, please, Ashish.

- Yeah.

Yeah.

There are a couple of things going on here, Wayne, that are, I think, worth understanding.

So first of all, we're hearing from some of our pediatric leaders, hospital leaders on the front lines in the south use words like, this is a totally different virus.

We're seeing things we've never seen before.

They're describing hospitals that are totally full with young kids with COVID, ICUs that are full, kids dying, things we didn't see a lot of last year, really horrible.

So the question is what's going on?

And there are two things that I think are at play here.

One of them I'm sure of, one of them I'm less sure of.

What I'm sure of is it's a super contagious virus and it is ripping through families that are unvaccinated.

And so what you're seeing is massive spikes in all people and kids of course are not immune.

And so when you see a big spike everywhere, kids are going to end up being part of that, are going to get caught up in that surge.

And we're seeing that.

The big question people have is, is the virus worse for kids than the previous versions?

That one is where I'm not so sure.

There is some evidence that this virus's version, the Delta variant is just a more virulent version, meaning it does make people more sick.

That evidence is not rock solid.

It leans that way.

And if it does that for adults, it might do that for kids too.

So my take is a lot of this is just because we're seeing such a massive surge.

It may be that it's also doing more harm directly to kids as well as adults, but that last part we just know less.

We'll know more in the upcoming weeks.

- Dr. Ashish, we regrettably are out of time, but thank you so much for being with us.

He's Dr. Ashish Jha of the Brown University School of Public Health.

That is all the time we have this week.

But if you want to know more about Story in the Public Square, you can find us on Facebook and Twitter or visit pellcenter.org, where you can always catch up on previous episodes.

For G. Wayne Miller, I'm Jim Ludes asking you to join us again next time for more Story in the Public Square.

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