Voices: Q&A with White House Covid-19 czar Dr. Ashish Jha.

Last week, I interviewed White House Covid-19 Response Coordinator Dr. Ashish Jha for Medpage Today and Inside Medicine. The video and transcript is now online and free on Medpage Today and the full audio and transcript can be found here (see below).

Let me set this up with a little description of my interactions with Dr. Jha and my sense of his trajectory as a public figure and his views.

Some background: Early in the pandemic, when Dr. Jha was still on faculty here at Harvard, we had a couple of phone calls. We’d never met or interacted previously, but I needed advice on some work I had been doing and he was quite helpful. Shortly after, we randomly ended up the air on CNN together in 2020. After that, we’d chat occasionally about policy and scientific issues. But until 2022, we had never met in person. Dr. Jha left Harvard to become the Dean of the School of Public Health at Brown University and then last year he was tapped to become the White House Covid-19 Response Coordinator, replacing Jeff Zients (who had replaced Dr. Deborah Birx).

Last year, I finally met Dr. Jha in person twice at the White House (once while I was attending the Indoor Air Quality Summit that Dr. Jha’s team hosted, and once to discuss some data and analysis with his team of experts). We have also occasionally discussed COVID issues offline and off the record over the last three years. We often agree but not always (and in general, at this phase of the pandemic, there’s very little point in us spending much time discussing anything we already agree on). Even in that context, I find that he spends more time listening and asking questions than most people in positions of power. That’s to his credit.

The present: Meanwhile, Dr. Jha has become something of a polarizing figure since taking over the White House Response Team, which may be surprising given his general reputation for being a calm and rational voice at earlier times in the pandemic. My sense is that Jha spends a lot of his time and energy in his job navigating the waters between the very Covid-19 concerned (who point to places where he and White House could be doing more) and the Covid-19 minimizers (especially those in Congress whose opposition to doing anything at this point spells no more funding). The former group may hold the moral high ground (especially in their focus on the immunocompromised), but the latter group is the one that must be more urgently and carefully managed, lest absolutely nothing get done going forward. Regardless of whether you think the White House is succeeding in its COVID efforts, I don’t think the job is an easy one. Having had the chance to have a few glances of how this all works on the inside, I would say that this work is more challenging than it may appear from the outside.

Overall approach: My goal in conducting this interview was to bring Dr. Jha questions that I believe reflect the concerns of my readers, many of whom remain on the more cautious/concerned side of the spectrum. Many of the questions asked were ones suggested by members of the Inside Medicine community. (Thank you for your ideas!) I did my best to really lean in on that. Jha’s answers to our questions were often measured and careful, which may not be what some people in this particular audience wanted or need to hear. But he did provide useful information and he was generous with his time.

So, I’m curious: what do you think of his answers? Please leave your comments below.

Faust: Hello, it's Jeremy Faust of MedPage Today and Inside Medicine. Today, we're going to be joined by Dr. Ashish Jha. 

Dr. Jha is the dean of the School of Public Health at Brown University, but he's on leave right now because he is currently serving as the White House COVID-19 Response Coordinator. 

Dr. Jha, thanks so much for joining us.

Jha: Hey, Jeremy. Thanks for having me here.

Faust: A seven day average of 368 covid deaths. Is the pandemic over? Is the COVID-19 pandemic still an emergency?

Jha: So we're in a much better place, right? 368 deaths or 400 deaths, wherever we are, is still way too many, and I can come back to that. But we're down about 90% from when the president took office, so clearly in a better place, and we've just got to keep focusing on making that number come down and down. 

[As to] whether the emergency is over, we can talk about the public health emergency, which is a very specific set of technical tools that we have said is going to end in a few months, but clearly COVID is still a major problem.

Faust: Let's talk about the end of the public health emergency. I think that there's a good sense that a lot of this stuff is being sort of redistributed -- it'll go on. Telehealth can go on and other things don't need the PHE to continue. 

But how do we deal with tens of millions of Americans who don't have health care, who won't have vaccines and boosters and therapeutics and even COVID care paid for? Will they be back to the, I hate to say it, law of the jungle where the American system doesn't have the safety net that our European counterparts do?

Jha: Two things, Jeremy. First of all, I think people really need to differentiate what 'public health emergency' means and doesn't. I think there's been a lot of confusion caused by a lot of people who don't understand what the ending of the PHE does. So let me be very, very clear: the public health emergency has nothing to do with access to free vaccines and treatments. Zero. They're completely unrelated. 

The public health emergency is a set of tools we often call 'flexibilities' that health systems and others have around how they deliver healthcare. 

So you're a hospital and you want to set up beds in your parking lot before 2020. You couldn't just go do that, and for good reason. But in May of 2020, if you wanted to set up beds in the parking lot, the federal government said, "Go for it." Because we knew why you were doing that. You were getting crushed; you needed that space. 

Our point is, after May 11th, that ability to go set up beds in a parking lot goes away. If you need to set up, you're going to have to go through a whole different set of rules. 

There are supervision rules that Medicare has of who can supervise whom, how. We suspended all those rules under a public health emergency because we needed to be able to let residents do things that, in general, only attendings would do. Because in the middle of a horrible crush of infections and deaths in April in New York City, we didn't want supervision rules getting in the way. We think in June of 2023, those supervision rules should probably go back. 

We made all these rules around telemedicine because we said remote care is going to be great. We did it for the public health emergency, and we realized that actually, that is great. We want it, so we're going to keep it when the public health emergency ends. 

None of this is about free access to vaccines and treatments. Free access to vaccines and treatments is driven by the fact that we bought a bunch, right? And we will run out of that stockpile. I remind people, even if we kept the public health emergency going for another year or two years or 20 years, sometime this summer to fall, we would run out of our vaccines and treatments and we'd have to go to the healthcare system. 

So, these are unrelated issues and it's frustrating to me that there are still people who conflate them. It's really important for your readers to understand that on May 12th, the day after the PHE ends, they can go to a CVS, get the free vaccine, and get free treatments. None of that changes. 

Now, my last point. We will run out of vaccines and treatments -- the free ones -- and we're going to have to move to the regular healthcare system. We all know the regular healthcare system has a lot of strengths and a lot of problems. One of the problems is that you have 8% of Americans, 30 million Americans, who are uninsured, who are not going to be able to easily access these things. 

So we are developing a plan for making sure the uninsured have access to free vaccines and free treatments after we move to the regular healthcare system. All the details of that plan are not worked out, but I can assure people that this is something we're working on. 

Then because of the Affordable Care Act, people will have free vaccines forever. And then there's the issue of making sure that copays for treatments are minimized, particularly for low-income individuals. So there's a lot of policy work being done, but this idea that somehow the public health emergency ending has any impact on access to free vaccines and treatments -- zero, they're just unrelated issues.

Faust: A lot of my readers and viewers are focused on what they should do even in this moment, which to us seems old hat, but they have the same questions -- simple questions about healthcare facilities. Do you think that masks should be required in healthcare facilities forever? Just from now on? I'm willing to do that. Should that just be the thing?

Jha: This is a place where I lean a lot on CDC guides. The CDC has laid out the context in which masking in healthcare facilities makes sense. I think their strategy and approaches are very reasonable, which is: focus on transmission in places where you have high levels of transmission, when asking people to wear a mask in healthcare facilities makes a lot of sense. In places with very little transmission, saying that it's not required also makes a lot of sense. 

My general feeling on this stuff is that things like, "You should always do this" or "You should never do this" or "We should do it forever" or "We should never have done it at all," those rarely work. That's not how we live our lives. It's pretty reasonable to say, "Yes, when there's a lot of transmission, masking in healthcare facilities makes sense."

Faust: I'm actually finding that my readers are a little bit more on the concerned side, and I want you to address them. What do you say to people who just aren't really ready to move on from peak vigilance? 

In many cases, my readers are people who have very good reasons to be worried. They're less protected, they're immune-compromised, and then there are some people who I sometimes wonder if their current level of concern doesn't match where we are. I'm wondering what your message is to people who feel like what you just said, which is sort of a nuanced answer, leaves them behind.

Jha: I have concerns. I think there's still a virus out there that's causing a lot of infections and causing a lot of people to get sick. I think being concerned is reasonable. I think the question is: what are you doing with that concern? What action is it leading you to, right? 

The single most important thing people can be doing if they want to protect themselves, and this is by the way also true for people who are immunocompromised and we can come back to that, is being up-to-date on your vaccines. Because you can try to do lots of other things to avoid the virus, but it's going to be very hard with this virus to avoid it completely forever. So you want to make sure that your immune system is as ready as it can be, that if you confront the virus, you're ready to take it on. And that means being up-to-date on vaccines. 

Then, thankfully we have a couple of really terrific -- one really high-quality -- antivirals. If you do get infected, take it. I think that combination means if you do those things, it is exceedingly unlikely, and we could talk about people who are truly profoundly immunocompromised, but that's a very tiny portion of even immunocompromised people, but for everybody else, it means you're not going to end up in the hospital. You're not going to end up dying. Your risk of long COVID is going to be dramatically cut. 

Then you could decide, given all of that, what do you feel comfortable with? Most Americans are comfortable going out to restaurants, doing social things, including most elderly and most people with immunocompromised conditions, but some people are not. I totally respect that and I think we've got to continue to find ways of continuing to help protect those people.

Faust: All right, before we get to some reader questions, let's talk about long COVID. I think you've been quoted as saying maybe the real risk is in the single digits. I think there are some people who say it's higher, some people say it's lower than that. If it's 5%, that's still 16 million people in this country. 

Do you predict that disability claims are going to go up, and who's going to adjudicate that? Because this is a condition that's really hard to define.

Jha: Let's talk about long COVID. Here's how I think about it and how the administration thinks about it. 

First of all, it's a real thing. Clearly there are people who get infected who recover, but then have persistent symptoms for long periods of time. The reason I say it's single digits is there are a bunch of badly done studies that don't have controls that at four weeks ask people, "Are you still tired?" and people say, "Yes," and then you get 35%. That's not long COVID. But there are well done studies that look out to three months and six months and find a series of patients who still are really suffering. Some of them are incapacitated, some of them just have significant issues. That number probably is in the single digits in terms of proportion of people.

The second thing we know about long COVID is that you can reduce your risk of long COVID by 50%, 80%, 90% depending on the study, by being up-to-date on your vaccines. The single biggest thing you can do beyond avoiding infection is making sure you're up-to-date on your vaccines. 

Third, there is a little bit of evidence, it's not very good and I don't want to over-torque on this, that antivirals -- and by the way, if you think about the mechanism of long COVID, it stands to reason that antivirals should reduce your risk of long COVID -- and so there is a little bit of evidence. Little, I don't want to overstate that, and work is being done. 

Okay. Now, here's what else we know. Long COVID is probably three or four different conditions that are all getting lumped into one category, right? For some people, it's persistent antigen or persistent virus. For some people, it's immune dysfunction. For some people, it's organ damage from the original infection. For some people, it's about endothelial damage that comes and then the sequelae of that. That's not meant to be a comprehensive list. A lot of research is being done to both sort that out and figure out how we treat folks. 

And then, there's an administration-wide, government-wide approach to thinking about how we understand the disability impacts and how we adjudicate that. All of those things are being developed. And then of course, how do we make sure we continue caring for those people? That work is ongoing. 

We put out a report in August listing all the stuff the administration is doing, and it's getting updated. But we have mechanisms for adjudicating people's disability, and people who are disabled are going to get the care and the resources they need.

Faust: James writes: as of today, there's no guidance regarding whether older and high-risk people who received the bivalent booster in September/October are eligible for an additional boost this April and May. Is this decision going to wait until fall of 2023? How do people who need to be up-to-date more than once a year stay up-to-date?

Jha: We've always been guided by evidence on this, and the FDA makes this decision when they see evidence that an additional shot protects people against serious illness and death, then they make a recommendation. 

That's what the FDA did last February/March about that second booster. They saw data from Israel that was very compelling that an additional shot made a big difference in reducing illness and death. So the FDA came out and authorized it and the CDC recommended it, and then a lot of seniors got it. That's the process we follow. We look for evidence, the FDA looks for evidence, and when they see it, they will make that recommendation.

Faust: Alright, last reader question then I'll end with some of mine. Caroline asks: what's being done to monitor and improve air quality in high-density public spaces to reduce transmission of airborne diseases, including healthcare facilities, nursing homes, airports and schools?

Jha: A lot of progress, more to go.

There was a lot of money in the American rescue plan for schools to upgrade their ventilation. We have done a ton of work with schools around the country to make sure of that, because it's not just about giving people money, it's about how they do it, technical standards, and who do they call? School leaders are not indoor air quality experts. We've seen a lot of progress in schools around the country in this area. 

ASHRAE [American Society of Heating, Refrigerating and Air-Conditioning Engineers] is the standard-setting agency or body. It's an independent body that sets standards for indoor air quality. They have made a promise that they're going to come out in early April with new air quality standards. I think what we will see there is that a lot of states and a lot of building operators will adopt those standards and upgrade their indoor air quality through that. That's been important work. 

We've done a ton of stuff inside the federal government to make sure our buildings have substantial improvements in indoor air quality. And then we have been trying to get more guidance out to other sectors. 

Healthcare is different. Healthcare indoor air quality has usually been regulated by states. OSHA, and this is publicly known, has been working on healthcare standards for a whole set of issues including indoor air quality. Those are going through some final inter-agency work and all of those will be coming out. 

So what I would say on indoor air quality is, we are a complicated country. Some of the stuff that we do as a country is regulated by local cities, some other stuff regulated by states, and very little is regulated by the federal government except for, of course, federal entities. But the federal government can do a lot in leading the way, in showing people what good indoor air quality is -- raising the profile. That's one of the reasons we had that indoor air quality summit. Obviously Congress has put a lot of resources into this as well. 

I think we've seen a lot of progress, we just have a lot more work to do on this, and you're going to continue seeing that progress in the weeks and months ahead.

Faust: You're one of the high-profile COVID experts who went from civilian to government insider pretty much overnight. Obviously you were advising very closely, but your position changed quickly. What is something that you understand now from doing this job that you couldn't have understood before? What's it like going from outsider to insider?

Jha: Very quickly on this, Jeremy, what I will say is that we have a very complicated form of government in America, which is because we have a complicated country. 

People have this idea that somehow the federal government can make anything happen. Turns out, state governments have a lot of say over lots of things. There are times when, for instance, in 2020 I did not agree with policies of the Trump administration, and I was really pleased to see that states had the ability to say no and go their own way. That is a feature of our democracy. 

The job inside the federal government is certainly to coordinate all the complex agencies within the federal government, but also to work with states, to work with localities. Just in the last week I've spoken to mayors in a whole bunch of different states, because mayors have a fairly big role.

What I have learned is that in this very complicated and diverse country of ours, the ability to move policy resides at lots of different levels. If you want to try to move it all in one direction, you have to coordinate and bring people along. Soft power matters as much as anything else. And it takes time and it takes effort and it takes work to build that trust and coalition, but that's what we've been focused on doing with the very simple goal of wanting to make sure we're protecting people as we pull out of this public health emergency.

Faust: My experience has been that when you took your role, you actually opened your circle and brought more voices in, even those you didn't agree with. I think that's been to your credit. 

Thank you so much for sharing your views and for all the work you've done on this project. [These are] very complex issues, and you're a genius at explaining them. Thank you so much for being with us.

Jha: Jeremy, thanks for having me here.