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I’m Ezra Klein, and this is “The Ezra Klein Show.”
On January 28, I published a column that began like this. “I hope in the end, that this article reads as alarmism. I hope that a year from now it’s a peace people point to as an overreaction.” It was not an optimistic column. The point was that the new coronavirus strains that were circulating in the U.S. — they were filling the next six weeks with peril. On the one hand, cases were falling and governors were lifting lockdown orders. They were reopening restaurants and gyms. Vaccinations were beginning, which of course, was creating a lot of optimism correctly, but it was going pretty slowly at that point. And meanwhile, the super contagious B.1.1.7 strain, which had sent cases and deaths exploding in England and in Portugal, we knew it was circulating here, too. And so was the South African strain, which seems to have some vaccine resistance. And so I was pretty scared. I was worried that between here and mass vaccination, it would be months of hell with a combination of new strains and political exhaustion, allowing cases to go into the stratosphere and leading to maybe even hundreds of thousands of people dying. And this wasn’t just my weird fantasy or nightmare. This was something that experts were telling me. But that is not what happened. That piece now does read, thank God, like alarmism. Instead, cases fell and they kept falling. They fell here in California, where I live. So now our daily case rate is down to what it was in late October. The same thing happened nationally. Cases have fallen from about a daily peak of 300,000 down to a little bit over 50,000 a day. And while this country by country variation, the same thing is happening globally, including in countries we know are afflicted by particularly dangerous strains, including countries that don’t have big vaccination programs, including countries with very different weather and policy equilibriums. Meanwhile in the U.S., vaccinations have really picked up. We’re getting more than two million shots in arms each day. Half of Americans 75 and older are now vaccinated. In San Francisco, one out of four adults has received at least one shot. I mean, one out of four of the people I see on the street — on the rare occasion I’m ever on the street — have received a shot. I mean, wow. And the supply of available vaccine is about to open wide in America as Johnson & Johnson ramps up and Pfizer/Moderna expand production and the American Rescue Plan is passing with it’s tens of billions of for vaccine distribution. Like there is real reason to be hopeful right now. And I say this as someone who was really pessimistic, you know, at the end of January. Particularly in the United States, there is a path right now. There’s a path out of this, a reason to believe this crisis, or at least this form of it, will largely be over and soon. Hope is a scary emotion to feel right now. A lot of us don’t want to let ourselves believe it’s going to get much better, only to be back in lockdown in two months. And to be sure, I can’t tell you the future. But I think it’s easy right now, particularly in the media, where we don’t want to repeat the mistake of being insufficiently alarmed, to endlessly focus on what could still go wrong, to just tell you all the caveats and the maybes and the way it could go off the rails. But I think hope is an important emotion, important also as a policy emotion, so people know that if they hold on a little bit longer, there is an end in sight. So I want to spend this episode talking about what is going right, talking about our way out of this. And I’m joined today by the perfect guest on this subject. Dr. Ashish Jha is a physician. He’s a researcher. He’s a dean of Brown University School of Public Health. Before that, he was a Professor of Global Health at the Harvard T.H. Chan School of Public Health and director of Harvard’s Global Health Institute. And if you follow him on Twitter over the past year, @ashishkjha, as I have, you know he’s been one of the clearest and most active and most thoughtful guides through this crisis. And he, like me, is feeling optimistic and is feeling that some of that message, some of how well things are going — at least in the U.S. right now — isn’t breaking through. And so I asked him here today to guide us through these next months, to help us see what he’s seeing. I can tell you having done it, this is one Covid conversation, finally, it is not going to leave you feeling despair. As always, my email is ezrakleinshow@nytimes.com. Always interested to know who you’d like to see on the show next. So send me your guest suggestions. Here we go.
A month or two ago, I wrote this really dire column, warning that with the new variant circulating, things could get a lot worse before they got better. But instead cases, they’ve plummeted. In America, they’ve plummeted, almost everywhere around the world. What happened?
We don’t know for sure, is the bottom line. We have theories. I have my theories, which I’m happy to get into. But anybody who tells you they know exactly what happened, I think, is making it up. So the three main theories are one, we have a lot of population immunity. We have a lot of people who have gotten infected. And that’s really now starting to make a difference in terms of keeping infection numbers from getting too high. Second, is there really is a seasonality to this virus. And it’s a little weird to talk about seasonality when you see cases plummeting in late January, February, because I remember one day, I was talking about seasonality with somebody, and I looked out my window. And it was literally was 15 degrees and snowing. And I was claiming that there was a seasonal benefit of this time we were in. You see that with other coronaviruses, where they start really coming down in terms of how many infections they cause, sort of around mid-January. And so maybe, this is acting like other coronaviruses. That’s the second theory. And third is I really do think that after the holidays, with the horrible crush of infections, hospitalizations, and deaths, there really was a pulling back of activity. People were being more careful. I don’t think any of those three theories fully explains it. But maybe the combination of all three is how we got there.
But is one takeaway here that the variants are not as horrifying as some of the earlier reporting led us to believe? I mean, you have the B.1.1.7 variant, which is more contagious. You have the South African variant, which has at least some — creates some challenges for the vaccines. You have a Brazilian variant, this one in California. And the reporting on this, including some of mine, was these might completely break our firewalls. But now it doesn’t seem they have. Even in places where we know the variants are quite dominant, things are back under control.
The story on variants is interesting. The one that I’ve been most worried about is B.1.1.7, because it is — depending on which analysis you look at — between 30 percent and 60 percent more contagious. And if you run the numbers, you totally understand why in places like the UK, Ireland, Denmark, Portugal, almost everywhere where B.1.1.7 became dominant, you saw a two, three, four-fold increase in cases. And so I think all of us were looking at the U.S. and saying, if we see a four-fold increase, even if we’re at 70, 80,000 cases a day, four-fold is awful. It’ll be much worse than any moment of the pandemic. This is why I think people like Mike Osterholm — Michael Osterholm, one of the most respected epidemiologists in Minnesota, somebody who I turn to for guidance and somebody I’ve known for a long time, really respect deeply — even as of this past week, he was saying the worst is still ahead of us. I don’t think that’s true. I think the reason why B.1.1.7 hasn’t crushed us yet — it may still cause a spike. We’re not we’re not anywhere near done with that virus — but may not be so bad is because again, seasonality. It’s hitting us in March. In those other countries, it tended to hit in December, November, December, January. And the second is at this point, probably about close to 30 percent of Americans have been infected from this virus, somewhere between 25 percent and 30 percent. And now we have another 10 percent to 20 percent of people vaccinated. Even if you assume some overlap between those two groups, that’s a lot of population immunity that B.1.1.7 is running up against. And I think that’s a major part of the reason we’re not seeing a huge spike in cases.
So I want to talk a little bit about vaccination. But I want to start with some of the subgroups that are getting vaccinated. So I saw the number just yesterday that now, 50 percent Americans over age 75 have at least one dose of the vaccine. Numbers are similar, although a little bit lower, for Americans over age 65. And so if we get to a place in a couple of months where the real majority of seniors are vaccinated, given how concentrated hospitalizations and deaths are among seniors, even if one of these strains did become more contagious, wouldn’t that lead to a very different outcome, one that has, sure a lot of coronavirus, but a lot less death and a lot less hospital overwhelm?
Absolutely. So I think certainly by the end of April, we will have vaccinated almost everybody who’s high risk, over 65 or with major chronic diseases. Everybody who wants a vaccine will have gotten at least one dose. And that is huge. And that means that the massive crush of hospitalizations we saw in California over December, and other places as well — Arizona, et cetera — that won’t happen. What is going to be weird, though, is if we do see a really bad spike, is we’re going to start seeing a large number of young people hospitalized. Because even though young people tend to be hospitalized at much, much lower rates, if the infection numbers get bad enough, you know, you will see a proportionate chunk of them getting hospitalized. And that will be strange because what we will be seeing is young people getting sick and dying in much bigger numbers than we have seen. That’s the fear. That’s the thing that still sits out there that we have to be careful of is these variants are not done and we are not done vaccinating enough people to really stop them.
I want to hold two parts of your answer there emotionally at the same time. Because I want to tell you something that happened to me in the first part of your answer. When you said that you think by the end of April, we will have vaccinated every high risk person in the country — who wants a vaccine, at least — like, I actually shivered. I got emotional. That’s an extraordinary thing to say. But then I feel — and I’m not in any way criticizing it — you did what I sort of always hear in this conversation, which is a move to what could still go wrong. And I do wonder — without taking anything away from what you said there, which is true — if we’ve almost like lost the ability to focus in on good news. I mean, if you had told me a couple of months ago that we would have a vaccination campaign that effective by the end of April, I would have sobbed.
Yup. Oh, it’s amazing. The tightrope that I have been trying to walk — I mean, and really just being driven by honesty of how I think about these things — is on one hand, it’s unbelievable, right, like by the end of April — and people are like, “How sure are you?” I’m like, “Oh yeah, I guess it could spill into like the first week of May.” So somewhere around there.
Dammit, Ashish.
Right. You promised April 30 and it’s May 4. Right. No, but the point is somewhere latter half of April, early May, we’re going to open this thing up to like 35-year-olds who are low risk and say if you want to get vaccinated, you probably can. I mean, that’s kind of where we’re going to be heading into May. So it’s unbelievable. We’re going to see hospitalizations plummet. We’re going to see deaths from this disease plummet. It is absolutely wonderful. The problem is that there are plenty of folks — Governor Abbott, for instance, in Texas — who hears a version of this — not necessarily he’s listening to me — but he sees this on the horizon and says time to open bars and restaurants fully. It really is a problem. And it will cause real suffering. So the question is how do you express both incredible optimism, enthusiasm, happiness, while at the same time saying, you’ve got to be careful? It’s a tough, tough act.
I’ve been struggling with this question because I’ve been thinking about what’s happening in Texas, which I think is reckless. But I’m in California. And I think California’s has gotten way, way better on what it’s doing. Like, I really — like, it’s accelerated its vaccination program. I think a lot of the ways it is apportioning vaccines make a ton of sense right now. I have a lot of good things to say about the way California’s response has evolved in the past couple of months. But there is still not an answer in California of when things go back to normal. Like you cannot look at a website, you cannot listen to a public health official and have them tell you that when this percentage of the population is vaccinated, we’re going to open everything back up. And I’ve been thinking about whether there’s a real mistake being made among some public health officials, I think among some liberal office holders, who are so afraid, for very reasonable reasons, of going to open too quickly, that they’re not giving people a way out of this they can hold on to. I mean, it’s one thing for me to hear from you, “Listen, man, you’ve got to hold on till May. Like, by May, like, we should be in a totally different place.” And then another thing to hear, as often we do, this is getting better. We don’t know how fast. There are scary strains out here. We don’t know what you can do once you’re vaccinated. And if you just keep hearing endlessly from people that there may be no light at the end of the tunnel, it makes some of the more reckless voices a little bit more attractive. And so I worry that there isn’t enough of a clear set of benchmarks and narrative of success, among the office holders taking this very seriously.
The problem with public health officials, and I think a lot of political leaders, is they don’t know what the benchmark is. And so they don’t know how to talk about it. And my take is, like every month, we’re going to feel like life gets better and better and better. There will be things that will feel more comfortable and reasonable to open in April that we shouldn’t do now. And in May, we’ll be able to do certain things. And so let me just talk about it. Outdoor activities. I see California opening up outdoor dining in April. And I think that’s great. Indoor dining is going to be later, right? And I mean, you can have that very at low levels. But I wouldn’t really open up indoor dining much more substantially until we’re more into May or June. And it sort of should be a rolling opening. More people are getting vaccinated. Things are getting better. And riskier and riskier things are becoming safer and safer to do. And then if you ask the question, like what are things — like I think about like super jam-packed lecture halls in universities. Like we’ve been talking a lot at Brown University about like, do we need to have the 300, 400-person lectures anymore? Maybe those just go away. Maybe those we always now do online and do everything else — from those classes, everything is small group, in-person, right, because maybe the 500-person lecture is just not necessary. And I’m not sure it was ever all that great. But my point is there are some of those changes that are going to come about in terms of the pandemic that we’re going to live with. And that might not be the worst thing in the world.
But there’s a difference between changes and restrictions. So you bring up the 500-person lecture hall. What I miss doing, like almost more than anything else, is going to shows. I live in San Francisco. I like going to public works and seeing things that a lot of people wouldn’t even classify as music, probably, but I enjoy it. And there are a lot of people in the room and everybody’s dancing and it’s a great ecstatic experience. That’s more dangerous than a lecture hall pandemic-wise. But once people are vaccinated, can’t I do it again?
Absolutely. And so there are two parts to that question in my mind.
Thank you.
Yeah, absolutely. And the question is when. And I would say it depends a little bit, but somewhere probably over the summer, maybe early fall, but maybe summer. And let me just say, if somebody called me from one of those places and said, “How do we make this safe?” I would say, “You have two choices. You can either require that everybody be vaccinated. That would make it pretty safe. Or if you’re going to let vaccinated and unvaccinated people mingle, then you may want to think about some additional safety measures.” Like maybe you get everybody to do a rapid test that takes 10 minutes to come back. It’s $5 and you just throw it in as a part of — I was thinking about this for musical concerts — it’s part of the thing. You show up 10 minutes early you get a test. As long as everybody’s negative, everybody gets to go in. So there are modifications like that that will make it easier, and not just easier, safer to do. I can imagine with some of these modifications, that stuff becomes very safe by sometime this summer or early fall.
So it doesn’t sound, when I talk you here, to be honest, that you’re saying we are not going to go back to something people understand as normal. It sounds like you’re saying this will change society in certain ways. Companies might retain remote work, because it’s efficient. There are things we were doing before that we didn’t need to do. Different things are going to come back at a different pace. But it doesn’t sound to me like you’re saying there is something about the coronavirus’s continued existence that is going to make the things we used to do perpetually unsafe.
Absolutely. If your normal is 2019, we may never get there. If your point is how do we get to a point where we have a rich, high quality life where the coronavirus doesn’t dominate it, but it’s something that’s an annoyance and sometimes we have to deal with, that’s coming sooner than most people think. It’s coming at some point over the summer into early fall. Let me give you just one other caveat on this, Ezra, because again, as a public health guy, I feel like I ought to at least put all the negative news out there. Look, this is a seasonal virus, we think. I could see a small bump in cases in November, December, January. I can imagine for the first couple of years that for a couple of months every year, you have to pull back a little bit. Maybe you have to — people have to wear masks a bit more. Maybe we have to ramp up some of our testing stuff. I can imagine for short periods of time in certain communities having to make adjustments, certainly in the first year or two. But that’s not going to be most of the time. That’s going to be small periods of time in some communities over others.
One thing you’re getting at here that I’ve wanted to talk to you about, and I want to just talk about more, is a question of what is acceptable level of risk. And that’s a conversation I think we’re not having well, because as you’re hinting at here, the other side of this is not zero risk, which is I think something people often want to be told or implicitly believe. The other side of this is the risk we experience from coronavirus is more on the order of magnitude of risks we have from things like the flu, from driving, from climbing a ladder. There are all kinds of things we do in life that have risks attached to them — eating bacon — but we do them anyway. And one thing that worries me about the other side of this is I actually think something lurking in the conversation is people are quietly saying they have very different levels of acceptable risk. Texas is saying it has an incredibly high level of acceptable risk, or at least its governors are saying that. On the other hand, some other states are saying, you know, it’s quite low and we’re not even sure what it is. And I don’t even know how we’re going to have that conversation exactly, because different people are going to have different levels. And yet, they might be in a community that disagrees with them. But I think at some point, we need to be talking about what is OK, because OK is not perfectly safe. OK is something like life, which is a risky enterprise.
I get this all the time on social media and in other forums where people say, “Can you guarantee that this will be safe?” And I’m like, “Nope, cannot guarantee it.” The C.D.C. just put out guidance saying vaccinated grandparents can hug their unvaccinated grandchildren. And literally, I was praising this. I said, “That’s exactly right.” And somebody asked me, they said, “Well, can we be 100 percent sure that like the unvaccinated grandchild won’t give their vaccinated grandparent the infection, and we know these vaccines are really good but they’re not 100 percent and someone might still get sick and die.” And the answer is yup, like there is still that theoretical risk. But it’s so exceedingly low that at that point, we’re like well below the risk we tolerate for influenza. We don’t say to grandparents, “You can’t come visit grandkids during influenza season.” We tolerate a certain amount of risk. Now, maybe we should be a bit more careful about that. That’s a different conversation. So one is zero risk has just got to go off the table, because it’s not — we can’t live life that way. I think the issue of individual risk tolerance is a bit complicated by the fact — this has been the big issue of 2020, right, and President Trump constantly — and a lot of kind of right wing, I think misinformationists is often talked about letting people make choices about risk. The problem was you weren’t just making a choice about yourself. You really were putting others at risk. When young people went out to bars, yes, they got infected and maybe they didn’t get all that sick. But they went home, infected their parents and grandparents, and they got sick and died. That begins to change with vaccinations. If high risk people are all vaccinated, or have chosen not to be vaccinated, then I think individual risk calculus is a bit more reasonable than in 2020 and early 2021 when we didn’t have vaccines and your individual risk behaviors had this profound spillover effect on everybody else. And certainly governments, governors are going to think about all of that very differently. [MUSIC PLAYING]
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So I want to talk about what we’re learning about the vaccines. A couple of months ago, what we had was trial data. And it looked great, but there’s a difference between trial data and then the vast real world test we’re in right now where millions and millions of people have actually gotten these vaccines. In reality, are we seeing anything surprising or anything alarming or anything unexpectedly encouraging about what seems true after people get vaccinated?
I have to say I have been pleasantly surprised at how few adverse events, bad outcomes there have been from vaccinations. I mean, we are now at a point where 60 million Americans have gotten at least one dose. That’s a lot of people. And you know, like, if there is a one in a million event, you still see 60 of them, right? So that’s part of the challenge is that we should be seeing the rare events, especially given how hypervigilant the entire country is. And we’re seeing very, very little. Like, we’ve seen a few people get infected after their vaccination. Well, you’d expect that. I mean these vaccines are terrific, but they’re not 100 percent. I have not seen clear data that people who have been fully vaccinated, have been hospitalized, or died from Covid. But even that is likely to happen. Again, these vaccines are terrific. They’re not 100 percent. Israel’s got the best data of people in real life who’ve been vaccinated. And the key here is to look at people after they’ve been fully vaccinated, right? So if you look at them in the first week after their first dose, they’re not really vaccinated. But if I remember, it was like less than 10 people who after full vaccination ended up getting hospitalized with Covid. And there are two potential deaths that might have been from Covid out of a sample of 600,000 people who got vaccinated. So if we’re talking about less than 10 in each of those buckets, those are pretty small numbers.
So I just want to say this here, because the human mind and big numbers and small numbers and all, that’s incredible, actually. I mean, as I understand a lot of vaccination data, that’s an incredible level of effectiveness.
Incredible level of effectiveness, way better than we have for a vast majority of vaccines, better than the original polio vaccine. I mean, people just sort of forget, like, the level of efficacy that we’re talking about here is amazing. And again, particularly given how quickly these vaccines were developed.
One thing that I am hearing all the time right now reporting on vaccinations is that everybody is anticipating a giant supply expansion in the coming weeks and months, that everybody seems to feel that within a couple of weeks a month, the number of vaccines flooding into the U.S. is going to be like nothing we’ve seen unto this point. Is that what you’re hearing, and why is that?
It is. I am like super bullish on how much vaccines we’re going to have as we finish up March and get into April. I mean, one of the reasons why I feel comfortable saying that sometime in April, every high risk person who wants a vaccine will be able to get one is we’ve just had this huge ramping up of supply. And a couple of things have gone into that. One is some of it was kind of built into the system. Operation Warp Speed pre-purchased a bunch of vaccine doses, worked on supply, but didn’t have nearly as much ready as they had promised. But that it was always going to get better over time. So one part of it is Operation Warp Speed. The second part is the Biden administration. And the Biden administration has done two things. They’ve gone back and worked with the manufacturers to say can you do any more on supply in the short run and have worked on increasing supplies in the short run. And then the other thing is that there’s a bunch of little tweaks. Like you remember that in the early days, we found that actually in the Pfizer vaccine files, they were overfilling it a little bit and you could get an extra dose or two. But that was pretty hard and was unreliable and you needed a special kind of syringe. So the Biden administration went and did a bunch of stuff to make that much easier. So now like one little fix gives you a 20 percent to 40 percent bump in your supply because you could just get more doses out of each vial. So a combination of a bunch of small things and a couple of big things. Johnson & Johnson coming online. We are going to have a lot of vaccines into April. I mean, by May, we’re going to be like swimming in vaccines.
I’ve never thought I wanted to be swimming in vaccines, but actually it sounds good the way you say it.
That’s nice, right?
I’ve heard people saying that they think in the next couple of months, we’re going to get to a point where vaccine supply in America outstrips demand. Do you think that’s true?
Absolutely. The big question that a bunch of us kind of debate offline is is that going to happen in early April? Is that going to happen in late April? Might it not be till early May? I tend to come down on the middle on these things. So I think sometime in late April, we will find ourselves with more vaccines than adults who want them. And I actually hope that’s not true, Ezra, because that may mean that we have a decent amount of hesitancy and a decent number of people who don’t want it. And so my hope is it’s more like early May, and that’ll just mean a lot of people are actually signing up and getting vaccinated.
I do want to talk about vaccine hesitancy. So I exist in a world online, in my own social circles, where everybody wants a vaccine. Everybody wants the federal government to have higher risk tolerance. Approve AstraZeneca; I’ll get Johnson & Johnson. But then you look at polling. And there’s about a third of the population says they probably or definitely won’t take a vaccine. And I’m worried that pollsters, they tend to undercount low trust people. This is a continuous problem, because those folks don’t tend to talk to pollsters. And so it may even be higher. So how does a world look different — let’s call it six months from now — if we have 60 percent or 70 percent immunization versus 90 percent immunization because we haven’t gotten over our hesitancy?
It looks pretty different is the point. And so I’ve been doing a lot of talking to university leadership at Brown and saying, what will the fall semester look like? And my assumption is we’re going to require vaccinations for certainly all students and a lot of other people. If 80, 90 percent, 90 percent of people on campus are vaccinated, it’s going to look great, close to normal. The problem is there is a big drop off when you go from 90 to 60, because that’s so many more people who are vulnerable that the level of infection in that community is just dramatically, dramatically higher. And that also means that, especially in certain communities where it might be even lower, like 50 percent, because as you know, it’s in pockets and it’s not randomly distributed. You’re going to have places with big outbreaks. You’re going to have places where hospitalizations are going to get full. You’re going to have to think about our national testing strategy in a very different way. There will be things that will be hard to do. And those people who are vulnerable and infected will be coming all the time and walking into communities with 90 percent vaccination, but then start sort of setting off little fires, which kind of eventually burn out because at 90 percent vaccination things are great. But I really worry about this patchwork nation that we’re going to see if the national number is like 60 percent to 70 percent.
Do you think of vaccine hesitancy as stable or lagging? And what I mean by that is there’s a world where you say, a third of the population does not want to get the vaccine and will not. And there’s a world where you say most of those people just don’t want to be early adopters of this. They want to see if it works for their friends and family and their community. And when everybody’s got the vaccine, or a lot of people have the vaccine, they’re going to be more comfortable, and you’re just dealing with a lagging — a lagging level of comfort. What do you think?
So I think it’s both. I think there probably are 10, 15 percent of the people in this country who are not going to take the vaccine, almost under any circumstances. And we can talk about what circumstances they might take it. But then there’s another 15, 20 percent that gets you to about the third who are much more on the fence, leaning against, but potentially open. They want to see what happens. And that group is pretty persuadable. And I think some chunk of them are just going to wait. They’re going to see all their friends and family get vaccinated. Everybody’s doing fine. No one’s having horrible outcomes from the vaccination. And they will take the plunge. The other thing is that we’re going to see a lot of institutions require vaccinations, workplaces that say if you want to come back to the office you have to be vaccinated. Universities are going to require this of students and thinking about what they can do for faculty and staff. Those kinds of things are also going to push that 15 to, 20 percent lagging group, as you say, over, because they’re just going to decide that the inconvenience of not being vaccinated, is it worth it, and they’ll get vaccinated. I hope I’m right that the hard core group is more like 10 percent to 15 percent and not bigger than that.
We’ve used the terms efficacy and effectiveness a couple different times. Can you just quickly go through the difference between them as related to vaccines?
Absolutely. And we use this for vaccines, for therapeutics. What I say simplistically to my students is efficacy is like, what is the impact of that therapy or that vaccine in the kind of ideal setting, in a clinical trial. And then effectiveness is what’s the impact in the real world setting once you actually go give it to regular people. So the Moderna trial, we often talk about like 95 percent efficacy, because it was in a very well-constructed trial. It was a very pre-selected group of individuals. And what we know from every clinical trial in history is when you go give a drug to the regular population, it’s never quite as good as what you saw in the clinical trials. There’s always a drop off between efficacy, that kind of ideal world setting, and effectiveness, the real world setting.
I want to talk a little bit about the vaccines and the differences, or lack thereof, between them. And in particular about Johnson & Johnson, which is a big part of this huge supply increase. What do we know about the effectiveness of that vaccine? The number of people hear, is it is 72 percent efficacy? But is that the right number to look at? Are people, when they say, well, that’s 72 percent effective, are they looking at the right thing?
My concern about the numbers — and I’ve gotten pushback for saying this, but let me walk through — that I think it’s not a fair apples to apples comparison to look at any of the headline numbers on J&J and compare it to Moderna and Pfizer. And for a couple of reasons that are simplistic and then a couple that I think are more important. So the simple ones are J&J has actually been — it was tested in Brazil and South Africa. Moderna and Pfizer weren’t. So the 66 percent overall number for J&J includes being tested against variants that are clearly more kind of vaccine-resistant than Moderna and Pfizer ever were. So that’s one part of the reason why it’s not a fair comparison. The second is well, people say, what about just the United States? What if we just focus on the U.S. numbers? It does look like J&J numbers are a little bit lower. J&J was also tested at a time — so it’s not just place — but at a different time. And that time, we had many, many more infections happening. And there is at least a theoretical argument that when you’re testing a vaccine during a large outbreak, its efficacy number can decline, because if you think about the vaccinated person in that clinical trial, they’re being constantly challenged, interacting with infected people, much more often than if the level of underlying infection is lower. So there’s at least an argument to be made that you might see a bit of a drop off in efficacy in J&J — from again, we’re talking about symptomatic infections. So that’s why I’ve never felt like there was a totally fair comparison. But at the end of the day, it may be slightly lower on symptomatic infections. But let’s get to the really big issue, which is what we really care about, which is hospitalizations and deaths. And what do we know? Even against the South African variant, the B.1.351 that people worry a lot about, J&J was tested. Nobody in the vaccine trial — vaccine arm of J&J — was hospitalized or died after the vaccine had a chance to work. We’ve never tested Moderna and Pfizer vaccines against the South African variant in that way. So there is a lot going for the J&J vaccine. You could make the case that maybe its efficacy is a little bit lower. I could make the case that we have a lot more real world data with J&J against these variants than we do with Moderna and Pfizer. J&J’s a well-established platform for building vaccines in the way that they did it. It’s a tried and true method. And that’s why I at the end of the day, look at all of this and think, I’d be pretty comfortable getting any of the three.
Well, there’s another thing here, which is that J&J is one dose and Moderna and Pfizer are two. And I’ve heard this argued both ways. One way is that, well if you made J&J two doses, it would be as effective as they are in these headline numbers. But the other way I’ve heard it argued is actually maybe Moderna and Pfizer don’t need to be two doses and they’re all quite effective at one. How do you think about the one dose versus two dose protocols?
So in early January, I wrote an op ed with my colleague Bob Wachter basically saying, delay the second dose of Moderna and Pfizer, because with these variants, a lot of people are still getting sick, and we don’t have enough vaccine, so let’s delay the second dose. And essentially argued that the one dose has an efficacy number that’s like 80, 85 percent, looks really good, let’s do that. And people got very upset. And a lot of people accused me of being anti-science, which is sort of funny. Their argument was this is how we tried it in the clinical trials and we should stick to the recipe at hand. And my point has always been like these recipes were not like ordained by God. For a variety of strategic clinical timeline decisions, we set it up this way. There’s again, nothing preordained in my mind about these vaccines that require this to be one dose versus two. And it looks like two doses probably are a little bit better. And we’ll have data on two dose Johnson & Johnson at some point, maybe over the summer. And people who got the one dose of J&J may get a second dose at that point. Or it may turn out that it’s not that much better. We don’t know. But I just want people to not think that there’s something like preordained reason to think that one should be a two dose, one should be a one dose vaccine.
One of the things I’m worried about, I’ve heard a lot of people who are hesitant about J&J who say they’re going to refuse it if offered. I want to say, just so people know where I am on this, if I had a choice, I would personally take J&J. I like the one dose protocol. I like that it’s a more known vaccine platform. It seems plenty effective to me. But also, that the one dose protocol and the ease of storage, it makes it a lot simpler to do mass vaccination. So I mean, we’ve seen studies on hepatitis B vaccine that show about of patients fail to get their follow-up shot within the first year. About three million Americans haven’t received their second Covid vaccine dose on time. So is there an argument that J&J is in some ways, the better protocol for the kind of mass vaccination we need to be doing?
Yeah, absolutely. So certainly, you can imagine certain populations of people for whom not having to come back is a huge boon and therefore, you may be targeting certain groups, thinking like young people who you may have a harder time getting to come back for a second dose. Even more broadly than that, you could definitely make the case that the one and done has got so much simplicity built then you don’t have to figure out a second appointment, you don’t have to like call people up to have them come back when they forget, that there is so much benefit that the maybe the small loss in efficacy — against symptomatic disease, not against serious disease — not against severe disease, but against mild or symptomatic disease — is worth the cost. That’s a pretty reasonable argument to make. We’ll have to see how this actually plays out in real life. But I think J&J will end up being a really important part of our toolset for getting people vaccinated.
Right now the best estimates hold that we’re not going have a vaccine approved for children — and there are a lot of children, they’re like 20 percent of the population — until late this fall, maybe early 2022. Why is it taking so long?
Yeah, that’s a great question. And actually, I was testifying earlier in the Senate today, and Senator Bill Cassidy and I had a very kind of vigorous exchange about this. And so let me lay out why it’s taking so long and then let me talk about this exchange, because I think it was interesting, and he made some really important points. So the fundamental issue is we haven’t tested this stuff in kids. And you want to test it in children before you give it to them. And for two different sets of issues, both on the safety front and on the effectiveness stuff. So right now, Moderna, a couple of other vaccine makers are running trials in kids. And I think that we will have really good data, certainly on safety and maybe on efficacy, on 12-plus by maybe late summer, maybe early fall. But what about under 12? That may take us 9 months, a year. And there are a couple of problems. One is it’s hard to often recruit children into clinical trials, as you might imagine. It’s a bit more complicated from an ethical point of view. And getting consent and all that is difficult. And a lot of parents don’t want to enroll children in clinical trials, which I obviously understand. So that’s one part of it. The second part where we’re going to get into real trouble — and this is the part that led to the discussion with Senator Cassidy — is measuring efficacy. As you know, Ezra, it’s really easy to run clinical trials in the middle of large outbreaks, because there’s so many people getting infected that you run the trial and within a few months, you start seeing enough cases. But what happens if over the summer, as I expect, case numbers plummet, and hopefully in the fall they stay really low. We’re going to have to enroll massive numbers of children and follow them for long periods of time to show whether this vaccine works or not. And that might put us into 2022 before we have any efficacy data on children. And that’s a problem, because that means we’re going to have a lot of kids we’re going to be vulnerable and they’re not going to be vaccinated. So the discussion went to first and foremost, we got to know about safety. And as a dad of three kids, I like — for me, the number one issue is safety. I do want these vaccines tested in kids. And the bottom line is that we need to test for safety. What Senator Cassidy brought up, which I thought was important — and this is something a lot of us have been talking about — is can you identify correlates of protection. And instead of showing that these vaccines actually prevent infection, what if we had pretty good data that they generate the right kind of antibodies and the right kind of T-cell response and we knew what those right kind of antibodies and T-cell responses were and that they really did protect you from the disease. Maybe we don’t have to run the trial to show efficacy. Maybe as long as we can show that it’s generating the right immune response, we could be done. That would be great. That would make all the stuff so much easier. It would allow us to have these vaccines authorized for kids probably by the end of the summer, certainly by early fall. The key scientific issue there is how confident are that we know how to measure the correlates of immunity. That we know which antibodies, which T-cells really confer protection. I would say right now, we have a pretty good idea, but we’re not totally there yet. So if the science on this advances a little bit more, then it’s possible. And then the F.D.A. is going to have to be comfortable authorizing it for children, saying it generates this correlative of immunity, and therefore, it’s good enough, and of course, that it’s safe. [MUSIC PLAYING]
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So C.D.C director Rochelle Walensky recently outlined new guidance for people who have been vaccinated. Can you walk me through the headlines on that guidance, and then whether you think it ended up in the right place? Like, is that how you will act once you are vaccinated?
I’ll start with the headline. Like, I thought it was really good. I’ll give you my assessment. I thought they got it right. Always tricky. They’re weighing a few different things. So let’s talk about what’s in it. The easy one was can vaccinated people hang out with other vaccinated people. And the answer is absolutely. So I’m vaccinated. If I wanted to have a friend over for a drink, who’s also been vaccinated, we could hang out in my home, no mask, no social distancing. Really, really, really safe, no question. Where it gets a bit trickier is the grandparent question, right, because the challenge is lots of grandparents are vaccinated. Almost no grandkids are vaccinated. And so can you have vaccinated people mingle, spend time with, hug, be in the same household with unvaccinated people? And it’s tricky. But what C.D.C said, which I thought was right, was they said, if you’re talking about a single household — so we’re not talking about large groups mingling, but we’re talking about relatively focused mingling — and nobody in the unvaccinated group is high risk — so the grandkids don’t have some horrible chronic illness that puts them at risk, or the parents are not particularly high risk — then, yeah, it’s quite safe. And then, what about like more broadly, can you go socialize — if you’re a vaccinated person, can you go socialize with large groups of unvaccinated people. And C.D.C on that one said no, not yet. And what they’re doing is they’re balancing obviously people’s needs to start socializing and seeing each other with two facts. One, of course, we know that if you’re vaccinated, you’re very protected, you’re very well protected. But we still think you might be, not a big source of transmission, but you might still transmit the virus a little. And therefore, if you’re hanging out with low risk people in a household, it’s probably not a big deal. Again, not zero risk, but so low that it’s fine. But if you’re spending time with high risk people, you could transmit the virus and obviously cause really horrible outcomes. And so that’s where C.D.C said you should probably not be doing that right now.
And so let me try to get at what the implied mechanism is here. So the idea is that maybe you’ve been vaccinated. We know these vaccines are incredibly protective against severe infection. But maybe it’s possible that you get low level or asymptomatic infection, not a big deal to you, and that while you’re not going to be as much of a carrier for others as you would be without the vaccination, it’s possible that you’ll have this low level infection and you could give it to someone else, even if it’s kind of unlikely. Am I describing this correctly and its magnitude?
Yeah, exactly. And that’s a nice way to describe it. It’s unlikely, but it’s possible. And then you want to think through what are the consequences of that. If you’re with a low risk person, it’s unlikely, and the consequences are not huge, go for it.
And then you get into a question here where this is guidance that will change as more people get vaccinated. The situation here has to do with the relationship between the vaccinated and the unvaccinated, particularly when most people are unvaccinated. But when most people are vaccinated, this will not look the same, correct?
Absolutely. And one of the points, like a lot of people have pushed back on the guidance saying, well, why do I have to still wear a mask? Why do we still have to do social distancing if we’ve been vaccinated? And my point is a large majority of people who are high risk still have not been fully vaccinated. Once they’ve been fully vaccinated, then it’s a different ballgame.
I think this brings us in a way back to Texas and some of the other states that are beginning to lift restrictions. So Texas and Mississippi announced they would lift mask mandates and allow businesses to reopen at full capacity. But also Massachusetts removed capacity limits on restaurants. South Carolina said you can have gatherings of more than 250 people. Connecticut is opening up quite a bit. So things are getting better. Some states are racing real fast on reopening. What, to you, would responsible reopening look like here?
Yeah, so people ask me like what’s your mental model here. And my mental model is I want high risk people vaccinated. Like that’s what I really, really, really, really want. I want people who are over 55 and I want anybody under 55 who’s got significant chronic diseases. I want them vaccinated. I would be happy with one dose, at least two weeks. I want them to ideally, obviously, with Johnson & Johnson, that’s good enough. But what I really want is ultimately two doses and two weeks after the second dose. But the point is most of the people I describe as high risk, again, sometime later part of April, they’ll have at least one dose. Somewhere around there, most of them will get to two weeks after. That’s a point where the vulnerable people in our society are pretty well-protected and you can start peeling back. Again, you’ve to be careful a little bit. I don’t know that I’d pull all mask mandates. But outdoor mask mandates have never made that much sense to me. That can definitely go. I think indoor retail, I’d keep it until, again, the infection numbers are down a little bit further and all of these folks are vaccinated. I think restaurants can go to a pretty high level of capacity. 100 percent is a little tough, because you are going to still have some number of unvaccinated people walking around. So you can imagine a ramping up, or let’s say like pulling back of public health restrictions, that begin in the latter part of April. And watch what happens, right? Like look at the infection numbers. Look at what’s going on. Keep vaccinating. And once you get into May and June, and you’ve got 60, 70 percent of people vaccinated, infection numbers are low, you probably can go back to a pretty close to a normal. That’s what I find frustrating about what some of these governors are doing. Like, they’re going about a month or six weeks too early. And the problem with that is a lot of high risk people are still very vulnerable. A bunch of them are going to get infected. And a bunch of them are going to die. And anybody who got infected and died, like now, it’s somebody who’s going to get vaccinated in a month. Like just hold a little longer.
You know what it feels like to me is, I don’t know if you’ve read that many histories of old wars, but particularly before we had instantaneous global communication, you’d constantly have these events where a war would end. There would be a treaty. But the information that the war was over would not yet have got into all of the units. And so people would die in these battles in a war that had already finished because they didn’t know it was over. And there’s a way in which it feels very resonant to this moment. It’s like the war is ending, like, we have some of the agreements here, and you just need to wait. Like the information needs to get out, the vaccines need to get out. And it’s not that it’s any less of a tragedy for a person to die a couple of months ago than it is now. But it feels so unbelievably useless for somebody to die three weeks before the vaccines would have taken ahold.
Yeah, and useless, frustrating, and like we know this. These are not uncertainties of, oh my God, we have no idea when vaccines will get out. We know exactly what they’re going to get. out. We know exactly what people are going to get vaccinated, like within a couple of weeks timeframe, right? Like we can predict this stuff with a lot of certainty. And I just, I wish we could hold on for a little longer.
So we’ve been talking a lot about the U.S. here. I want to talk a little bit about the global picture, both because it is important, because everybody’s lives matter, and also because it is important because what happens globally affects us. How are vaccinations going outside the U.S.?
This is one where I am not so optimistic. I am really actually quite worried about the global situation. So obviously, there are some places that are doing great. Everybody knows about Israel. The UK is doing fabulously. There are pockets, right? UAE, Chile is doing a great job of vaccinating. So we can find those places. That’s great. India is starting to vaccinate, but slowly. The big problem is that even under the best of estimates, 90 percent of people who live in low and middle income countries will not have gotten vaccinated by the end of 2021. And that’s a huge problem. And it’s a huge problem — if you just go carry the models out, you’re probably talking about 2024 before we reach global herd immunity. And the reason why that’s a problem — well, some of it is obvious, right. Like lots of people are going to unnecessarily die. But the second is we have seen a good number of variants, including some pretty aggressive ones, within a year of this virus circulating. And the question that I’ve been asking folks is like how lucky do we feel about letting this virus run for — in large chunks of the world — for another two, three, four years? I don’t feel that lucky. And the nightmare scenario, which I think is low likelihood, but not zero, is the scenario of there is rampant outbreaks in Brazil or somewhere else. And there is a new variant that essentially renders our vaccines useless. Likely, no. Possible, yeah. And imagine that happens this fall. We’re all vaccinated. Life is back to some version of normal. And this variant will find its way to the United States. And we’re all sitting ducks. And then we have to go and formulate new vaccines and test them and then make hundreds of millions of doses and get them out to people. And it’s hugely disruptive, costly, people will die. And all unnecessary if we took a really aggressive global vaccination strategy. And we’re not doing that. No one is taking it as seriously as they need to. I think we can get a large chunk of the world vaccinated in 2021 into early 2022. But we need a totally different approach on the global scene than we are taking right now.
To add to this with some numbers, so the Think Global Health Project of the Council on Foreign Relations, they estimate that only 14 percent of low income countries have vaccinated anyone at all, anyone as of March 4. So that’s really bad, actually. That’s really, really bad. To what you were just saying then, what are the biggest chokeholds in getting low income countries vaccinated? Is it supply? Is it distribution? Is it money? When you say we need to take this more seriously, what does that mean?
It’s supply. I think countries can figure out distribution. Look, a little bit of distribution help will be necessary in some places. But a lot of countries have fabulous vaccination programs. And they can vaccinate large chunks of their population very quickly. Problem is they just don’t have vaccines. You know, so countries have pledged — the U.S., thankfully, under President Biden has pledged $4 billion into Covax, which is the global vaccine program for Covid. The problem isn’t money we might bump into. The problem is that the rich countries, the high income countries, have bought up about 90 percent of all vaccine supplies for the world. And Canada has enough in contracts to vaccinate every Canadian, I don’t know, five or six times over. We probably can vaccinate every American multiple times over. This is not helpful. First of all, we don’t need to. And second, we need to think very differently about supply. So it’s not just that we’re hoarding, but we’re doing a little bit of that. It’s we’ve got to figure out how to make a lot more vaccine doses than we are making. And the one sort of simple, simplistic thing that people often say, “Oh, this is all about intellectual property and we should just take these patents and make them public.” It’s not about that. There aren’t that many companies that can make these things. They’re actually complicated to make. If you think about the Johnson & Johnson vaccine, it’s a live virus. It’s an adenovirus that you’ve injected some RNA actually into, and it’s got to be done incredibly well. There are companies that can do it. Merck can do it, which is why Merck is now going to make J&J vaccines. I think that’s great. But there really is a problem here of production. And what needs to happen, in my mind — I mean, we do need more money. But I think lots of people will be able to — will be willing to throw money at the problem and we have plenty of money to do that. What needs to happen is U.S. leadership. I think President Biden needs to bring the manufacturers throughout of the world together, probably along with W.H.O. and some of the other leaders of some other countries, and really think about, what do we need to do to substantially scale up production. How do we get more raw materials? Who else can make more? I think this is a harder task than it looks and we’ve got to take this on, because the current approach is going to take way too long, and it has horrible outcomes for people in those countries and big risks for everybody else.
What could the U.S. specifically do differently here?
I mean, one is certainly I would like to see America start to — once we get into June and we have like more vaccines than we know what to do with, we should start shipping them out to other countries. Like there’s no reason for us to be holding back vaccines once everybody who wants to be vaccinated has gotten vaccinated. I realize that’s a hard thing for the president to talk about right now, because Americans are still feeling like we need more vaccines here. But once we get into May, June I’d like to do that. I do want to see more pressure on really figuring out what’s happening with supply chains with these vaccines and production. I mean, in some ways, we almost need a global vaccine, somebody who works out of the White House and is focused on both ramping up of production and distribution of vaccines around the globe.
I think it’s a good place to end with your application for global vaccines are. So I assume they’re listening at the White House. [LAUGHTER] Let’s go to some book recommendations here before I lose you. So what’s the book that has most influenced how you think about public health?
Well, I have to tell you, a book I just read — it came out a couple of years ago. Not a public health book, but it certainly has made me rethink public health, which is — and I’m blanking on the name of the author, but the book is called like wars. It’s about kind of social media and wars, information wars in the social media age. And the reason I found that so profound in the way it shaped my thinking, is I really saw, before I read that book, as misinformation as like some version of your Uncle Bob sends you a link to a story that’s junk news, and you’re like, eh, Uncle Bob’s always showing that kind of stuff. But what I’ve come to realize is that the information pollution in our kind of information ecosystem, so much of it is so deliberate. So much of it is well orchestrated. And it has had a profound impact on the way I think about public health, public health messaging, public health communication, because you realize you’re not just trying to counter people who are ignorant, you’re actually trying to counter people who are very deliberately trying to undermine public health messages. And so even though this was not a public health book, per se, it certainly shaped the way I have seen the world, and not necessarily made me all that much more optimistic. It’s made me realize what we’re up against.
That is “LikeWar,” just for the authors. It’s by Emerson Brooking and P.W. Singer. It looks super interesting. Favorite book that has nothing to do with your work?
So I reread a book I read in college, that I loved when I was a college student and loved it even more. It’s “The Autobiography of Malcolm X.” And it was interesting because I read it as 19-year-old Indian-American kid having this huge identity crisis. Am I Indian? Am I American? How do I reconcile these things? And found the book to be kind of profound in how it shaped my sense of personal identity. And I reread it recently because obviously, with our national conversation kind of restarting, in a very different way about racism, systemic racism in our country, even though it’s an old one, I thought worth revisiting. And it really is quite impressive in how timely and how relevant it feels in 2020, 2021.
And finally, you’ve got three kids. What’s your favorite children’s book?
The hungry, hungry caterpillar who ate everything. That was the book that we, like — from my oldest, that was the book we went to like every night. We would read other stuff and then we would finish with the hungry, hungry caterpillar.
Dr. Ashish Jha, thank you very much.
Thank you. This was a lot of fun. [MUSIC PLAYING]
“The Ezra Klein Show” is production of New York Times Opinion, it is produced by Roge Karma and Jeff Geld. It is fact-checked by Michelle Harris. Original music by Isaac Jones and mixing by Jeff Geld.