How America’s Covid-19 Nightmare Ends

On Jan. 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 piece people point to as an overreaction.” Today, that column, thankfully, does look like alarmism. Cases fell, and kept falling, even in places beset by new variants. The U. S. vaccination effort accelerated. And there’s going to be vastly more vaccine supply in the coming months. Few emotions are as unnerving right now as hope. No one wants to permit themselves optimism, only to be crushed when death tolls rise. But the case for hope is strengthening. And there are important policy reasons to take that case seriously. Dr. Ashish Jha is a physician, leading health policy researcher and dean of the Brown University School of Public Health. He’s been one of the clearest and most thoughtful voices through this crisis. And he’s feeling hopeful, too. So I asked Jha on the show to guide us through these next months, to help us see what he’s seeing. Don’t get him, or me, wrong: This isn’t over. But in America, things are going to feel very, very different in 45 days, for reasons he explains. And then comes another question: How do we make sure the global end to this crisis comes soon after? A note: This episode was recorded before President Biden’s March 11 address directing states to make all adult Americans eligible to receive Covid vaccines by no later than May 1; however, the timeline Jha and I discuss here is just as ambitious and its implications are just as promising. This is one Covid discussion, finally, that is not going to leave you feeling in despair. Recommendations: "LikeWar" by P. W. Singer and Emerson T. Brooking "The Autobiography of Malcolm X" by Malcolm X and Alex Haley "The Very Hungry Caterpillar" by Eric Carle You can find transcripts (posted midday) and more episodes of "The Ezra Klein Show" at nytimes.com/ezra-klein-podcast, and you can find Ezra on Twitter @ezraklein. Thoughts? Guest suggestions? Email us at [email protected]. “The Ezra Klein Show” is produced by Rogé Karma and Jeff Geld; fact-checking by Michelle Harris; original music by Isaac Jones; mixing by Jeff Geld.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:06Ezra Klein?

  I'm Ezra Klein and this is the Ezra Klein Show.

• 0:18Ezra Klein?

  On January 28th, 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 piece people point to as an overreaction." It was, it was not an optimistic column, though the point was that the new coronavirus strains that were circulating in the US, 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

• 1:01Ezra Klein?

  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 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.

• 1:44Ezra Klein?

  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 in countries that don't have big vaccination programs, including countries with very different weather and policy equilibriums. Meanwhile, in the US, vaccinations have really picked up. We're getting more than 2 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...

• 2:25Ezra Klein?

  Wow. And the supply of available vaccine is about to open wide in America as Johnson & Johnson ramps up and Pfizer and Moderna expand production and the American Rescue Plan is passing with its tens of billions of dollars for vaccine distribution. Like, there is real reason to be hopeful right now. And I say this as someone who is really pessimistic, you know, at the end of January, particularly in the United States, there is a path right now, there is a path out of this, of 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

• 3:10Ezra Klein?

  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 is 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've followed him on

• 3:52Ezra Klein?

  Twitter over the past year at @ashishkja, 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 US 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, that is not going to leave you feeling despair. As always, my email is [email protected]. Always interested to know who you'd like to see on the show next. So send me your guest suggestions. Here we go.

• 4:34Ezra Klein?

  A month or two ago, I wrote this really dire column, warning that with the new variants 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?

• 4:49Speaker 01

  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 to 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've 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, it was 15 degrees and snowing.

• 5:33Speaker 01

  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.

• 6:13Ezra Klein?

  But is one takeaway here, that the variants are not as horrifying as some of the early reporting led us to believe? I mean, you have the B.1.1.7 variant, which is more contagious. You have the South Africa variant, which has at least some, creates some challenges for the vaccines. You have a Brazilian variant, there's 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.

• 6:43Speaker 01

  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 and 60% 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, fourfold increase in cases. And so I think all of us were looking at the US and saying, if we see a fourfold increase, even if we're at 70, 80,000 cases a day, fourfold is awful. It'll be much worse than any moment of the pandemic.

• 7:28Speaker 01

  This is why I think people like Mike Osterholm, Mike 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. It's 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, no, at this point, probably about

• 8:11Speaker 01

  close to 30% of Americans have been infected from this virus, some between 25 and 30%. And now we have another 10 to 20% 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.

• 8:35Ezra Klein?

  So I want to talk a little bit about vaccination, but I want to, I want to start with some of the subgroups that are getting vaccinated. So I saw the number just yesterday that now 50% of Americans over age 75 have at least one dose of, of the vaccine. Numbers are similar, although a little bit lower for, for Americans over age 65. And so if we get to a place in a couple months where the, 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, a lot less death and a lot less hospital overwhelm?

• 9:16Speaker 01

  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, in 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,

• 9:59Speaker 01

  if the infection numbers get bad enough, you know, you will see a proportion, a chunk of them getting hospitalized. And that'll 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.

• 10:25Ezra Klein?

  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, who wants a vaccine at least, like, I actually shivered. I, I got emotional. That's an extraordinary thing to say. But then I feel, and I'm, 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, 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

• 11:09Ezra Klein?

  the end of April, I would have sobbed.

• 11:13Speaker 01

  Yep. Oh, it's amazing. The tight rope 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 you know, 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 like somewhere around that.

• 11:37Ezra Klein?

  Damn it, Ashish.

• 11:38Speaker 01

  Right? You promised April 30th and it's May 4th. 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. I'm not sure he's listening to me,

• 12:17Speaker 01

  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 gotta be careful? It's a tough, tough act.

• 12:40Ezra Klein?

  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 gotten way, way better on what it's doing. Like I really like it's, 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, the population is vaccinated, we're going to, you know, open everything back up. And I've been thinking about whether there's a real mistake being made among some

• 13:24Ezra Klein?

  public health officials, I think among some liberal office holders who are so afraid for very reasonable reasons of going too 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 gotta hold on till May. Like by May, we really 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

• 14:07Ezra Klein?

  a clear set of benchmarks and narrative of success among the office holders taking this very seriously.

• 14:15Speaker 01

  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 gonna feel like life gets better and better and better. There will be things that'll 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 gonna be later, right? And I would, I mean, you can have that 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

• 14:57Speaker 01

  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, you know, 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, in those classes, everything is small group, in person, right? Because maybe the 500-person lecture is just not necessary. I'm not sure it was ever all that great. But my point is, there

• 15:40Speaker 01

  are some of those changes that are gonna come about in terms of the pandemic, that we're gonna live with. And that might be, that might not be the worst thing in the world.

• 15:49Ezra Klein?

  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?

• 16:20Speaker 01

  Absolutely. And so there are two parts to that question in my mind.

• 16:22Ezra Klein?

  Thank you.

• 16:23Speaker 01

  No. Yeah, absolutely. And the question is when? And I would say, you know, it depends a little bit, but somewhere probably over the summer, maybe early fall, but maybe, maybe summer. And let me just say, like the way, if somebody called me from, 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 gonna 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 five bucks and you just throw it in as a part of, I was thinking about this for musical concerts. It's part of that, you know, part of the thing.

• 17:08Speaker 01

  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.

• 17:28Ezra Klein?

  So it doesn't sound, when I talk to her, to be honest, that you're saying, we're 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.

• 17:57Speaker 01

  Absolutely. If your normal is 2019, we may never get there. If your point is what's, 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, I, as a public health guy, I feel like I got 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 could 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.

• 18:42Speaker 01

  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.

• 18:57Ezra Klein?

  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

• 19:39Ezra Klein?

  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, like, 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 okay? Because okay is not perfectly safe. Okay is something like life, which is a risky enterprise.

• 20:17Speaker 01

  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 that this like there's there no, the CDC just put out guidance saying vaccinated grandparents can hug their unvaccinated grandchildren. And literally, I was praising this, I said, it's exactly right. And somebody asked me, they said, well, can we be 100% 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% and someone might still get sick and die. And the answer is, yep, like, there is still that theoretical risk.

• 20:57Speaker 01

  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 how 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 often talk 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.

• 21:42Speaker 01

  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 2020, 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.

• 22:42Ezra Klein?

  So I want to talk about what we're learning about the vaccines. 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?

• 23:09Speaker 01

  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 you, if there's a one in a million event, you still see 60 of them, right? So that's part of the challenge is that you, we should be seeing the rare events, especially given how hyper vigilant 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%.

• 23:54Speaker 01

  I have not seen clear data that people who've 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%. Israel's got the best data of people in real life who've been vaccinated. And the key here is to, is to look at people after they've been fully vaccinated, right? So if you look at them in like 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've been from COVID out of a sample of 600,000 people who got vaccinated. So if we're talking about like less than 10 in each of those buckets, those are pretty small numbers.

• 24:39Ezra Klein?

  So I just want to say this here because the human mind and big numbers and small numbers, it all gets all that's incredible. Actually, that I mean, as I understand a lot of vaccination data, that's an incredible level of effectiveness.

• 24:51Speaker 01

  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.

• 25:13Ezra Klein?

  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 US is going to be like nothing we've seen on to this point. Is that what you're hearing? And why is that?

• 25:36Speaker 01

  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 couple of things have gone into that. One is some of it was kind of built into the system, right? Operation Warp Speed, pre-purchased a bunch of vaccine doses, worked on 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 that's the 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

• 26:21Speaker 01

  the manufacturers to say, can you do any more on supply in the short run and have worked on 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 like actually in the Pfizer vaccines 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 like went and did a bunch of stuff to make that much easier. So now like one little fix gives you a 20 to 40% bump in your supply because you can just get more doses out of each file. So a combination of a bunch of small things and a couple of big things, Johnson and Johnson coming online.

• 27:06Speaker 01

  We are going to have a lot of vaccines into April. I mean, by May, we're going to be like swimming in vaccines.

• 27:13Ezra Klein?

  I've never, I've never thought I wanted to be swimming in vaccines, but actually it sounds good the way you say it.

• 27:18Speaker 01

  That's nice, right?

• 27:19Ezra Klein?

  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?

• 27:29Speaker 01

  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, and that'll just mean a lot of people are actually signing up and getting vaccinated.

• 28:06Ezra Klein?

  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 of higher risk tolerance, approve AstraZeneca, all get Johnson and 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 the world look different? You know, let's call it six months from now, if we have 60 or 70% immunization versus 90% immunization because we haven't gotten over hesitancy.

• 28:46Speaker 01

  It looks pretty different is the point. And so I've been doing a lot of kind of, you know, talking to, 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. And if 80, 90%, 90% of people on campus are vaccinated. It's gonna look great, close to normal. The problem is, there's a big drop off when you go from ninety to sixty, 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, like, especially in certain communities where it might be even lower,

• 29:27Speaker 01

  like fifty percent, because as you know, it's in pockets, this, and it's not randomly distributed. You're gonna have places with big outbreaks. You're gonna have places where hospitalizations are gonna get full. You're gonna have to sort of think about our national testing strategy in a very different way. There will be things that'll be hard to do. And those people who are vulnerable and infected will be coming all the time and walking into communities with ninety percent vaccination, but then start, you know, sort of setting off little fires, which will kind of eventually burn out, because at ninety percent vaccination, things are great. But I really worry about this patchwork nation that we're gonna see. If the national number is like sixty to seventy percent.

• 30:07Ezra Klein?

  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, you know, most of those people just don't want to be early adopters of this. They wanna 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 gonna be more comfortable. And you're just dealing with a lagging, a lagging level of comfort. What do you think?

• 30:38Speaker 01

  So I think it's both. I think there probably are ten, fifteen percent of the people in this country who are not gonna take the vaccine almost under any circumstances. And we can talk about, like, what circumstances they might take it in. But then there's another fifteen, twenty 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 aren't just going to wait. They're going to see all their friends and family get vaccinated. Everybody's doing fine. No one's, you know, having horrible outcomes from the vaccination and they will take the plunge.

• 31:18Speaker 01

  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% lagging group, as you say, over the because they're just going to decide that the inconvenience of not being vaccinated isn't worth it. And they'll get vaccinated. I hope I'm right that the hardcore group is more like 10 to 15% and not bigger than that.

• 31:52Ezra Klein?

  We've used the terms efficacy and effectiveness a couple of different times. Can you just quickly go through the difference between them as related to vaccines?

• 31:59Speaker 01

  Absolutely. And we use this for vaccines, for therapeutics. What I say simplistically to like my student says 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% 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.

• 32:41Speaker 01

  There's always a drop off between efficacy, that kind of ideal world setting and effectiveness, the real world setting.

• 32:48Ezra Klein?

  I want to talk a little bit about the vaccines and the differences or lack thereof between them. And in particular about Johnson and 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 here is it is 72% efficacy. But is that the right number to look at? Or are people, when they say, well, that's 72% effective? Are they looking at the right thing?

• 33:12Speaker 01

  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 and J and compare it to Moderna and Pfizer. And for a couple of reasons that are like simplistic and then a couple that I think are more important. So the simple ones are J and J has actually been, it was tested in Brazil and South Africa. Moderna and Pfizer were. So the 66% overall number for J and 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?

• 33:56Speaker 01

  What if we just focus on the US numbers? It does look like J and J numbers are a little bit lower. J and 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, with infected people much more often than if the level of an 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 and J from, again, we're talking about symptomatic infections.

• 34:41Speaker 01

  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 1351 that people worry a lot about. J and J was tested.

• 35:05Speaker 01

  Nobody in the vaccine arm of J and 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 like, there's a lot going for the J and 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 and J against these variants than we do with Moderna and Pfizer. J and J is 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.

• 35:46Ezra Klein?

  Well, there's another, another thing here, which is that J and 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 and 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, at one. How do you think about the one dose versus two dose protocols?

• 36:10Speaker 01

  So in early January, I wrote an op ed with my colleague, Bob Walker, basically saying, delay the second dose of Moderna and Pfizer because we have 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 argue that the one dose has a efficacy number that's like 80, 85% looks really good. Let's do that. And people got very upset. 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, you know, ordained

• 36:48Speaker 01

  by God. Like, 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, you know, two doses probably are a little bit better. And we'll have data on two dose Johnson and Johnson at some point, maybe over the summer. And people who got the one dose of J and J maybe 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 some like preordained reason to think that one should be a two dose, one should be a one dose vaccine.

• 37:30Ezra Klein?

  One of the things I'm worried about, I've heard a lot of people who are hesitant about J and 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 and 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, 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 50% of patients fail to get their follow-up shot within the first year. About 3 million Americans so far haven't received their second COVID vaccine dose on time. So is there an argument that J and J is in some ways the better protocol for the kind of mass vaccination we need to be doing?

• 38:16Speaker 01

  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 is got so much simplicity built in. 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 of against symptomatic disease, not against serious disease, not against severe disease, but against mild or symptomatic disease, is worth the cost.

• 39:00Speaker 01

  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 and J will end up being a really important part of our toolset for getting people vaccinated.

• 39:10Ezra Klein?

  Right now, the best estimates hold that we're not going to have a vaccine approved for children, and there are a lot of children, they're like 20% of the population, until late this fall, maybe early 2022. Why is that taking so long?

• 39:24Speaker 01

  Yeah, it's a great question. And actually, you know, 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 it, and he made some really important points. So the fundamental issues, 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

• 40:02Speaker 01

  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 nine 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 of 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,

• 40:46Speaker 01

  Ezra, it's really easy to run clinical trials in the middle of large outbreaks, because there are 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 in 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.

• 41:28Speaker 01

  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.

• 42:10Speaker 01

  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 this 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 we that we know how to measure the correlates of immunity? That we know which antibodies, which T cells really confer protection? And 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.

• 42:52Speaker 01

  And then the FDA is going to have to be comfortable authorizing it for children, saying it generates this correlate of immunity, and therefore it's good enough, and of course, that it's safe.

• 43:21Ezra Klein?

  So CDC Director Rochelle Walensky recently outlined new guidance for people who have been vaccinated. Can you walk me through like 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?

• 43:36Speaker 01

  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. It's always tricky. There's 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 masks, no social distancing. Really, really, really safe. No, 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.

• 44:16Speaker 01

  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 CDC 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 are not, 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, you know, a vaccinated person, can you go socialize with large groups of unvaccinated people?

• 45:02Speaker 01

  And CDC on that one said, no, not yet. And what they're doing is they're balancing, obviously, people's like 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 a, you know, 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 CDC said you should probably not be doing that right now.

• 45:47Ezra Klein?

  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. I am I describing this correctly in its magnitude?

• 46:19Speaker 01

  Yep, 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? And if you're with a low-risk person, it's unlikely and the consequences are not huge. Go for it.

• 46:34Ezra Klein?

  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?

• 46:51Speaker 01

  Absolutely. And one of the points, like some, 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.

• 47:11Ezra Klein?

  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 could 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?

• 47:45Speaker 01

  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 fifty-five, and I want anybody under fifty-five 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 get, ideally, obviously, with Johnson & Johnson, that's good enough. But what I really want is ultimately two doses and two weeks after their 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, you know, most of them will get to two weeks after.

• 48:26Speaker 01

  That's a point where the vulnerable people in our society are pretty well-protected, and you can start peeling back. Again, gotta be careful a little bit. I, 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 these folks are vaccinated. I think restaurants can go to a pretty high level of capacity. Hundred percent is a little tough, because you are gonna still have some number of unvaccinated people walking around. So you can imagine a ramping up, or just, let's say, like, pulling back of public health restrictions that begin in the latter part of April.

• 49:11Speaker 01

  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 sixty, seventy 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 gonna get infected, and a bunch of them are gonna die. And anybody who got infected and died, like, now, is somebody who's gonna get vaccinated in a month. Like, just hold a little longer.

• 49:51Ezra Klein?

  You know what it feels like to me is, I don't know if you've read many like histories of old wars, but particularly before we had instantaneous global communication, you would 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 gotten to 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 that 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 there, it's not that it's any less of a tragedy for a person to die a couple

• 50:32Ezra Klein?

  months ago than it is now, but it feels so unbelievably useless for somebody to die three weeks before the vaccines would have taken hold.

• 50:42Speaker 01

  Yeah. And useless, frustrating, and like, we know this. This is not, you know, these are not uncertainties of, oh, my God, we have no idea when vaccines will get out. We know exactly when they're gonna get out. We know exactly when people are gonna 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.

• 51:07Ezra Klein?

  So we've been talking a lot about the US 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 US?

• 51:21Speaker 01

  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 on 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% 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.

• 52:02Speaker 01

  And 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, you know, 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,

• 52:46Speaker 01

  but not zero, is the scenario of there's, you know, 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.

• 53:25Speaker 01

  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.

• 53:49Ezra Klein?

  To add to this with some numbers. So the Think Global Health Project of Council on Foreign Relations, they estimate that only 14% 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 of 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?

• 54:19Speaker 01

  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. The problem is you just don't have vaccines. You know, so countries have pledged, the US, thankfully, under President Biden, has pledged, you know, and the $4 billion into COVAX, which is the global vaccine program for COVID. The problem isn't money in my mind. The problem is that, you know, Canada has enough in contracts to vaccinate every Canadian, I don't know, five, six times over. We probably can vaccinate every American multiple times over.

• 55:01Speaker 01

  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, that 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.

• 55:46Speaker 01

  There are companies that can do it. Merck can do it, which is why Merck is not 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 US leadership. I think President Biden needs to bring the manufacturers around of the world together, probably along with WHO, some of the other leaders of some other countries, and really think about like, 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

• 56:28Speaker 01

  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.

• 56:42Ezra Klein?

  What could the US specifically do differently here?

• 56:45Speaker 01

  I mean, one is certainly, I would like to see America start, 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 for these vaccines and production. I mean, in some ways, we almost like need a global vaccine czar, somebody who works out of the White

• 57:24Speaker 01

  House and is focused on both ramping up of production and distribution of vaccines around the globe.

• 57:32Ezra Klein?

  I think it's a good place to end with your application for global vaccines czar. So I assume they're listening up in the White House.

• 57:40Ezra Klein?

  Let's go to some book recommendations here before I lose you. So what's a book that has most influenced how you think about public health?

• 57:47Speaker 01

  Huh. Well, I'll 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...

• 58:10Speaker 01

  Profound in my and in the way it shaped my thinking is I really saw before I read that book as of misinformation as like some version of, you know, your Uncle Bob sends you a link to a story that's junk news and you're like, ah, Uncle Bob's always sharing 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

• 58:52Speaker 01

  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, you know, 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.

• 59:16Ezra Klein?

  That is like war, just for the authors. It's by Emerson Birking and P. W. Singer. It looks super interesting. Favorite book that has nothing to do with your work?

• 59:24Speaker 01

  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 a nineteen year old Indian American kid, having this huge identity crisis of 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, you know, in a very different way about racism, systemic racism in our country, even though it's an old one, I thought

• 1:00:07Speaker 01

  worth revisiting. And it really is quite impressive in how timely and how relevant it feels in 2020, 2021.

• 1:00:18Ezra Klein?

  And finally, you've got three kids. What's your favorite children's book?

• 1:00:22Speaker 01

  The Hungry Hungry Caterpillar, who ate everything. That was the book that we like, for my oldest, that was the book we went to like every night. We would read other stuff and then we would finish with Hungry Hungry Caterpillar.

• 1:00:34Ezra Klein?

  Dr. Ashish Jha, thank you very much.

• 1:00:36Speaker 01

  Thank you. This was a lot of fun.

• 1:00:47Ezra Klein?

  The Ezra Klein Show is a production of New York Times Opinion. It is produced by Roche Karma and Jeff Geld. It is fact checked by Michelle Harris. Original music by Isaac Jones and mixing by Jeff Geld.