Ashish Jha: On the Delta Variant, Vaccines, and where things to stand

July 28, 2021 (Episode 195)

Taped July 27, 2021

Table of Contents

I: The Delta Variant and Vaccines (00:15 -24:58)
II: Outlook for the Fall and 2022 (24:58 – 1:09:55)

I: The Delta Variant and Vaccines (00:15 -24:58)

KRISTOL: Hi, welcome to CONVERSATIONS. I’m Bill Kristol, and I’m very pleased to be joined again today by Dr. Ashish Jha, Dean of the School of Public Health at Brown and a guest on Conversations in December and February, where you were uncannily correct, I would say, about the course of the pandemic and what was about to happen. And especially in February. I recommend both conversations because they’re models of how to think about public health issues, I think in addition to being a very sharp analysis of the moment we were in.

But in February you said you thought we’d be up for fairly normal summer, I think you might’ve even said, and you were ahead of the curve in that prediction, and I think vindicated.

But anyway, thank you for joining me again today on July 27th, let me just get the date down, so people know when we’re speaking. And where are we, and where are we going? And what are the options ahead and so forth?

JHA: Yeah, Bill. So I’ve really enjoyed both of our conversations before, and I was delighted to get back together. And partly because, when I was sitting here with you in February and looking out at the next few months, I could see a pretty clear path to where things were going. And applying what we knew about the virus, what we knew about the vaccines, one could make some pretty reasonable predictions about how infection numbers were going to plummet as we got through the spring and summer, and we could feel pretty confident that we were going to have a normal summer. And I feel like that largely worked until it didn’t.

And all of the sudden here we are, I would say about three, four weeks ago, so right in the beginning of July, I started feeling nervous that things were heading in the wrong direction.

And here we are on July 27th, and it’s very clear that we have some challenges in front of us. So let’s just be very explicit about what those challenges are and what they mean.

I think there are three things that have surprised me, or let’s just say weren’t part of my mental model in February, whether they were surprising or not, we can talk about actually. One is the Delta variant, it didn’t exist as far as we know in February, and it certainly did not become prominent in the United States until June or July.

And the biggest thing about the Delta variant that I think has been a bit of surprise is just how contagious it is. It is way more contagious than any variant of this virus, and that really changes things. And it changes things in terms of how much population immunity you need. It changes things in terms of what the breakthrough infections are for the vaccinated. And that wasn’t really part of our mental model, a super, super contagious version of the virus. That’s number one.

Number two is I did not expect that a large minority of the American population would not be interested in taking a vaccine that was as good as these vaccines are and that came at the end of what was a horrible year. I thought everybody was just done, let’s move on. And my assumption was everybody was going to get vaccinated. Five, 10% of people might refuse, but if we got to 90 plus percent, I thought, “It’s fine, we’re going to have this pandemic largely dealt with.”

And then the third part where I will say that it’s still a bit preliminary, but we are starting to see some data around the durability of the vaccines, at least as far as preventing breakthrough infections. And this is preliminary data from the UK, preliminary data from Israel, maybe a little data from the US, that as you get six, seven months out of vaccinations, you start seeing some more breakthrough infections, particularly in elderly people. And the reason that’s important, because obviously it’s important for those people, but it’s also important in the sense that the — The mental model was vaccinated people will prevent forward transmission. Once you’re vaccinated you’re not going to be somebody who’s going to spread. But if you start seeing a lot of breakthrough infections, then that mental model also changes a little bit.

Those three things, a much more contagious variant, fewer people vaccinated, and now some waning immunity means this is a very different situation than we thought we were in a few months ago.

And again, I can talk about whether they should have been predictable, in some ways they could have each of them been predictable, but that means the next few months are going to be pretty tough. A lot of Americans are going to get infected. A lot of vaccinated Americans are going to get infected. Most vaccinated Americans are going to do extremely well, the unvaccinated Americans are not going to do extremely well. And we’re in for a bumpy few months.

KRISTOL: So maybe just disentangled those things briefly, and then I want to look at the current moment and then look ahead at the choices we face, how much we can affect this future, which looks bumpy at least, as you say? If there were no Delta variant, or if the Delta variant were just like the previous ones, how serious a problem with 30% of adults not being vaccinated be? And I guess, conversely, if — Well, so which of those two is the key factor that’s causing us all to become much more nervous? And not just nervous, this isn’t just psychological, but actually seeing pretty big upticks in hospitalizations and so forth, especially in some places.

JHA: Yeah. It is really the combination, right? So imagine that we still have the old variant, the Alpha variant, which was pretty contagious, but that one at 30, 35% of American adults not being vaccinated, it wasn’t going to be great. We would have seen some increases in infections, but we wouldn’t have seen what we’re seeing right now.

And what’s really interesting is we’re seeing increases in infections in all 50 states. And as you know, that 67, 68% of American adults with at least one shot, that’s not evenly distributed. I mean, in Vermont, it’s in the 80s, and in Mississippi, it’s in the upper 30s, low 40s, right? So large variations, but I think we still would have had a pretty okay summer in large parts of the country, everything indoors would have been pretty darn safe. The problem is that the Delta variant’s contagiousness makes the 30% unvaccinated just too much of a risk for everybody.

KRISTOL: And for those of us who are total layman, I mean, how much more contagious is “more contagious,” if you know what I mean?

JHA: Yeah, there are different ways of thinking about it. So if you start with the original strain, the original Wuhan strain from last year, from 2019, 2020, the Alpha variant, which was the one originally from the UK, B117, that was a super contagious variant. If you remember back in March, April, we were like, “it’s a race between the variant and the vaccine.” We were trying to beat the Alpha variant. And that we thought was 50 to 70% more contagious than the original Wuhan strain.

This one is, and again, people have different numbers, kind of in the 60 to a hundred percent more contagious than the Alpha variant. All right, so what does that all mean? And how do you think about it? There are a couple of ways of thinking about it. One is, if you look at the amount of virus in the nose, throat of a patient with Delta variant, it’s about a thousand times more virus than what we saw with the previous strain. So it’s a lot more with a much higher viral load.

Another way people think about this is where the original Wuhan strain virus, the average person might have infected two or three people, about three people. The Alpha, we thought the average person infects four to five. The Delta variant now, the average person may be infecting six to eight. And if you think about exponential growth, 1, 3, 9, 27, 81, that’s pretty substantial growth. 1, 6, 36, three, four generations of spread and it’s massive, you just get to much higher numbers, much, much faster with the Delta variant.

So from a clinical and public health point of view, it’s a lot. This is not like, “Oh, it’s a little bit more contagious.” It’s a lot more contagious, it’s a lot bigger problem.

KRISTOL: Yeah, I’m not sure people have fully internalized that, they have a sense of it. And so obviously among the unvaccinated, it has exactly what you just said, a kind of exponential ability to really sweep through unvaccinated populations.

JHA: And if you think about it, unvaccinated people tend to cluster together, they’re in families or in communities that are largely unvaccinated, and that’s why we see these explosive outbreaks in those communities.

KRISTOL: And for the vaccinated, it sounds like also, what once would have been, I at least thought, I understood, very small odds of getting infected if you were vaccinated, if you were having lunch with an unvaccinated person. Even a person you wouldn’t have known whether or not he was infected, but even if you were — I remember one physician saying the whole point of the vaccine is not to protect you from other people who are vaccinated, it’s to protect you from people who are infected, right? And people were pretty confident about that protection. How much more worrisome is now that the vaccine is just not able to knock down this strain nearly as easily?

JHA: Yeah. And the way to think about the vaccine, and I’ll give you an analogy of how to think about this vaccine, because this will get into waning immunity issues as well, is the vaccine has, essentially think of it as, it’s an army, and it has two kind of main things. It has the antibodies, which are your active forces. They’re the ones that would protect you from getting infected. Then you have your reserves, the T-cells and the B-cells, and they kick in once an invasion has happened, once you’re infected.

Your T-cells and B-cells are still doing fabulously well with the Delta variant, that’s why we’re not seeing a lot of hospitalizations and deaths among vaccinated people. But the problem is when the amount of virus that shows up is just much, much larger, because of this huge viral load, your antibodies can get a bit overwhelmed and that’s why we’re starting to see more breakthrough infections: you just don’t have enough antibodies and they do wane over time. And that’s why we’re seeing more breakthrough infections.

How many more breakthrough infections? It’s actually hard to tell because the CDC isn’t tracking it. This is one of the areas where I think the CDC has really fallen down on the job, is we should be tracking breakthrough infections to figure out how much is this happening. We don’t really know.

So we can look at some data from Israel, which has done a much, much better job, and see that the breakthrough infections are happening at a higher clip. But again, even from Israel, the data says that people who have intact immune systems, they’re not getting super sick, they’re not dying at nearly the rates. I mean, just 90, 95% protection against hospitalizations and deaths.

KRISTOL: So yeah, it seems like the hospitalization, death story remains a good one, to put it that way, for the people who’ve been vaccinated. But, this may be a stupid way of asking it, but what are the kind of orders of magnitude, how much more are we at risk with the Delta variant than we would have been if we were vaccinated? I mean, are we’re going from 1% chance if you go into a restaurant to a 2% chance of something bad happening? Stipulating that the bad, thank God, is not at all likely to be nearly as bad as the bad would have been pre-vaccine. Or are we going from 1% to 10%, 50 — Does anyone have a sense of —

JHA: Yeah, it’s a good question. So here’s how I would think about it. So the way we usually measure these things, vaccine efficacy, is we say, “Well, what are your risks compared to if you were not vaccinated?” So you’re having lunch with your friend indoors at a restaurant, your friend is unvaccinated and infected, what would your risks be if you were unvaccinated of picking up the virus from your friend, and then how much does the vaccine knock it down? And we think based on the best data that your vaccine knocks it down about 80, 90%, so that’s pretty good.

The problem is that when there’s very little infection in the community, it’s fabulous. But when you imagine that you’re having lunch with an infected friend every day, one of those times —

KRISTOL: If the denominator is much larger, the 80, 90%, is much larger. Did I say that right?

JHA: Yeah, it’s 80, 90% of percent of Y.

KRISTOL: You know what I mean, yeah, yeah.

JHA: Yeah, yeah.

KRISTOL: And is it only that more people will be infected, or also that there’ll be infected more potently or however to say it, so that the odds of it penetrating the vaccine are a little greater?

JHA: We think the odds of penetrating the vaccine are a little greater. The part that’s less clear is, are you more likely to get severely ill than if you had gotten a breakthrough infection from the Alpha variant? We don’t think so, and again, that part remains unclear.

But it certainly is enough of a change, that I’ll be honest, from my perspective, in May and June, I had lunch and dinner indoors with vaccinated friends several times and felt very comfortable doing so. And in the last 10 days, two weeks, when a friend reaches out for dinner, I’m like, “Let’s see if we can find an outdoor place to have dinner.” Not because I’m worried, because all my friends are all vaccinated, but I don’t know that I want to be in a packed restaurant where other people may be unvaccinated.

And here’s why, and this is really important, because people say, “Well, what’s the big deal?” I actually have had colleagues who’ve had breakthrough infections, and one of them had fevers for about three days, 103, felt pretty lousy. About a week later he was mostly back to normal, but just felt like he was kind of wiped out for a week.

And my thought was, “I don’t want that.” If I could avoid a week of my life being wiped out by an annoying viral infection, I don’t want that. So it’s not so much that I’m terrified that I’m going to die or get hospitalized. It’s easy enough to avoid and there’s a lot of Delta starting to spread the country, I think I’m going to stick with mostly being outdoors for a little while until this Delta surge subsides.

KRISTOL: And then just one last thing on the percentages. So 70%, I mean, if it were 80%, would you have a radically different view of the next few months? Not that we can make it 80% immediately. Even if people showed up tomorrow they still have three or four weeks until it’s in effect. But 90%, what kind of numbers are you looking at on the — Since we can’t change the variant, I suppose. And the vaccine, and we should come back to this, it is the vaccine for now, at least, there might be boosters and so forth. The one thing we can change, I guess, well, the two things we can change is the percentage of people vaccinated and the behavior of both vaccinated and unvaccinated people.

But just on the percentage side, we’re not going to get to a hundred. So do you hit a tipping point or is it just, more is better?

JHA: More is better, but there is a point, it’s not totally linear and here’s how I think about it. So right now, I mean, it’s true that 67%, 68% of adults have one shot, but with the Delta variant, you really need both shots because that’s what offers full protection.

And the second thing is you got to look at the whole population, because kids become part of the equation. So right now about 50% of Americans are fully vaccinated, that’s kind of my mental model of where we are from a population immunity point of view, 50% of all humans in America, of all people.

Okay. I look at the 50% that’s unvaccinated and my best guess is about a third of those people, 35% have probably been previously infected, based on some CDC modeling data that’s probably about right. And even if I assume that all those people have full protection, which they don’t, by the way, if you’ve been previously infected and are not vaccinated, your risk is actually pretty substantial.

KRISTOL: I was going to ask you about that, that’s not quite — People like to talk as if that’s like being vaccinated, but that’s —

JHA: It’s really not. It’s really not. The data on that is very clear, it really isn’t as good as being vaccinated. But let’s say for a second that it was, that gets you to about 68% of the population having some immunity.

Based on the Delta variant and the analyses, most of us think you need to get to at least 85% population immunity, maybe closer to 90. So that’s not a crazy high number, we got to get another 17, 18 to 20% of Americans, all Americans vaccinated.

Whenever they release the new data on kids under 12, five to 12, that’ll help, that’ll immediately give us a few percentage points. But we really got to make a lot of progress on the remaining — We got to get a majority of the remaining population vaccinated, or it’s just not going to work. I suppose, if we got a majority of the remaining population infected that would help, but that’s a pretty horrible way to go.

KRISTOL: Right, and those people are not vaccinated so some of them will be seriously ill.

JHA: Exactly. But once we get to 85, 90% population immunity, this pandemic really comes to an end in the United States. Again, my mental model was once we get to 65 to 70% based on the alpha variant, and we’re basically there, but we need to be at a higher level now because the Delta variant is so much more contagious.

KRISTOL: Okay. So that’s very helpful. So I guess, let me now, so going forward, I guess the question would be absent any big change in people’s behavior, maybe some incremental continuing with vaccinations, where do we go and how do we look?

And B, and you can answer these in whichever order you want, kids, what are the prospects for the vaccine being approved for them? Because that does take a chunk of the humans as you say, out of the — off the unvaccinated onto the vaccinated side. Also has its own social consequences in terms of schools and all, which we can talk about a little bit later. And yeah, so where do we — The kids, but also if nothing much happens, I guess, what are we looking at?

JHA: Yeah. So one way to think about this is this virus, I mean, there’s a group of people, many of whom I respect, but I totally disagree with, who still are in the kind of zero COVID crowd. “Let’s just eliminate the virus.” The amount of social engineering and activity change you’re going to need to do that is A) beyond us and I’m not part of that crowd. I never have been.

So therefore we’re not eliminating this virus. Therefore, it’s going to become endemic in our society, it will just circulate around. And another way to think about it is all of us, every single American will encounter the virus up close and personal, and we all have a choice. Do you want to encounter it vaccinated or do you want to encounter it unvaccinated? And I’d much rather encounter it vaccinated.

But what happens is because it’s so contagious, we’re going to just, I think most people end up either being immune from vaccines or they’ll end up getting infected over time. I think there are going to be very few people who will end up — We’re going to get to 90, 95% even, but we’re going to do it either through vaccinations or through infection.

KRISTOL: Let me just interrupt.

JHA: Yeah, please.

KRISTOL: So what you’re saying, I think, I sort of lost my train of thought for a second before we just — That if you could pull the levers of vaccination on the one hand and behavior modification on the other, staying at home, masking, back to Zoom and so forth — that the behavior is less promising unless — given just the country we are and people need to make a living and a million other things and send kids to school. The gains one gets from re-masking or re-distancing are limited, it sounds like what you’re saying.

JHA: Yeah, And by the way I was pretty willing to call for masking and social distancing and all of that last year, because there was an end point, right? And the end point was wait for the vaccines. Let’s do these things until vaccines show up. And then the vaccines are the ticket out.

KRISTOL: Flatten the curve till we get the vaccines.

JHA: Yeah. And now the vaccines are here. Are we asking for people to do this forever? I’m not, I think it’s untenable.

And one of the things I think sometimes people in public health, I think don’t fully appreciate is that these things are really costly. We’re social animals. We want to see our friends and we want to see our families. These are not luxury things like, oh, I’d like to see my family sometime. No, no, no. I actually really want this meaningful part of my life. And I can forgo it for a year if it means that people stay alive and get vaccinated. So I am fine with very short term requests for behavior change, but it’s just not a realistic long term or medium term approach.

So what is, is getting people immunity. And I want to be very clear, everybody, most people in America will end up having immunity to this virus, not full 100% immunity, but some immunity to this virus. And the question for everybody really is, do you want to do it through natural infection? Or do you want to do it through the vaccine?

KRISTOL: And so on the — Whichever order you want, on the kids, how fast do you think we can get them vaccinated? And then the 30% of adults who aren’t, do you see more or less promise in different strategies to encourage, require, incentivize, would persuade them to get vaccinated?

JHA: Yeah, kids, I’m going to make some guesses. And these really are guesses. Five to 11 year olds. So obviously 12 and over right now can get vaccinated. Five to 11 year olds by the end of August, maybe middle of September, somewhere in that range, we’ll certainly have data. And then FDA will hopefully act reasonably quickly. So sometime in the early part of fall, let us say, that that’ll start happening. Kids five to 11 will start getting vaccinated.

Zero to four, I don’t know, it’s a different group. There are a very specific set of issues on the — And it wouldn’t be zero, it’d be six months to four years. And it’s a pretty small group and also they’re really low, low risk. So that may take more time, but I think five to — And by the way, they’re also pre-school age. So it doesn’t have any impact on schools. Therefore it doesn’t have impact on the ability of women and men to go back to work. So it doesn’t have the same labor market effects.

So I think in general, it’s the five to 11 crowd that we got to get vaccinated next. And I see that happening by early fall.

KRISTOL: Well, that’s encouraging, a little more encouraging than I realized. And I take it with our current system of distributing the vaccines it’s not that different for an eight year old than for me or you, and therefore it should happen fast once it’s authorized.

JHA: Yeah.

KRISTOL: There’s no practical problem of getting CVS to figure out how to do this again or something like that.

JHA: Exactly. And you can do it now. I mean, CVS still has their infrastructure. And then what’ll happen is —

KRISTOL: Schools.

JHA: These vaccines will start going out to pediatricians and pediatricians will start doing it. And that’ll happen. And kids have a lot of touch points with their pediatricians for all the wellness stuff and vaccinations. So I suspect that we’ll be able to move reasonably quickly on getting five to 11 year olds vaccinated. So I’m pretty optimistic about that side of things.

I’m sorry. You asked the second part on that —

KRISTOL: The second was sort of on the adults.

JHA: Yeah. Oh what to do with —

II: Outlook for the Fall and 2022 (24:581:09:55)

KRISTOL: Where are you on the mix of persuasion incentives, mandates, giving up and just accepting what’s going to happen, and sort of what do you think would work, might work? What are we not doing that we should be doing, et cetera?

JHA: Yeah. So a couple of things on this. So actually let’s talk a little bit about some of the things we should not be doing. There are too many people who have turned this issue into some sort of an identity issue. And by the way, this is a problem of the left and the right. But I think definitely on the left, there are a lot of people who are like, “Oh, the people who are hesitant are the Trump voters.” Or the — I find that totally unhelpful and not necessarily even true, but particularly unhelpful Bill, because if you’re a Trump voter, you say, “Oh, Trump voters don’t get vaccinated.” Like you’ve just tied vaccinations to their identity. And my question is, why are we doing that? Why is that a useful framework for anybody? So you’ll see me, whether it’s on social media or on television, I try to stay away from identity politics around vaccines.

I just don’t think it’s a useful way to look at vaccinations. And the truth is there are plenty of Trump voters who have gotten the vaccine, and it’s just, again, part of the problem is that there is an overlap between people who voted for our former president and where the misinformation that has been targeted has stuck. And you know that this goes beyond vaccinations to other areas of our democracy and all sorts of issues.

So it’s a broader problem, but I think from a public health point of view, keeping it away from identity is really, really important. And that means I was thrilled to see Leader McConnell come out and tell people that people should get vaccinated. It was great to see Sean Hannity tell people that they should get vaccinated. I have been trying my very, very best. I was on Fox News twice, yesterday and Newsmax the day before.

KRISTOL: Man, you’re a better man than I am, but that’s good, that’s good. You’re actually responsible —

JHA: No, it’s just, look.

KRISTOL: No, It’s important. I couldn’t agree more but getting the Republican governors and so forth to say it, that’s what’s more important than me saying it. “I got a dose so they should do it.”

JHA: Yeah.


JHA: They should do it. And Governor Kay Ivy of Alabama, she got a little mad at the unvaccinated, but I don’t know. I don’t get mad at people for where they are, but I think it’s really important for people to hear from her and from Governor DeSantis and others about this. That’s going to move the needle. So I think first of all, it’s great to have everybody talking about it.

I think that for me, one of the most interesting things on this was what happened with the Houston Methodist Hospital in Houston, Texas. So back, I’m going to get the dates wrong, but somewhere around April, they said, everybody’s got to get vaccinated in our hospital. This is in Houston, Texas. And there was a lot of pushback. And a lot of people said, 20, 30% of your workers are going to leave. And basically they have about 25,000 people who work there and 150 ended up leaving.

But basically more than 99% of people got vaccinated. And what it tells me is that — And by the way, this is borne out with other data that a lot of people who are quote unquote hesitant are just not sure, not quite ready, don’t know if it really matters, but if their job depends on it, they’re happy to get vaccinated.

KRISTOL: Totally.

JHA: It’s really not that big a deal. That’s been our experience. Now that’s in Texas. I work in Rhode Island. We have a mandate at our university. I don’t know, we’re still tallying the numbers, but we’re in the early or low to mid nineties. And I think we’re going to get to like 99%. A lot of quote, unquote, hesitant people, when you push them a little bit, they don’t cry foul. They don’t claim that this is a huge violation of their civil liberties, they just get vaccinated.

KRISTOL: And I think maybe I’m crazy with this, but I’ve been pushing this argument a couple of weeks, psychologically I think it’s easier for people if they’re somewhat hesitant. If their friends are telling them based on misinformation that, oh, it’s dangerous, all these negative effects. They don’t want to confront their uncle whom they see every Sunday and have to tell them that they chose to get vaccinated because then they’re sort of disrespecting him because he’s the one who has all this fake information that shows how dangerous it is.

The great thing about a mandate, I think this is true in life in general in some ways, it takes the burden off you. “I’m sorry, I had to do it. I’m in the military. And they told me I had to get vaccinated. I’m not giving up my career. I’m a nurse, I’m a physician, I’m a employee at this particular corporation. I had no choice.” It’s much better and much easier.

There was all that argument, do you respect the people who are vaccine hesitant or resistant? It’s more respectful of them in a sense to say, “Look, this is for the country’s sake, we all have to do it.” Than to say, “We’d kind of like you to do it, we’re really urging you to do it, we’re going to nag you to do it, we’re going to sort of berate you for not doing it. “That doesn’t —

JHA: No.

KRISTOL: Anyway, that’s my view. I’ve been very pro mandate for a while, but then you are too, I think. But is it happening and how much of a difference is it going to make?

JHA: I think it’s — So, first of all, I was one of the first people to start banging the drums on healthcare organizations doing it. And I have been pushing, pushing, pushing. And then just in the last few days, I feel like it’s shifted. All the major healthcare organizations have come out, American Medical Association, American Hospital Association, all of them have come out in favor of mandates. And now you’re seeing one large health system after another.

I think it’s going to make an enormous difference for two reasons. One of course, healthcare is a major employer. And so we’re going to get a lot of people vaccinated just for that. The second is symbolism. Every doctor, every nurse, every physical therapist, all of those people vaccinated, there’s a symbolic power there.

I think the same things are going to start happening at more and more universities.It’s been interesting watching universities because, universities are like the worst place for social distancing and masking. It’s just, if you think about kids, 19 year olds are going to show up to campus in a month. And they’re going to be like, if you don’t have very strong social distancing protocols, they’re going to spread the virus around like crazy. Because they’re 19, this is what they do. They go to a frat party and everybody’s drinking and it’s in a gym, I’m sorry, in a basement, it’s perfect for the Delta variant to spread. So universities that are actually bringing students back, but don’t have everybody vaccinated, I don’t understand what they think they’re going to be able to pull off here. I don’t see it. I think you’re going to — You’re just going to see large outbreaks in places and they’re going to have to send all the kids home and it’s going to be a mess.

So I think there’s only one responsible way to open up colleges and universities this fall. And that’s a lot of people who are in colleges, universities, and all the people who work there. So you’re going to see little, more and more sectors of the economy.

I talk to a lot of businesses, a lot of CEOs and kind of heads of human resources and their big question is, “Is there any way to do this and get workers back full time? Sure, let people work from home one or two days a week if you want, but largely full time back in the office without mandating a vaccine?” And I say, “Yeah, you got to reduce the number of people in there by a third or a half, make sure everybody’s wearing a mask, test everybody twice a week.” And they’re like, “For how long?” And I’m like, “Probably for the next few years.”

KRISTOL: Crazy. Yeah.

JHA: And they just look at me and think, no. I’m like, “Or you can just mandate a vaccine.” So I think that really resonates with people.

And I think companies are struggling on this because they think that somehow you can’t mandate while the FDA still has emergency use. And we can talk more about the FDA, and I tell them that’s not true. And I’m not a legal scholar, but that’s what the courts are finding that they don’t have to wait. But I do think that once companies start mandating this, it’s going to move.

And by the way, your point that you are making, I am very grateful for you making that point. I think it’s exactly right. That we always think of choices as this wonderful thing, but sometimes choice is a burden for some people. And sometimes you want to do something, but the social pressure around you makes it hard. And if we make it easier for people and ultimately people always have a choice, they can leave their job and go elsewhere. It’s not like we’re forcing anybody. I actually think it will help people feel better.

KRISTOL: I think universities saw in a way, what you’re saying somewhat earlier, and even though they’re normally liberal institutions that don’t like to impose too much, they were pretty forward leaning on this. I would say more than most parts of the country.

Corporations, I have the feeling that these sort of, if I can put it this way, white collar employers are coming to the view that you just articulated. I know that one financial firm in New York yesterday, quietly, HR sends out a note. Everyone has to be vaccinated. We just can’t have the system. They had thought a month ago, we can do it with some caution and some masks and 90% de facto will be vaccinated anyway, they just can’t. And now they’re going to ask people who are visitors for meetings also to show a card.

What about the really big, like I said, two questions. Let me ask my particular pet peeve, which is the military. I do think one thing that makes it hard for people to have a sense, has made it harder to convey. I think an important sense of urgency about this over the last few weeks, I’ve found just in arguing it as a layman is people say, “Well look, 30% of the military is not vaccinated.” The military, the federal government runs the military. The military is used to being ordered to do things. One of the things they’re ordered to do incidentally is get like a ton of shots and vaccinations when they show up. And then however often they need them afterwards or when they deploy to someplace which has other diseases and so forth.

So if Joe Biden — I’m not making this Biden specific, but if the administration can’t order the military to do it, I think an employer says, “How do you expect me to tell my employees they have to do it?” And someone who’s sort of vaccine resistant or hesitant says, “I mean, see, I mean, the military is not — Even these military guys aren’t doing it.” So I kind of feel like the military thing is, it’s a problem in terms of they’re quite a lot of people, but also it’s a problem, it seems to me symbolically in terms of the effect. And then they say, “Well, they can’t order it because the regulation is not permitted if it’s only under emergency use.” But can’t those regulations be changed? What’s the story with that?

JHA: So I don’t understand the argument about it can’t be done under emergency use. And I know if there is a regulation, presumably it can be changed. But I think.

First of all, it’s very clear to me, again, speaking to legal scholars about this stuff and watching how the courts have handled this, that EUA, emergency use authorization, is more than good enough for people to mandate it.

KRISTOL: And that is true in reality, right? And that is to say, the actual distinction, the moment they flick the switch and they go to permanent authorization, it doesn’t mean that they’ve suddenly gotten troves of new scientific evidence.

JHA: No. In fact, and this is where I am butting heads I think pretty strongly with the leadership of the FDA. I think it’s just unconscionable to me that the FDA is not moving more quickly on fully approving these things.

And look, there are a couple of complex issues here. One is that the FDA would argue, “Okay, well, it typically takes us six months to approve.” Typically, whatever, we’re in the middle of a global pandemic here, people. Then they say, “Well, we don’t want to cut any corners.” I say, “I completely agree with that.” The biggest thing that should determine approval is the quantity and quality of data you have, the evidence you have that this thing is worth approving. We have more data, and I said this earlier, we have more data on these vaccines than anything the FDA has ever approved in the history of the FDA. So there’s no question about the data and not only that we have on more people, but have you seen data that’s more thoroughly scrutinized? We’re just looking at this data every day. Everybody’s finding this flaw, that flaw, this thing, that thing.

So there’s a bunch of regulatory stuff that slows the FDA down, and my question for the FDA is, what of those is so important that you’re willing to let probably a few 1000 extra Americans die because they will not have gotten vaccinated? It better be really, really important stuff that you’re delaying the approval for, because the question isn’t, “Well, we always take six months,” no, no, no. We’re in a global pandemic. Do it as quickly as you can justify with the science and the evidence. Don’t cut corners on evidence and science, but don’t take extra time because you always take extra time.

KRISTOL: Do you think that message is getting through or getting more widely propagated out there? I don’t know.

JHA: Yeah, we’re trying. I mean, I’ve been banging on this and a bunch of other people have written about this. The FDA is the FDA. They’re like, “Hey, it takes a while for us to do this stuff.”

KRISTOL: But they are a part of the federal government. I mean, it’s perfectly within the rights of the President and Secretary of HHS to call in the Head of the FDA and not to obviously tell him, “Approve this or don’t approve that,” but say, “Why is it? Can’t you have an emergency expedition of the permanent approval?” And/or can’t the military or the Secretary of Defense or the President, if need be, waive whatever regulation that somewhere was put in place 30 years ago not for a pandemic?

JHA: Right.

KRISTOL: That said, actually, you should only require vaccines that have permanent approval, not an EUA.

JHA: There are two parts of this. I mean, one is the FDA doesn’t have a permanent commissioner, and I think that really does slow things. And you understand the federal government better than I do, but permanent leaders appointed by the President confirmed by the Senate have a different set of abilities to move agencies than someone who’s a Temporary Acting. They just can do more. And I don’t want president Biden to call up the Head of the FDA and say, “Approve this.” We don’t want that. That’s not what we’re looking for.

KRISTOL: But you do want Ron Clain to call up the Head of the FDA and say, “Explain to me why it couldn’t be done.” I think that’s legitimate.

JHA: Yeah. And what I would actually like is Janet Woodcock, who’s the Acting Commissioner to come out and say, “Here are the five reasons why we can’t go faster.”


JHA: And by the way, if you need more staff, if you need more money, talk about those. I bet Congress would kick in a few million dollars or a couple $100 million, if they even need that much, I doubt it, to like, get this thing done. So is it money? Is it staff? What is it? What do you need? But we don’t have any of that. It’s just this vague, “Hey, it takes us a while.” I think that’s not acceptable.

KRISTOL: No, that shouldn’t be acceptable, it seems to me. Just one last thing on the private. Anyway, there won’t be a federal government universal mandate, obviously. There will be sectoral and business and municipal and state, I suppose, level.

JHA: Yeah.

KRISTOL: And so I guess, do you think there’ll be Walmart level employers at some point? I mean, that’s tougher for them than for a firm that employs 300 people on Wall Street, obviously, but I mean, could you imagine that? That would be a big deal, wouldn’t it, if the big store, the biggest employers, the FedExs and the Walmarts say, “I’m sorry, you just have to be vaccinated.”

JHA: Yeah.

KRISTOL: Do you have a sense of that could happen?

JHA: I hope so. I think the problem for a Walmart is they are obviously looking across the whole country and know that in some places that’s going to be harder. And I think I’m sure they’re thinking about, what if 10% of our workforce decides to leave? Are we going to be able to fill that?

And here’s a bit of a problem, which is, when it’s a few companies or a few sectors alone doing it, it’s harder because people can then leave. If you think about Houston Methodist, about 150 or 200 people ended up leaving, got fired, or quit. They went and started working at other healthcare systems in Houston. By the way, you don’t want to go to one of those health systems, because basically you’ve got a lot of un-vaccinated workers. But if all the health systems in Houston together came out and said, “We’re doing this,” that would make a big difference.

KRISTOL: You meant to hold hands on this. I think it’s not illegal in terms of anti-trust.

JHA: No, I don’t think so either.

KRISTOL: Certainly, the White House can call in the heads of Target, Walmart, FedEx, and an Uber and say, “Well, you guys need to make sure that all of your employees or even contractors or whatever are vaccinated.”

JHA: Yeah, and I’m sure the Justice Department or whatever can give them relief on this. This is not a competitive issue. This is a public health issue.

KRISTOL: Yeah. So I guess, what are the future scenarios for the short and medium term if, one, we really flounder and there’s not much decisiveness and some of the corporations don’t go much beyond where they are now and we just muddle ahead very slowly?

I guess two would be the in-between scenario of a fair number of people listening to you, but not real urgency at the FDA — I want to go back to the CDC and ask about that too.

And then three, a sort of happy — the government and the private sector and state and local governments and people from both political parties really do mobilize with a sense of urgency and some combination of mandates and persuasion really start to kick in.

How divergent are the outcomes in terms of health, on the one hand, deaths and disease and illness? And then also in terms of fullness of being able to open up and function as a society and the economy?

JHA: Yeah. So two things, and we should talk about all three of those scenarios, but the timeframe for the differences across those scenarios is really the next four months or so.

Meaning, let’s take the most lax one of little to no action, things muddle along. August is going to be a pretty bad month. September will probably be worse, and by October, it’ll start turning around, but not be great. And November, December, it’ll start getting a bit better, but we’ll be in the holidays winter season, still a lot of infections. But basically what’s going to happen is Delta is so contagious it’s going to burn through a lot of un-vaccinated people and you’re going to see a lot of infections, a lot of suffering, a lot of death, but reasonably quickly over the next few months. I don’t believe in that scenario that we’re talking about high infection rates in 2022. That, to me, is a scenario that is just really unfortunate because a lot of people are going to die.

KRISTOL: I mean, it’s a substantial amount. It’s another real bump on the curve there. It’s not a little hill.

JHA: Yeah, I can easily imagine 400 deaths a day, 500 deaths a day. That’s 15,000 Americans dying a month. So that may be another 30,000, 45,000, 50,000 deaths between now. And that’s when we have these vaccines. It’s just unbelievable.


JHA: The middle scenario, the scenario of more companies get on board, federal government does a little more, things turn around, it still has August pretty tough because right now August is baked in. Not a lot we can do for August. But things start getting better in September, especially as we get further out into September and October. And mostly the middle scenario has us just doing a bit better as we get into the holidays. Because with fewer infections, you’ll stretch things out a little bit more, but you’ll keep improving on vaccinations.

The great scenario you lay out of large businesses, the government with its own employees, federal, and state and city, big uptick in vaccinations. August, as I said, pretty baked in. To me, it’s really what happens into the fall and winter. And we will have a much, much better fall and winter, especially if we get into the 67% and 68% of adults right now and 50% of the population, if we can add 15 percentage points to that, both of those numbers, 15, 20 percentage points, it looks way better by the time we get to the holidays.

And a lot of this is in my mind looking out to the holidays and saying, “I really hope we can have pretty close to normal holidays.” But the seasonality of this virus makes that harder. We’ve got to push for as much vaccinations as quickly as possible.

All those scenarios, by the way, assume that Delta is the worst variant we’re going to deal with. And in some ways that was the mistake I made in February where I thought Alpha, the variant that was starting to get bigger, I thought that was the worst variant we were going to deal with. I did not expect Delta to show up with us. And so it’s just the back of my head, I’m going to pay a bit more attention, because we can’t make that same mistake. And this is the virus in evolution. This is what happens, and we are experimenting with letting large outbreaks happen around the world.

And so the other part where the Biden administration needs to be doing more than it is right now, I believe, is on global vaccinations, because, A, it’s good for America, it’s good for the world. We’ve got to end this thing. I mean, a part of me is like, have we not done this long enough? Aren’t we done with this thing? And Delta began in India. Alpha began in the U. K. Beta began in South Africa. Gamma began in Brazil. These things begin in countries with large outbreaks. We’ve got to stop the large outbreaks.

KRISTOL: And it makes a huge difference if a new one, hopefully not, but even more contagious, severe one comes along. Huge difference if that comes into a country that’s 90% vaccinated we presume with the ability to get boosters and so forth than a country that’s 70% vaccinated, right?

JHA: Absolutely.

KRISTOL: So the variants really matter in a forward-looking way, not just today.

JHA: Yeah.

KRISTOL: I mean, one thing about those three scenarios is the two less good ones that worries me is in addition to the real health consequences is I just don’t know what the social and economic consequences are either. I mean, if you start getting hesitancy on schools because they’re a little slow getting the kids vaccinated. Slow is unfair, but it just doesn’t move that quickly. And you can’t be guaranteed that the teacher’s assistant is vaccinated, and how many parents don’t send their kids to schools? How much do school systems, the teachers unions start to bark? How much the school systems say, “Maybe we have to go hybrid.” Maybe we have a chaotic opening of the school year. That would be very bad in my view for the country, almost as a country.

JHA: I agree.

KRISTOL: I mean, leaving aside what the kid isn’t learning in third grade. And similarly, with the economy, one scenario has people back to business in October, basically. Certainly, if they’re vaccinated, and many more are. And the other has even vaccinated people, this is where the Delta thing really makes it worse, even vaccinated people, as you said earlier, are hesitating to get on a long flight, go to a conference. And then suddenly chunks of the economy. I don’t know, it just feels to me like we’re at —It’s more than a speed with which we get out of it question, it really has a lot to do with the whole way this next year or at least the next half-year looks.

JHA: Absolutely. And whereas I have felt so confident that we were going to be back in school full-time, no questions, starting this fall and saying it shouldn’t even be on the table. And I still think we have all the capability to get every kid back in full-time, there’s no reason. But the Delta variant creates enough of a set of questions that I worry that we’re going to have another bad fight over schools. It doesn’t help our country. It hurts kids. It pits teachers against parents. None of this is good for our nation, not at a point where we already have other forces tearing us apart.

KRISTOL: It sounds like though if we can get to December — well, one way or the other we’ll get there— but at that point, we’re in a world of hopefully many more people vaccinated, and kids being vaccinated, and certainly everybody who wants to getting themselves and their family vaccinated. And boosters, what do you think about that? If necessary, available? Is that a manageable problem or something to worry about?

JHA: It’s manageable. There are a couple of problems with it. So let me tell you where my thinking on boosters has changed and why. Because my thinking on things change when new evidence comes out.

So if you and I were speaking two months ago, I would have said, “Don’t worry about boosters.” And now I am thinking, a lot of people are going to need boosters. Not everybody, but some people are going to need boosters. We’re seeing more waning immunity, those anti-bodies. Not the reserves that kick in and protect you from severe illness, that’s not waning. But we’re seeing more waning of the anti-bodies causing breakthrough infections. And we’re seeing it a bit more in the elderly.

And here’s the problem, we’re now getting about six months out of the time that we vaccinated people in nursing homes and other congregate care settings. And about 40% of nursing home workers are not vaccinated. And so what you’re going to see in August, Bill, is a return to large outbreaks in nursing homes, and nursing home patients are frail enough that a bunch of them are going to end up getting hospitalized because they’re just frail and a bunch of them are going to end up dying.

And this is almost completely predictable. And so what’s going to happen, and there’s going to be a call and I think it’s appropriate and I would argue that we could even move proactively on this, is there’s going to be a push to, first of all, give boosters to nursing home residents. And I think that’s almost surely right. Now, I want to see a little more data before I make that as a recommendation. But I think the data’s heading that way. And my hope is that the FDA, if the data’s there says, “Yes, let’s give boosters to nursing home residents.” There’s a question of, do you give the same boost or do you give a Delta variant booster? I just need to see a little more data on that. But even the same booster I think would help a lot.

Then there will be a question of, okay, if it’s good enough for nursing home residents, how about all elderly Americans? How about people with chronic diseases? How about people who are immunocompromised? What about the rest of us? And those are going to have to be driven by data and it’s going to be a bit of a —

But look, we have the vaccines. I mean, we don’t have any shortage of vaccines. Where there’s going to be a political problem on this, two things, one is some people worry in the administration and the public health community that if you say that people need boosters, it’ll make some people even more hesitant to take the first. “Okay, now I need a booster. Forget it. I don’t want any of it.”

I have generally rejected that argument because I feel like that’s playing pop psychology with what makes people hesitant or not. If people need boosters, let’s give them boosters. Let’s not worry about, will giving a booster to grandma mean that some 30 year old who’s hesitant becomes more hesitant? I don’t know. Just protect grandma.

Okay, the second political issue on this is people really, really are worried about global vaccinations. And there is a sense that, are we really going to be giving out third shots to Americans when like 97% of Africans haven’t gotten their first shot? And that really bothers people, and I’m very sympathetic to why it bothers people.

I don’t know that that’s the right trade off. I don’t know that’s the right way to frame it. And what I’ve been trying to say to public health folks is I don’t see at this point that if we hold off giving boosters to nursing home residents, somehow we’re going to take those vaccines and give it to people in India. I don’t think that’s quite how this stuff works, though I do understand we have a scarce resource.

So those issues aside, I think boosters are coming. They’re coming for the most frail. They’re coming for immunocompromised. And then we’re going to have to look at the data and make decisions about, what about a healthy 70 year old? What about a 50 year old with cardiovascular disease? Et cetera, et cetera, et cetera.

KRISTOL: So we’re not past all the decision making and all the squabbles about some of it and genuine tensions to be fair, genuine trade-offs, as you were saying. That’s going to continue as the disease is going to continue to circulate for quite a while.

So you mentioned the FDA, you were pretty, I think, had some urgency in urging them to accelerate their efforts. What about the rest of government, the CDC, and in general, the governments at all levels? We did a pretty impressive job, it seemed like, rolling out the vaccine, but how are they doing now? And what’s your sense?

JHA: Yeah. So I think the vaccine rollout was nothing short of brilliant. I really do. I think they did a very, very, very good job and deserve a lot of credit. And look, yeah, as I said, I’m critical of the way FDA is managing things. I have some beefs with the CDC. So it’s not like I’m a Biden Administration booster on all accounts, but they deserve credit, much the way the Trump administration deserves enormous credit for getting us vaccines in the first place.

And another place where I would actually just, as a side point, push the Biden Administration is — I don’t know. And maybe this has happened. I would love to see President Biden invite President Trump to the White House to take credit for getting America these incredible vaccines quickly. I think that will do enormous good for us. But I’d like to see more acknowledgement of the Trump Administration’s really important efforts in this area.

Because just be very clear about this, Bill. Lots of countries have the opportunity to make bets on vaccines. Most countries passed. They said, “You know what? We want to see the data before we make any decisions.” And the Trump Administration was one of the very few that said, “We think this is really important and we’re going to put dollars down and we’re going to purchase this stuff even before we know whether it works or not.” I thought that was great. So Trump Administration just deserves a lot of credit. Biden Administration deserves a lot of credit for the rollout, which was fantastic. FDA, we’ve talked about.

CDC, I think in general, has been far superior to where they were under Bob Redfield. Bob Redfield ended up being really quite an ineffective and poor leader of the CDC. Rochelle Wollensky is doing a very, very good job. There are places where I disagree with them on some of their science. It’s fine.

The place where I think they’re really not doing a good enough job is tracking breakthrough infections. We’ve talked about that a little bit. That’s a real problem. And I don’t fully understand it. The CDC gets beaten up for almost anything that they do. Somebody doesn’t like one of their things. I, in general, feel like they have stuck to the science, they’ve done a good job. And reasonable people can disagree with them on the reading of the science, but they’ve been largely pretty good.

The foreign state department, Samantha Powers, USAID, I think they’ve been trying really hard to push the global agenda. My sense is, at the end of the day, the White House cares a tremendous amount about domestic. And global vaccination’s important. It doesn’t get the same energy and the same interest. And I think this is a little bit of a mistake. Because it turns out global vaccinations is not just a humanitarian thing, it’s not just a foreign policy thing. It will affect us. If we get a more contagious variant, if we get a variant that bypasses our vaccines, it will affect us. I think the White House should lean in more on a global strategy than they have.

KRISTOL: Yeah, that’s interesting. But the one thing that strikes me on this is that I was in government and I think I’ve seen this a couple of times, and one sees it in every good organization, they took over, they really put their shoulder to the wheel on the vaccines, picking up with a good start from the Trump Administration. And they did very well and people thought they did well and they took credit for doing well and so forth.

It’s hard to pivot from that and say, “We did very well.” And there’s a big temptation to then say, “We did very well. Things are really okay. They’re not quite as bad as you think. And for those people who were alarmist, and we just want to reiterate that we did well. And if only a few more people get on board, we could do even better. So let’s just urge a few more people to get vaccinated. We’ve done this well so far without the mandates, without the drama, without leaning on the FDA, without military process,” let’s just say, take that as an example, of mandating vaccines, which would meet some resistance.

I don’t think it would be very much. But if 10,000 people leave the military and protest and their relatives show up somewhere, it’s going to be a couple of days of news and so forth. And I think it’s very hard for people in government to pivot from, “We’ve done well, we’re doing well. Don’t take away from that basic storyline,” to, “Yikes. We sort of have an urgent problem that’s not our fault that we did do well, but now we need to address that with real urgency.”

I’d feel better if I thought there were more meetings happening with the President himself, with Ron Klain at high levels and with corporate leaders. I think some of this is happening behind the scenes because they don’t want to look quite as alarmed, and they also think they could persuade better in private, and that’s fine.

I’d feel better if I had a little more of a sense of urgency on this. It feels like they’re spending more time on the infrastructure legislation than on making sure that we’re really damping down this next wave of COVID. And I think the next wave of COVID ultimately, we’ll get infrastructure eventually, but the next wave of COVID is time sensitive here.

I can’t put my finger on it, but it reminds me of a couple of times I was in government where we didn’t step up the way we should have, partly because we had a slight investment in not seeming alarmed. But sometimes it’s good to be alarmed.

JHA: Yeah. Yeah. I’m sure there’s a sense, and I’ve felt this in a few things that I’ve done in government, is a sense that if you work really hard, you want to declare, and you’ll excuse my words here, but you want to a little bit declare mission accomplished.

KRISTOL: Yeah, totally.

JHA: You want to say, “I got it done. We did that.” And so it feels like if you revisit it, that somehow you’re acknowledging that you’re not done and you didn’t do as much as you wanted.

And I think the administration just has to understand that they did a great job for the problem they had in February. There’s a different job now. And they just have to pivot. They have to.

It also is very, very clear to me, by the way, that if the fall and winter become horrible, that there’s going to be a very large political cost to this. Because at this point, the Biden Administration owns this fully. It no longer can we go back and say, “Well, the Trump Administration didn’t do X, Y, or Z.” So there’s a lot of good reasons why the federal government has to fully lean in and get this thing under full control.

KRISTOL: And just to conclude, you’ve been very generous with your time, you have a million other things to do here, which are actually important for the country, so I’ll let you get to do them, but assuming we, one way or the other, get through, let’s just hope, get through pretty well the next four months and flatten this latest curve, I guess maybe one might be one way to put it, and come out the other side, then where are we? Are we in a flu type situation where people need boosters and there’s — Look, it does people, and people get sick and hospitalized, but basically we live with it and it’s not a crisis? Are we still worried that this is somehow a different kind of disease where there could be more variants that would just be out of control? What do you think?

JHA: Yeah, so it’s a really good question. So let me think about it in the following way with you. Let’s actually project out a few years and then let’s work backwards. So 2024, which I know is three years away, but where are we in 2024? We’re not talking about COVID-19. We’re just not. The world’s vaccinated. There are pockets. You get a little this, a little that. America is largely immune, and it’s a bit of an annoyance. And it’s just something that we have to deal with every once in a while, but it’s really in the background.

Okay. But that’s a ways away. So what about 2023? I think 2023 should be in pretty good shape for America. Again, I don’t think you and I could be sitting down and talking about the epidemiologic curves of COVID in 2023. And the only reason I bring up 2023 in any way different from ’24 is there may be bigger problems on the global scale, that we have not fully vaccinated as many people as we need to globally. There’s still parts of the world that are struggling. You’re still seeing large-ish outbreaks in some places, but most of the world’s in good shape.

Okay. That’s 2023. What about 2022? What about next year? This is the transition year where things, I think, are going to go in the following way, but there’s a bit more uncertainty. I think America is in really good shape next year. I think 85, 90% of Americans are immune. I’m hoping a lot of that is through vaccinations. A lot of people have gotten boosters. And much of the economy, much of the country is humming along. It’s where I thought we were going to be this summer, but it’s now moved by six months because both Delta and the lack of enough people getting vaccinated.

But 2022 is a year where much of the world is still struggling. Vaccines are coming online in large numbers. We’re working really, really hard to get them distributed. But ’22 does not look fabulous from a global point of view. It’s the transition year where you’re still having large outbreaks, parts of the world where there’s no vaccination.

And I think early ’22 looks bad, late ’22 looks pretty good from a global point of view. But again, I’m pretty confident about where the United States is going to be. And what does that mean in 2022 for us? It means you and I are going to get together and we’re going to have a drink indoors and we’ll feel really comfortable.

And I think we’ll hear about somebody who had a breakthrough infection and spent three days in bed and was really wiped out from it. You’ll occasionally hear about somebody who got it and got really sick and maybe even died, but those are rare. But you hear that about, “Oh, my friend got sick and got pneumonia and died.” That’s awful and it’ll happen, but they’re going to be pretty infrequent.

And I think 2022 is really the year that we learn to live with it. It changes some of our behavior. Maybe you say, “You know what? I’m done with large indoor rock concerts.” So, Bill, I don’t know how many indoor pop concerts you’ve been going to, but maybe you’ll go to fewer of them in the future. That’s a longer-term behavior change, but maybe the 20 year olds will continue doing that. So there’s some things that feel a little bit different. The next four to six months is the time. But I think next year, it feels pretty good. And then again, it’ll be around and we’ll have to deal with it every once in a while.

KRISTOL: Well, that’s encouraging. Now, just finally on this next four to six months, when would you hope with good policies, aggressive policies, and reasonable compliance, and everyone listening to you, when might that curve that’s now rising pretty steeply start to rise less steeply and then turn over? When do you think we get to start seeing the other side of this particular bump in the road?

JHA: Yeah. I think August remains rising pretty steeply. If things go well, maybe late August into September, we start seeing a turn.

KRISTOL: And if things don’t go well — And if we don’t begin to see it turn, and it means we haven’t done what we should have done, and there’s still continued widespread —

JHA: Yeah. And the models are suggesting a peak in October, but I’m hopeful that we’re going to get there a bit faster because the alarm that’s being raised about Delta and what’s happening is real.

My most single piece of data that I have come up with that has given me the most amount of hope in the last couple of weeks is a few nights ago, I just said, “I wonder which states are seeing the biggest uptake in vaccinations.” And they were Louisiana, Arkansas, Missouri, Florida, and I can’t remember the fifth. But it was the five states with the largest surges. And I thought, “Okay. The behavior is starting to change. More people are getting vaccinated. We are starting to see some movement.”

So the models that say mid-October as the peak, I think they’re too pessimistic. I think it happens earlier. I think it happens earlier because of behavior change, vaccinations. And I think that companies just decide, people decide, “We’re just done with this. Let’s just get everybody vaccinated and move on.” And I think that’s so tempting that I think more and more people will give into that temptation. It’s a good temptation. People should give into that temptation. Just get people vaccinated and move on.

KRISTOL: From your lips to God’s ears. And look, thank you, really, for everything you’ve done. You’ve been both a voice — brought so much clarity and understanding, but also, I think, important sense of urgency and of policy recommendations to this whole debate over the last year and a half.

And now we thought we would be having a look back session maybe now, where we’re, as you say, where we now hope to be in early 2022, lessons learned. We’re not quite at the lesson learned stage. We’re still at the acting to mitigate the damage stage, in a pretty important way, I think. The difference between sound and urgent and aggressive policies over the next few weeks, the difference in effects and not doing those is pretty great, right?

JHA: Yep. It’s pretty great. It’s a lot of people. And as you said, it’s not just the lives lost, which are, of course, enormously important, but it’s all the social and economic effects that are also quite substantial.

KRISTOL: Okay. Go back to work, make all this happen, Ashish, and we’ll have hopefully a very cheerful conversation in early ’22, but maybe before if we need to pick your brain again, but thank you.

JHA: I’m happy to do it, and I look forward to actually getting together indoors.

KRISTOL: Well, that would be exciting, in person and indoors.

JHA: And have a drink.

KRISTOL: Wow. That would be a twofer.

JHA: Outdoor, we could do anytime and that would be delightful.

KRISTOL: Right. But I think maybe January, February up at Brown or in Rhode Island or Massachusetts maybe indoors might be better.

JHA: Yeah. Let’s plan on that and let’s work towards making that a real safe thing to do.

KRISTOL: Absolutely. Ashish, thank you very much for joining me on CONVERSATIONS.

JHA: It was my pleasure, Bill. Thank you very much.