Life in a Half-Vaccinated Country

The last time I spoke with the physician Ashish Jha, the dean of the School of Public Health at Brown University and a leading expert on COVID-19, Americans were just beginning to get their shots. Now, more than half the country has been vaccinated, but the Delta variant of the virus has caused a surge in infections and hospitalizations—largely among the unvaccinated—and renewed debates about what reopening should look like. I recently called Jha to discuss breakthrough infections, mask and vaccine mandates, and how vaccinated people should think about COVID safety. Our conversation, edited for length and clarity, is below.

How would you define where we are right now with the pandemic in America?

We are at a precarious moment for a couple of reasons. We’re certainly over the worst of the pandemic. I don’t think we’re ever going to go back to the level of suffering and death we saw at the end of last year. But, in some ways, people feel like the pandemic is done and it’s behind us here in the U.S. And yet the surge of infections from the Delta variant is just getting going, and is really going to challenge us over the next several months. And most Americans, I think, aren’t aware of how much worse things could get.

What would worse look like, given the percentage of the country that’s already vaccinated?

The good news is, about half of America is fully vaccinated, and that is going to help, certainly. And of course our most vulnerable patients are vaccinated, and that means that there are going to be a lot more infections before hospitals really start filling out. But there are two other sets of issues in my mind. One is that vaccinations are not evenly distributed, so there are communities where the proportion of the population that’s vaccinated is more like twenty per cent to thirty per cent. And, in those places, we are already seeing a pretty substantial surge of infections. We’re going to see a lot more infections in the weeks and months ahead. The reason that really begins to become a problem is that hospitals are going to start filling up. And we’re going to have situations where hospitals are out of beds, and communities where people can’t get health care because the health-care system is at complete capacity. I think that will really be a rude awakening for a lot of people who thought the pandemic was behind us.

One fact that you alluded to is that older adults are getting vaccinated at higher rates than younger adults. I think most people assume that’s because older adults are at greater risk, and so they’re more willing to get vaccinated. Does that change the way you think of the public-health challenge of getting young people to take vaccines? It suggests to me, perhaps, that it’s less that they’re scared of putting something into their body, or that they’re scared the vaccines won’t work, and more that they still don’t fear the coronavirus.

I think there are a couple of things. One is that young people always feel invincible, right? If you remember back to the conversations about the Affordable Care Act, they always talked about the young invincibles—the people who think, I don’t need health insurance. I’m going to be fine. A vaccine is a little bit like insurance, right? It’s insurance against encountering the virus and not wanting to get sick from it. And young people tend not to buy insurance for health stuff because they tend to think they’re invincible. I think that’s a broader societal issue. But there’s a second problem here, which is that, for a year and a half, they have been bombarded with misinformation that says that, for them, the coronavirus is no worse than a bad cold. And when you’ve been hearing for a year and a half that there’s a cold going round, and then someone shows up with a vaccine, you won’t be surprised that lots of people aren’t going to necessarily avail themselves because they already think they’re pretty invincible, and now you’re asking them to get vaccinated against what they perceive to be a mild disease. The truth, of course, is that, while young people do better than old people, this is probably the most significant infection that any of us can get right now in America. And, even for people who do just fine and get better, there are a lot of people who end up getting really quite sick. And I think the misinformation really has made it hard for people to believe that.

Nearly all public-health authorities in the country are urging people to get vaccines. We see the incredible results that the vaccines have had and how many lives they’re saving, and still the F.D.A. has not offered full, permanent approval of the vaccine. President Biden suggested it might take several more months. How do you understand that, or how can that be defended, if it can be?

I find it incredibly puzzling what exactly the F.D.A. is doing. The F.D.A. says that it typically takes them six months or sometimes as much as a year to fully approve a new product. And, generally, we appreciate that. There are two components to that. One is that they want to see a large amount of data, and they want to go through that carefully, and I think that’s essential. Then the second is that there’s a process, which can take a while. This is a global emergency, and while all of us want to make sure that the F.D.A. does its job, most of us also feel that just operating on standard procedures may not be the right thing to do here, and that there are things that can be sped up. Just as with the development of vaccines, we didn’t cut any corners. We did all the steps, but we did it much, much faster. The F.D.A. has to go much, much faster.

The other thing about the data—the amount of data that the vaccines have generated, the number of people who’ve been vaccinated, and the scrutiny that the data has received. I mean, my goodness, this data has been scrutinized and looked over more than—

I’d imagine it’s more than any data in modern history, right?

Any therapy, any vaccine ever. These are the most highly scrutinized medical products we have ever had, and I don’t understand what the F.D.A. is doing.

What do you make of the debate over whether indoor masking should continue for vaccinated people?

I think it’s complicated, because there are several things going on in that debate at once. First of all, I think most people agree that what we really, really want is unvaccinated people to be wearing a mask indoors. The problem is that we don’t know how to actually effectuate that. And therefore what we’re left with is a broader policy that says everybody should be masked up. I mean, if you could figure out how to get only the unvaccinated to wear masks, you wouldn’t need to push the vaccinated to be masked.

Let me ask you about that, because it seems like we’re dealing with two issues here, right? One is whether there should be a policy that everyone still wears masks indoors, and the second is whether you, a vaccinated person, should be wearing a mask indoors for your own health and the health of others. So one’s a policy question, and the other is an ethical and moral one. How do you differentiate those?

I actually think they’ve gotten mixed up, which is why I think we need to separate them out. From a policy point of view as well, what you want to be doing right now is demanding indoor mask mandates for unvaccinated people. But because we have no ability to differentiate vaccinated and unvaccinated people, the blunt policy tool is to ask everybody to be masked up indoors.

But I don’t think that could be a national policy. I don’t think the C.D.C. should come out and say this should be the new policy for everybody, and here’s why. It’s not clear to me that you need to be masked up indoors if you’re fully vaccinated in Vermont, say, because most of the people around you are vaccinated, and infection numbers are very low. I think in southwest Missouri, it’s really reasonable to have an indoor mask mandate because there are so many people who are unvaccinated, and there are such high levels of infection that it would be effective. So, from a policy point of view, the question in my mind isn’t whether vaccinated people should be masked up. It’s, do you have an indoor mask mandate for everybody or nobody?

If you were travelling to Vermont and there were no policies in place around an indoor mask mandate, would you wear a mask to a coffee shop? And, if you went to southwest Missouri and there was no policy in place, would you wear a mask in a coffee shop?

No to the first, yes to the second.

Explain why, even though you’re vaccinated, you think there’s some value in wearing a mask in southwest Missouri.

I live in Newton, Massachusetts, where about ninety-three per cent of our adults are fully vaccinated or partially vaccinated. I will pop into a grocery store and not be wearing a mask. Of course, it’s interesting, because ninety per cent of people are wearing a mask in the grocery stores in Newton, which I think is interesting. So why do I not do it in Newton? Because, and this is the same reason I would do it in southwest Missouri, I don’t want a breakthrough infection. I’ve talked to people who’ve had them. They’re really miserable. I’m not worried about dying, but it turns out there’s a lot of other stuff I care about. I don’t want to break my arm. I won’t die, but who wants a broken arm? Who wants a really miserable viral infection that’s going to make me feel lousy for a week? I’m not looking for it.

If influenza numbers were super high, I’d probably wear a mask too. I have a nine-year-old kid at home, and he’s obviously not vaccinated. My teen-age daughters are, but people ask if I’m worried about giving it to him, and I’m not. I’m not worried about asymptomatically spreading it because I don’t know that there’s much evidence that vaccinated people do a lot of asymptomatic spreading.

Let’s say I decide, as a vaccinated person, that I don’t need to wear a mask because I’m not that worried about it for my health. Is there some value in vaccinated people wearing it for the general welfare? If all vaccinated people wore masks, would that seriously cut down on community transmission?

So there’s one other thing, which is, a lot of people argue for wearing a mask if you’re vaccinated out of social solidarity, that it creates pressure on everyone to wear a mask. If I felt that my wearing a mask would prompt a lot of unvaccinated people to wear a mask, then I would do it for that reason. But, if all the vaccinated people in America started wearing masks, and just the vaccinated people, it would have little to no impact on community transmission and hospitalizations and deaths in America. Really trivial.

Are more breakthrough infections happening than we were led to expect? It seems like people are a little surprised at the number of breakthrough infections, but I can’t tell if that’s because the data was wrong somewhere along the line, or increased community spread in a country of three hundred and thirty million people inevitably seems like a lot.

I think it’s more the latter. I think people have a hard time understanding what numbers like ninety-per-cent or eighty-per-cent efficacy against symptomatic infection means. I wouldn’t be surprised if a couple of thousand Americans are having breakthrough infections every day right now. But, of course, it’s very easy to amplify on Twitter, right? Somebody has a breakthrough infection, and so all of a sudden, on Twitter, it feels like it’s all over the place. It’s exactly what you’d expect with a vaccine that has ninety-per-cent efficacy against symptomatic infections.

If I am a vaccinated person and I know for a fact that I was exposed to someone with the virus, or even if I test positive without symptoms, is it worth quarantining?

The C.D.C. says no. They say if you’re asymptomatic you shouldn’t really be getting tested, and if you’ve been exposed you don’t have to quarantine. This is a critical question that we just don’t know the answer to—if you are asymptomatic as a vaccinated person, can you spread it to others? So far, I have not seen any evidence that you can. That evidence may emerge. So, if it happened to me tomorrow, I’d probably avoid unvaccinated people. I’d probably take a few days, and I would not spend time with my nine-year-old kid. I would not go visit my elderly parents who are vaccinated. The risk of giving them the virus is so high. Why am I going to mess with that? But, unless there’s better evidence that all those people should be quarantined for an extended period of time, I don’t think that’s a necessity.

Even if vaccinated people aren’t too worried about getting a breakthrough infection, the long-term effects of getting even mild COVID seem to be a big unknown. Is that still a big unknown in the medical community?

We don’t have a definitive answer. My own assessment, and that of most people I speak to, is that, if you’re vaccinated and have a breakthrough infection, chances that you’ll end up getting long COVID, long-term post-COVID syndrome, is probably much, much lower. Having a kind of immune training with the vaccines probably dramatically reduces your likelihood of ending up having long-term complications. But we don’t know for sure, and, if people say they want to continue avoiding breakthrough infections, I’m very sympathetic to that. I don’t want a breakthrough infection. This is why I’d wear a mask in southwest Missouri.

Do you have any thoughts about more coercive ways of getting people to take the vaccine? It seems pretty clear we’re not going to have a law telling people they have to get vaccinated, but you could have certain nudges or rules, whether you’re paying people to take it or whether you’re telling people that they cannot come to public or private spaces unless they prove that they’ve been vaccinated.

This comes back to a conversation I had with our university president, a few months ago. Chris Paxson, the president of Brown, asked, What if we don’t have a vaccine mandate? My assumption was that, if seventy, maybe seventy-five per cent of people will get vaccinated, we’re going to probably continue to have everybody masking up, and we’re going to continue doing some amount of social distancing. And this would probably be for a very long time, not just for a few months. And then she asked, What if we do a vaccine mandate? And the answer was, we don’t have to have indoor masks, classes can go back to normal, dorms can go back to normal. Life can go back pretty close to what life was pre-pandemic.

My sense is that this was a no-brainer. And that’s what companies are starting to do. I’m talking to businesses that said, I just want my employees back. How do I do it? And my answer is, if you don’t require vaccinations, then you have to put in a whole bunch of mitigation measures and you have to be doing ongoing testing and you need to make sure people are wearing masks. And you’re not going to have a dozen people crowded around a table in a conference room. Then they say, For how long? And I’m like, Probably for years. Then it dawns on them that this is untenable. I think businesses, universities are going to jump off the fence and start mandating. A lot of them are just waiting for the F.D.A. I really think people are underestimating the power of F.D.A. approval. I think when it happens you’re going to see a large number of organizations require it for returning back to work, partly because their senior leadership is older people who don’t want a breakthrough infection.

Since we are less worried about asymptomatic spread among vaccinated people, should we be moving toward a testing regime that is more about testing viral loads than testing the presence of COVID-19 in someone’s body? Is that feasible, and is it possible, and is it desirable?

Yes, yes, yes. It is feasible. You can do that both with P.C.R. and antigen tests. Antigen tests won’t give you a viral load, but you can get a threshold that makes sure that you know that somebody has a high enough viral load for the results to matter. And it is absolutely desirable in the sense that what you want to know, especially for vaccinated people, is whether someone is contagious. If they have a little virus in their nose, that’s not compelling, and that’s not necessarily all that meaningful. You really need to have a much better sense of quantification. We’re not spending enough time thinking about that.