Coronavirus

Ashish Jha on what Massachusetts got right — and wrong — during the COVID-19 pandemic

"They were slow to see it coming."

Dr. Ashish Jha is the former director of the Harvard Global Health Institute. Last September, he started as dean of the Brown University School of Public Health. Nick Dentamaro / Brown University

Dr. Ashish Jha may have left Harvard last year to begin work as the dean of Brown University’s School of Public Health. But he remained in Massachusetts — riding out the pandemic in Newton with his family — as he became one of the country’s most prolific voices on COVID-19.

Now, with the pandemic subsiding and the COVID-19 state of emergency lifted, he’s been taking a step back from what was once near-daily commentary — on cable news and Twitter — on the infections, restrictions, and vaccines.

“The need to be communicating to the public has changed,” Jha told Boston.com in an interview. “It’s not that it’s gone. But it has changed.”

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Still, the 50-year-old recently took the time to reflect on his adopted home state’s response. And while he generally gives Gov. Charlie Baker high marks, Jha says the administration made several “costly” mistakes.

He know it’s easy to play Monday morning quarterback. But whether it was surging infections last fall or issues around vaccine access, Jha returns to the question of whether the Baker administration should have seen it coming.

Often, for him, the answer is yes.

The following interview has been lightly edited for clarity.

Boston.com: You’ve generally praised how Massachusetts responded to the pandemic compared to other states. But let’s take it from the beginning. How do you assess the Baker administration’s response?

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Jha: We’re about 16 months in, 17 months in, and my feeling is you really could not have expected states to do much in January or probably most of February. We were really looking to the federal government for information and data. And the botched response of the U.S. is really I think primarily a federal failure in the month of February of last year.

March is when states start getting involved. And again, I want to reiterate that I think the Baker administration has done a really good job, and I think there are two or three instances where I think they’ve made mistakes and they’ve made decisions that I don’t think have served the commonwealth well. But, my God, in a 16-17-month pandemic if you have only a few, it’s hardly a catastrophe. But one where I would say they probably were a little slow to respond and shut things down was in the [response] in March of last year. It probably would have been helpful and would have saved a bunch of lives if it happened a week or two earlier.

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It’s very clear in retrospect, which of course is easy, but one of the questions I’ve asked myself is, “How obvious was that prospectively?” And I would argue that it was pretty clear prospectively. They really shut down after many of us started saying, “We’re in a lot of trouble and we’ve really got to stop here.” And so I think they were a little slower. That to me was one important mistake, but at the same time, one that was made by almost everybody else as well.

Boston.com: I think California was one of the first states to shut things down early.

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Jha: California was the one state that did it right — one major state that I can think that moved more quickly. I think, Massachusetts, New York, many of these states moved a little bit more slowly than they should have.

And it was a costly mistake. I mean the problem of pandemics or any exponentially growing infectious disease outbreak is a week or two delay can be very, very costly. A week delay can double the number of people who die.

Boston.com: One statistic that I think about a lot is that Massachusetts had the third highest per-capita death rate due to COVID-19, and I wonder if that’s the result of policy choices or happenstance — things outside of the government’s control, like the Biogen conference — that resulted in Massachusetts getting hit hard early on.

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Jha: If you ask is it happenstance or is it a policy choice, can I just say yes?

Because, clearly, the cities were hurt the most in the first wave — Boston, New York, Detroit, to some degree — they’re not random places in America, right? They are the places that were much more international hubs. We had a lot of travel to Europe, we had a lot of travel to Asia. And so it’s no surprise that those are the places that got seeded first.

The policy part was the slowness of response in the first weeks in March. If we had acted like California, we could have cut those deaths by a lot.

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Boston.com: What about after the first wave initially hit, heading into the rest of spring and summer?

Jha: I would praise the administration on how it handled things.

Look, there was a lot of pressure from the president at the time to “open things up.” The Baker administration didn’t. They followed evidence, and they really used good metrics. At the end of the day, you can always find somebody who’s going to quibble on one metric or another. But the question is was it sound and largely right? I think the answer is absolutely.

The other thing that the Baker administration did — I think quite brilliantly — was the way they tapped into the life sciences community of Massachusetts to ramp up testing, helping the Broad Institute get online. There were other companies that the Baker administration worked closely with to kind of get into the testing business, which has had large payoffs, not just for Massachusetts but for the country. And I think the Baker administration probably doesn’t get enough credit for some of that stuff.

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And so I think those months were terrific, not just doing the bare minimum, not just following the science, but really being aggressive about trying to create a response and build up capacity for what was coming, which was going to be the surge in the fall, which all of us knew about and worried about. And it’s hard not to give the response in that period like an A, an A+. They did really well.

Boston.com: As you just mentioned, there was a lot of forewarning about a potential second COVID-19 surge headed into the fall. Do you think the Baker administration was too slow to react to that?

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Jha: I think the fall response was disappointing. They were slow to see it coming, when really everybody saw it coming, and they put in restrictions and they kept, I think, playing catch up. Many of us were saying, “They were slow to see it coming. This is not the disease you want to play catch up with; you want to get ahead of it, bring it under control, and then you can pull back.” And they didn’t.

It often felt like the Baker administration was being pulled into doing things that might harm the restaurant industry. And again, the last thing I want to do is harm — well, not the last thing, the second to last thing I want do is harm the restaurant industry. The last thing I want to do is see a lot of people in Massachusetts die unnecessarily. And I think they got a lot of that balance wrong. You could see it in the frustration that the governor felt, that the governor wished the pandemic would just go away or at least the public health people would stop raising these issues. And unfortunately, the pandemic wasn’t going away. With people like me, we weren’t going to stop talking about what was important. And so I think that when there was very clear data things were getting worse, the administration was consistently slow. I think it was part of the reason why you saw a lot of deaths in the fall and winter.

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There were states that did that part better. I think of, for instance, Gov. Whitmer in Michigan. In November, when cases were starting to rise in Michigan, I mean talk about political courage. Gov. Whitmer was in a state with a very, very Republican legislature and then you had like the militias who wanted to kidnap her. I’ve talked to her about it, and she basically was like, “I just felt like it was what Michiganders needed.” And she acted. We didn’t see that kind of action from Gov. Baker.

Boston.com: What were the actions that you wanted to see? Shutting down indoor dining?

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Jha: Look it was very clear what was causing spread in the fall, and I’m thinking about late October, November, December. It wasn’t a mystery. We knew by then that the way the virus spread was when people gathered indoors without masks. That was it. So start applying that. Yeah, restaurants, either really, really thin them out or just close them for a while, especially in the worst days where things are bad. Bars have essentially no justification being open in the middle of a pandemic until you have large numbers of people immunized.

Boston.com: And when you say bars, bars were technically required to be closed in Massachusetts…

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Jha They were, but they could still be open as long as you were dining at the bar, and so what bars started doing was saying, “Look, you gotta order an appetizer with your drink.” But fundamentally we’re still talking about people you are gonna be in close proximity with drinking alcohol. And I think that ended up being a huge problem.

The governor did do a good job — and I think several governors did — talking about how a lot of the spread was happening in homes. And I think he did well, but part of the mixed messaging was you know you had the governor and people saying, “Hey, you can’t gather indoors with your friends, but if you want to go to a restaurant, it’s fine.” I think a lot of people were like, “Well that doesn’t make any sense.” And so you can’t have restaurants largely open, even if it’s at 50 or 70 percent capacity, and then tell people to try to avoid gathering indoors with their friends, because they’re more likely to trust their friends instead of a restaurant, where they’ll say, “Well, there’ll be strangers. I can control who comes [into my home].” Of course you can control who comes in; you don’t know if they’re infected.

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Boston.com: I remember the emphasis was very strongly during that fall period on like, “Don’t gather with friends.” And I know the contact tracing data is sort of limited, but it did seem like gatherings were the predominant source of spread. You think the messaging of allowing restaurants to be open sort of undermined the efforts to persuade people against private gatherings?

Jha: Absolutely. You can’t possibly tell people don’t gather with friends at home, but feel free to gather with friends in a restaurant.

And the contact tracing data was interesting because even some of the people working on and leading the contact tracing data were saying, “Look, we’re picking it up more at home, because it’s easier for people to recall who they spent time at home with.” And there was data from other states that indoor dining was a major source of spread. So why would it be that indoor dining is a major source of spread in lots of other states but not Massachusetts? I mean, again, I love our restaurants, but they’re not physically that different. And we’re also talking about November to December. We’re not talking about the time where people were largely eating outdoors. And so I think that was unfortunate, and clearly, I think, led to a lot of unnecessary infections and deaths.

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And what I thought was particularly problematic about it was — by November, certainly, and then by December, completely — we knew vaccines were coming very, very soon. What you can say is anybody who gets infected and dies this week is somebody who is going to be vaccinated in three months. We really are at the end of the trail here. Let’s just hold until people get vaccinated. And there was an impatience, and I understand the impatience. But I think the lack of willingness to do what was necessary, in the months of November, December, and January, really did harm us. That’s really unfortunate.

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Boston.com: I was curious for your thoughts about some of the flashier actions at the time. There was the universal outdoor mask mandate with no exceptions for when you were distanced from other people or the curfew at one point that said people had to be home at night. Did you feel like those had any particular impacts or consequences?

Jha: I thought some of it was sort of more performative than impactful. I thought the outdoor mask mandate — I think I even said it to reporters at the Globe — I said, this actually probably sets us back, because actions like these often make you think you’ve done something when you haven’t. What that means is that reduces the political will to do more, because you’re like, “Hey, I just acted.”

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None of us believed that outdoor mask mandates would do much at all, because it was clear that most of the infections weren’t happening outdoors. And you can tell a story for why on the margins outdoor mask mandates might be marginally useful, like if you have a gathering of 100 people outdoors. But they could have done that. They could have set up a [mask mandate] for outdoor large gatherings. I would take my dog out for a walk at like 11 o’clock at night, and I put on my mask. And I remember thinking like, “This is fine. I’m doing it because it’s a mandate and I’m not the guy who’s going to flout the mandate, but it’s clearly not doing anything.” And I am of the opinion that when you’re going to ask people to do things and restrict people’s actions, you want to be as narrowly targeted as possible and you want to target the high risk stuff. So I actually think some of that stuff was not only not useful but probably took away from our ability to do what was really going to be helpful.

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Boston.com: Around that time was also when the Baker administration really started to push for schools to reopen and that kind of gradually went along through the winter. I know reopening schools were a big priority for you. Did you feel the state was right to make that aggressive push, even when infection rates were generally pretty high?

Jha: Yeah, so I generally again I thought this was one where the Baker administration was right. I thought their push to open schools was largely right on, because with everything you’re weighing costs and benefits, and maybe I’m being unfair by saying, for me, the cost of keeping casinos closed is not that high. Obviously, it is for the workers, but I can live in a state for six months in a pandemic where the casinos are closed. Six months and schools being closed is a huge problem.

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What we also knew — and this was a point that many of us made — was that essentially, you had choices, and you could keep restaurants open or you could keep schools open. You couldn’t probably do both, because if you keep restaurants open infection numbers get high enough that it makes it hard to explain to people how you’re gonna justify keeping schools open. Because again with very, very high levels of infection in the community, even if there’s not a lot of transmission happening in schools, it just creates a level of fear that makes it very difficult to open schools.

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So many of us were arguing that if I had to choose between casinos, tanning salons, restaurants, and schools, I would pick schools first. And that’s not what the Baker administration did. I think they actually hurt their own ability to keep schools open, even though they claim they wanted to and I believe they wanted to, by not being more aggressive on the other things, and I think that ended up really being unfortunate and it delayed school openings by months.

Boston.com: What were your thoughts on the vaccine rollout? Baker has stood by the initially slowed approach to deliberately target the most vulnerable populations, before pivoting to mass vaccination sites.

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Jha: I would say that the vaccination rollout was slower than it should have been, but boy, once they got going, it’s been awesome. Massachusetts has consistently been second-best in the country.

I mean, Vermont has just been killing it, and Vermont’s a small state. Get beyond Vermont, depending on which metric we look at, it’s Hawaii or Massachusetts or Maine or sometimes Connecticut as the four states that have pretty consistently come in second or third. So overall, you gotta give the Baker administration very high marks for how it has done, but I would not say that it was necessarily such a smooth start in the beginning.

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Boston.com: Right, there were obviously issues with the signup website, and accessibility in general at the start.

Jha: Yeah, even though they have landed in a very good place, it’s also very clear to me that in the early days, they could have planned more. Everybody saw it coming.

After November 9th, when Pfizer first released its first set of data, we all knew exactly what the timeline is going to be. We knew that the vaccines were going to get authorized sometime in early December, we knew that it was going to be health care workers and nursing homes first, and we then knew it was gonna be older people. You could tweak that around the edges, but everybody had a pretty good sense of where we were going to land. You would have thought that we would have built good websites.

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Connecticut kicked our butt in the early days in getting nursing homes vaccinated. Why is that? Because they planned. They knew since November that they would have to do nursing home, so they started working on setting up consent forms and getting things ready, so by the time the vaccines arrived in mid-December, Connecticut was ready to go. Massachusetts was not. And that definitely slowed things down. And nursing homes are such high risk and this was in the middle of the horrible surge of November, December, January. And so any infections that happened in December and January in nursing homes and high risk situations are all things we could have prevented with better planning.

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In the early days, it wasn’t just the website and the clumsy kind of complex rules. Overall, I just think we should have planned better. We knew this was coming.

Boston.com: You recently pointed out how, even though Massachusetts has very high vaccine coverage overall, there are pretty glaring differences in vaccination rates between places like your hometown of Newton and lower-income communities like Springfield. Are there things the administration should have done — or should be doing — to address those gaps?

Jha: First of all, I always begin with the question of, “Is anybody surprised?” Is anybody surprised that Newton is doing better than Springfield? I would say no. We all could have predicted that, right? The second question I would ask is, “OK, if we knew this was going to happen, what did you do to try to prevent it?” And, yes, there are plenty of places in Springfield where you can go. No one questions whether we have vaccination sites in Springfield. The question is, what are the barriers for Springfield and how do they differ from the barriers in Newton?

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In Newton, the barrier was just there are no vaccines around, and as soon as vaccines became available, everybody got one.

Whereas we knew that that’s not what was going to be the issue in Springfield. In Springfield, yes, it was gonna be supply and demand, but as soon as supply showed up, there was still going to be a problem in Springfield, because it would also have to do with other things, like trust in vaccines, access that goes beyond just can you get a shot but can you get time off from work because you’re gonna feel lousy for 24 hours. There’s been a lot of misinformation campaigns that have targeted minority communities — how you deal with that. There’s a lot of misinformation campaigns that talk about how expensive vaccines are and how it’s going to charge you hundreds of dollars, which of course isn’t true. Even the website in Massachusetts asks for your insurance information. You can say you don’t have it, but then people wonder, “Well, am I going to get a bill?”

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If you’re a poor person, if you’re uninsured or you’re marginally insured or your insurance isn’t so good, you don’t have a card on you — you’re gonna think twice about like, “Do I give up on those things?”

[Editor’s note: The state’s vaccine website does say the COVID-19 vaccine is free and that ID and insurance is not required.]

Boston.com: The state has done some pretty big PSA campaigns, and in some communities, there are people literally going door-to-door to increase awareness about the vaccine. What are the additional steps they should take?

Jha: You are seeing vaccination rates in places like Chelsea that are starting to get comparable to maybe not quite to Newton but certainly to the state average. You’re seeing a lot of community-based organizations step up, and I would say the Baker administration has been helpful.

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That’s why overall I started where I started, which is Massachusetts is one of the top in the country and the Baker administration deserves real credit for that. But if you ask could things have been done better — and I always say what should we have known about upfront because it’s easy to look at things in retrospect, and this is one where I think we all saw it coming. We all knew what the barriers were gonna be. And I would say they’ve done some stuff on it but not enough. And they should have done more upfront earlier.

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Boston.com: Headed into the summer, in many places in Massachusetts it does feel like we’ve basically returned to normal. But do you have any outstanding concerns?

Jha: No, I think we’re in very good shape in Massachusetts, largely because of the excellent vaccination campaign.

If I were advising the Baker administration — which I am not, but if I were — I would say you gotta keep going. No letting your foot off the accelerator on vaccinations. There’s still plenty of opportunities to reach more people, even here. And we’re at over 80 percent of adults with one shot. I want to get to 90. And I’d love it if we got to 95 percent. We may not be able to, but we should try and we can.

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The second thing is getting ready for the fall and winter. We are gonna have a fall and winter in New England, as we do every year, and we’re probably gonna have a little mini-surge. And that mini-surge could be really, really tiny, if we get to 90 percent. It may be a bit bigger if we don’t get much above where we are now. I’m not worried about a big surge. I’m not suggesting that we need to like get our hospitals ready — none of that stuff. We just have to know that there will be a little surge, and we just have to control that.

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Obviously, that’s one reason to get people vaccinated, but the other thing is we should come up with our plans. What are we gonna do at schools if there is a surge of cases and we still have a lot of unvaccinated kids? Are we gonna have mask mandates. Are we gonna go to remote for some period of time? What’s our plan? I want to start seeing some communication about how they’re thinking about the fall and winter, because we’re in the great days of summer right now, but we know a fall and winter is gonna come and we know that the virus is not going to be gone.

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