Misinformation is the Biggest Challenge of Our Time – Dr. Ashish Jha, Brown University School of Public Health

Shiv Gaglani: Hi, I'm Shiv Gaglani. Dr. Ashish Jha has emerged as one of the leading medical figures during the COVID pandemic, dispensing evidence-based information and insights in a clear and helpful way through hundreds of interviews with TV, print, and radio journalists -- with more than a few podcasts thrown in for good measure. Dr. Jha, currently dean of the Brown University School of Public Health, was on the faculty of the Harvard T.H. Chan School of Public Health for many years and is recognized as one of the leading health policy scholars in the nation. One small world connection, we actually had his medical school roommate, Dr. Josh Sharfstein, on the podcast a few months back. That must have been quite the power room back in the day, and continues to be today. So, Dr. Jha, it's a great pleasure to welcome you to Raise the Line. 

Dr. Ashish Jha: Hey, Shiv, thanks so much for having me here. 

Shiv Gaglani: So, our audience has probably seen you on TV and knows a lot about you, but just for good measure, do you mind giving us a sense of what got you interested in public health and medicine to begin with?

Dr. Jha: Yeah, it's a great question that goes back to college. I think I can admit it now given how many years it's been…if we're going to be honest, part of it was clearly driven by the fact that my parents really, really -- particularly my mom -- really, really, really wanted one of her sons to be a doctor, and my older brother had zero interest. So, it was me or bust. And as an immigrant kid from India who felt like, "Oh, I really shouldn't think about this," I have to say, that was definitely a big part of the influence. It was interesting, though, Shiv. I arrived in medical school and I loved it. I fell in love with medicine. I'm not sure I went for the right reasons, but I certainly stayed for the right reasons. I just decided medicine was awesome. Why did I think it was awesome? Because it gives you all of these really interesting and important skills you can use to alleviate suffering to make people's lives better, and that was very powerful. 

The only other thing I'll say is, during medical school as I started on the wards and started seeing patients, I quickly realized that so much of what shaped people's lives -- that landed them in the emergency department or landed them in the hospital -- really was outside of the traditional sphere of medicine, right? It was about where they lived and the neighborhoods they lived in and what kind of food they had and the jobs they had. I thought about that, and I thought about ‘how do I help people more broadly’ and realized that's the purview of public health. So even back in medical school, I started taking classes at the public health school just because I wanted to understand all of that broader context and my love of medicine and my love of public health has never really diminished, and I've tried my whole life to try to keep both going.

Shiv Gaglani: Well, that's a very relatable story. I'm a son of immigrants and an immigrant myself, and I joke that I'm the black sheep of the family because I still haven't gotten my doctorate. I haven't finished med school at Hopkins because I left to start Osmosis. But one day, I'll make my mom proud and go back. So, after earning your medical degree you went and did an MPH. You could have done an MBA and all sorts of other things and ways to contribute to public health, but what specifically has been most impactful to you within your public health career pre-COVID?

Dr. Jha: I think the reason I got an MPH and the reason I really loved practicing and being in public health was, I spent most of that time being a researcher. And research is a funny thing because a lot of times you think the output of research is papers and grants, but it's not. I mean, papers are really important. But papers are only as important as much as they shape thinking and as much as they shape the world and then help people make better decisions on things. 

I loved spending most of my time doing research because I felt like I could help answer questions that policymakers and clinical leaders needed to answer to make smarter choices about how our healthcare system is structured, how we pay for health care, our new delivery models, what's the role of information technology...there are all these issues that I worked on because I thought they were important to improving the health system. The only way to really have done that was to have gotten an MPH with really good research training, so that's what pulled me into MPH, and then ultimately kept me in it.

Shiv Gaglani: Awesome. So, you recently made the switch from Harvard School of Public Health to become dean of Brown. I actually did my thesis research in college with Dyann Wirth out of HSPH, so I may have passed you in the halls at that time. How has it been adjusting to Brown and being the Dean of that program, especially during the COVID crisis? Can you tell us a bit about that experience?

Dr. Jha: Sure. So there are two parts of that, right? One is switching jobs, which is always interesting. The second is switching jobs in the middle of a pandemic, which I would not recommend to most people. Pandemics in general I don't recommend to people, but in all seriousness...look, Harvard's great place. I spent 16 years there. It's a wonderful school of public health, a great university. But I was ready for a new opportunity and Brown is different. It's smaller. It's far more interdisciplinary. I have always thought that if you want to solve the big public health problems of our time, they're not just going to be done by epidemiologists and biostatisticians, you really do need sociologists and anthropologists and economists. Brown makes that really, really easy. That was what attracted me to come to Brown. 

Now, I decided to come before the pandemic really got going. Arriving at a new university with new colleagues in the middle of a pandemic -- where I still have not, to this day, met 90% of faculty in my school...I've seen them all on Zoom, but I haven't physically met a vast majority -- that's weird. It's funny, even though I've finished my first year I feel like this fall when everybody starts coming back close to full time that will feel again like another first year because I'll get a chance to start meeting people.

Shiv Gaglani: That's actually quite a common thing we're hearing from students as well. We had the dean of Wayne State's School of Medicine, Dr. Mark Schweitzer, on the podcast who switched to that job in middle of the pandemic as well. So, we've had a number of really well-known people on the podcast, including Arianna Huffington and Chelsea Clinton. You're among that list of extremely well-known recognizable folks. How does a physician and public health researcher and professor wind up becoming so well-known and such a trusted voice? Do you mind walking our audience through how that happened?

Dr. Jha: Sure. So, I've done media stuff and have always tried to figure out how to translate my research for other people for a long time, but obviously the pandemic changed everything, right? In early March, it became obvious that we were headed towards a lot of trouble. What we did -- I was still at Harvard, running the Global Health Institute -- is we started building models for what hospital capacity was going to look like in the U.S. and was America going to be able to manage the surge of cases. That really was the underlying data for a lot of that "flatten the curve" and “stay at home.” And as we were doing that work, it really became clear to me that we were not, as a country, we had not been preparing for this pandemic. By late January, it was very clear that we were gonna end up having a global pandemic, and yet we wasted all of February and early March, and so I started raising the alarm. I started talking about why this was important. 

When the media stuff started happening in early to mid-March, my mental model was it'll be a couple of weeks of media and then the government will really take over. CDC will start doing daily briefings. Everybody will start hearing from Tony Fauci and then no one's gonna need to hear from me because if you get Tony Fauci, you don't need me. So, my mental model was a couple of weeks of media, it'll die out, it'll be fine. I'll tell you, it just never really stopped. By the end of March, early April, I was getting 100-150 Media requests a day. Obviously, I can't physically do that. I went for a while, then I thought, "Is this a good use of my time? Should I just stop?" And I started talking to friends and family. Because in the beginning it was kind of fun. You're on TV. But then the question was, is this useful? Is this making any kind of a difference? 

I think what I came to realize from the feedback I got was that one of the key things that happens in a pandemic is people are scared. They don't know what's happening. And if you can help -- both alleviate fear, but also help guide people in decision making -- that's what public health people should be doing. That's what physicians do on a one-on-one basis in the clinic or in the hospital: we alleviate fear, we help people make better decisions and I felt like that was my responsibility. When I switched to a new job, I had to cut back a bit more, but I felt like it's an important part of all of our responsibilities as physicians, as public health people, to speak out and help the American people through this difficult time.

Shiv Gaglani: Absolutely. I couldn't agree more. As far as the question of whether it's making a difference...I remember the op-ed you wrote on the COVID pandemic in India as it was surging just a couple of months ago, and the impact that had on the public consciousness and getting the administration to send a lot of vaccines and oxygen over to India. That felt like a bit of a different thing. That was obviously very personal to you, to me...not a single Indian American doesn't have family who've been affected in some way. Our chief medical officer Rishi, who's himself been on TV a couple of times -- he went viral for a Fox News interview he had done back in March...

Dr. Jha: I remember that.

Shiv Gaglani: ...some family members passed away in India because of it. And so, that felt different...personal, you know? Obviously, it did have an impact. I'm sure when you wrote that, there was a ton of follow-up on how best to address it and spur the U.S. to take action, right? 

Dr. Jha: Yeah, that was an interesting process. Part of it was, it was very clear to a lot of us that India was getting into a lot of trouble and the Biden administration was not being responsive enough or not moving fast enough. I have a lot of friends in the administration. They're good people. I just think they can get distracted and have lots of other stuff on their plate, but they weren't moving as quickly as they needed to. So I started talking to my friends in the administration and saying, "You really have to push the administration and the White House to move. And a lot of them said, "Okay, fine. If we do that, what do we need?" 

Then I thought, "Well, I can tell you what I think India needs." But what I did was I called senior people in the Ministry of Health in India, and I said, "Here's what I think you need, but what do you really need?" because they know much better than I do, sitting here in the U.S. Through that, I kind of triangulated and came up with a list of things and both shared it with the administration, but then also wrote it up as an op-ed in the Washington Post. It was clearly not just all me. There were lots of other people who were saying very similar sets of things and I think the administration responded, not out of pressure, but because we helped the administration have a path forward. They get yelled at a lot for all sorts of things and I think instead of yelling and saying you're doing badly or you're not doing enough, it's much more constructive to say, "Here are three things you could do" because it lets good people have a path forward. So, it was an important moment and it was a moment where I think public health leaders came together with the administration to make a difference in India, and it was meaningful. I have a lot of family in India who have gotten sick as well and so I think we all felt a moral responsibility to act.

Shiv Gaglani: We're finding India's handling of this has led to the Delta variant coming back to the U.S. and globally. So, that's a good transition to the next question, which is, what is your current assessment -- we're speaking in July 2021 -- of the trajectory of COVID, in the U.S. and globally? 

Dr. Jha: So, in the U.S. I think we're seeing a bifurcation as we certainly are globally as well. But let's talk about the U.S. first. I live in Massachusetts and I work in Rhode Island. These are highly vaccinated states and I expect that as vaccinations continue to rise in the States, the Delta variant will maybe be a nuisance, but I don't expect it to cause large outbreaks. I don't expect it to harm our hospitals. We all have to be a little bit careful, but mostly, I think, we can kind of go about our daily business. I suspect that there may be more variants down the road, but they're unlikely to fundamentally challenge our vaccines. 

That's Massachusetts, that's not Missouri. Their vaccine rates are much lower, and you have parts of Missouri where hospitalizations have gotten bad enough that they're shipping patients to other hospitals. The CEO of one of the largest hospitals systems in Springfield, Missouri is Tweeting that he needs more ventilators and more respiratory therapists. When the CEO of a large hospital system goes to Twitter to get more help, it's not a great sign. We have large chunks of America that are largely unvaccinated and they are at substantial risk so I see a very different future for them in the weeks and months ahead...with a lot more infections, hospitalizations, and deaths, unfortunately. 

Globally, I can tell the exact same story. Western Europe is doing really well in vaccinations. A lot of Western European countries are still struggling with the Delta variant, but I think they'll get it together. Africa as a continent has barely been vaccinated at all and we're gonna see a lot of infections and suffering in Africa. The difference between the global picture and the U.S. picture is, of course, on the global side, there are a lot of countries that just don't have access to vaccines. In the U.S. the counties and states that are low vaccinations have plenty of access in the traditional sense, but they have not gotten vaccinated for a variety of other reasons, misinformation among others, that are really holding people back.

Shiv Gaglani: Speaking of misinformation, we had the editor in chief of WebMD, Dr. John Whyte, who I'm sure you know...

Dr. Jha: I do. 

Shiv Gaglani: ...he's been in the podcast as well. One of the main questions I asked him, and I'd be curious about your thoughts on is, how do we get people to start trusting in experts and institutions again? Do you have any recommendations or things that have to happen to get us to a truthful world again, a more realistic world?

Dr. Jha: I think this is the biggest challenge of our time. I think people under appreciate the power of the information ecosystems that we all live in. All of us. We live in an ecosystem where we hear certain messages, and then we hear those messages reinforced and amplified. When people live in a very different information ecosystem than ours, don't be surprised if they have very different world beliefs. 

As you might imagine because I'm pretty public, I get a lot of everything from hate mail to voicemails. I had a voicemail literally yesterday from a woman who pleaded with me to not spread lies about vaccines. She said, "These vaccines are killing people across the country." She said, "I've watched you on TV. You seem like a good person. I don't understand why you're spreading these lies." And I think she meant it. She wasn't being dishonest. She meant it. It made me wonder what she hears in her daily life that makes her believe that doctors and nurses are out there spreading lies to make a buck. Second, she's not dumb and she's not a bad person. We have to find ways of reaching out to people who live outside our information ecosystem and engaging them. 

I do think that there's that personal responsibility that all of us have to talk to people who are not part of our bubble. But I also think this is one where individual action alone won't work. We also need responsibility from things like Facebook. Almost all the misinformation is spread via Facebook and Facebook can't forever say, "Well, we have no responsibility, we're just a platform." At some point, they have to realize that they are the source and the cause of tens of millions of people around the world who are going to get infected, and many, many who will die because of stuff they read on that platform. So, I'm hoping to see a bit more action from some of these platforms, especially really blocking some of the most noxious disinformation campaigns. I have hope that that combination might work if we can do that, but this is going be a struggle for years. This is not going to end with this pandemic, and we're going to have to continue working on this.

Shiv Gaglani: Absolutely. We partner with YouTube Health to develop content around vaccines and awareness with them and the CDC. I know the platforms have put disclaimers on different content -- whether it's the election or January 6, or it's public health information -- but there's a lot of debate whether that's enough, or are we in an ‘age of censorship’, etc.

Dr. Jha: Now, I will say I think the different platforms are a bit different. I actually think YouTube has done a good job in this space. They could do better. But I find Google and YouTube -- a subsidiary of Google and Alphabet -- in general, has been more proactive on this. I think when they are, we should love them for it and we should say, "Hey, thanks for being better stewards of our information ecosystem."

Shiv Gaglani: Yeah, absolutely. So I know we're coming up on time. I had just a few more questions. The reason we call the podcast Raise the Line is, as you can imagine, it's what your research has focused on, which is do we have enough healthcare capacity for this pandemic and for future pandemics whether they are viral or a chronic disease like diabetes. What are your recommendations for ways we can invest post-COVID...whether it's investing in public health or training more healthcare workers or whatever it may be? What are the most impactful recommendations you would have for us to raise the line?

Dr. Jha: Really good question. I love your podcast, and for a variety of reasons. Not only is it just fun, but also because you're raising the issue around health systems that I think is critical in the following way. One of the debates that often goes on in healthcare is, how much does healthcare really matter and how much do health systems matter? Because all these things outside of health care end up having this profound effect on health and it's true, obviously. Environment matters -- climate change is going to be a major stress on the public health world and people's health - and there's pandemics and chronic diseases…but what's interesting is all of that at the end of the day gets confronted through a health system. 

When we couldn't control the outbreak in New York, or in Missouri right now, it's the health system that manages it. When we couldn't control it in the public health space in India, it was health systems that got crushed. So, we need strong, robust health systems as the ultimate safety net for people's health and well-being. We don't have that in much of the world. Then the question is, how do we get it? And here's where I think we need to think a little bit differently. For 50 years, we've had these mental models of what we need: this many doctors, this many nurses. I'm gonna think about India, for instance. Sure, it needs a lot more doctors and nurses, but it's got to be more than that. 

One of the things that has been interesting to me is realizing that there are millions of people out there in India providing health care. They're often untrained, or they're poorly trained, or they may be community health workers. Instead of constantly saying," "We need more doctors and more nurses," let's take the people who are already there and figure out how to augment them, how to make them better. How do we use technology to build up their skills and what they are capable of? I think the interface between frontline health workers and technology and investing in that is going to end up being the most powerful way we're going to strengthen health systems around the world. So, I want to spend a little less time saying how many more millions of doctors do we need to train and I want to spend a little more time talking about the folks who are already there -- how do we make them better and more effective?

Shiv Gaglani: Yeah, exactly. How do we scale them? There's been a boom in digital health and consumer-driven health care and value-based medicine. So, I think a lot of those trends are going in the right way. 

Dr. Jha: I agree. 

Shiv Gaglani: We have an audience of millions of current and future health care professionals. What advice would you give to them about pursuing their careers in health care and meeting the challenges of COVID and post-COVID?

Dr. Jha: I would say a couple of things. First of all, it's an awesome career. If you're thinking about it, or you're beginning, it is a great career. I have to tell you that the thing that I found personally to be the worst over the last year is I wasn't able to practice medicine because I was switching jobs in the middle of the pandemic. I am now in a new state, so I've got to be credentialed and I'm starting back up on the wards again in a couple of weeks. I am so excited. I've been practicing medicine for 20 years and I still am, like, so incredibly excited and feel like I can't believe I missed a whole year without practicing. It's a way of reminding people that there's nothing as meaningful, as much of a privilege, as being a physician who can take care of patients. So, if you're interested in being a practitioner, it's awesome. 

Second is, there's another kind of important role. When you are a provider -- a physician, a nurse -- people trust you and you become a trusted voice. So in the middle of health crises, it's incredibly important that you speak up about and back science and talk about data and talk about evidence. Because if you don't, other people will step in and fill that void, and they're not going to do what you can do. It's not just a privilege to have that platform, but it's an obligation to use it well.

Shiv Gaglani: That's some wonderful advice. Is there anything else that I haven't asked you about that you'd like to be able to convey to our audience?

Dr. Jha: Maybe I'll finish with the following...one of the questions I often got asked last year, and still do sometimes this year, is 'when are we going back to normal?' I would say, "Well, what do you mean by normal?" and the questioner would say, "We know what life looked like before the pandemic." My answer was, "You mean 2019? Never. We're never going back to 2019." And that's okay. It's actually not a problem, because there's no reason to think 2019 was the greatest year in human history.

Pandemics change societies, but how they change societies is largely up to us. There is a moment now and in the next 6 to 12 to 18 months, but not forever, where a lot of things that we took for granted and felt couldn't be changed -- whether they are systemic inequities in our society, whether they are the way we pay for health care, the way we think about social determinants, how we do we really invest in global partnership, things that felt really, really hard to move -- they just got a lot easier to move. So, what I would ask all of your listeners is to use this moment to say, "How do I make our society better? How do I move the needle on things that are important?" Because this is the moment to do it. It won't be here in five years. It won't be here in 10. It wasn't around five years ago. That's the big silver lining of what has otherwise been a pretty horrible pandemic.

Shiv Gaglani: That's extremely well-said and reminds me of the saying 'a crisis is a terrible opportunity to waste.' So, hopefully, we can all make use of this crisis to, as you said, move the dial on health care. Dr. Jha, thanks so much for taking the time to be with us today and more importantly, for the work that you've done to educate the world about the pandemic. And I'm really glad to hear you're going back to practice soon.

Dr. Jha: I'm looking forward to it. And again, thanks for having me here, Shiv. I really enjoyed it, and take good care and hope to stay in touch.

Shiv Gaglani: Likewise. And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to flatten the curve and raise the line. We're all in this together. Take care.