As Joe Biden takes office, his most immediate priority is dealing with the catastrophe of COVID-19, which has killed hundreds of thousands of people in the U.S.—the highest toll of any country—and sickened and harmed millions. He is inheriting a dire situation from his predecessor, who resisted some of the most important measures to contain the new coronavirus, such as prompt testing and tracing and mask wearing, and who appeared unconcerned as a winter surge of infections devastated the country.
Biden and Kamala Harris, the new vice president, have outlined a COVID-19 plan to reverse this neglect. In addition to promoting more testing and mask wearing, the new administration wants to boost the production of personal protective equipment (PPE), provide economic support for small businesses, ensure a trustworthy vaccine rollout, and address racial and ethnic disparities in COVID's impact. Looking ahead, Biden's team has to get the country ready to handle the next pandemic better than it has dealt with this one.
Some of these goals are likely to face severe headwinds from Republicans in Congress and among millions who voted for Donald Trump. Both groups have fought against masks. Many opposed restrictions on business and personal activity. Congressional Republicans have signaled opposition to funding some of Biden's efforts—especially if, in early January, they retain their majority in the Senate after Georgia's runoff elections. So any amount of money Congress offers will probably be less than what Biden asks for.
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One of Biden's responses has been to say he is “not going to shut down the economy—period. I am going to shut down the virus.” The incoming administration sees restrictions as a “dial” rather than an on-off switch. “That's a perfect metaphor,” says Monica Gandhi, an infectious disease physician at the University of California, San Francisco, School of Medicine. “It's triggering to use the word ‘lockdown.’” Biden aims to direct the U.S. Centers for Disease Control and Prevention to provide guidelines for ways to dial up or down restrictions on businesses, schools and gatherings. The evidence is clear that COVID transmission is higher at restaurants, bars and gyms but not so much at schools, so it makes sense to dial down restrictions on the last, Gandhi says.
There are also highly effective measures Biden can take that do not require congressional sign-off. Nearly every expert I spoke with agreed that one of the simplest and most important things Biden's team can do is encourage people to wear masks or face coverings. Despite extensive evidence supporting this measure's effectiveness, Trump made it a political statement not to wear one, mocking people—including Biden—for using them. Biden can try to change that. “President-elect Biden and Vice President–elect Harris have always modeled responsible behavior throughout the campaign,” Robert Rodriguez told me in November. He is an emergency physician at the U.C.S.F. School of Medicine and a member of the Biden-Harris administration's new coronavirus task force. “They're going to continue to promote the concept that wearing masks is noble—it's a civic duty that shows you care about the country and about others,” he said. Because masks have become so political, however, the messaging needs to strike a careful balance, Gandhi says. Like “lockdown,” the phrase “mask mandate” seems to really rile people up, she points out, “whereas ‘mask guidance’ doesn't.” Biden plans to work with governors and mayors to implement state and local mask rules and has asked Americans to wear masks for his first 100 days in office. And he does intend to make masks mandatory in federal buildings and on interstate public transportation.
A second key step will be to overcome some people's reluctance to get a coronavirus vaccine when shots become widely available later in 2021. Refusals will prolong the outbreak. According to a Pew survey in November, 42 percent of Black Americans said they would get a shot, slightly up from 32 percent in September. Much of this resistance stems from a history of racism and mistreatment of Black people in medicine. “We can't do anything without first reconciling that history,” says Nneka Sederstrom, director of clinical ethics at Children's Minnesota. Biden and his officials need to admit there is legitimate reason for distrust, and they must work to earn that trust back. Saying “we're acknowledging that history of racism ourselves” is the most important thing the Biden-Harris administration can do, Sederstrom says.
To convince skeptical populations, the new president and his team also need to reach out to community leaders who have the trust of their constituents, Sederstrom adds. Rodriguez says that is already in the works; further, the Biden administration has said it plans to address the pandemic's unequal effects on people of color by establishing a separate task force on racial and ethnic disparities in COVID, headed by Harris.
Vaccine skepticism is also linked to political affiliation. Just 50 percent of Republicans or Republican-leaning respondents said they were likely to get vaccinated, compared with 69 percent of Democrats or Democrat supporters, according to the November Pew survey. To reach Republicans, Biden will need to get the help of conservative leaders as well.
Both vaccine acceptance and mask wearing depend on the new president's ability to restore trust in science. “One of the biggest reasons that trust has been lost is [the Trump administration] essentially not letting science and scientists direct the pandemic response efforts,” says Angela Rasmussen, a virologist and affiliate researcher at the Georgetown Center for Global Health Science and Security. Political meddling at health agencies and repeated announcements that undercut public health measures exacerbated the problem. The Biden team can start to reverse the damage by showing that it is following scientific advice and delivering it in a clear, consistent message, Rasmussen says. “Some of that trust will be earned back, but it's not going to happen overnight.”
Beyond winning back trust, Biden needs to scale up COVID testing. Until vaccines reach most Americans, the virus will continue to spread, and testing is the way to identify and contain outbreaks. Yet it is still hard for most people in the U.S. to get a test and receive results quickly. Biden is going to have to increase the number of places for individuals to procure a diagnostic molecular test (something he has promised to do in part by doubling the number of drive-through testing sites). A national pandemic testing board, akin to the War Production Board that President Franklin D. Roosevelt created during World War II, could marshal resources for this initiative, and Biden has said he plans to create one.
Another promising approach is to have companies produce millions of so-called rapid antigen tests. These work well when people are most infectious. They can be taken at a local testing site and yield results in less than 30 minutes. The U.S. Food and Drug Administration has issued emergency authorization for eight such tests as of this writing, but they are not widely available. Michael Mina, an epidemiologist at Harvard University's T. H. Chan School of Public Health, has been an avid proponent of producing tens of millions of them for at-home use. “We have still failed to recognize that it's frequency of testing, not sensitivity,” that matters, he says. “You could have the best test in the world, but if it's not available or it takes four days, it's not useful.” The Biden administration should work directly with companies to develop and produce more tests, Mina says, the way the government contracts with Lockheed Martin and Raytheon to manufacture airplanes and military equipment. The tests should then be made freely available to homes, schools and businesses.
More tests alone will not be enough. People who test positive must be able to safely isolate, and they must be given the resources to do so, says Stefan Baral, an infectious disease epidemiologist at the Johns Hopkins Bloomberg School of Public Health. “If we want people to not go to work when they're sick, we need to provide paid leave,” he says. “If we want to prevent them from infecting their household, we need to provide them a place to isolate.” One way to do that is to let infected people who live in crowded housing or who are homeless stay in a hotel for a few weeks. Some states have already taken this approach. Just as important, contact tracing should be used to stop single cases from becoming clusters or big flare-ups. Currently there are not enough tracers working in the U.S., but the Biden administration aims to hire more as part of a Public Health Jobs Corps of at least 100,000 people. Obtaining financing for this project, as well as for more isolation facilities, would require legislation, however. This effort—like other spending plans—could face an uphill battle in the Senate.
Biden also needs to drastically increase the availability of PPE—such as face masks, face shields and gowns—to protect health care workers. To do so, Biden has said he will quickly use the Defense Production Act of 1950, which Trump as president invoked late and sparingly. If Biden employs the act more aggressively and on companies all along the PPE supply chain, it could lead to the development of a more robust centralized stockpile.
And even as he tries to quell the current pandemic, Biden needs to ensure that the U.S. is better prepared for the next one. Restoring commitments to the World Health Organization (Trump planned to leave it in July 2021), as well as a stand-alone National Security Council directorate for global health security, is a good way to start.
Biden also needs to relaunch the U.S. Agency for International Development's PREDICT project to strengthen abilities to detect pathogens with pandemic potential; it ended in 2020. PREDICT was built on the concept of “One Health,” which focuses on connections among the health of people, animals and their shared environment.
“The Biden administration has a real opportunity to bring a One Health approach to the pandemic because it's clearly not just about humans,” says Christine Kreuder Johnson, one of PREDICT's leaders. A professor of epidemiology and ecosystem health at the University of California, Davis, School of Veterinary Medicine, Johnson notes that changes to the environment are forcing animals out of remote habitats and into closer contact with humans, and people, driven by population and economic pressure, are moving closer to wild animals. Aggressive global surveillance for dangerous pathogens that live in these animals is one way to prevent the catastrophes of 2020 from repeating in coming years.