If Joe Biden beats Donald Trump this November and ends up in the Oval Office in January, he’ll quickly face one of the gravest challenges any president has seen in the modern era: Hundreds of thousands of Americans will be dead from Covid-19. Public trust in scientific and government institutions will be depleted. If the fall and winter goes as badly as some experts fear, coronavirus outbreaks may be at a new peak. And if a vaccine gets approved, it will still need to be distributed to hundreds of millions of Americans quickly and equitably.
Biden’s immediate job would be fixing the mess left behind by his predecessor — one that’s left America with one of the worst coronavirus outbreaks in the world and, as of September, more daily Covid-19 deaths than all but two developed countries.
Experts say these problems are fixable, but fixing them will largely come down to political will. The policy solutions are things that we’ve all heard about throughout the pandemic: aggressive testing and tracing to contain new outbreaks. Mask-wearing to slow the spread of the coronavirus. Economic support for those affected by the epidemic, at once providing financial support and making social distancing more feasible.
“It’s not rocket science. It’s not that we need some new thing that hasn’t been thought of before,” Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, told me. “There are things that have been done in some cases, or can be done. But if there was a stronger, coordinated federal role … that could really make a difference. It’s happened in other countries.”
Another part of Biden’s job will be to, in effect, repair Americans’ trust in science — bolstering public health institutions like the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA), widely considered the gold standard of public health agencies in the world before the pandemic.
Biden will also have to prepare the country for the rollout of a coronavirus vaccine that could take months if not years. The challenge here isn’t just discovering a safe and effective vaccine; many experts, in fact, are hopeful the world will do that by the end of 2020. The difficulty will be figuring out how to quickly produce and distribute up to hundreds of millions of doses of the vaccine to the general public — an unprecedented effort. That will also require persuading the public to take the vaccine, which could be particularly challenging coming off the heels of a highly contentious presidential election.
Biden, for his part, has vowed to do much of this. His website promises to adopt a masking mandate and boost testing and tracing. His campaign has vowed to “listen to science” and “restore trust, transparency, common purpose, and accountability to our government.” And he’s promised to “plan for the effective, equitable distribution of treatments and vaccines.”
Trump could do all of this, too. But there’s very little faith among experts that Trump will change his current approach to the pandemic, especially if he wins reelection. Instead, he’ll likely continue doing what he’s done: deliberately downplaying the pandemic, demanding states reopen far too quickly, punting testing and tracing to local and state governments with more limited resources, mocking masking, and continuing to try to politicize the CDC and FDA.
That failed response helps explain the US’s current Covid-19 outbreak, leading the country to more than 200,000 deaths from the disease — by far the highest recorded death toll in the world. When controlling for population, the US hasn’t had the highest death rate for Covid-19, but it’s among the top 20 percent for developed nations, and has seven times the death rate as the median developed country. If the US had the same Covid-19 death rate as, say, Canada, more than 120,000 more Americans would likely be alive today.
That damage can’t be reversed. Those 200,000 deaths are on the US’s record forever. But Biden, at least, could take actions that would help prevent America’s outbreak from getting even worse.
1) Implement policies we know work: Testing, tracing, masks, and social distancing
There are problems in the world with really difficult or unknowable answers. That’s not as true for Covid-19: While there’s a lot about the coronavirus we’re still learning, there are many policy approaches that we know work and the US hasn’t really embraced. This is, then, more a matter of will than knowledge — which is something that Biden, especially if he has a sympathetic Democrat-controlled Congress, could address.
Testing is among those proven policy approaches. When paired with contact tracing, more testing can help public health officials detect outbreaks, get the infected to isolate and the infected’s close contacts to quarantine, and use broader public health measures as needed. This is an approach that has worked well in many other developed countries, from Germany to South Korea to New Zealand.
The US, however, has struggled to build up its testing capacity. It’s made big improvements since the start of the pandemic, but testing hasn’t increased above 1 million tests a day — far lower than experts say is needed, given the country’s large epidemic overall. As a result, the percentage of tests coming back positive, which experts use to measure testing capacity, stubbornly remains at 5 percent or more; it should be, experts suggest, far below 5 percent and preferably below even 3 percent. It can still take days to get test results back, and that can spike to weeks if demand, due to a new outbreak, is high.
According to experts, part of the problem is the US never fundamentally fixed supply line problems — with shortages popping up for swabs, reagents, testing kits, and other needed equipment throughout the pandemic. There was also an economic disincentive to building out capacity too much: If a lab, for example, massively scales up its coronavirus testing, but the pandemic is over in a few years, it will be left with a lot of infrastructure it doesn’t use or get revenue from, a huge money sink.
A Biden administration could address these problems, using the powers of the federal government to coordinate the supply line, maintain its stability, and guarantee that any businesses and organizations will be made whole for investments into coronavirus testing. To do all of that, the country needs a national plan — which it currently lacks.
There’s a chance the supply problem fixes itself. With the development and mass production of new antigen tests that don’t have to go through a lab and hospitals, Americans could get access to many more tests that also return results within minutes instead of hours or days. Compared to the hold-ups with the current PCR tests that go through labs or hospitals, it would be a welcome change.
Still, there would be remaining questions about how to deploy and distribute those new tests based on equity and need — questions that a national plan could address.
After that, the US would still face another problem: how to actually use those tests. That’s where contact tracing comes in, as “disease detectives” track down newly infected people and their close contacts to convince them to isolate and quarantine. Earlier this year, Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security, projected that the US would need at least 100,000 contact tracers. She estimated the US still has fewer than half of that number.
Since Watson’s original estimate, Covid-19 outbreaks in the US have also gotten much worse and more widespread. That presents two major problems: First, the US now needs even more contact tracers than she originally estimated. Second, it’s now likely impossible for contact tracing to really bring down the epidemic on its own, because there are just way too many cases for even a massive team of tracers to track down and contain.
So while a large federal investment in a contact tracing workforce and equipment could help, it probably won’t be enough. “We really have to take other measures to bring down transmission in order for contact tracing to be effective,” Watson told me.
Among the other measures: masks. The scientific evidence for masking has gotten much stronger since the start of the coronavirus pandemic, with multiple studies linking the widespread use of masks and new mask mandates to drops in Covid-19 cases and deaths. One study in Health Affairs suggested that, with caveats that this is just an approximation, “230,000-450,000 COVID-19 cases may have been averted on the basis of when states passed these mandates.” If mandates were nationwide instead of left to a minority of states at the time, it stands to reason the impact would have been much bigger.
Whether the federal government could impose a mask mandate on its own gets into legally dicey territory. But a Biden administration and Congress could use financial incentives to encourage cities and states to adopt masking mandates and provide extra resources to enforce them. That could get the remaining 16 states without a mask mandate, or at least some of the municipalities in those states, to adopt the policy.
Just having a president who is unequivocal about the benefits of masking and consistently wears a mask in public, experts claimed, would also signal to the rest of the country that this is the right thing to do. It’s “just the public image of a responsible adult doing what they’re supposed to do,” Cedric Dark, an emergency medicine physician at the Baylor College of Medicine, told me.
Even with all these measures in place, the US will have to continue social distancing to some degree. No one wants this, but, depending on how bad fall and winter outbreaks get, some cities, counties, and states may have to bring back lockdowns.
The federal government can provide clearer guidance on how and when to do this. It can also, with Congress’s backing, pass legislation that financially supports people affected by lockdowns. A commonly cited idea is a bailout for bars, restaurants, and other businesses, which would not only help keep these employers and their employees afloat but make the negatives of closing down much more tolerable and, therefore, make closing down easier and more likely if it’s deemed necessary to fight the coronavirus.
Ultimately, this could benefit the economy by mitigating the need for such harsh social distancing efforts. A preliminary study from the 1918 flu pandemic found that cities that took more aggressive action against outbreaks back then emerged stronger economically. Germany and others have similarly seen their restaurant businesses recover by controlling the coronavirus. As Watson put it, “In order for our economy to recover, we really do need to resource our public health response more effectively.”
Again, none of this is really new. The experts I spoke with often joked that we were having the exact same conversations now that we had back in the spring and summer. But the US hasn’t fully committed to these kinds of policies — and a Biden administration could.
2) Rebuild trust in science and public health institutions
Under Trump, and particularly throughout this pandemic, trust in many institutions has dwindled. This has applied even to American institutions that were in the past considered the best of the best in the world for public health, such as the CDC and FDA.
The country needs “a long campaign to get people to trust science again,” Dark said. “My colleagues don’t trust anything coming out of the CDC now, due to how politicized it’s been.”
A report from the Covid-19 Consortium for Understanding the Public’s Policy Preferences Across States, based on a 50-state survey on Covid-19, captured the trends: Across the country, trust in “doctors and hospitals,” “scientists and researchers,” and especially the CDC has fallen. Trust in all of these is still relatively high — much higher than trust in either Biden or Trump — but it’s a concerning trend. Among different political and demographic groups, trust can be even lower, too.
“Six months ago, the FDA and CDC were shorthands for gold-standard scientific advice,” Ashish Jha, dean of the Brown University School of Public Health, told me. That’s changed, he lamented.
Some of this reflects genuine failures by these institutions. The CDC and FDA both played roles in the US’s testing problems — the CDC by botching its tests, and the FDA dragging its feet in approving more testing from private and independent labs — leading to what’s been widely called a “lost month” for testing in February. The CDC was also slow to recommend masks, then failed to admit to messing up and explain its about-face on the issue. The FDA, meanwhile, has acted in ways that seem politically motivated rather than based on rigorous evidence, such as when it allowed, before warning against, hydroxychloroquine, which was always unproven but Trump spoke favorably about.
Although the CDC and FDA are supposed to stand above partisan politics to help maintain their credibility, Trump and his administration have actively meddled in their affairs and work. Trump and his political cronies have, for example, repeatedly pushed the CDC to do things solely to support Trump’s unproven claims about Covid-19 — forcing the agency to briefly recommend less testing, loosen its guidelines for reopening, and delay studies that contradict the president. All of that has called into question just how independent the CDC truly is.
Fixing this will take time, but it’s fairly straightforward: Biden and the political actors in his administration should back off, allowing scientists to take a leading role in these agencies and the US’s Covid-19 response in general.
Carlos del Rio, executive associate dean of the Emory University School of Medicine, put this simply: “Pay attention to science. Let the science guide the response, not the politics.”
That includes giving these institutions control of the public messaging. While Trump appointed Vice President Mike Pence to lead the White House’s coronavirus task force, Biden could put a scientist or public health official in charge. While Trump sidelined the CDC after Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, warned in February that “disruption to everyday life might be severe” due to Covid-19, Biden could allow the agency and its experts to speak plainly and truthfully to the public.
That should also translate to the policy level. When the CDC makes recommendations, the Biden administration shouldn’t, as Trump has, undermine the guidelines or force the agency to change them. When scientists are recommending a pivot in the country’s approach, that should be seriously considered, even if it contradicts what the administration said or did in the past, while clearly and transparently explaining why a change is needed.
“The CDC has the expertise to lead us in this pandemic,” Jorge Salinas, an epidemiologist at the University of Iowa, told me. “We just need to ask them.”
The idea is to prove to the public time and time again that the country’s response to Covid-19 isn’t driven by politics but by science. It’s an admittedly difficult task for a country that’s consumed by politics and polarization at every level, but it’s something, experts said, that’s simply necessary to improve America’s response to the coronavirus.
3) Prepare the country for a months-long rollout of a vaccine
If we get a little lucky, there’s a chance that the world will finally have a proven, safe, and effective coronavirus vaccine by the end of the year. It would be an incredible achievement — the fastest turnaround on a vaccine for a major disease in human history.
But that won’t be the end. After a vaccine makes it through the last rounds of research necessary to get FDA approval, it’ll have to be distributed to potentially more than 300 million people in the US alone. Given that some of these vaccines will require two doses, that means manufacturing hundreds of millions of doses of the medication — something that the country simply hasn’t done at the scale and speed that the pandemic demands.
There’s already a lot of work, from both governments and private actors like Bill Gates, to manufacture all those doses. It’s possible, even likely, that the current work isn’t enough — and that will demand more action and more funds by a Biden administration.
After that, there will be tough questions about who gets priority. There’s a consensus that first responders and health care workers, at least, should get a vaccine first. Beyond that, there are genuinely difficult questions: Should older adults get priority because they’re more vulnerable? Should essential workers? What about younger people, who seem to be behind the country’s most recent large outbreaks? “It gets complicated,” Jha acknowledged.
Another element will be persuading the public to actually take a vaccine. If a vaccine is 50 to 70 percent effective, as appears likely at first, experts argue that close to 100 percent of the population will need to take one to reach true herd immunity. That will be a tall order as the country deals not just with traditional, unscientific anti-vaxxer sentiments but also more nuanced concerns about whether the current politicized, fast process coronavirus vaccines are going through can really test adequately for safety. Different surveys have found a third to half of Americans don’t plan to or don’t know if they’ll get a coronavirus vaccine.
“It does seem like there has been less of a push to actually come up with a really good communications plan,” Watson said, “but also to just have a general dialogue with people as you go along about what the process has been like for creating a vaccine, what standards have been upheld, and the results of the safety and efficacy trials.”
Breaking through those concerns will require research and surveys to subsequently build a massive communications campaign that will try to push people to get vaccinated. This will be a huge undertaking, and it might not even work, depending on if a new administration can rebuild trust in science and depoliticize its public health institutions.
All of this could take a long time. Experts were unanimous in arguing that getting a vaccine by the end of 2020, should that happen, won’t be the end of the pandemic. They said that getting a vaccine out there could take at least months. Some spoke in terms of years, well into 2022 or 2023. “President Biden and Vice President [Kamala] Harris, should they be in office, should understand they will be dealing with Covid for much of their first term,” Jha said. “It will continue to come up as an issue in the next midterms. It’s not going away.”
To put it another way: If Biden takes office, it’s possible a vaccine will finally present some kind of finish line in this pandemic. But we might quickly realize that the finish line is still a few months or years away. And that will make the work of preparing the country for a vaccine — and all the other steps needed to contain Covid-19 in the months and years ahead — necessary. With hundreds of thousands of Americans already dead, it’s the most important task Biden should prepare for right now.