On Day Zero of the presidential administration of Joe Biden, the single priority of the federal government must be Covid-19. Without torquing the numbers of deaths and infections downward, no other policy—economic improvement, immigration reform, even a serious approach to stopping climate change—can happen. And that sentence works in reverse too; dealing with Covid-19 is dealing with all that other stuff.
Like any big machine, the federal government’s public health system takes time and energy to come up to speed. It hasn’t functioned at its peak efficiency during the administration of Donald Trump. So nothing will change at first. And then something will. And then everything will.
Assuming all goes as planned. For the last year, nothing has gone as planned, when there was a plan at all.
So, the new plan: Last week, Biden laid out a new, more aggressive approach, part of a promise to let science lead policy during his term. The US public health system, broken and underfunded, hasn’t been able to cope with the pandemic, leaving vaccines as the best and only hope, for now, of controlling it. But for all the blazing speed of their development and testing, vaccine rollout has been, in Biden’s (and everyone else’s) words, “a dismal failure.” Biden has now set a goal of giving 100 million shots of vaccine in the first 100 days of the administration. (As of January 19, the number in the US was 14.7 million, according to Bloomberg’s tracker.)
That won’t be easy, but it is possible. Biden proposed opening up who’s allowed to get vaccinated—sidestepping the tier system recommended to states by various government panels in an attempt to ensure equity along with speedy shot-giving. The Federal Emergency Management Agency will build 100 mass vaccination centers in places like stadiums and convention centers, and the feds will deploy mobile vaccination clinics as well—run, Biden said, by FEMA and the Centers for Disease Control and Prevention, and staffed by the public health corps, retired medical professionals, even the military.
Of course, to make all that work, the government will need to increase vaccine production and improve distribution. Last week, outgoing Health and Human Services secretary Alexander Azar also proposed releasing doses that had been “held back” to guarantee the second shots required by both the Pfizer and Moderna vaccines, and opening up vaccinations to everyone over 65 years old. That was just before The Washington Post reported that there wasn’t enough vaccine to go around. “Our plan is as clear as it is bold: Get more people vaccinated for free. Create more places for them to get vaccinated. Mobilize more medical teams to get shots into people’s arms. Increase supply and get it out the door as soon as possible,” Biden said on Friday. “This is going to be one of the most challenging efforts ever undertaken by our country, but you have my word, we will manage the hell out of this operation.”
(Biden also said he’d mandate mask-wearing wherever federal policy allowed him to do so, and ask everyone else to mask up. That’s one of the only public health efforts that could have some real effect, but the politicization of mask use has hampered its effectiveness. “Quite frankly, it was shocking to see members of Congress, while the capitol was under siege by a deadly mob of thugs, refuse to wear masks while they were in secure locations,” Biden said. “Republican colleagues refusing to put them on—what the hell’s the matter with them? It’s time to grow up.”)
These are all not only good ideas, but the only ideas. Their success or failure will be the encryption key to the rest of the Biden presidency. Biden acknowledged that these plans need a lot of money, which means they need Congress. But, like, these moves are what public health professionals have been begging the government to do for a year.
The fact is, the feds don’t have many other levers they can pull. When it comes to public health, the United States is all but unique among advanced industrial nations in not having a single unified system. “We are 50 states and several territories, and virtually all aspects of public health and public health law are at the state and territorial level,” says Art Reingold, an epidemiologist at the UC Berkeley School of Public Health. “So the federal government can facilitate. The federal government can provide. The federal government can bribe. The federal government can coerce. But we’re not one system.” So Biden’s federal government has to instigate, to work the gaps.
State public health agencies wanted clear information on numbers of infections and, more recently, vaccine doses available. They wanted access to resources like protective equipment without having to compete with other states to get it. And they wanted funding to shore up a denuded infrastructure. As I’ve written before, pandemics don’t happen only because of the transmission dynamics of a disease. They’re a consequence of sociopolitical structures. Countries with well-funded, high-functioning public health systems and the support of their governments simply haven’t seen the kind of illness and death that the United States has. In the last decade, funding for public health preparedness has declined by half at the CDC. A study by Kaiser Health News and the Associated Press this summer found that public health funding in states has gone down 16 percent since 2010, with 38,000 state and local public health workers losing their jobs since 2008.
“Most states and locals do know what they need, if they have some resources—things like IT systems and employment systems,” says Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials. “That means we’ll have more accurate data so we actually do know what the current level of vaccine administration is, and it means the systems and appointments work a little better.” Information goes a long way toward calming people down, even if the information itself isn’t the best news. It’d be nice to know if you were number gazillion in line to get your shot, or number gazillion-plus-one.
Plescia also emphasized what other public health experts told me—that restoring the power of the CDC as the preeminent federal public health agency will help a lot, in terms of confidence and distribution of information. Rochelle Walensky, Biden’s nominee to run the agency, is widely respected in US public health, and she has already acknowledged that its scientists were muzzled early during the pandemic. “They need to put CDC forward as the lead agency on this and let them do what they do well,” Plescia says. “We wouldn’t really contact anybody else. Not that there’s any animosity. It’s just, that’s where you go.”
At a seminar sponsored by Johns Hopkins University last week, a member of the Biden team’s Covid-19 task force added even more specificity to the federal plan. Celine Gounder, an infectious disease physician at New York University, acknowledged that vaccinations have been going slowly—in part, she said, because of the complex recommendations from groups like the CDC’s Advisory Committee on Immunization Practices, or ACIP. “Some of the guidance of CDC and ACIP, while very well intentioned in terms of trying to prevent disease and death and do so equitably, the vaccination recommendations have just been very hard to operationalize on the ground,” Gounder said. “We essentially need to make things simpler.”
Even if vaccine manufacturing keeps getting better instead of worse—no guarantee—the logistics of “everyone just come on down” have already proven, in Florida among other places, to lead to disastrous lines and chaos. Making more people eligible doesn’t mean there will be enough people to administer the shots. “Part of the problem is there aren’t enough people to actually do the injections, in addition to the actual lack of vaccines,” says Nicole Huberfeld, a health law and policy professor at Boston University. “The money is helpful. It isn’t everything, but it makes it so that it’s possible to get set up. The staffing is the question mark, in addition to the actual vaccine supply.”
This balance will also be the first test of the Biden administration’s values. ACIP’s recommendations attempted to address both a tight vaccine supply and the consequences of an inequitable society. “I feel like we’re so focused on the efficiency metric at a national level that we’re losing sight of the equity metric,” says Grace Lee, an infectious disease physician at Stanford Children’s Health and a member of ACIP. “There’s scientific underpinning for why those recommendations exist, and it’s because of the inequitable distribution of the burden of disease, the burden of hospitalization, and the burden of death. I agree we need to vaccinate everybody as quickly as possible, but we have to be thoughtful and flexible about implementation.”
The values fight only gets bigger from there—and will sharply contrast the Biden administration with Trump policies. If the federal government had made open enrollment into the ACA easier, more people would’ve been part of a system that could have reported insurance enrollment and demographic numbers to a central clearinghouse. Separately, the Centers for Medicare and Medicaid Service could have shared data about what kinds of treatments were working for Covid-19 sooner. If state public health agencies had maintained large disease surveillance teams and contact tracers, they could’ve deployed a year ago. “These atmospherics are all of the ways that health care has been undermined for the last several years,” Huberfeld says. “The circumstances before the pandemic are absolutely feeding how bad the pandemic is.”
A national housing crisis meant people were crowded into too-small living spaces with too many other people, letting the disease spread. A national health care crisis meant people had no access to physicians and had preexisting conditions that made them more prone to serious illness when infected with the virus. A national labor crisis meant people had to work in jobs that put them at risk of infection, or not work at all. A lack of federal policymaking on any subject other than immigration restriction and lowering the tax burden of the wealthy meant that nobody was paying attention to signs of impending catastrophe, much less actual catastrophe. “One of the leadership issues for the Trump team has been that it’s been a revolving door, so someone’s always learning the ropes. This is a team for Biden that knows their way around. There’s less startup and more diving in,” Huberfeld says. “It doesn’t have to be as hard as it has been. Centralized decisionmaking will be more evidence-based, and oriented toward working with states and reducing risk. Those are not necessarily what those approaches have been to this point, to put a fine point on it.”
And if all that works, the Biden administration’s pandemic response could also be its best argument to those 42 percent of people who, according to a CBS News poll, think the new president’s biggest challenge is political division. More than half of Republican voters say they don’t believe Biden’s election was legitimate; maybe the best way to get them on board will be to give them a country where it’s safe to go to restaurants again, where schools are open, and 4,000 people aren’t dying every day.
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