When Joe Biden is inaugurated as United States president on January 20 he will inherit the legacies of Donald Trump and one of the worst will be a coronavirus pandemic that is out of control during the depths of winter.
Public health experts who had pinned their hopes on a Biden presidency could barely celebrate because the skyrocketing number of Covid-19 cases heralded daunting challenges ahead. The two-month wait before he takes power also means the country will not immediately get a long-overdue organised federal response to the pandemic.
Coronavirus infections are already surging at an unprecedented rate, passing the milestone of 10 million cases with the last million accumulating in just 10 days. An average of 130,000 cases per day were recorded in the past week and hospitals are being flooded with patients, including nearly 67,000 in hospital as of Thursday.
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The imminent winter will drive people indoors where transmission is more likely and gatherings during America’s Thanksgiving holiday and Christmas could cause superspreading events. When these risk factors occur during flu season they present a formidable test for the health system.
“[The Covid-19 pandemic is] going to peak around the time he’s coming to the office and it could be much higher,” said Steve Morrison, director of the Global Health Policy Centre at the Centre for Strategic and International Studies (CSIS).
“It’s estimated that we could have 400,000 deaths by the time of inauguration. It’s going to be a very dark moment.”
Trump will also leave Biden with a divided society which sees the virus differently and has strong opinions on how to deal with it. Biden will have a huge task to get people focused on understanding the pandemic and its consequences, according to Morrison, with the country needing much greater mask use, better social distancing and less politicisation of the issues.
“Obviously we have huge challenges ahead in terms of testing, local capacity, public health capacity, vaccine resistance and hesitancy, a polluted social media environment full of falsity of vaccines and the pandemic. All the things out there he has to deal with and I believe he will,” Morrison said.
Biden has used his transition website to announce the measures he promises to take, including ensuring free access to regular, reliable testing for all, science-based guidance for social distancing regulations, rules around wearing masks and effective and equitable distribution of free vaccines.
The advisory board of 12 public health experts and doctors Biden chose for the Covid-19 response were “very reputable people”, Morrison said.
They include Vivek Murthy, who was surgeon general when Biden was vice-president to Barack Obama but replaced by Trump; David Kessler, a former commissioner of the Food and Drug Administration; and Marcella Nunez-Smith, a Yale public health expert and a doctor.
Also on the board is Rick Bright, who was director of the Biomedical Advanced Research and Development Authority but criticised the Trump administration’s pandemic response and quit working for the government in October.
“[Biden] has put together a very strong team with diversified experts who made a plan for the domestic response and internationally. It is a radical reversal from the approach under the Trump administration, which is incoherent, full of falsity, doesn’t take the pandemic serious and [misrepresents] the reality,” Morrison said.
But all these transition plans come with a hefty bill and the Republicans in Congress must be won over. Morrison said plans for the US to rejoin the World Health Organization, after Trump moved to withdraw from it by July 2021, and to support the Covax initiative to equitably distribute Covid-19 vaccines would also have to pass Congress.
Scott Rosenstein, director of Eurasia Group’s global health practice, said he expected the new administration to put greater emphasis on health communication, with federal government messages changing “significantly”.
Under Biden’s administration scientists would take the lead, unlike during the Trump era when the president launched attacks on scientists, smeared doctors, discredited public health agencies and spread conspiracy theories, he said.
“Public health experts, particularly the CDC [Centres for Disease Control and Prevention], will be front and centre, as was the case during the 2009 H1N1 pandemic. Individual behaviour is such an important component of outbreaks, so health communications is therefore critical – more so than many people realise,” Rosenstein said.
He said he expected that after Biden assumed office, attention would shift to a national vaccination campaign, but that could bring its own complications.
“When a vaccine is approved and starts to become widely available, public sentiment will likely improve drastically, but that will also reduce the appetite for more restrictions,” Rosenstein said.
“So Biden will need to strike a balance – roll out an effective and efficient national vaccination campaign without giving the country a false sense of security before the public health benefits of that vaccination campaign are realised.”
It also meant Biden must fight vaccine misinformation, Rosenstein said. This was a critical yet challenging task, especially if supporters of Trump rejected vaccination because of Trump’s suggestion that the approval timeline was politicised to thwart his re-election campaign.
Dr Krutika Kuppalli, an assistant professor of medicine at the Medical University of South Carolina, said she hoped the Biden administration would listen more to scientists and allow evidence to lead the pandemic response but she also believed communities should be more involved in the response to address their concerns.
“Having community engagement is key to containing the pandemic as it allows for empowerment and buy-in of citizens,” Kuppalli said.
But it is still two months before Biden moves into the White House and can implement all these changes. He is still fighting to get the General Services Administration, which oversees a presidential transition, to free up funding and allow the transition team to visit agencies.
Morrison from the CSIS said that during the two-month power void, Biden could try to convince people to put aside their differences and forge consensus that the pandemic must be taken seriously.
“As president-elect, Biden has the ability to communicate to the American public day in and day out saying, ‘this is a crisis, it could kill you and cost us astronomical loss of lives and fundamentally [undermine] our economy and our position in the world, and we need to fix it’,” Morrison said.
Between now and January 20 the president-elect could also announce his appointments to public health agencies to show how he was going to restore the prestige and influence of the CDC and “free them from political interference and repression”, Morrison said. He could show he is going to renew the respect for science.
“Americans can begin to see that there is an administration beginning to take this seriously,” Morrison said.
“I think we can argue it’s too late to turn around the pandemic and it won’t be easily reversed. The gravity of the crisis will be undeniable, but we just can’t give up.”
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