One of my favorite professors in grad school—an expert in cost-effectiveness analysis—when asked about the worth of individual medical interventions, would respond, “Compared to what?” You always need to have a benchmark. Economic analysis of a drug is relative to the other choices available to you—even if that choice is nothing at all. Upon graduation, one of my fellow PhD students gave him a trophy for best professor, but with a specially engraved question on the pedestal—you guessed it—“Compared to what?”
In evaluating the Biden administration’s performance in response to Covid-19, we must ask the same question: Compared to what? When benchmarking the Biden administration’s perfomance against that of his predecessor, the current president comes out looking spectacular. No one pines for the days of hydroxychloroquine, bleach, and UV light, the “let ’er rip” lunacy of Scott Atlas, the bumbling of Jared Kushner, Robert Redfield, Alex Azar, and others who saw indulging Donald Trump as their key civic duty.
But at the end of a terrible summer—with the Delta variant still ripping through the United States, with ICUs in many states now filled to capacity, and global plans in free fall to vaccinate the billions who are still without even one dose—perhaps it’s time to look forward, not backward. Politicians in the Democratic Party love to say, Compared to my Republican predecessor, don’t I look great on the things that matter: health care, the economy, civil rights? I’ve always felt this was a cop-out, an excuse not to do more, a way to temper aspirations, offering crumbs from the table as sustenance.
Besides, in the context of the pandemic, comparisons with the Trump administration really don’t matter anymore. That’s history. And with no end in sight to Covid-19, it’s way past time to ask more of the Biden administration. I’ve been loath to do so myself because I personally know many people who are now working for the administration. And because I’ve seen some criticisms of what’s happening now as self-promotion, angling for a job in D.C.—or just reflexive naysaying and the arrogance of the new pandemicists, who think they know more than they do about how public health works. I hereby confess my own reticence in this regard—and you can have at me for being slow on the uptake. If I cut the administration too much slack in its first six months, consider this a start of a corrective.
The worst failure of the Biden administration thus far—and I have written about it here and talked about it elsewhere—is the complete disaster that is US policy on global vaccine access. Hundreds of experts have written to the president asking him to establish public production of the currently approved (by EUA) vaccines, ramp up support for the World Health Organization vaccination hubs, and airlift unused doses to countries who need them now. Plans for doing this have come from various NGOs and public health leaders, but Biden either has no interest in what is happening around the globe, sees domestic political concerns as overriding here, and/or does not want to confront the monopoly control of Pfizer, Moderna, or the other vaccine makers.
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Last week’s announcement of vaccine boosters for Americans was another false step. There was no need to roll out a Politburo-worthy line-up of every high-ranking health official in the administration to declare that boosters would be made available to Americans starting this fall. Just the week before, the CDC adopted a recommendation from its Advisory Committee on Immunization Practices to extend booster doses to the immunocompromised. As new data rolls in on the effectiveness of vaccines among the elderly and other high-risk populations, the CDC advisory committee and the FDA could consider the data and recommend extending boosters to larger portions of the American populace. Boosters for all might very well be justified down the line, but the announcement last week caused confusion about “waning vaccine efficacy” when the data tells us that current vaccines are still quite potent in protecting against serious illness and death, even if their ability to protect against infection slips over time.
In addition, given the crisis in many places across the country right now with the Delta variant, third doses among the vaccinated do nothing to address the immediate crisis. Getting a first jab to those in the United States who have yet to receive a single dose is far more important. While political resistance is behind vaccine refusal among many—fueled by the notion offered up by some Republican politicians that vaccination is an assault on freedom—there are ways to lower the barriers to access and acceptance by offering transportation to appointments, sending vaccine teams to places of employment for those who cannot take time off work to get to a clinic, or out into the community to get those who simply haven’t gotten around to getting vaccinated. Lots of this is happening already, but as health departments around the country were struggling even before the pandemic, many are trying to do the best they can with the limited staff they have (more on this later) in the face of constant attacks from politicians. This week’s full approval of the Pfizer-BioNTech vaccine will spur a round of new vaccine mandates, and we should all lean into this opportunity. Opposition to vaccine mandates is a GOP political invention stoking anti-vaccine sentiment around the country and should be confronted directly. Everyone reading this had to be vaccinated for measles, mumps, and rubella to go to school, and other immunizations are required in other settings. The resistance coming from some governors and Fox News commentators is agitprop and dangerous nonsense.
The CDC’s shifting guidance on masking this spring and summer created whiplash among Americans. But rather than Monday-morning quarterbacking those decisions, we need to figure out how to get more Americans to mask up right now. Social norms around mask-wearing are slipping just as we are heading into the winter when many of us will be indoors for large portions of our days. If you really want someone to do something, it helps to make it easy. The US government should use the Defense Production Act to scale up production of high-quality masks and send 100-packs to every American household. The Trump administration was actually on the verge of doing this and then gave up on the idea. Biden should claim it now as his own. Back in the 1980s, it was almost impossible to go anywhere in the gay community without seeing free condoms on offer. No one should have to think twice about whether to wear a mask because of cost or the inconvenience of having to go out and get them for themselves and their loved ones.
And while we’re at it, we should make it easier for people to get tested for SARS-CoV-2. At-home, rapid tests are vastly underused and too expensive for many. Michael Mina at Harvard has been calling for wider use of these diagnostics for months now—and they still can help us manage risk among our friends and family. Making tests kits available to every American household—rather than a luxury item for the wealthier and worried well—would be a true service to all of us. Invoking the DPA and getting these manufactured and distributed nationally might turn out to be overkill, but right now we have over 150,000 new cases daily, meaning that belated under-diagnosis is clearly still widespread across the country.
In June, the Biden administration instructed health care institutions to provide PPE to their staff, to ensure adequate ventilation and distancing, and to offer adequate paid time off for workers to receive vaccinations. Yet these OSHA standards were not extended to other high-risk workplaces. Why, despite the urging of unions and public health officials, didn’t the White House extend these new requirements to meatpacking plants, warehouses, and other settings where we have seen outbreak after outbreak since 2020? This is inexcusable. These workplaces have been ground zero during the pandemic—particularly for Black and brown workers. At a very minimum, these new OSHA standards need to be applied across all high-risk industries. But Elizabeth Warren and Ro Khanna have gone further and called for an Essential Workers Bill of Rights; the president should get behind it. In addition to health and safety protections, their bill would provide retroactive hazard pay to people on the front lines, universal paid sick leave, and protection for whistleblowers, and would hold employers responsible for endangering their workers.
Finally, we have to confront the fact that despite spending trillions in emergency funding, we still have not addressed the underlying deficiencies of our public health infrastructure. While complaining about the CDC and public health agencies is a cottage industry on both the left and the right, the truth is that the CDC is grossly underfunded—and the situation at state and local levels is catastrophic. Yet we keep beating on these institutions hoping that a tired old workhorse is going to turn into Secretariat. Unless we invest in public health from the ground up now, we’re going to continue to lose ground against Covid-19—and be just as unprepared for the next pandemic around the corner.
So good riddance to Trump. But Biden has to do better. The yardstick against which this president will be measured is not the disaster of mismanagement and incompetence of last year. It’s in lives saved, infections averted now, how his efforts compare to the achievements of his global peers—and how they stack up against our own aspirations for a better country and better world after this pandemic.