When the Biden administration came into office in January, plans for a robust COVID-19 vaccine rollout lagged. What the administration accomplished over its first six months in office was nothing short of a miracle: working to stabilize vaccine production and getting shots in arms.
Since then, nearly 60% of the U.S. population has been fully vaccinated. That’s remarkable progress, but what’s still missing is a vision and public health strategy for what our new normal with COVID-19 will look like and how we’ll live with it.
This begins with acknowledging some hard truths. First, vaccinated people are far less likely to get COVID-19 or to die from COVID-19 than unvaccinated people, but vaccinations provide a relative risk reduction, proportional to the level of SARS-CoV-2 transmission in the community (the percent risk reduction is how we define vaccine effectiveness).
If you live in a community where there’s a high level of SARS-CoV-2 transmission, you’re still at risk for infection, even if you’re vaccinated and even if you’ve gotten an additional dose of vaccine. Furthermore, so long as the virus is allowed to spread anywhere in the U.S. or the world, more will get sick and die, the virus will continue to mutate and new variants will emerge. The SARS-CoV-2 virus has not yet reached peak fitness, as the emergence of the omicron variant has shown us, and could still evolve to become more infectious, immune-evading or virulent.
This is why we need a clear public health strategy, not just clinical guidelines. A public health approach is focused on populations, protecting the most vulnerable, and equity. Clinical guidelines help doctors care for individual patients and weigh risks and benefits of different options.
It has also become increasingly clear that although our current vaccines are safe and highly effective in preventing severe disease, hospitalization and death, they are much less effective in preventing infections. Vaccines work best at a population level to curb infection, and boosters may help restore protection against infection for some period of time. This does not mean our vaccines are failing. It means we have to decide how best to use them in combination with other tools.
From a public health perspective, our top priority should be to suppress severe disease, hospitalization and death. The U.S. still sustains about a thousand COVID-19 deaths a day, which is ten times the death toll of influenza. These are not acceptable losses. We must fully vaccinate a larger proportion of the American population.
In the early months of vaccine rollout, demand for vaccines was brisk, but by May, our rate of vaccination plateaued. Expanded eligibility to include children 12 and up, and now those ages 5-11, has helped increase vaccination coverage. So, too, have vaccine mandates, which will broaden to include more workplaces in the coming weeks.
Some groups continue to lag behind in vaccination rates, including those with low trust in the health system and government, uninsured and undocumented persons, and those with ideological objections. There is no quick fix here. SARS-CoV-2 will become endemic, meaning that we’ll have to adapt to some level of ongoing community spread. Whether that level of community spread is high or low will depend on us, but any long-term control strategy must address the barriers to vaccine uptake.
To build trust in the health system and public health, it’s essential that we build a public health workforce staffed by the community and with the capacity to serve and be responsive to the community. The Biden administration is taking some positive steps in the right direction with, for example, the establishment of a Public Health AmeriCorps, a $400 million investment over five years in public health workforce development. But this will require a sustained commitment, not just a short-term influx of funds. Embedded in these efforts must be plans to deliver essential health services to populations that are ill-served by our health care system, especially those who are uninsured or undocumented.
Overcoming ideological objections to vaccination and other public health measures is an even longer-term project, which won’t pay dividends on the election cycle calendar. It will require a moral awakening and soul-searching, calling people into a common American “we” that we feel a part of and a duty to protect, and that we’re willing to serve and sacrifice for. This is not the first time in history that we’ve been so ideologically polarized. We’ve been able to rebuild that sense of “we” before. We can do it again. But doing so will take strong moral leadership.
But the Biden administration has no comprehensive plan to deliver additional doses of the vaccine to the most vulnerable, the hardest to reach and those who got what they thought was a “one and done” shot. Only 42% of people age 65 and over have gotten an additional dose of vaccine – the population that would most clearly benefit. There hasn’t been public discussion of how evolving vaccination regimens might impact vaccine mandates. What we have is, by default, a clinical approach in which individuals can (or not) seek out any booster they want (or don’t).
We need to differentiate between public health and clinical approaches. Based on our experience with influenza vaccination, it’s unlikely that we’d achieve more than 50% vaccination coverage with a yearly COVID-19 booster. It’s also unlikely that we would consider mandating yearly boosters outside of health care, long-term care facilities and other specific settings, where the risk of transmission is especially high.
We must acknowledge that if we move toward giving additional doses of COVID-19 vaccine or even yearly boosters, this will have an impact on global vaccine supply, increasing consumption here and in other countries that follow our example. Meanwhile, only about 7% of Africans have been fully vaccinated. While we cannot say with certainty that higher levels of vaccination would have prevented the emergence of the omicron variant, the origin of which is currently unknown, when we leave much of the globe unvaccinated, we face a higher risk that a new variant may emerge to jeopardize our pandemic recovery.
Vaccine production remains fragile. Red tape prevents expiring doses from being shipped overseas. Moderna and Pfizer refuse to share their vaccine manufacturing recipes and know-how with other countries that have the capacity to produce locally.
The Biden administration has chosen not to use all the levers at its disposal to force this sharing, despite the U.S. government having been a co-inventor with Moderna of its mRNA vaccine and owning patents on key technology used in that and other vaccines. Some fear doing so would disincentivize innovation and could mean handing valuable proprietary information to the Chinese or Russians. We need moral leadership here. Why must profits be maximized at all costs, even at the detriment of public health?
Finally, if our goal is to suppress infections at a population level, we’ll need a less vaccine-centric strategy, regardless of the state of global vaccine supply. We’ll need to use other tools at our disposal, like masking, testing, antiviral therapies, and, in particular, measures that do not depend on individual acceptance and action, measures like ventilation and air filtration.
Masks have, unfortunately, been politicized. Many say the pandemic will be over when they don't have to wear masks, but masks may be with us in certain times and places for the foreseeable future. Efforts to shift cultural norms could take years, but must start now. The Biden administration recently took steps to make rapid, point-of-care testing more widely available, but unless they are provided for free, these will remain out of reach for most individuals to use on a regular basis.
And though Congress is providing hundreds of billions of dollars to improve K-12 school infrastructure, including ventilation and air filtration, there are significant bottlenecks standing in the way of that funding having a real impact on indoor air quality in schools. We haven’t even begun to address ventilation and air filtration in other public buildings. These are all areas ripe for public-private partnership and where leadership from the Biden administration is needed.
President Biden showed great competence and leadership when he first took the reins. But now, as we transition from the short-term emergency phase of the pandemic to the long-term reality of living with COVID-19, we need a vision and public health strategy. That starts with helping the public understand the real choices we’re facing. We don't have a time machine to take us back to November 2019. We all have hard work to do now.
Dr. Céline R. Gounder is an internist, infectious disease specialist and epidemiologist at the New York University's Grossman School of Medicine and Bellevue Hospital. She is the host of the “Epidemic” podcast and served on the Biden transition COVID-19 advisory board.
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This article originally appeared on USA TODAY: Biden has shown leadership during COVID-19 pandemic. He could do better.