A 7-Point Action Agenda to End the COVID-19 Pandemic for President-elect Biden

President-elect Joseph Biden has a historic opportunity to reset the US response to coronavirus disease 2019 (COVID-19), but it is unrealistic to expect a sharp turnaround, given steep spikes in cases and deaths. Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the US, the federal government has undermined science, conveyed confusing health messages, politicized public health agencies, and sowed distrust. Despite being ranked by the Global Health Security Index as first in pandemic preparedness before COVID-19, the US has been among the world’s worst performers, with the most cases and deaths. The Biden/Harris plan to tackle COVID-19 has strong public health support. Had the plan been implemented earlier, it might have saved tens of thousands of lives. Drawing from, and going beyond, Biden’s plan, here is a 7-point action agenda for the new administration.


Develop a National Plan
States possess primary public health powers, not the president. Yet, it is impossible to control SARS-CoV-2 without a national plan. President Biden, therefore, should partner with governors to develop a national COVID-19 plan, including face coverings, physical distancing, limiting gatherings, and safely reopening schools and businesses.
Although the federal government cannot compel states to act, financial and other incentives might persuade governors to coalesce around core public health strategies. Funding could include building robust public health capacities at the state, tribal, and local levels and financial protections for businesses, schools, families, and individuals with lower incomes through a robust COVID-19 emergency relief appropriation.

Lead With Science
The new administration must lead with science, restoring confidence in key agencies.
Public trust in the US Centers for Disease Control and Prevention (CDC) dropped 16 points (from 83% to 67%) between April and September. All government health messaging should be science-based, reinforcing CDC guidelines. The Congress should sustainably fund the CDC and state and tribal health departments; appoint qualified, apolitical leaders; and eschew political interference. Consistent health messages delivered by respected scientists would gain wider public cooperation and restore trust.

Ramp up Testing and Tracing
Finding cases and tracing contacts is a vital public health strategy because infected or exposed individuals can be isolated, especially given the high number of asymptomatic transmissions. Yet, the utility of testing and tracing is diminished as infections rise. Given privacy concerns, it is unlikely states will widely adopt smartphone tracing applications. Instead, traditional manual tracing should become an essential means to find potentially exposed individuals. Thus, building human resources to test and trace is a key component of ending the pandemic and ensuring critical capacities for future outbreaks. Expanding testing, including drive-through sites, at-home and rapid tests, and a pandemic testing board to coordinate testing efforts. Biden's public health jobs corps, mobilizing 100 000 workers to perform contact tracing, should become a permanent force.

Support Health Workers
Health workers care for the sick, placing themselves at risk. There is a moral duty to protect workers from infection, yet there has been a shortage of personal protective equipment (PPE), with states and hospitals often competing for PPE. Strategic deployment of the Defense Production Act could vastly increase supplies vital to the COVID-19 response while restoring stockpiles for future epidemics. President-elect Biden should go further to allocate resources for hazard pay, childcare, and family care for health and other essential workers, as contained in the House-passed HEROES Act.

Promote a Robust COVID-19 Vaccine Campaign
In mid-December, 15 COVID-19 vaccine candidates were in phase 3 clinical trials, with 7 vaccines receiving either full approval or emergency authorization outside the US. As the US Food and Drug Administration authorized the Pfizer-BioNTech vaccine for emergency use in the US, a historic vaccine campaign was launched. Although it is difficult to determine herd immunity levels for a COVID-19 vaccine, it is likely to require at least 70% of the population gaining immunity from natural infection or immunization.
However, logistical obstacles are vast: wide-scale manufacturing; requirement for cold storage; national distribution (likely twice for a 2-dose vaccine), especially difficult for hard-to-reach (low-income and rural) populations; establishing equitable priorities; and vaccine hesitancy. The vaccine campaign must build a comprehensive vaccine infrastructure, including human resources, data systems, supply chains, and vaccine education from trusted sources.

Focus on Equity
The pandemic has accelerated historical inequities already pervasive in the health system. People of color have experienced infections and age-adjusted death rates at 4-fold higher rates compared with non-Hispanic Whites. Prisoners, nursing home staff and residents, low-income individuals, immigrants, and persons with disabilities have been similarly affected. Presidentelect Biden must commit to structural reforms to create equitable conditions for health ranging from universal health care to safe housing, childcare, nutritious foods, and safe workplace conditions. Equity begins with collecting disaggregated data to identify those left behind, followed by well-targeted strategies to reduce health disparities. The Biden plan would mobilize 150 000 community caregivers for society's most vulnerable. With likely shortages of COVID-19 vaccines and therapeutics, priorities based on indices of social disadvantage are also essential.

Restore Global Health Leadership
US health security depends on global capacity to rapidly detect and respond to threats originating anywhere in the world. On day 1, President Biden should rescind notice of withdrawal from the World Health Organization (WHO), while submitting a World Health Assembly resolution to double member states' assessed contributions. WHO's 2020/2021 biennial budget is only $4.8 billion (about one-third of the CDC's budget), with two-thirds earmarked by donors. The new administration should also reinvigorate the Global Health Security Agenda, designed to build and evaluate country capacities for rapid response to pandemic threats. Similarly, the Biden administration should reinstate USAID's virus-identifying and tracking PREDICT Project.
Beyond the WHO, the US should also join the vast majority of countries in supporting the COVID-19 Vaccines Global Access (COVAX) Facility to guarantee fair and equitable access for 92 lower-income countries. Congress has appropriated only about $2 billion to this global crisis (most undispersed), far less than a $5.4 billion West Africa Ebola emergency appropriation approved in December 2014. Beyond COVID-19, massive resources are required to reverse steep rises in poverty, hunger, and disease. Congress should dedicate at least 1% of COVID-19 spending to international humanitarian assistance. The US should lead the G20 to suspend debt payments for lower-income countries, while supporting an International Monetary Fund proposal for Special Drawing Rights, akin to international currency.
Out of the wreckage of COVID-19, there is a historic opportunity to strengthen domestic public health infrastructure, narrow cavernous health inequities, and restore global health leadership. Success in ending the pandemic would safeguard national and global health, jump-start the economy, and forge a path toward health justice.