A year in, how has Biden done on pandemic response?

President Biden delivered a speech on the afternoon of the winter solstice, 2021, while the highly contagious Omicron variant started to sweep the country. For the hundred million Americans who remain unvaccinated, the president’s speech warned of the imminent risk of hospitalization and death. For the vaccinated and boosted, Biden’s message was: Keep Calm and Carry On, all will likely be fine. And for Wall Street, the speech was meant to provide a crucial piece of reassurance: There would be no federal support for public health measures that restrict commerce.

The markets approved of this last message. As a MarketWatch headline put it, “Dow, S&P 500 book best day in two weeks after Biden vows no return to March 2020-style lockdowns as Omicron rages.” But all was not well in the economy. In the following days, in places where Omicron got an early start like New York City, many businesses and entertainment venues shuttered. Nationally, thousands of flights were canceled, disrupting holiday travel. Workers, sick or exposed to the virus, stayed home.

On December 27, 2021, in a bid to keep businesses open amid the mass infection event, the CDC abruptly changed its guidance on quarantine and isolation. Most controversially, the agency suggested that workers should stay home for only 5 days, down from 10 days previously, even as many could still be contagious to their coworkers. There would be no need to test negative or even wear a more-effective N95 mask upon returning (CDC guidance states returning workers should wear a mask, but generally recommends less-effective cloth masks). Federal officials, including Anthony Fauci and CDC Director Rochelle Walensky, have repeatedly told the press that the move was, at least in part, meant to keep commerce moving unobstructed.

How did we get in a situation where a Democratic president — who ran, in part, against Trump’s horrid pandemic response — is letting the virus rip? How did we get to a point where a key organizer of the Great Barrington Declaration, a right-wing libertarian campaign opposed to public health measures, has stated that Republican and Democratic states alike have adopted policies in line with their philosophy? As hospitals fill up around the country, why are political leaders doing nothing to at least try to ‘flatten the curve’?

White House insiders admit that they were unprepared for Omicron, just as they were unprepared for Delta. Vice President Harris recently told an interviewer that the administration was caught flatfooted because their scientific advisors never warned that such variants could crop up (at least two of these advisors, Rick Bright and Celine Gounder, begged to differ). Some observers who had high hopes that the pandemic response would improve significantly under a Biden presidency feel let down, while others argue that the administration is doing the best it can under the circumstances of a divided public, entrenched Republican opposition, and a right-wing judiciary.

The Biden administration, I argue, made a strategic decision to prepare for one specific pandemic scenario. In that scenario, high levels of disease and death would continue in early 2021, followed by widespread population immunity from both vaccination and prior infection. This population immunity would lower the death toll to manageable, ignorable levels, like that of seasonal flu. In this scenario, the Biden administration’s pandemic response would focus on vaccination and medical treatment while largely rejecting other public health measures ­– so-called “non-pharmaceutical intervention” policies ranging from contact tracing to mass testing to temporary closures of non-essential businesses.

Biden’s gamble made sense on a political level, because a more comprehensive public health response would have required new laws and regulations, many of which are costly to business owners and run the risk of energizing the far-right Republican base. Some of these measures would require support from the Senate’s slim and unreliable Democratic majority. Pursuing a comprehensive public health approach would have also involved expending political capital, which ran the risk of displacing Biden’s Build Back Better agenda.

Biden’s advisors chose a narrow path of pharmaceutical intervention because they saw the politics of a comprehensive public health response as a losing proposition. The White House did not want the pandemic to define Biden’s presidency. The virus, however, had other plans.

Shutting down the virus or shutting down the economy

As a presidential candidate, Biden made it clear that his pandemic response would focus on economic concerns using an approach that his advisors branded “safe reopening”. A guiding principle was that there would be no closures or restrictions on businesses. Advisories against travel would be lifted and fully in-person school would return. Even this last aspect, school reopening, had an explicit economic angle. Biden’s transition team worked closely with the Rockefeller Foundation to develop a coronavirus mitigation plan for schools (it was never implemented). Early in the winter, the Foundation warned that in addition to concerns about education quality, a central problem with remote instruction was that “tens of millions of adults cannot work effectively, or at all until their children are back in the classroom consistently.”

Rather than pursue public health measures that impede commerce, the Biden administration promised to speed up vaccination while supporting masking and mask mandates, protecting workers through occupational health regulation, and expanding testing availability. They would deploy a new federal public health service corps of 100,000 workers to help with tasks like contact tracing and vaccination. Biden’s campaign message went, “I’m not going to shut down the economy. I’m going to shut down the virus.” There would be a cautious ‘return to normalcy’, with the emphasis decidedly on the normalcy.

This tone was struck early, even before Biden assumed office. First, the transition team distanced itself from one of its scientific advisors who, in a New York Times op-ed, called for a national shutdown of four to six weeks. Later, after internal debate, Biden’s transition team decided not to warn the public against attending social gatherings during the 2020 holiday season, even as few were vaccinated and hospital beds were quickly filling. When Biden assumed office in January, he warned the public that, “There’s nothing we can do to change the trajectory of the pandemic in the next several months.” For his top pandemic policy advisor, Biden appointed Jeffrey Zients, a wealthy campaign donor with a background in private equity and management consulting, not public health. Zients has been known as the “ambassador to the business community” under the Obama administration.

In the first months of Biden’s presidency, the administration’s focus was almost exclusively on speeding the pace of vaccine distribution. Vaccination far surpassed the initial target of 100 million doses in the first 100 days. Around this time, polls demonstrated consistent public support for public health measures that restricted commerce — for instance, one survey found that the percentage of Americans who supported non-essential business closures was double that of those who opposed. There were few such measures in place, however. In Republican-dominated states, many of which had implemented restrictions for at least several weeks in the spring of 2020, these policies had become untenable for various reasons. On top of pressure by business interests, the far-right electoral base that can make or break governors in primaries had come to reject many public health measures.

In Democrat-dominated states, the rationale was more likely a simple economic calculation. The assistance programs to businesses and unemployed workers that made restrictions on business palatable during the spring of 2020 had run out. Many public health measures had therefore become far more expensive than when they were implemented earlier in 2020. When I counted in early January of 2021, only four states in the entire US had fully closed indoor dining. Then-Governor Andrew Cuomo of New York put it bluntly, “We simply cannot stay closed until the vaccine hits critical mass. The cost is too high. We will have nothing left to open.”

The first apparent Biden administration policy towards non-pharmaceutical intervention policies was to gently recommend that states avoid lifting business restrictions or end mask mandates too soon. Walensky was circumscribed in her public statements (her off-script note of “impending doom” aside) and did not recommend new restrictions nor single out specific states. More than 130,000 people died of covid in the first two months of the Biden presidency, many of whom did not yet have the opportunity to get vaccinated.

In February and March of 2021, Biden went to Congress with his proposed spending bill, dubbed the American Rescue Plan. The bill was mainly aimed at giving people money: more stimulus payments, the return of pandemic unemployment boosts, and new, largely unrestricted funding for state and local governments. Notably, there were few carrots or sticks in the bill designed to promote the adoption of public health measures by state and local governments. A few examples:

  • Little funding (compared to the CARES Act) was made available to businesses through the Paycheck Protection Program. This made it difficult to close or restrict businesses, because it would not be sufficiently subsidized.
  • The Rockefeller Foundation estimated that widespread covid testing in schools would cost $8.5 billion per month. But the American Rescue Plan allocated $10 billion total, one time, for school testing.
  • Funding was not contingent on adopting particular public health policies or triggered by increases in viral transmission.
  • There were no occupational health regulations in the bill. While these could be issued without the support of Congress (more on that later), enshrining covid safety regulations into law would sidestep numerous obstacles.
  • There were no paid sick day requirements for employers (a requirement was passed in March of 2020 but expired on December 31 of that year, replaced with a much weaker voluntary tax credit).

The American Rescue Plan passed on a party-line vote in the Senate as a spending bill, meaning it did not need the 60 votes that a filibuster would have required. One could argue that the bill could not have gone any further given various political and legal obstacles. Budget bills are limited in the kinds of provisions they can contain (though this is not always cut and dry, and there is recent precedent for sidestepping the filibuster tradition) and there may not have been support from right-wing Democrats like Joe Manchin.

But at the same time, there was no visible attempt by the Biden administration, or even any of the more progressive Democrats, to improve the bill from a pandemic response perspective. We know what failed efforts look like: certain senators dissent, the Senate Parliamentarian rejects provisions, statutes are blocked by courts. None of these happened in this case and, as I’ll show below, the Biden administration has maintained a pattern of declining to use its power and influence to promote public health measures beyond vaccination.

A Pandemic of the Unvaccinated

In September 2020, while the vaccines were still being tested, key figures in Biden’s orbit warned that it was unlikely vaccination alone could sufficiently control the pandemic. Anthony Fauci highlighted the importance of continuing non-pharmaceutical interventions unless there was a near-perfect vaccine, giving the example of the MMR vaccine’s protection against measles. Another figure was Andy Slavitt, who would go on to become a special advisor to the White House covid task force during the first 100 days of the administration. Slavitt warned that a key danger in re-electing Trump was that it would lead to an insufficient, vaccine-only response to the pandemic, whereas Biden would promote other needed public health measures as well.

In November 2020, a few weeks after the election, Pfizer announced results of its phase 3 trial: the Pfizer-BioNTech vaccine had an unexpectedly high efficacy of 95% against severe disease. These results almost certainly influenced the Biden transition team’s approach. The Biden administration came into office with a pandemic management plan that included many non-pharmaceutical interventions, but never promoted the legislative agenda that would have enabled the plan. As far as I can tell, from January 2021, the key players in the administration’s pandemic response policy (Jeffrey Zients as well as White House Chief of Staff Ron Klain) planned to phase out any remaining support for public health measures once all adults were eligible for vaccination.

The marked policy shift came in mid-May, 2021, a few weeks after all adults were eligible for vaccination. The move that received the most attention was a revision to CDC guidance: the agency no longer suggested that fully vaccinated people wear masks in indoor public places, with very limited exceptions. The science on the vaccines’ ability to reduce transmission was unclear at the time. But more than that, the guidance led to an entirely predictable response by businesses as well as state and local governments to remove mask requirements. And even if they were to strictly adhere to the new guidance, there was no practical way for most institutions to enforce rules differently by vaccination status.

The second shift, which received virtually no media attention, was the White House’s decision to abandon an OSHA regulation that would have protected most workers nationally. The agency had proposed requirements for masking, testing, and paid quarantine and isolation, among other provisions, but had become the target of various business groups. Instead, the administration went forward with a narrower rule restricted to health care workers.

And finally, mid-May, 2021, marked a shift in language in federal public health messaging: Personal responsibility and the individual choice to get vaccinated became the central themes. “Your health is in your hands,” Walensky told the public on May 13th. This would be followed with the refrain commonly invoked by the administration, “the pandemic of the unvaccinated” in July.

The narrative of a pandemic that can be pinned on the irresponsibility of unvaccinated people is so pervasive and powerful that I find it important to assess here. When the mid-May, 2021 policy shift occurred, many unvaccinated Americans were not ideologically opposed to being vaccinated. Throughout the month of May, more than a million doses continued to be administered daily. There were also various social, cultural, and economic barriers that made it difficult to receive vaccination in a timely way, such as not having paid time off from work to recover from potential side effects. Large racial inequalities in vaccination rates also remained in May — as of May 20, only about 22% of Black people had received their first dose, compared to 33% of whites. There have also been minimal federal efforts to coordinate vaccine community outreach beyond simply making vaccines physically available. In the summer of 2021, Biden gave a speech implying forthcoming federal efforts to go “door to door” with vaccines. To the limited extent this ever happened, it was not federally coordinated, but carried out by some local governments and non-governmental organizations.

Who remained unvaccinated by late 2021? While the media often highlights the notable partisan divide in vaccination rates, it’s also notable that half of unvaccinated adults didn’t vote for Trump — many did not vote at all. The unvaccinated are largely low-income, uninsured, pregnant, incarcerated, and children (including those under 5, for whom vaccination has not been authorized). While vaccination rates are high for people ages 65 and up, those in their late 70s and older have lower vaccination rates than younger seniors, suggesting a lack of autonomy (i.e. needing to rely on others to access health care) may play a role. And while racial gaps in vaccination rates have narrowed considerably, huge inequalities in covid death rates remain. By my own calculations, age-adjusted covid mortality rates in the US between August 1, 2021 and December 4, 2021 were 30% higher for Black and Latino people, 100% higher for American Indians/Alaska Natives, and 340% higher for Pacific Islanders compared to non-Hispanic whites.

Finally, the Biden administration has exaggerated the proportion of hospitalizations and deaths attributed to the unvaccinated. For instance, Fauci claimed in July, 2021 that only 1% of covid deaths were among vaccinated people, but CDC’s data for the previous week showed the actual figure was 17%. By December, 2021 when Zients assured vaccinated Americans that they had “done the right thing” and “will get through this”, the share of vaccinated deaths had increased to 28%. Vaccines continue to provide powerful risk reduction for severe illness, but they are not a panacea. Amid high viral transmission levels, more than a thousand vaccinated people will continue to die each week (particularly those who are older, immunocompromised, or otherwise high-risk). But framing vaccination as a way to opt out of the pandemic, and understanding the unvaccinated to be political enemies, has helped absolve the administration of its responsibilities.

Let’s get back to the timeline. When we left off, it was mid-May and the Biden administration had abandoned a comprehensive OSHA workplace regulation for covid risk. By June, 2021, Biden’s major pandemic economic policy ­– expanded unemployment ­insurance — was coming under attack. For background, the 2021 unemployment expansion added $300 per week to the normally paltry jobless benefits. For many workers receiving the benefits, they were earning more from unemployment than they had on the job. Workers who have traditionally been restricted from the unemployment system, such as freelancers or the self-employed, were made eligible. The benefit also did not count against income limits for Medicaid eligibility, so many were able to enroll in the public health insurance program. Major reasons for remaining unemployed were, and continue to be, well-grounded fears of exposure to the virus in unsafe workplaces as well as needing to stay home due to childcare arrangements that changed as a result of the pandemic, even as schools are largely reopened.

Between May and August, 2021, Republican governors in what would ultimately be 26 states ended their participation in the pandemic unemployment programs before their federal expiration date in early September. There were multiple options the Biden administration could have pursued to keep the benefits going in these states, ranging from lawsuits to transferring responsibility for administering benefits. While success was not guaranteed, officials did not even make an attempt. Why not? I think the most plausible explanation is that, as argued by the authors of this comprehensive Bloomberg Law analysis: “A war with GOP governors would carry significant political risk for the administration as it tries to sell more than $2 trillion in infrastructure spending and a massive families-focused legislative package.”

Then in early September, 2021, amid a steep increase in deaths from the highly transmissible Delta variant, the pandemic unemployment programs expired at the federal level. The Biden administration was not in favor of renewing the benefits, and in August had told Congress, “the boost was always intended to be temporary and it is appropriate for that benefit boost to expire”. There were growing concerns among businesses that the expanded jobless benefits were fueling a worker shortage and, depending on who you asked, either ‘holding back an economic recovery’ or increasing wages. The programs’ expiration had little immediate effect on job participation rates, but workers are gradually burning through their savings, which suggests an increased need to reenter full-time employment regardless of occupational hazards or living situation. Towards the end of 2021, Secretary of Labor Marty Walsh told journalists that the administration continues to believe allowing jobless benefits to expire was a good idea, saying, “The president made it clear [letting benefits expire] was part of his reopening plan.”

On September 9th, 2021, days after federal unemployment benefits expired, Biden delivered a speech prompted by the Delta variant’s mounting death toll. This speech would mark the next major policy shift — an embrace of vaccine mandates. According to unnamed insiders interviewed by the Washington Post, the administration had eschewed mandates up until September because they feared the political repercussions, particularly an electoral challenge by Florida Governor Ron DeSantis. One effort that Biden announced was a regulation that would require vaccination for health care workers at facilities that accept Medicaid or Medicare reimbursement. Another was not technically a mandate: an OSHA regulation (much narrower in scope than the proposal abandoned by the White House in May) would require larger employers to ensure workers were vaccinated or, if not, that they were tested weekly. Workers could be obligated to pay for their tests, however, so there would be a strong incentive for vaccination. These initiatives could not take effect immediately. Predictably, they had to go through regulatory processes at their respective federal agencies, and both were then subject to legal challenges by industry groups. The Supreme Court set to hear arguments on both issues on January 7th, 2022.

We Have the Tools

The 15 weeks between Biden’s two major covid speeches on September 9 and December 21, 2021 witnessed more than 150,000 covid deaths but no developments that I would characterize as major policy shifts. The previous summer, concern grew that the vaccines were not providing the near-perfect protection against symptomatic disease and transmission that had first emboldened the administration to jettison other public health measures. It was initially unclear whether the issue was Delta’s higher transmissibility or waning immunity from vaccines, as the first groups had been vaccinated nearly a year prior. There was noticeable concern from CDC, which acknowledged the “war has changed” in a set of leaked slides from July 29, 2021. Of particular concern were case reports from Massachusetts and internationally of high viral loads observed among those who were vaccinated and infected. In late July, CDC reversed course on its mask guidance and recommended indoor masking for all, including the fully vaccinated, in counties with high transmission. In late September, 2021, CDC reversed course on its quarantine guidance, which had previously stated that fully vaccinated people should not quarantine after a known SARS-CoV-2 exposure.

These changing epidemiologic realities could have brought about a course correction and a push for other public health policies to complement vaccination. Instead, the administration mostly adapted by shifting its messaging. Where “pandemic of the unvaccinated” was the Biden administration’s mantra during the summer of 2021, another phrase had been added in the fall: “we have the tools”. These words were first uttered by Biden in his September 9th speech, and later invoked over and over by the CDC, administration officials, and White House allies. Beyond the standard exhortation to get vaccinated, the tools included booster shots, rapid tests, and masks. The ‘tools’ stood for individual choices based on personal risk tolerance rather than elements of regulatory frameworks to be pursued by various levels of government. Let’s address each of these three tools.

The White House was pursuing a plan to approve and distribute vaccine boosters during the summer of 2021, and was emboldened by the Israeli government’s decision to approve Pfizer boosters at the end of July. The American booster push was controversial, because the scientific evidence on the need for and effectiveness of boosters was limited, and the White House exerted an unprecedented level of pressure on the FDA and CDC’s ‘independent’ scientific review processes. In response to the perceived overreach, two high-level FDA vaccine regulatory officials resigned in protest. Ultimately, both the FDA and CDC gave their blessing to boosters. But this involved the CDC’s Walensky overruling its vaccine advisory group, authorizing boosters for the general population instead of high-risk individuals only.

The White House was ultimately vindicated on boosters, as clinical trial data became available showing they were very effective at preventing symptomatic disease relative to those who were vaccinated-but-unboosted. Then, with Omicron’s ability to partially evade immunity, boosters became even more important. What many of Biden’s critics failed to appreciate in the administration’s machinations around boosters was that, if they were to remain public health minimalists, they would have to be vaccine maximalists. The entire pandemic response hinged on vaccination as a silver bullet.

The more warranted criticism with respect to boosters was not moving swiftly and urgently to distribute them throughout the vaccinated population. By mid-December, 2021, only half of vaccinated adults over age 65 had received a booster and there were large racial inequalities in booster distribution. Some other countries, and some private institutions in the US, moved to change the definition of fully vaccinated to include boosters, but the White House has not suggested this yet. And the initial messaging on boosters was about individual choice. As Walensky told a reporter, “We made it possible for people to be eligible, but they really have to identify their own individual risk and they own their own individual benefit.”

Another kind of criticism emerged that booster doses would slow the rate of vaccination of the Global South. But this criticism does not challenge the artificial scarcity of vaccines created by intellectual property restrictions. While I will not do it justice here (it’s beyond the scope of my expertise), Biden’s biggest failure on pandemic response has been inaction on sharing the vaccine recipes or initiating technology transfer so they can be manufactured globally. This failure has cost millions of lives so far, and has increased the risk of new variants appearing.

Perhaps the only major, sustained point of media criticism against the Biden pandemic response has been its mishandling of rapid antigen testing. SARS-Cov-2 is notoriously good at spreading because, among other reasons, transmission often occurs before any symptoms appear. A key purpose of antigen tests is to detect the virus when levels are high enough for transmission during this pre-symptomatic period. In this context, they are best used shortly before social interactions.

In many countries, antigen tests are abundant and very affordable, if not free. In the US, they often cost about $24 for a pack of 2 and are in short supply. After a number of media articles critical of the administration’s neglect of antigen testing appeared, the issue came to a head on December 7, 2021, when White House Press Secretary Jen Psaki mockingly and sarcastically replied to a question about testing with, “Should we just send one to every American?” Following backlash, the White House announced that it would attempt to do just that — make 500 million rapid tests available for free on a website some time in early 2022. This should allow each person in the US who wants tests to order a few over the coming months, but it is far from enough to supply settings where they could be used for regular testing like schools and workplaces.

Investigative reporting into the administration’s handling of antigen tests have highlighted a few issues. A flawed approval process by FDA meant only a couple of antigen tests were authorized until late in the fall. The administration also failed, until recently, to order these tests in large numbers, subsidize their manufacture, or invoke the Defense Production Act to ensure a ready supply of precursor materials. What has received less attention is how the White House’s commitment to a vaccine-only strategy and reluctance to expend political capital contributed to the problem. In early June, 2021, when CDC announced that vaccinated people without symptoms should not be tested, it led to a collapse in demand for antigen tests. This prompted Abbott, the primary manufacturer at that point, to destroy millions of unused tests and lay off thousands of workers. The White House has also been lobbied at various points by testing experts who asked the federal government to order more tests, but they were rebuffed. Administration officials did not want to request more money for testing from Congress, and also believed that most people in the parts of the US hit the hardest by covid (largely the South, at that point) would not want to use tests.

When Omicron first hit the US, the White House could not take swift action to make antigen tests widely available due to its prior policy stances. Its initiatives, like improving the FDA authorization process, involving NIH in rapid test development, and eventually invoking the Defense Production Act, would bear fruit only gradually. In the short term, it could only propose a rule for insurance reimbursements of tests and purchase tests in quantities of tens or hundreds of millions, far short of the many billions needed to regularly test a large portion of the population. On top of this, it is unclear how effective it is, as a public health strategy, to simply distribute large numbers of tests to a population. Making a consumer product available should not be confused with a regulatory framework that would involve science-based testing strategies and quarantine and isolation policies for schools and workplaces (with paid time off for the latter). These regulatory frameworks were never pursued in a serious way by the Biden administration. The notable exception is the paid quarantine and isolation provision in the OSHA Emergency Temporary Standard for health care workers (which was allowed to expire in late December as it entered a legal gray area), but even that rule did not require regular surveillance testing.

The White House’s approach to masks has many parallels with its relationship to rapid testing. Since I’ve already discussed masks a bit, I will focus on two aspects here: (1) the administration’s failure to make N95 (or similar) masks widely available, or even promote them, and (2) their framing of masking as an individual choice rather than as a component of public health policy frameworks. Research shows that even modestly increasing the number of people wearing less-effective cloth and surgical masks can result in substantial SARS-CoV-2 transmission reduction at the societal level. But N95 masks (along with FFP2, KF94, and KN95 masks) can do a substantially better job of blocking transmission. While other countries have promoted, provided, or required high-filtration masks for the general public, the US has not (although, if you want to meet with Biden or Harris, you’ll have to wear an N95). The main mask recommendation on the CDC website is, at present, a two-layer fabric mask whose protections are relatively weak. US mask manufacturers have lobbied the White House for the entirety of the Biden administration to use federal resources to buy N95s for the general population, and say that they are capable of producing hundreds of millions per month. Their attempts have been ignored.

But again, as with rapid tests, merely providing individuals with “the tools” would not make for a public health strategy. As I’ve mentioned, the Biden administration initially stated it would promote mask mandates at the state and local level, and then in its first months at least warned states against lifting mandates. While CDC eventually suggested all people wear masks in public indoor places when county transmission rates are high (this currently includes the entire US), it has not promoted — and has even dissuaded — mask mandates by state and local governments. In early December, 2021, Walensky responded to a question about mask mandates by saying, “I’d rather not have requirements… people should do this for themselves.” Similarly, Biden sidestepped a reporter’s question on state and local mask mandates by simply saying he encourages people to wear masks. Finally, Vermont Governor Phil Scott told reporters that Zients dissuaded him from issuing a statewide mask mandate, saying they were unnecessary. Further support for this account comes from Marcus Plescia, who leads the professional association for state health department directors. He told NPR reporters on December 17, 2021 that the White House was not encouraging states to adopt covid mitigation policies like mask mandates. It’s worth noting that public support for mask mandates has generally been high, with one poll from mid-December finding 64% of Americans in support. Some jurisdictions have brought mask mandates back during Omicron, but many heavily Democratic areas that would be amenable to pressure from the White House have not.

Winter of Death

On December 1, 2021, the CDC issued a press release announcing that it had identified a case of the Omicron variant in the US for the first time. Omicron would soon become the predominant variant in the country. While evidence is mounting that the risk of hospitalization and death is lower for each person infected compared to Delta, Omicron’s extremely high transmissibility means that a large fraction of the population will become infected in a short time period, particularly in the absence of additional public health measures. While vaccination still provides powerful protection against hospitalization and death, protection against symptomatic illness is weaker than before, particularly among those who have not received boosters. Hospitals are becoming overwhelmed in various parts of the US, and one model predicts more than 120,000 covid deaths will occur in the first two months of 2022.

The benefits of public health policies to slow the spread and flatten the curve have rarely been so clear. In just a couple of months, the production and distribution of two drugs that allow for effective outpatient treatment (sotrovimab, the only monoclonal antibody that is effective for Omicron, and nirmatrelvir, the powerful new antiviral) could ramp up. If the Supreme Court goes in the government’s favor, the OSHA vaccination-or-test mandate would go into effect in January 2022. The peak number of hospitalizations would be lower, easing the burden on the health care system. But measures to restrict business and school are expensive, and funds that would allow businesses and workers to lay low have been allowed to run dry.

Furthermore, inflation has become a key economic concern for the Biden administration. The rate of inflation was nearly 7% in 2021, which is unprecedented in recent economic history. The White House believes this inflation has been caused by increased consumer spending on manufactured goods, whose prices have risen sharply as pandemic-related supply chain issues have created shortages. In contrast, spending on in-person services has not been quite as robust due to concerns about patrons becoming infected with SARS-CoV-2 while participating in activities like going out to eat or on vacation. This creates a conundrum where a key economic goal — preventing further inflation — is at odds with public health policies or even messaging that would dissuade consumers from spending time in indoor commercial spaces.

In this context, the Biden administration decided to go full speed ahead into a wave of Omicron infection, even as other countries have introduced targeted restrictions on indoor dining and other high-risk settings. In a December 17, 2021 press event, Jeff Zients warned that the unvaccinated were in for a “winter of severe illness and death”. Biden’s speech a few days later, on December 21, struck a somewhat milder tone. He assured the country that work and school would go on as normal, and encouraged people to continue with their holiday plans while referring to unnamed “precautions that we all know well” that people could consider using to keep themselves safe.

Days later, the administration unveiled its policy response to help ensure that businesses and schools would stay open through the wave of infection. The policy can best be described as ‘go back to work or school while you still may be contagious’. Most notably, CDC shortened the recommended isolation period to 5 days after testing positive (it was originally 10 days). This came after a lobbying campaign by the airline industry, which has canceled thousands of flights, and requests by Republican governors. While the administration initially promised it would issue a scientific justification for the change, it walked that statement back and the justification may not be forthcoming. CDC’s counterpart in the UK, the Health Security Agency, has stated it believes CDC’s policy would allow between 10 and 30 percent of workers to still be contagious upon return. Despite figures close to the White House suggesting a testing requirement would be added for return after 5 days, the CDC has declined to make the change owing to scarcity of testing. Instead, officials like Walenksy and Fauci are defending the policy based on practical economic concerns (“maintain[ing] the structure of society”, as Fauci told MSNBC viewers).

The talking points for the 5-day isolation period are simple to distill: Emphasize that Omicron is mild in relation to Delta, even if many will be hospitalized, die, or develop long covid. Highlight the need to keep essential workers on the job, even as the guidance also applies to restaurant servers and all varieties of office workers. Frame the move as more ‘realistic’ in terms of getting individuals to comply while obscuring the real purpose of this guidance: to change policies at the institutional level for workers and students. And for health care workers who received a different set of guidance, it opens the door for hospitals to make them work while they are sick, with no isolation requirements, if there is a critical shortage of workers. Despite 2021 seeing rising wages, the ‘Great Resignation’, and a number of strikes, it is hard to argue at the beginning of 2022 that the economic balance of power has shifted in favor of workers.

Conclusion

The political realities of the United States are such that we were never going to have a pandemic response as successful as New Zealand, Singapore, Vietnam, or Cuba. But I think, when you consider everything I have laid out above, it is hard to argue that the Biden administration could not have done any better. It is worth looking at Canada — another settler-colonial state with a federal system and a number of right-wing provincial leaders — which has consistently maintained about half the mortality rate of the United States over the entire course of the pandemic. Even Doug Ford, Ontario’s premier who supported Donald Trump for most of his presidency, has been more amenable to public health measures that restrict commerce than nearly any Democrat in the US. Even the UK government under a right-wing prime minister has rejected the five-day isolation period embraced by a US Democratic president. Many of the failures of Covid Year 2 result from specific decisions by specific people in the Biden administration. The pandemic response could have gone another way, even in light of the many challenges of governance in the US political economy.

The final point I’d like to make for those of us who are critical of Biden’s response is that we need to understand and learn from our own failures. There has been a failure of various social institutions — the media, the political left, scientists, and unions, to pressure the Biden administration into a course of action that would better prevent mass death. In some other countries, scientists banded together to form organizations like the UK’s Independent SAGE that counters government policy with its own, more precautionary policy recommendations. This has not happened in any substantial way in the US, where scientists have made statements only as individuals or in informal, ad-hoc groups. To the extent they have weighed in, American unions have been narrow in their demands for the pandemic response and have not called major strikes over it. Progressive members of the Democratic Party have not put pressure on Biden over pandemic measures except in narrow ways, such as Bernie Sanders calling for an extension to unemployment programs or Cori Bush demanding the Biden administration fight for an extension of the eviction moratorium. Leftist groups like the Democratic Socialists of America have not developed a pandemic response platform, and to the extent they have politicized the pandemic, it has been to talk about long-standing policy goals like Medicare For All.

Instead, the loudest voices in civil society have largely supported Biden’s approach to the pandemic or pushed him to reject non-pharmaceutical interventions more fervently. This select group of media pundits, public health scientists, and economists has been in direct dialogue with White House officials. The administration has cited their opinion pieces in speeches, coordinated messaging on regular phone calls, and promoted these views on social media (one need only look at the Twitter timelines of Ron Klain, or communication staffers like Ian Sams or Ben Wakana).

Those of us who see ourselves as concerned scientists or leftists, or otherwise imagine ourselves to be part of an engaged civil society, should learn from this failure to respond to a crisis, particularly since we do not know how long this one will last. And we can only expect more crises on a 4-degree-warmer planet.

I’m a social epidemiologist and Health & Human Rights Fellow at the Harvard FXB Center.

I’m a social epidemiologist and Health & Human Rights Fellow at the Harvard FXB Center.