This series, which will run in four parts, has been adapted from “A year in, how has Biden done on pandemic response?” which was originally published on January 5, 2022 on Medium. Read the first and second parts here.
By Justin Feldman
Over the summer of 2021, 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 U.S., 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 U.S., 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 U.S. 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 U.S. hit the hardest by COVID (largely the South, at that point) would not want to use tests.
When Omicron first hit the U.S., 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 U.S. 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. U.S. 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 U.S.), 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. Recently, some jurisdictions have brought mask mandates back in light of the Omicron variant, but many heavily Democratic areas that would be amenable to pressure from the White House have not.