The 9 biggest challenges Biden will face on Covid-19, from today on

WASHINGTON — No president wants a federal emergency. No one in that role is waiting to call in FEMA reservists or deploy the National Guard.

But on Wednesday, after Joe Biden raises his right hand and swears his oath to preserve, protect, and defend the U.S. Constitution, that’s exactly the plan. Their mission: to set up a slew of new vaccination clinics.

The 20,000-strong FEMA workforce normally responds to the types of events that dominate 24-hour news cycles and leave towns and cities flattened to the ground, like the hurricanes and wildfires that have ravaged New Orleans and New York or California. FEMA can only deploy, in fact, when state and local governments decide they are incapable of responding on their own to whatever act of God is battering their community.

The National Guard’s more than 400,000 troops are often called on to respond to natural disasters, but they’re better known as the shock troops brought in to quell civil unrest: They were the ones clashing with rioters in Washington, D.C., after the assassination of Martin Luther King Jr., in Los Angeles after the beating of motorist Rodney King, and in Baltimore after the death of Freddie Gray.

Nearly everywhere both entities go, controversy follows: FEMA’s response to Hurricane Katrina prompted the ouster of its director and federal legislation reorganizing the entire agency. The National Guard has been criticized for its heavy-handed crowd control tactics.

Biden’s reliance on both — starting from the very first day of his presidency — underscores the magnitude of the challenge facing his administration as they embark on trying to rightside the Covid-19 response. As of Tuesday, 400,000 Americans have died from Covid-19, and a new, more contagious strain of the coronavirus is rapidly gaining a foothold in the United States. Health care workers are dangerously tired, and issues that have plagued the United States since the start of the pandemic, like shortages of protective equipment, still aren’t solved. Meanwhile, Biden will inherit a Congress that has shown itself unwilling to pony up the level of support needed to combat the pandemic, and a spate of Republican governors who seem outright willing to thumb their noses at his efforts.

“We are at a crisis point and Biden’s making that perfectly clear,” said Stephen Morrison, director of the Center for Strategic and International Studies’ Global Health Policy Center. “It’s proof of seriousness: When you say the National Guard will be there, there will be 100 mass vaccination sites, that is a pretty good retort to the chaos and incompetence that we have seen by Trump.”

Below, the nine biggest challenges that now confront a President Biden, wrangling an out of control pandemic.

Suppressing the current spread of Covid-19

The state of the U.S. Covid-19 epidemic is not good. Daily cases have started to come down a bit, but they have been so high that lots of people will still get sick, even if infections keep trending in the right direction. It’s not like hospitals are all of a sudden going to be free of strain. What’s more, the country hasn’t really suffered the impact of more contagious variants of the virus yet, but they could fuel yet another rise in cases as they claim more territory in the United States or, at the minimum, make it harder to keep a lid on transmission.

The Biden administration has plans to try to suppress spread as it expands vaccinations, but elevated viral circulation in the country isn’t something the new president can alleviate with a snap of his fingers. Many states and communities also remain opposed to adding restrictions or implementing new measures that can more rapidly reduce transmission, either because of philosophical reasons or concerns about the subsequent economic or social costs.

“It’s going to take a while to turn this around,” Ron Klain, Biden’s incoming chief of staff, who served as President Obama’s Ebola czar during the West African epidemic, said on CNN Sunday.

Even as months of difficulties await, there’s a sense that the country has not been grappling with all that’s been lost already during the pandemic. But Biden has signaled he might move that issue to the forefront. The night before his inauguration, he and Vice President-elect Kamala Harris spoke by the Lincoln Memorial’s reflecting pool about the 400,000 Americans that have been lost to Covid-19.

Changing minds on masks

One of the bigger inconvenient truths Biden will face is that in many ways, his power to shift nationwide pandemic-response policy is fairly limited. There’s no better example than policies to require mask compliance: Biden has no real authority to enact a nationwide mask mandate. He’s planning a first-day executive order to require people to wear masks in federal buildings and in the interstate travel facilities run by the federal government, like an Amtrak train (where there’s already a mask mandate in place), but that’s a tiny slice of public space. Practically, governors and mayors have far more authority to force people to mask up in the presence of others, and Biden’s best weapon for making Americans don face coverings is asking nicely and hoping they listen.

There’s good news and bad news for Biden: The good is that a large majority of Americans — three-quarters, roughly — support his call for governors and local officials to enact what would effectively be a nationwide mask mandate, according to a recent NPR/NewsHour/Marist University poll. The bad is that the remaining quarter of Americans remain at least somewhat resistant, particularly Republican men. President Trump, of course, has periodically mocked Biden’s enthusiasm for mask use and was almost never seen wearing a face covering in public even before he contracted Covid-19 in October.

Getting Americans to mask up will be critical during the early months of Biden’s tenure, with highly transmissible coronavirus variants spreading through the population, many hospitals stretched to capacity, and the country’s vaccination effort moving slower than anticipated. But it’s an open question whether Biden’s characterization of mask use as “a patriotic act” will resonate with those who, for whatever reason, still don’t buy the science that face coverings can lower your odds of being infected.

Setting up mass vaccination sites

Setting up 100 mass vaccination sites might sound pretty simple, but it’s not something the United States has much experience with.

FEMA and the National Guard both have already been involved to some degree in the nation’s Covid-19 response: A Department of Homeland Security webpage states that all 50 states are currently working with FEMA to respond to the Covid-19 pandemic. A smattering of states have already called in the National Guard to help coordinate mass vaccination efforts.

But by and large, setting up mass vaccination clinics is out of the ordinary for both entities.

“It’s going to stretch them,” said CSIS’ Morrison, regarding FEMA. “It’s not like they have their regional stockpile fitted out for vaccination campaigns. Their regional stockpiles are for hurricanes and fires.” Morrison, however, added that he thinks FEMA can handle the job.

Biden has insisted he wants 100 of these federal vaccination sites set up within a month, but it’s unclear how up to the job FEMA is, especially given FEMA has struggled with staffing shortfalls in recent months.

Extracting money for Covid-19 relief from a narrowly divided Congress

Biden has cultivated a reputation as a Senate veteran who can make deals across the aisle, but his horse trading skills will be tested as he works to secure funding for his most ambitious Covid-19 response plans. Democrats control both chambers of Congress, but by the narrowest of margins. Funding for public health measures could be slowed by bickering over some of the more controversial items he proposed.

Capitol Street Managing Director Ipsita Smolinski said Republicans will likely whittle down Biden’s asks.

“When I saw the stimulus bill and certain provisions, it almost seemed like a wish list. He has to start up here to get something down here at the end of the day,” Smolinski said.

But the pressure will come from progressives, too. Some are already pushing Biden to use more aggressive procedural maneuvers to achieve his goals. Democrats will at some point use a budget process that would allow them to pass legislation with a simple majority in the Senate, but the process comes with limitations that could hamstring some of Biden’s health care priorities.

Improving a worn-down supply chain for just about everything

The Biden administration is going to inherit a medical supply chain that has been beaten down by a year of pandemic-induced demand. Virtually everything needed to deal with the Covid-19 pandemic seems like it’s perpetually in shortage, and the Biden team is going to need to figure out how to fix that — and fast.

Health care providers still aren’t getting the amount of personal protective equipment they need to respond to the pandemic. The situation is not as atrocious as it was in the early days of the pandemic, when health workers were wearing garbage bags instead of gowns, but PPE shortages are still widespread. GetUsPPE, a national organization that fields PPE requests from health care professionals and organizes donations, recently reported that requests for PPE rose 260% from November to December.

The most pressing supply issue for the Biden team likely is around vaccines and other related supplies, like syringes. After all, a mass vaccination campaign depends on having shots ready to go into people’s arms. In recent days, state and local officials have begun complaining about so-called vaccine shortages: New York Mayor Bill de Blasio has warned that his city may have to cancel appointments, despite recently setting new mass vaccination sites. Some states, including New York and Michigan, are now pressuring drug maker Pfizer to begin selling its vaccines directly to them.

There’s no easy fix for the vaccine supply issue. Both Pfizer and Moderna say production is on schedule and the Trump administration has stopped holding back doses, so there are few levers to pull. Klain, Biden’s incoming chief of staff, told CNN this weekend that the team plans to use the Defense Production Act to produce more so-called low dead space needles, which can be used to extract a sixth dose of the Pfizer vaccine from each vial — that will increase the current supply of vaccines 20%, he insisted. Some relief may also come when a third vaccine is cleared for use; most likely, that will be AstraZeneca’s vaccine, which is expected to be reviewed by the FDA in April. The United States has already purchased 300 million doses of the AstraZeneca vaccine pending FDA clearance, but until then it’s unclear how Biden can drastically increase the number of vaccines going into people’s arms.

Using technology to track vaccinations and ensure equity

The president-elect has said ensuring equity will be a top priority in his administration’s immunization campaign. But creating more vaccination sites, including mobile clinics, is only part of the solution.

To reach disadvantaged populations, the new administration also must use data and technology to understand who’s getting left behind and how to reach them. So far, technology is faltering badly in the vaccine rollout: Online portals to schedule vaccinations are filling up fast in many communities, threatening to cut out people who lack internet access or hours to spend navigating registration bureaucracies.

Fixing those problems will require setting standards for equity and fairness, and providing resources and guidance to state and local officials on how to achieve those benchmarks, health information experts said. In addition to scheduling initial doses, officials will have to track the delivery of booster shots and create ways to identify who’s been vaccinated on a disconnected network of state registries.

Ignoring the existing technology problems will not make that any easier.

Wrangling local officials resistant to Covid-19 mitigation tactics

Another problem for the Biden administration: Most practical control over Covid-19 response tactics, like school closures, mask mandates, and testing strategies, rests with governors and local officials. A number of Republican governors, in particular, have been stunningly resistant to mask mandates, citing concerns about personal freedom and scientifically inaccurate doubts about their effectiveness at reducing transmission. Gov. Kristi Noem of South Dakota has flatly refused to issue a mask mandate even after a worst-in-the-nation spike this fall and winter. Gov. Brian Kemp of Georgia at one point overturned mayors’ efforts to enact mask mandates in their own cities. Even Republican leaders who’ve changed their minds and ended up issuing masking requirements, like Gov. Greg Abbott of Texas, have faced lawsuits and stiff resistance from local GOP officials.

America is hopelessly divided — so much so that millions of Biden’s constituents don’t accept that he was legitimately elected in November. He’s not exactly starting from a place of universal trust, and it’s not hard to imagine state and local officials undercutting his main Covid-19 initiatives. Biden has pledged bipartisanship and an attempt to rebuild American unity, but as with his ambitious vaccine and testing plans, it won’t be easy. He’ll need cooperation on both messaging and logistics from mayors and governors even in red states, and there’s no guarantee he’ll get it.

Boosting morale among burnt out health care workers

As the pandemic rages, hospitals’ top concern is that health care workers are more burned out than ever before. Early on, nurses and physicians could travel to hot spots to offer backup, but no such aid is arriving now, with nationwide stress on the workforce.

The collectivist spirit of sewing masks and applauding health care workers from the spring has given way to vitriolic politicization of basic public health measures like mask-wearing, said Wendy Dean, a physician who co-founded the nonprofit Moral Injury of Healthcare to highlight issues of clinician distress.

“Fighting on the viral front and the messaging front are what’s really wearing people down,” Dean said.

The Biden administration can take some measures to mitigate the burden on health care workers, such as implementing clear public health messaging and funding mental health resources, but the issue isn’t one that Congress can throw money at to solve.

Tackling everything else

The pandemic has taken most of the energy, but there are plenty of other health issues — both domestic and global — that the Biden administration will have to deal with, some of which have been exacerbated by the pandemic.

Some people haven’t been going to preventive care appointments or getting cancer screenings. Overdoses are on the rise again. “I know we’ve lost ground in the HIV epidemic, and mental health and suicide — there are so many things that the CDC needs to tackle,” incoming CDC Director Rochelle Walensky told The Lancet. Plus, there all the health policy initiatives Biden wants to address, like shoring up and expanding Obamacare and lowering prescription drug costs.

Oh, and one more thing: The Biden administration will have to rebuild the country’s pandemic preparedness and strengthen the public health network around the country. The next one is always right around the corner.

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