Wednesday, January 20, 2021.

The day of the inauguration for US President Joseph Biden and Vice President Kamala Harris will be a somber one for many Americans. The latest projections from the Institute of Health Metrics and Evaluation at the University of Washington indicate that nearly 400,000 Americans will lose their lives by then to coronavirus disease 2019 (COVID-19) [1], and the epidemic will still be raging in many parts of the United States. We might anticipate that in the preceding weeks many hospital emergency rooms and intensive care units will be inundated with patients, especially in regions where there was poor compliance of masks and social distancing. In some US states, both elected leaders and citizens linked their defiance of public health mandates to political allegiances. The 2020 anti-science disinformation campaign led by the White House Coronavirus Task Force dismissed the severity of the disease or the epidemic, claimed COVID-19 deaths resulted from co-morbidities, offered false hopes about herd immunity or cures such as hydroxychloroquine, and downplayed the importance of masks. The message was amplified by far right extremist groups, Russian propaganda, and even some mainstream news outlets [2,3].

When Biden and Harris take their oaths of office in January (Fig. 1 ), they will be leading a nation in the middle of its worst public health crisis in more than 100 years, possibly becoming a full-on homeland security threat due to a defiant US population, or even post-election unrest. What steps should the Biden Administration consider during its first months of office?

Fig. 1

Presidential inauguration at the western front of the U.S. Capitol facing the National Mall. whitehouse.gov, CC BY 3.0, via Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Inauguration-01-20-2009.jpg.

Protecting homeland security

The first priority will be to reassure the American people that the current public health crisis will not continue in perpetuity and then take immediate steps to save lives and reduce surges on hospital ICUs. The President and Vice President will need to communicate to the country on a frequent and periodic basis, similar to how Governor Andrew Cuomo spoke to the citizens of New York last March and April. In some cities or states, it will be necessary to implement aggressive social distancing measures, which will require one-on-one discussions between the President and Governors in the worst affected areas. President Biden will need to rely on his years in the US Congress to cultivate Republican champions to help him in this endeavor.

Leading a federal response and moving it to Atlanta

A major reason for the horrific death toll in America from COVID-19 was the refusal or inability by the White House Coronavirus Task Force to lead a national response. As was pointed out previously, allowing the states to lead with the federal government backing up in a supporting role - manufacturing and supply chain management - was doomed to fail [4]. The states did not possess the epidemiologic depth and breadth of knowledge required to contain COVID-19, and the governors needed the political cover of the CDC to deflect opposition arising from their political extremes [4]. Given the terrible legacy of the White House Coronvairus Task Force, the leadership of the federal response should relocate to Atlanta, Georgia from Washington DC, and set up at CDC headquarters. Recruiting a new CDC Director with respected scientific and public health credentials, as well as high emotional intelligence (EQ), and management and communication skills will be a top priority for President Biden.

Convening experts

All during 2020, the White House could have had access to some of the world’s greatest virologists, vaccinologists, epidemiologists, and public health experts. Most work at our nation’s great research universities and institutes. They should be convened and their opinions sought while shaping our national strategy.

Fixing the health and human services (HHS) agencies

Something went terribly wrong with the CDC in 2020. The agency missed the entry of the virus from Europe resulting in the March–April epidemic in New York City, it failed to deliver diagnostic testing, and it was largely invisible in terms of preventing the summer COVID-19 peak across the US Southern states, and then the deadly fall-winter surge. The CDC never released coherent predictive epidemiologic models - we had to rely on IHME, or models from Johns Hopkins, Penn, UT Austin, and Harvard universities. An unknown is how many of these failings were due to internal collapses versus White House incursions and interference. Many questions must be addressed, including whether a new pandemic threat response agency should be established within or outside the CDC, or if we need to refocus the agency. In contrast, the NIH went on largely as before, while the FDA was somewhere in between. These aspects require investigation as restructuring initiatives are considered.

Vaccines

Given the White House refusal to launch a national strategy for COVID-19 control and containment, our nation became overly reliant on the promise of biotechnology solutions, especially vaccines. Presumably, the first vaccines through Op Warp Speed will roll out in early 2021. There is a possibility that these first vaccines will be partially protective in terms of reducing severity of illness but not necessarily blocking virus infection so that existing COVID-19 prevention measures, e.g. masks, social distancing, contact tracing would continue. Also, the durability of protection is unknown, especially given that Op Warp Speed depended heavily on new technologies never before licensed as human vaccines. We will need to consider adding traditional vaccines to the COVID-19 portfolio including inactivated virus vaccines or recombinant protein vaccines [5]. In addition, Op Warp Speed relied on the pharma CEOs to communicate to the American people about vaccines. This has not gone well, and the Biden Administration will need to convene government scientists to lead a communication strategy focused on high quality frequent and periodic contact with the American people.

Dismantling the anti-science empire

The fact that up to one-half of Americans will refuse COVID-19 vaccines is not an accident. It partly reflects the dominance of an anti-vaccine lobby in America that brought back measles in 2019 [6,7]. There are many discussions among pro-vaccine groups working to fine tune or amplify positive messaging about vaccines, but the reality is that such messages will continue to be drowned out by the anti-vaccine and anti-science ownership of the internet, social media, and e-commerce platforms. The Biden Administration must consider launching an inter-agency task force to begin the long and difficult process of taking down the empire. It must go beyond the Department of HHS and bring in elements from government departments or agencies related to justice, commerce, communications, and homeland security, among others.

On January 20, 2021, the Biden-Harris Administration could face a nation in disarray, as the US experiences one of its worst periods of turmoil in modern times. The new US government will be tested from day 1, but there is a path and roadmap to stabilize the country and restore public health and security. By next summer, we could be in a much better position, but it might take years for the US to recover from an epidemic that ultimately could kill more Americans than the 1918–21 influenza pandemic.

Declaration of Competing Interests

The author is an inventor on a COVID-19 vaccine technology owned by Baylor College of Medicine that was recently licensed non-exclusively to a company.