The Nightmare Pandemic Economy Joe Biden Is Inheriting, in 5 Charts

When President-elect Joe Biden steps into White House in January, he will inherit two inextricably linked crises: The worsening COVID-19 pandemic and a wide-reaching recession. As U.S. coronavirus cases are spiking to all-time highs, he will be responsible for keeping Americans safe while guiding a fragile economy through recovery.

That’s a tall order—and a somewhat paradoxical one. A fully open economy will most certainly lead to more viral spread and likely result in more deaths, while a closed economy could contain the virus but bring about even more financial hardship. And as the weather cools and fewer people want to dine, drink or otherwise spend time outside, it will become even harder to find the right mix of policies to both curb spread and keep businesses (and their employees) afloat.

Biden has already demonstrated a more hands-on approach to the pandemic than U.S. President Donald Trump. In his first order of business after being projected the winner, the President-elect established a COVID-19 advisory board to guide his thinking and work with state and local health officials. The group, Biden’s transition team says, will develop public-health strategies based on scientific information to “reopen our schools and businesses safely and effectively,” among other goals.

Still, the task at hand will be difficult, to say the least. The following five charts show what Biden and his Vice President-elect, Kamala Harris, are up against as they prepare to take the oaths of office.

1. Americans don’t agree on the best course of action

The coronavirus has affected almost every country around the world. Many have taken an economic hit this year as a result. However, while citizens of other countries generally agree on how to move forward, Americans have a wide ideological divide that could make Biden’s job much harder, as presidents often draw on public support to help push their agendas forward.

A Pew survey conducted over the summer found that, among citizens of economically advanced countries struggling to contain the virus, Americans were the most polarized along party lines in their assessment of their government’s response to the virus and the economy. Furthermore, another Pew poll from October revealed that only 24% of Trump supporters said the coronavirus outbreak was very important to their vote, compared with 82% of Biden supporters. Conversely, 84% of Trump supporters said the economy was very important, versus 66% of Biden supporters.

Biden has pledged to follow the advice of public-health advisors, even if they recommend shutting down businesses. Biden’s supporters may applaud that approach, but he will find it challenging to convince the rest of the country it’s the right way to go—especially Trump’s most ardent loyalists, many of whom have shunned even basic preventative measures, like masks.

2. Lawmakers don’t agree, either

Election Day resulted in a narrower Democratic majority in the House of Representatives, while two Jan. 5 runoff elections in Georgia will determine whether the Senate remains narrowly in Republican control or gets split down the middle, with Harris casting a tie-breaking vote when necessary.

Either way, the congressional situation is a major obstacle for Biden’s agenda, writes TIME’s Abby Vesoulis. As she notes, the President-elect may get only parts of his broad plans—spanning everything from childcare to infrastructure to climate change—through a gridlocked Congress.

On the coronavirus front, Biden has called for federal relief programs—including loans for small businesses, direct payments to working families and student loan forgiveness—to serve as a financial bridge until the virus is under control. He has also proposed employing tens of thousands of COVID-19 contact tracers as a means of both curbing viral spread and chipping away at the high unemployment rate.

Federal relief programs are not new for Biden, who, as vice president to Barack Obama during the height of the Great Recession, helped shepherd a $787 billion stimulus package through Congress in 2009. But back then, he had the benefit of a significant Democratic majority in both chambers, making it easier to put the Obama Administration’s goals into practice.

3. The unemployment crisis is worse than it seems

The overall U.S. unemployment rate is currently 6.9%, which, while better than April’s 14.7%, still means that 10 million pre-pandemic jobs remain M.I.A., according to Nov. 6 data from the Bureau of Labor Statistics (BLS). Economists have said that the jobs that haven’t returned by this point will be the hardest to claw back, in part because they are concentrated in the industries most affected by virus containment measures, like leisure, travel and hospitality.

The Trump-era employment gains may not continue at the same pace under Biden, because prolonged unemployment, especially in a weak labor market, can be harder to fix. People who have been unemployed for six months or more are about twice as likely to drop out of the labor force as to find employment, according to a U.S. Federal Reserve analysis of unemployment trends during the Great Recession. Additionally, the longer a person is out of work, the less consumer purchasing they do, which further slows economic growth.

Alarming BLS data show that long-term unemployment as a share of all unemployment is growing fast. In October, 3.6 million of the 11 million unemployed Americans—or one in three—had been out of work for six months or longer. That’s a ratio not seen since mid-2014, when Biden was VP and the unemployment rate, like today, topped 6%.

The continuing unemployment crisis has led economists to become increasingly pessimistic about when the country might return to pre-pandemic levels. Business and academic economists surveyed by the Wall Street Journal in April predicted the labor market would recover by 2022. But when surveyed again in October, 55% had extended their recovery forecast to 2023 or later.

4. Biden can’t fix the coronavirus or the economy without addressing systemic racism

2020 brought the country’s ongoing struggle with racism to the fore, as police brutality and other forms of violence against Black people led to nationwide Black Lives Matter (BLM) demonstrations. But systemic racism hasn’t been on display just in horrifying viral videos—it has also been apparent as COVID-19 ravaged Black communities in particular.

Systemic racism has made it harder for Black communities to achieve the wealth, access to health care and overall prosperity that white communities enjoy. As a result, Black people in the U.S. are most vulnerable to the virus itself, as well as the economic disruptions it has brought on. A disproportionate share of Black Americans have fallen severely ill from the virus. They are more likely to hold lower-wage, public-facing, front-line worker positions that put them at greater risk of exposure. And they are less likely to have accumulated savings to pay the bills if their jobs disappear. Addressing the pandemic’s health and economic effects requires acknowledging these facts, and acting accordingly.

5. We’re not out of this yet

On Nov. 9, pharmaceutical company Pfizer announced promising results from its vaccine effectiveness trials; other companies are also in late-stage trials. The stock market surged on the news, as investors predicted that the vaccine will suppress case rates and therefore expedite economic recovery.

But that won’t happen immediately, even if the vaccine is highly effective in a biological sense. Public-health strategies will continue to be critical during the time it will take to produce, distribute and widely administer a vaccine. The U.S. Centers for Disease Control and Prevention, which is planning a phased rollout starting with high-risk populations, is anticipating that a limited number of doses will be available at first. If the rollout happens as quickly as President Trump has touted, mass vaccination could take Biden’s entire first term.

Another obstacle: for a vaccine to work, people need to actually receive it—but survey data suggest that many Americans aren’t on board. The chart below, adapted from STAT and The Harris Poll, shows that only about 58% of Americans surveyed in October plan to get a vaccine as soon as one is available—down from 69% in August. The hesitancy is even more pronounced among Black Americans, with only 43% reportedly planning to get vaccinated right away.

It’s hard to say how effective Biden will be in balancing public-health measures with the economic consequences of viral containment. Other countries have shown such a balancing is possible—Germany, South Korea and Japan, for instance, have experienced fewer deaths per capita and less severe economic losses than the U.S., as measured by gross domestic product declines since late 2019.

But it’s not an apples-to-apples comparison. Other nations benefit from a stronger consensus among citizens on the best path forward. Moreover, some have social safety nets that cushion the blows from economic disruptions. And not all countries have the added complication of deep-seated racism that has disproportionately affected minority communities in the U.S.

Still, Biden believes the government needs to do better, and he campaigned on the promise of finding middle ground. In the last pre-election debate, he suggested that health and economic goals are not necessarily in competition—that if the nation is healthy, then the economy will be, too. His challenge now will be channeling that idea into effective policy. Given that states, rather than the national government, have the most power to issue and enforce public-health rules, expect him to start by working with—or, in some cases, perhaps even pressuring—the country’s governors to follow his lead.

Why You May Not Be Able to Get Pfizer’s Frontrunner COVID-19 Vaccine

The freezer in your kitchen likely gets down to temperatures around -20° C (-4° F). “That keeps your ice cream cold, but it doesn’t turn your ice cream into an impenetrable block of ice,” says Paula Cannon, an associate professor of molecular microbiology and immunology at the University of Southern California’s Keck School of Medicine.

Pfizer’s promising COVID-19 vaccine, by contrast, must be stored at about -70° C (-94° F)—a temperature cold enough to harden ice cream into a spoon-breaking block of ice, and that only specialized freezers can produce.

Those cold storage requirements are raising serious questions about who could get the Pfizer vaccine if it’s approved, and when. The reality, experts say, is that the Pfizer vaccine probably won’t be available to everyone, at least not right away. Large medical centers and urban centers are the most likely to have the resources necessary for ultra-cold storage. People without access to these facilities, such as those living in rural areas, nursing homes and developing nations, may have to wait for other vaccines working their way through the development pipeline.

Pfizer’s vaccine candidate, which has not yet been approved by the U.S. Food and Drug Administration but is reportedly 90% effective at preventing COVID-19, uses genetic material called mRNA. If it’s not kept at extremely cold temperatures, mRNA can break down, rendering the vaccine unusable.

If the Pfizer vaccine is kept at -70° C, it can last up to six months. But many hospitals, to say nothing of community medical offices and pharmacies, do not have ultra-cold freezers, which cost around $10,000 up front and are expensive to run because of their high energy usage. Retrofitting existing freezers to reach these temperatures isn’t possible either, Cannon says. “It would be like going from a Fiat car to a Tundra truck”—the technology and energy requirements are simply different.

There may also be shortages of the type of pharmaceutical-grade glass needed to make vials that can withstand such cold temperatures, says Dr. William Moss, executive director of the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health. New York-based glass company Corning won a $204 million government grant in June specifically so it could increase production of its sturdy glass, which is made without boron.

Distributing the vaccine will also be difficult, since it must remain frozen during shipping. Pfizer has built a storage container that, with the help of dry ice, can keep doses cold for up to 10 days in transit without any additional freezer equipment. Periodically replenishing the containers with dry ice can buy another 15 days, but depending on how often the containers are opened, and for how long, that timeline could be considerably shorter. (Dry ice is also in short supply right now because of the increase in food delivery during the pandemic, combined with the fact that fewer people are driving and buying gas, driving down the ethanol production required to make dry ice.)

Once they’re out of the box, the shots can last for about five days in standard refrigeration. But the boxes hold from 200 to 1,000 vaccine vials, each of which contains about five doses of the shot—more than most doctor’s offices could reasonably expect to use before some doses start to defrost and become useless, as ProPublica recently reported.

A Pfizer spokesperson told TIME that the company “is committed to ensuring everyone has the opportunity to have access to our vaccine working closely with local government.” The spokesperson added that global distribution has gone smoothly during clinical trials, and that portable and under-the-counter-sized ultra-cold freezers are available for smaller vaccination sites.

“We believe all countries will be able to effectively dose patients even with our cold chain requirements,” the spokesperson said.

For mass U.S. distribution, Cannon says the most practical solution may be setting up large, centralized vaccination centers that could rapidly go through doses, rather than trying to get the jab into every doctor’s office and pharmacy nationwide. The U.S. Department of Health and Human Services on Nov. 12 announced it will work with pharmacies nationwide to distributes COVID-19 vaccines for free, but it’s not yet clear which vaccines will be available through that partnership.

Some states are considering large vaccine depots, as indicated by their draft plans for vaccine rollout sent to the CDC, but such centralized hubs require additional staff, equipment and cost that some states can’t afford. Plus, in rural areas, reaching a “centralized” location may still require lengthy travel for some people. The Pfizer vaccine must also be given in two separate doses, which could be a hard sell to people who have to drive hours to get it.

Moss adds that those who need the vaccine most—like the elderly and those with prior health conditions—may be the least able to travel to get one. And distributing an ultra-cold vaccine may be a pipe dream in countries poorer than the U.S., Moss says.

“It would be extremely challenging, if not impossible, to get such a vaccine out to, say, countries and people in Sub-Saharan African and many parts of Asia, where the infrastructure is not what we have in the United States,” he says.

Pat Lennon, who oversees cold-chain storage at the global health nonprofit PATH, says ultra-cold vaccines were distributed during the recent Ebola outbreak in the Democratic Republic of the Congo, but that was an easier feat, since the virus did not spread as widely.

Moss says he’s not overly concerned about distribution challenges, at least right now. Pfizer’s COVID-19 vaccine is one of many currently in development, and “I don’t have any reason to think this Pfzier vaccine is special in such a way that its efficacy is going to be substantially higher than another vaccine,” Moss says. (Time will tell, of course, exactly how the efficacy and availability of the different shots stack up.)

Many of the other vaccine candidates currently going through clinical trials do not have such stringent cold-storage requirements. Pharmaceutical companies Moderna, Johnson & Johnson and AstraZeneca have all said their COVID-19 vaccine candidates could be kept at temperatures of -20° C or above, which should make distribution easier.

Cannon adds that Pfizer and other vaccine makers may refine their formulas over time. Some other vaccines, such as those for measles and yellow fever, are shipped in a freeze-dried format and reconstituted with water before they’re administered. Something similar may be possible for COVID-19 vaccines in the future, Cannon says. The Pfizer spokesperson says the company hopes to release a COVID-19 vaccine that could be stored at temperatures between 2-8° C in 2022.

But for now, people should be prepared to wait awhile before life returns to normal. Even once vaccines are available, it will take time to achieve the widespread inoculation required to stop the virus from spreading unchecked. “I would say a best-case scenario may be toward the end of 2021,” Moss says. “But it’s going to depend on not just vaccine availability and approvals, but the willingness of people to accept the vaccine. There’s a whole other challenge and layer there.”

In the meantime, the best tools are the ones we’ve already got: social distancing, wearing masks and washing your hands.

Stanford vs. Harvard: Two Famous Business Schools’ Opposing Tactics for the COVID-19 Pandemic

At the Stanford Graduate School of Business in Northern California, the stories got weird almost immediately upon their return for the fall semester. Students say they were being followed around campus by people wearing green vests telling them where they could and could not be, go, stop, chat or conduct even a socially distanced gathering. Some say they were threatened with the loss of their campus housing if they didn’t follow the rules. “They were breaking up picnics. They were breaking up yoga groups,” says one graduate student, who asked not to be identified so as to avoid social media blowback. “Sometimes they’d ask you whether you actually lived in the dorm you were about to go into.”

On the other side of the country, students at the Harvard Business School gathered for the new semester after being gently advised by the school’s top administrators, via email, that they were part of “a delicate experiment.” The students were given the ground rules for the term, then received updates every few days about how things were going. And that, basically, was that.

Two elite programs, two wildly different approaches in tone and execution. In terms of the substance of their efforts, though, Harvard and Stanford wound up aligning very closely with one another—and that may explain why, in the end, the schools both have achieved ongoing success in limiting the spread of COVID-19 in the age of pandemic.

For months, college and university administrators nationwide have huddled with their own medical experts and with local and county health authorities, trying to determine how best to operate in the midst of the novel coronavirus. Could classes be offered in person? Would students be allowed to live on campus—and, if so, how many? Could they hang out together?

“The complexity of the task and the enormity of the task really can’t be overstated,” says Dr. Sarah Van Orman, head of student health services at the University of Southern California and a past president of the American College Health Association. “Our first concern is making sure our campuses are safe and that we can maintain the health of our students, and each institution goes through that analysis to determine what it can deliver.”

With a campus spread over more than 8,000 acres on the San Francisco Peninsula, Stanford might have seemed like a great candidate to host large numbers of students in the fall. But after sounding hopeful tones earlier in the summer, university officials reversed course as the pandemic worsened, discussing several possibilities before finally deciding to limit on-campus residential status to graduate students and certain undergrads with special circumstances.

The Graduate School of Business sits in the middle of that vast and now mostly deserted campus, so the thought was that Stanford’s MBA hopefuls would have all the physical distance they needed to stay safe. Almost from the students’ arrival in late August, though, Stanford’s approach was wracked by missteps, policy reversals and general confusion over what the COVID-19 rules were and how they were to be applied.

Stanford’s business grad students were asked to sign a campus compact that specified strict safety measures for residents. Students at Harvard Business School signed a similar agreement. In both cases, state and local regulations weighed heavily, especially in limiting the size of gatherings. But where Harvard’s compact emerged fully formed and relied largely on the trustworthiness of its students, the process at Stanford was unexpectedly torturous, with serial adjustments and enforcers who sometimes went above and beyond the stated restrictions.

Graduate students there, mobilized by their frustration over not being consulted when the policy was conceived, urged colleagues not to sign the compact even though they wouldn’t be allowed to enroll in classes, receive pay for teaching or live in campus housing until they did. Among their objections: Stanford’s original policy had no clear appeals process, and it did not guarantee amnesty from COVID violation punishments to those who reported a sexual assault “at a party/gathering of multiple individuals” if the gathering broke COVID protocols. Under heavy pressure, university administrators ultimately altered course, solicited input from the grad student population and produced a revised compact addressing the students’ concerns in early September, including the amnesty they sought for reporting sexual assault. But the Stanford business students were already unsettled by the manners of enforcement, including the specter of vest-wearing staffers roaming campus.

According to the Stanford Daily, nine graduate students were approached in late August by armed campus police officers who said they’d received a call about the group’s outdoor picnic and who—according to the students—threatened eviction from campus housing as an ultimate penalty for flouting safety rules. “For international students, (losing) housing is really threatening,” one of the students told the newspaper. The people in the vests were Event Services staff working as “Safety Ambassadors,” Stanford spokesperson E.J. Miranda wrote in an email. The staffers were not on campus to enforce the compact, but rather were “emphasizing educational and restorative interventions,” he says. Still, when the university announced the division of its campus into five zones in September, it told students in a health alert email that the program “will be enforced by civilian Stanford representatives”—the safety ambassadors.

The Harvard Business School’s approach was certainly different in style. In July, an email from top administrators reaffirmed the school’s commitment to students living on campus and taking business classes in person in a hybrid learning model. As for COVID-19 protocols, the officials adopted “a parental tone,” as the graduate business education site Poets & Quants put it. “All eyes are on us,” the administrators wrote in an August email.

But the guts of the school’s instructions were similar to those at Stanford. Both Harvard and Stanford severely restricted who could be on campus at any given time, limiting access to students, staff and pre-approved visitors. Both required that anyone living on campus report their health daily through an online portal, checking for any symptoms that could be caused by COVID-19. Both required face coverings when outside on campus—even, a Harvard missive said, in situations “when physical distancing from others can be maintained.”

The Harvard Business School has continuously updated students and staff on medical and safety issues at the campus, which is located across the Charles River from the university’s main campus in Cambridge. While many of those missives were instructive (an Oct. 13 note reminded students to mask up indoors and conduct their self-checks), some attempted to reassure the community that a version of campus life was continuing, at times inviting staffers who were working from home to get pre-approved for a campus visit. “We hope you don’t consider the campus completely off limits,” read a Sept. 15 note from Nitin Nohria, dean of the business school, and top campus administrator Angela Crispi. “Come in, take a walk around, remember (or discover) what it’s like to have [Harvard Business School] as your destination for the day.”

So far, both Harvard and Stanford have posted low positive test rates overall, and the business schools are part of those reporting totals, with no significant outbreaks reported. Despite their distinct delivery methods, the schools ultimately relied on science to guide their COVID-19-related decisions. “I feel like we’ve been treated as adults who know how to stay safe,” said a Harvard second-year MBA candidate who requested anonymity. “It’s worked—at least here.” But as the experiences at the two campuses show, policies are being written and enforced on the fly, in the midst of a pandemic that has brought challenge after challenge. While the gentler approach at Harvard Business School largely worked, it did so within a larger framework of the health regulations put forth by local and county officials. As skyrocketing COVID-19 rates across the nation suggest, merely writing recommendations does little to slow the spread of disease.

Universities have struggled to strike a balance between the desire to deliver a meaningful college experience and the discipline needed to keep the campus caseload low in hopes of further reopening in 2021. In Stanford’s case, that struggle led to overreach and grad-student blowback that Harvard was able to avoid.

The fall term has seen colleges across the country cycling through a series of fits and stops. Some schools welcomed students for in-person classes, but quickly reverted to distance learning only. And large campuses, with little ability to maintain the kind of control of a grad school, have been hit tremendously hard. Major outbreaks have been recorded at Clemson, Arizona State, Wisconsin, Penn State, Texas Tech—locations all over the map that opened their doors with more students and less stringent guidelines.

In May, as campuses mostly shut down to consider their future plans, USC’s Van Orman expressed hope that universities’ past experiences with international students and global outbreaks, such as SARS, would put them in a position to better plan for COVID-19. “In many ways, we’re one of the best-prepared sectors for this test,” she said. Six months later, colleges are still being tested.

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This story was produced by KHN (Kaiser Health News), which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.

Will Thanksgiving Be a COVID-19 Disaster? In Canada, the Answer Was ‘Yes’

As coronavirus cases and hospitalizations spike across the United States, public-health officials, local leaders and others are urging Americans to rethink their typical Thanksgiving plans this year. “I would encourage everyone to follow the [Centers for Disease Control and Prevention’s] guidelines and plan for a smaller dinner, with your immediate household family only,” New Jersey governor Phil Murphy said during a Nov. 5 press briefing; his state, like many others, is facing a frightening new wave. “We do not want anyone’s Thanksgiving to lead to more cases of COVID-19.”

Prolonged indoor gatherings of many people from different households, after all, are a major risk factor for viral spread. Moreover, it’s tough to keep a mask on when you’re busy shoving grandma’s turkey and stuffing into your face, and alcohol consumption can make people less careful about practicing social distancing. One especially alarming analysis suggests the odds of having at least one COVID-19-positive person at a moderately-sized Thanksgiving gathering this year could be nearly 100% in some hard-hit parts of the country, and only slightly less elsewhere.

Will this year’s Thanksgiving gatherings lead to more viral spread in the U.S.? For a decent prediction, we need only look to our friends to the north, as Canada celebrated its version of Thanksgiving almost exactly a month ago, on Oct. 12. While Canada was already on an upward trajectory for COVID-19 even before Thanksgiving, several Canadian experts told me that, yes, the holiday almost definitely made things even worse.

“It’s not that we were flat and all of a sudden Thanksgiving happened and there we see an increase,” says Dr. Laura Rosella, associate professor and epidemiologist at the Dalla Lana School of Public Health at the University of Toronto. But, she adds, “the reason why we’re fairly confident Thanksgiving did increase cases is that we saw our highest numbers yet in the two weeks following Thanksgiving, which is consistent with the incubation period, when people would show symptoms and get reported.”

Furthermore, Rosella says Canada’s post-Thanksgiving increases are coming even as it’s getting harder for some Canadians to get tested; more cases with less testing suggests truly explosive growth. “Because our testing was getting strained, the requirements for getting a test actually became stricter,” she says. “So we’re seeing more cases even though we had to change the criteria for testing such that only those who are in high-risk situations and are symptomatic are getting tested.”

Rosella also added that contact tracing efforts showed that Thanksgiving gatherings directly resulted in viral spread—useful and informative information that wouldn’t show up in the overall numbers above, but underscore the importance of an effective testing and tracing program.

Dr. Matthew Oughton, assistant professor of medicine at McGill University and attending physician in the infectious diseases division of Montreal’s Jewish General Hospital, adds that Thanksgiving’s impact might have shown up even more prominently in the data, if not for some Canadian provinces’ decision to implement new measures, like shutting down indoor dining and movie theaters, around the same time as the holiday.

“Although we didn’t see a huge surge in the number of cases in Ontario and Quebec, what’s actually striking is that we didn’t see the decrease that you would have expected to see as a result of those lockdown measures,” says Oughton. “One of the theories is that at the same time the lockdown measures should have been bringing things down, it was actually Thanksgiving pushing those numbers back up.”

As it did in Canada, American Thanksgiving is coinciding with two other dangerous trends: COVID-19 cases are spiking across the country, while “pandemic fatigue”—people’s sense of being straight-up sick and tired of changing their behavior to help curb viral spread—appears to be rising. Even people who are being careful in their everyday lives may view Thanksgiving as an exception, a chance to pretend everything’s normal for a day. But the virus doesn’t care if it’s a holiday or not, of course.

Many Americans, this writer included, are planning on a pandemic-safe Thanksgiving, foregoing the usual big in-person family gathering in favor of a smaller meal and a hangout over video chat. But others will likely ignore experts’ warnings and gather regardless of the danger. So what can people do to try to reduce the danger if they insist on gathering in person this Thanksgiving?

“All this virus needs is close contact for a prolonged period of time, and especially indoors, because there’s poorer ventilation,” says Oughton. Distancing is better than not distancing, he says, and having an outdoor celebration, where the weather allows, is also preferable, given the better natural ventilation. If you can’t have Thanksgiving outdoors, Oughton says, consider keeping the windows open to improve ventilation, or rethinking how you seat people. “Can you have people seated farther away, so instead of just the one family table, can you have a few smaller tables?” he says. “Or do you have people get their food and sit down, but again with distancing so at least you can be together and have a meal together even if you’re still sitting at least six feet apart?”

Still, Oughton echoes the advice of many other public-health experts, saying that it’s better to connect with extended family online this year to help ensure everyone’s happy and healthy for next year’s holiday season—especially given that some family members, like grandparents, are more vulnerable to severe COVID-19 due to age and other potential factors.

“It’s not the same thing as being able to see them and hug them in person, but then again,” he says, “I wouldn’t want to have a nice Thanksgiving and then find out two weeks later that one of them landed in the hospital.”

The Political Coronavirus Paradox: Where The Virus Was Worst, Voters Supported Trump the Most

We will never know whether President Donald Trump could have won reelection if a novel coronavirus hadn’t torn across the planet in the final year of his presidency, just as the months-long impeachment saga was drawing to a close. (Did you remember that Trump was impeached?) There’s a strong argument that the President’s delayed response and mishandling of the pandemic was the one thing during campaign season that no amount of his trademark misdirection could deflect.

But while early indications suggest that the deadly disease was the most driving factor among those who voted for President-elect Joseph Biden, while the moribund economy it spurred was of most concern to the outing President’s supporters, there lies a strange conundrum here: The regions of the country that Trump carried have also been those most plagued by COVID-19 since late August, according to TIME’s analysis of Associated Press voting results by county and the local rates of COVID-19 since March. On Nov. 3, the day of the election, the counties that broke for Trump had a collective rate of 38 new infections a day per 100,000 people, compared to 27 in those that supported Biden.

A week out from the election, we have fairly complete data on returns in almost all of the 3,141 counties and county equivalents. At present, Biden has won 491 counties to Trump’s 2,544, which will shift marginally when the last few counties come in. This is a typically lopsided count that means very little since Democratic counties are vastly more populous. (Hillary Clinton won 487 counties four years ago, and Obama won 693 counties in 2012.) When one tallies the number of cases in those two different blocs of counties, day by day, the rate of new cases per day flipped from being consistently higher in Biden Territory to considerably worse in Trump’s physically larger, more rural turf on Aug. 20, days before Trump accepted the nomination at the Republican National Convention.

On one hand, this is not shocking, given that we’ve known since September that the virus, which first struck hardest in dense, urban areas, has gradually moved outward to suburban and rural regions (where more Trump supporters live) as the third wave far surpasses the first two in the U.S. Moreover, leaders in some Republican-leaning states have been reluctant to issue restrictions meant to curb viral spread. Still, all evidence suggests that, while COVID-19 may have been more paramount in the minds of those who supported Biden, it was considerably more prevalent among the population of those who did not.

Contact Tracing Apps Were Big Tech’s Best Idea for Fighting COVID-19. Why Haven’t They Helped?

When the Nevada Department of Health and Human Services launched COVID Trace, one of the nation’s first COVID-19 contact-tracing smartphone apps, on Aug. 24, state health authorities “strongly recommended” all 3 million-plus Nevadans download and use the app. But two and a half months later, adoption remained well short of that ambitious goal—the app has been downloaded just under 70,000 times as of Nov. 9, representing just under 3% of the state’s adult population. A total of zero exposures were registered in the app throughout the month of September, during which the state reported more than 10,000 new cases. One of the first positive test results logged into the app was submitted in early October by Nevada’s pandemic response director, who himself had contracted the virus. Nevada is currently reporting roughly 1,200 new COVID-19 cases daily, and the app doesn’t seem to be making a difference.

While researchers have worked for months to develop COVID-19 vaccines and treatments, contact-tracing apps like COVID Trace have been touted as one of the technology world’s most promising contributions to the fight against the pandemic. But seven months into the U.S. outbreak, such apps have made slow progress across the country, hampered by sluggish and uncoordinated development, distrust of technology companies, and inadequate advertising budgets and messaging campaigns.

“People are trying whatever they can think of, and this is one of those things,” says Jeffrey Kahn, a professor of health policy and management at Johns Hopkins University. “Whether it’s worth the investment, it’s really hard to answer that until there’s more information.”

Most U.S. contact-tracing apps are built by state governments, but underpinned by a Bluetooth-based exposure notification protocol released in May by Google and Apple in a rare joint venture. Smartphones running apps using the Google-Apple technology can exchange randomly generated identification numbers with other nearby devices; the apps then alert users if someone they’ve been in contact with later inputs a positive COVID-19 test so they can take appropriate measures, like getting tested. The idea was to augment, not replace, traditional contact tracing—a manual process in which human investigators interview infected individuals, then contact others with whom they recently spent time. (While many states have been ramping up their contact-tracing programs, many of these efforts have been overwhelmed by the sheer amount of viral spread in recent weeks.)

But five months after the Google-Apple project launched, apps using their protocol are available to the general public in only 10 states and Washington, D.C. Even in states that have rolled out contact-tracing apps, adoption generally remains low. Why?

Part of the problem, according to public-health experts, has been a lack of coordination by the federal government, which could have, for example, created a national digital contact-tracing solution and encouraged states to opt in. Absent direction or incentives from Washington, many states have chosen not to launch contact-tracing apps at all. Even states that have launched contact-tracing apps were initially wary of investing their limited resources in an unproven solution. Officials in New York, for example, told TIME they were interested in Google and Apple’s initial pitch as the pandemic battered the Empire State this spring, but first wanted to shore up their traditional contact-tracing program. The state eventually launched an app in early October.

Contact-tracing apps have also been slowed by state health departments’ lack of tech expertise, according to public-health officials and technologists. “From the perspective of an app developer that sat in those contracting queues in places like New York and California, states were utterly unequipped to start making procurement decisions on contact-tracing apps,” says Teddy Gold, executive director of Zero, a non-profit formed this spring to make pandemic response software. “You’d get sent from the public health department to the governor’s office, to the [chief information officer], back to a mayor’s office, back to the chief information security officer’s office. It was this Kafkaesque thing where no one had ever done this. No one had ever developed a contact-tracing app before. States don’t develop apps.” Dr. Norm Oliver, Virginia’s state health commissioner, agrees. “Public-health departments around the country, their strong suit is not going to be app development,” Oliver says.

At first, states using the Google-Apple protocol had to contract with developers on their own to build contact-tracing apps, an expensive and complicated process. In September, with only a handful of state apps online since the protocol’s May launch, the companies released Exposure Notifications Express, a basic, pre-built version that states can use instead of developing their own apps. Users in areas where the service is active can opt in after receiving a push notification, a feature likely to save marketing costs. A Google spokesperson says the company is seeing “momentum” in adoption among states thanks to collaboration with public health authorities and ongoing software improvements. Apple did not respond to TIME’s requests for comment.

Some officials say the technology companies have done the best they can considering the constantly changing pandemic situation and the inherent complexities of public-health administration. “Apple and Google as tech companies, I think they were trying to find where they could best fit in to help, using technology that they knew was available without saying that they’re the public health authority, which they’re not,” says Jeff Stover, an executive advisor at the Virginia Department of Health. But getting a contact-tracing app up and running is still not as simple as flipping a switch, and some technologists and health experts are frustrated over delays in getting these apps into wide use. “We’re 200,000 dead people late,” says Gold. “It’s like the plane has crash-landed and everyone has died and the captain scrambles out of the rubble and he’s like, ‘Okay guys, in an emergency landing there are lifejackets under your seats.’”

Of course, whether an app takes a week or six months to build doesn’t matter if people aren’t downloading and using the resulting software—a problem in most states that have launched contract tracing apps. Alabama’s contact-tracing app, for example, was downloaded only 125,000 times between its release in mid-August and late October, a figure equivalent to just over 3% of the state’s adult population. Wyoming, which launched a contact-tracing app around the same time, has seen fewer than 5,000 downloads as of late October, equivalent to just 1% of the state’s adults. Apps in North Carolina and Pennsylvania had been downloaded by an equivalent of only 3-4% of their adult populations by the end of October, just over a month after launching. In New Jersey and New York, which both launched apps on Oct. 1, an equivalent of around 4% of resident adults signed up for their apps in less than a month.

fg that contact-tracing apps are tracking their location or other personal information. “Concern about privacy is one of the things that’s suppressing adoption,” says Christian Sandvig, director of the Center for Ethics, Society, and Computing at the University of Michigan. That’s despite the fact that the Google-Apple protocol—which doesn’t track or share users’ locations or identities—represents the “gold standard” for privacy protection, Sandvig says. Some health experts have even argued that these apps were built with such an emphasis on privacy that they’re actually less useful in fighting the pandemic, in part because they don’t collect data like the locations where potential infections are taking place.

But many users may not see it that way, especially in an era when Americans’ trust in Big Tech is eroding and technology firms are catching flak from all sides of the political spectrum. In some instances, privacy concerns are even killing contact-tracing apps in the cradle—South Carolina, for instance, announced plans in May to deploy a Google-Apple powered contact-tracing app, only to shelve the plan the next month after lawmakers banned such software over privacy concerns.

In some states, sparse adoption may also be linked to a lack of advertising funding. In the two U.S. states with the highest adoption rates—Delaware (7.3% adoption) and Virginia (10.6% adoption)—officials have spent $0.11 and $0.18 per resident on advertising their apps, respectively. Officials in those states attribute their relative success to aggressive outreach efforts; in Virginia, that included a PSA featuring students from around the state as well as marketing materials in both English and Spanish. But in Wyoming and Nevada, where adoption sits at a paltry 1.1% and 2.9% of resident adults, respectively, advertising funds are scant. Wyoming isn’t spending any money at all to promote its app. The private-sector partners behind Nevada’s COVID Trace, who also paid to build the app in the first place, are spending a small amount on ads—around $0.03 per resident, plus ad inventory contributed by Google and a volunteer effort from Vegas-area performers—while the state is spending none of its own funds. The strategy has so far failed to bear fruit. “I feel like I’ve talked about COVID Trace every day since we launched it, and people will say ‘oh I didn’t know you did an app,’” says Julia Peek, Deputy Administrator of Nevada’s Community Health Services. “It’s like, ‘what are we doing wrong to promote this?’”

While it’s obvious that no U.S. state has achieved anything resembling a satisfactory adoption rate, it remains unclear how many people in a given population need to download and use contact-tracing apps to control viral spread. In May, researchers pegged that figure at 60%—far more than what U.S. states are seeing so far. But newer research from Oxford University and Google says that exposure notification apps could help reduce infections at any level of uptake. “There have been a lot of conversations in the past about [whether] you have to achieve minimum thresholds in terms of adoption levels,” says Larry Breen, chief commercial officer at Nearform, which developed a contact tracing app for Ireland as well as multiple U.S. states. “I’ve never accepted that as the right thing. As soon as you get the digital contact-tracing solution out into any cluster or group of people, it’s providing some level of protection.”

Even the highest adoption rates among U.S. states are far below those in countries like Ireland, where more than a third of the adult population downloaded the government’s contract-tracing app by early October, or Germany, which reached 27% adoption in September (though even both of those results fall well short of mass adoption). Breen says Irish officials and politicians have maintained a unified, consistent message promoting the app, which hasn’t been true in the U.S. “There’s a lot of confusion and different messaging coming out,” he says. Other countries, like Austria, have comparable adoption rates to Virginia.

All told, despite the relative success of states like Delaware and Virginia, agonizingly slow rollouts and uncertain public health benefits over the past few months have caused some experts to doubt the assumption that contact tracing apps can help bring the spiraling U.S. COVID-19 outbreak under control. “There’s an ultimate question here…which is, ‘Is this a great opportunity for software?,'” says Sandvig. “It may be that it is not.”

FDA Allows Emergency Use of Antibody Drug to Fight COVID-19

(WASHINGTON) — U.S. health officials have allowed emergency use of the first antibody drug to help the immune system fight COVID-19, an experimental approach against the virus that has killed more than 238,000 Americans.

The Food and Drug Administration on Monday cleared the experimental drug from Eli Lilly for people 12 and older with mild or moderate COVID-19 not requiring hospitalization. It’s a one-time treatment given through an IV.

The therapy is still undergoing additional testing to establish its safety and effectiveness. It is similar to a treatment President Donald Trump received after contracting the virus last month.

Early results suggest the drug, called bamlanivimab, may help clear the coronavirus sooner and possibly cut hospitalizations in people with mild to moderate COVID-19. A study of it in hospitalized patients was stopped when independent monitors saw the drug did not seem to be helping in that situation.

The government previously reached an agreement to buy and supply much of the early production of Lilly’s drug.

Only one drug — Gilead Sciences’ remdesivir — has full FDA approval for treating COVID-19. Government treatment guidelines also back using dexamethasone and other steroids for certain severely ill, hospitalized patients.

One other treatment has an emergency use designation now — convalescent plasma, or the blood of COVID-19 survivors. No large studies have shown it to be more effective than usual care alone, however.

The new drug is part of an emerging family of biologic therapies that offer a promising new approach to preventing serious disease and death from COVID-19. Experts say the infused drugs could serve as a therapeutic bridge to help manage the virus until vaccines are widely available.

The drugs are laboratory-made versions of antibodies, blood proteins which the body creates to help target and eliminate foreign infections. The new therapies are concentrated versions of the antibodies that proved most effective against the virus in patient studies.

Regeneron Pharmaceuticals Inc. also has asked for emergency authorization for an antibody drug it is testing, the one Trump received.

FDA regulators authorized the Lilly drug using their emergency powers to quickly speed the availability of experimental drugs and other medical products during public health crises.

In normal times the FDA requires “substantial evidence” to show that a drug is safe and effective, usually through one or more large, rigorously controlled patient studies. But during public health emergencies the agency can lower those standards and require only that an experimental treatment’s potential benefits outweigh its risks.

The emergency authorization functions like a temporary approval for the duration of the COVID-19 pandemic. To win full approval, Lilly will have to submit additional research to fully define the drug’s safety and benefit for patients.

The government has signed an agreement with Lilly to spend $375 million to buy 300,000 vials of the drug. How many doses that would provide is unclear. Each vial contains 700 milligrams and that dose proved ineffective in the early results. It took four times that amount — 2,800 milligrams — to show any effect.

The Lilly drug is authorized for people 12 and older who weigh at least 40 kilograms (about 88 pounds), and who are at high risk for progressing to severe COVID-19 and/or hospitalization. This includes those who are 65 years of age or older, or who have certain chronic medical conditions.

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AP chief medical writer Marilynn Marchione in Milwaukee contributed to this report.

Joe Biden and Kamala Harris Announce Their COVID-19 Advisory Board

On Nov. 9, the Biden-Harris transition team announced the members of its COVID-19 advisory board, and met with them for several hours in a virtual conference before President-elect Joe Biden made remarks stressing the importance of mask wearing as a continued “weapon” in the fight against COVID-19.

“As we work toward a safe and effective vaccine, the single most effective way to stop the spread of COVID-19: wear a mask,” Biden said, as he held up his own mask. “The head of the CDC [Centers for Disease Control] warned this fall that for the foreseeable future, a mask remains the most potent weapon against the virus.”

The message was a stark contrast to the position taken by the Trump administration, which has not fully supported public health measures including mask wearing and social distancing, despite the advice of public health experts. Biden’s plea sets a distinctly different tone for how his administration will approach the pandemic and the role that scientific advice will play in guiding federal, and ultimately state, policies in addressing COVID-19.

A statement announcing the board members stressed that the goals of the board will include working with state and local health officials “to determine the public health and economic steps necessary to get the virus under control, to deliver immediate relief to working families, to address ongoing racial and ethnic disparities, and to reopen our schools and businesses safely and effectively.”

The board is co-chaired by Dr. David Kessler, former commissioner of the Food and Drug Administration (FDA) under George H.W. Bush and Bill Clinton and currently a professor at University of California San Francisco; Dr. Vivek Murthy, former Surgeon General under Barack Obama and Trump; and Dr. Marcella Nunez-Smith, associate dean for health equity research at Yale School of Medicine whose research focuses on providing equal access to healthcare, especially for marginalized populations.

The other members include Rick Bright, a virologist who formerly headed the Biomedical Advanced Research and Development Authority (BARDA) under the Trump administration, and who has advised the World Health Organization and the U.S. Department of Defense on public-health preparedness. Bright filed a whistle-blower complaint last spring stating that his warnings about the dangers of COVID-19 were dismissed and alleging that he was removed from his BARDA position after noting the lack of solid evidence supporting the benefits of hydroxychloroquine, which Trump touted. His appointment to the board is a signal that the Biden team is prioritizing science in guiding its pandemic response.

Biden noted that global health leaders are also part of the board, in order to “restore U.S. global leadership to fight this pandemic.” For example, included are Dr. Luciana Borio, vice president at In-Q-Tel, a technology-focused company that provides tech-based solutions to security issues, and a senior fellow at the Council on Foreign Relations focusing on biodefense and managing public health emergencies; Borio has previously worked in the FDA’s office of counterterrorism and emerging threats. There is also Loyce Pace, executive director and president of the Global Health Council, who has worked with patient and scientific advocacy groups in the U.S. and around the world.

The team also includes a physician on the frontlines of the COVID-19 response, Dr. Robert Rodriguez, a professor at University of California, San Francisco. And the board is rounded out by former government advisors such as Dr. Ezekiel Emanuel, chair of medical ethics and health policy at the University of Pennsylvania, who has advised the White House Office of Management and Budget and the National Institutes of Health; Dr. Atul Gawande, professor at Brigham and women’s Hospital and Harvard Medical School, who advised the Department of Health and Human Services during the Clinton Administration; Dr. Julie Morita, executive vice president of the Robert Wood Johnson Foundation who served on the CDC’s immunization advisory committee; and Dr. Eric Goosby, a professor at University of California San Francisco who served as the U.S. Global AIDS Coordinator and Special Envoy for tuberculosis for the U.N. Secretary General; as well as state public-health experts such as Dr. Celine Gounder, a professor at NYU Grossman School of Medicine who served in the New York City Department of Health and Mental Hygiene, and Dr. Michael Osterholm, director of the center for infectious disease research and policy at the University of Minnesota who worked in the Minnesota Department of Health as an epidemiologist.

Pfizer Says COVID-19 Vaccine 90% Effective Against Virus

Pharmaceutical giant Pfizer has announced that its COVID-19 vaccine successfully prevented 90% of infections compared to a placebo, a more positive result than experts expected.

The analysis is based on 94 cases of infection with SARS-CoV-2, the virus that causes COVID-19, among both the vaccinated and placebo groups. Experts had set a minimum threshold of 60% effectiveness for vaccines to be considered for emergency authorization or approval. The company’s trial included data from 38,955 of the total 43,538 volunteers who enrolled.

Pfizer is the first company to release results from its COVID-19 vaccine, part of a planned interim analysis by an independent data safety monitoring board that is reviewing all of the handful of vaccine candidates from different companies that are currently being tested in people. The findings represent results collected seven days after the second of Pfizer’s two-shot regimen.

Pfizer, which developed and tested its vaccine with German company BioNTech, said in a release that it will continue following people in the study for a couple more weeks, until the middle of November, when everyone in the study will have been followed for at least two months. That’s the timeframe the Food and Drug Administration is requiring for COVID-19 vaccines before considering them for emergency authorization or approval.

The results represent a victory not only for public health but for science as well. The companies’ vaccine is based on a new technology that relies on a genetic material known as mRNA. No mRNA-based vaccines have received approval from the FDA yet, although several are being tested for other diseases. The results are a testament to the benefits of the platform — using mRNA speeds up development of a vaccine since the process does not require growing vast amounts of virus.

Instead, vaccine developers only needed the genetic sequence of SARS-CoV-2, which became available in January, to start building a vaccine. Other companies, including Massachusetts-based Moderna, and vaccine giant Sanofi, are also testing mRNA COVID-19 vaccines.

This is a developing story and will be updated throughout the day.

 

Biden’s Real COVID-19 Challenge Is Restoring a Nation’s Trust in Science

“If the public-health professionals, if Dr. [Anthony] Fauci, if doctors tell us we should take it, I would be first in line. If Donald Trump tells us we should take it, then I’m not taking it.”

That was Vice President-elect Kamala Harris’ response when asked by the moderator of an Oct. 7 debate whether she would get vaccinated against COVID-19. It perfectly captured the politicization of the U.S. response to COVID-19 under the outgoing Trump Administration—and how dangerous that red and blue tinting of the pandemic response has been for the American public. Behaviors like wearing masks and social distancing, which should be about protecting public health, have turned into loaded statements of party affiliation and have been twisted into campaign strategy, no doubt contributing to the high death toll from the disease and a worrying erosion in people’s confidence in the science that ultimately is the only way out of the pandemic.

Joe Biden’s public-health team now faces a two-pronged challenge: confronting a still mysterious virus that shows no signs of waning, and convincing the American public that parts of the pandemic response that began under the Trump Administration—particularly vaccine development—remain untainted by political influence.

To tackle that task, the new Administration will have a number of options. As President, Biden can appoint new heads of the government’s major health agencies, including the Secretary of Health and Human Services; the director of the National Institutes of Health; the commissioner of the Food and Drug Administration (FDA); and the director of the Centers for Disease Control and Prevention (CDC). Public-health experts have been critical of the lack of strong scientific guidance from these agencies over the past year, and the extent to which they appear to be influenced by the White House. Changing the leadership would be a signal that the Biden Administration will prioritize science and scientific integrity, and help to restore the public’s confidence in its pandemic response.

But replacing leadership may also backfire if the ultimate goal is to generate respect for science and scientists, since many, despite pressure from the Trump Administration, managed to stand their ground and not allow political pressure to compromise scientific principles. During his time as President, Trump repeatedly manipulated the public-health response to meet his own political needs: he admitted in a recorded March interview to intentionally “playing [the pandemic] down” so as not to “create a panic”; touted unproven treatments to give the public a false sense of security; opposed an FDA criterion for ensuring that COVID-19 vaccines are safe; and even pushed vaccine makers to rush the clinical testing process so people could potentially be immunized before the election.

Leading public-health experts, most notably Fauci, director of the National Institute of Allergy and Infectious Diseases and a member of the White House Coronavirus Task Force, took every opportunity to set the record straight when statements from the White House contradicted the scientific facts. And the FDA, with support from the pharmaceutical industry, prevailed in not shortchanging the rigorous scientific review process by preserving a requirement that all volunteers in the vaccine studies be followed for two months for any safety concerns.

If Biden does choose to replace the leaders of any of the federal government’s health agencies, it could signal to the public that government-employed scientists, and the research and policies they oversee, are tainted by politics and would only further compromise any of their public-health advice, including getting immunized if and when vaccines are available. Indeed, the paramount concern for Biden will be reversing the damage done by his predecessor’s assaults on science, which have led Americans—both Democratic and Republican—to worry that politics have driven COVID-19 vaccine development. In an Oct. 12 Gallup poll, only half of respondents said they would get vaccinated if a free, FDA-approved vaccine were available immediately.

That’s a “nightmare scenario,” says Dr. Howard Koh, a professor at Harvard T.H. Chan School of Public Health and former Assistant Secretary for Health and Human Services during the Obama Administration. The government funded the development and manufacturing, and has purchased millions of doses, of six vaccine candidates in its Operation Warp Speed (OWS) program. But even the most effective vaccine does no good sitting on a shelf.

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A Biden campaign adviser authorized to speak with TIME only if not quoted by name says Biden’s goal is “ensuring the safety and efficacy of the vaccine and ensuring there’s no politicization of that process.” But the campaign adviser also stood by comments like the one Harris made during the debate, when she said she would not take a vaccine recommended by Trump. “It’s Trump who has let us down, it is Trump who has lied to us, and I think it’s really important that that be called out” because it shows “we are watching,” the campaign adviser said.

By all accounts, the FDA, which will ultimately decide whether to authorize the handful of vaccine candidates currently in trials, has prevailed in deflecting the Trump Administration’s attempts to shortcut the review process. Each vaccine trial looking at safety and effectiveness was carefully designed and reviewed by both government and independent health experts and likely won’t change once Biden is in office. That said, the Biden team “is going to have to figure out what parts of OWS it keeps, and what parts it does not,” says Dr. Tom Frieden, former director of the CDC and current president and CEO of Resolve to Save Lives, a U.S.-based global public-health nonprofit. So far, OWS supported development and manufacturing of the vaccines, and will also help to distribute the doses once they are ready.

The new Administration may also need to address the fact that local health departments are struggling to keep up with the demand for testing, contact tracing and COVID-19 care coordination from their local clinics, hospitals and citizens. Because the Trump Administration didn’t prioritize a national pandemic strategy—including, for example, mandating mask wearing in public or prohibiting mass gatherings—state health officials say they have been left with the task of not only figuring out what policies to support but how to communicate them to a confused public.

“We never had a united plan for the United States,” says Koh. “The 50 states have been going in 50 different directions. To continue doing what we are doing now will only prolong the pandemic unnecessarily and cause more unnecessary suffering.” A more coordinated national plan will be particularly important for a successful vaccination program, since “vaccines don’t stop infections, vaccination programs do,” says Frieden. “We need a comprehensive vaccination program, and we’re falling behind. We’re not doing what we need to do to create strong vaccination programs.”

The CDC is working with state and local health departments, but much is still in flux and confusing, according to state health officials. The 64 public-health jurisdictions, made up mostly of state health departments that the CDC is funding for the vaccine program, submitted proposals in August for how many doses they would need and how those would be allocated. The CDC reviewed those plans and returned them at the end of October. But there are still uncertainties. For example, says Kris Ehresmann, director of infectious disease epidemiology at the Minnesota Department of Health, the federal government says it will distribute vaccines to both the state health department and to groups such as the Indian Health Service, and it’s not clear which tribal groups will be receiving doses through the Indian Health Service, and which will be the responsibility of the state.

One thing that has aided states in their planning so far is the fact that, by and large, scientists involved in the vaccine program—both in the government and at pharmaceutical manufacturers—have united in an unprecedented show of support for established scientific criteria for evaluating vaccine candidates. But it won’t be easy for the Biden Administration to persuade the public to get vaccinated if and when the COVID-19 shots are available. “I’ve heard from people all over the country who say they won’t get ‘the Trump vaccine.’ But it should not be ‘the Biden vaccine,’ either,” says Frieden. “The point is that it’s the COVID vaccine—it’s not a political vaccine.”

Vaccine researchers, including leading government scientists, maintain that the speed hasn’t involved shortcuts in the science, but instead reflects, in part, improved technology behind some of the vaccines, as well as more efficient review of data given the urgency of the pandemic. “The Biden Administration can relieve much of the public’s anxiety about the speed of development by making it clear that they are not going to sacrifice safety for speed,” says Dr. Kelly Moore, associate director for immunization education at the Immunization Action Coalition.

The best way to accomplish that would be to give scientists back their voice on the pandemic stage. Research shows people widely trust scientists and public-health groups—even after the beating they’ve taken this year. In August, researchers from the COVID-19 Consortium for Understanding the Public’s Policy Preferences Across States asked more than 21,000 U.S. adults which people or institutions they trust to handle the COVID-19 crisis. The top answers, in order, were doctors and hospitals; scientists and researchers; the CDC; and Fauci. These should be the voices the Biden Administration calls upon to communicate with the public, experts say.

“There should be a briefing at least several times a week if not every day until the crisis is over, led by top scientists,” says Koh. Seeing scientific experts share what they know and don’t know, and explain why they are recommending certain policies and advice, would go a long way toward alleviating the anxiety caused by current conflicting messages. “The real power that a President has is the bully pulpit,” says Dr. Eric Toner, a senior scholar at the Johns Hopkins Center for Health Security. “They should really have a communication campaign that looks like a political campaign. They should be flooding social media and the airwaves with public-health messages.” He also suggests relying on trusted scientific figures—as well as celebrities, religious leaders and other community figures people trust—to do it.

When it comes to the vaccines, that might include having Biden and Harris get immunized—in public view—to demonstrate their trust in both the scientific process and the importance of the vaccines in controlling the pandemic. “Our leaders would set a good example by getting vaccinated,” says Ehresmann. “They should be the first in line to give people the confidence that the vaccine is safe to take.”

Before the election, the Biden campaign outlined seven pillars of its COVID-19 response, including expanding access to testing and personal protective equipment, investing $25 billion in vaccine distribution, encouraging universal masking, and protecting vulnerable groups like the elderly and people of color. But it didn’t provide the details needed to reassure state health officials who are now preparing to order and distribute doses of vaccines.

“They should focus on the basics of communication during an emergency,” says Frieden. “Be first, be right, and be credible. Tell what you know, tell what you don’t know, and tell what you are going to find out. Don’t over-promise … If you do those things, you can trust people to do the right thing.” That includes helping people trust the science behind vaccines and understand that an inoculation alone won’t make them completely immune. No vaccine is 100% effective, and whatever protection vaccines may provide, people should continue to wear masks, maintain social distancing and avoid crowded indoor gatherings until health officials determine the virus is under control.

In their plan, Biden and Harris promise to “listen to science” and “restore trust, transparency, common purpose and accountability to our government”—but here, too, experts say the plan doesn’t go into enough depth about how that trust will be won. After months of misinformation and partisan interference in public health, communication may be Biden’s biggest challenge. And the stakes are high: those will be critical promises to keep if we have any hope of containing a virus that doesn’t respect national borders or political parties.