Looking back at the first month of Joe Biden‘s pandemic response, I recently realized that although he is taking more action than Trump, making important changes at the federal level, and talking about listening to science, underneath all of this Biden is actually still using Trump’s failed pandemic strategy. Biden is still using a “suppression” strategy to address the pandemic.
But there is another strategy he could be using: “elimination.” This is also known as a No COVID or Zero COVID strategy, but don’t let that name confuse you, it’s not a fantasy about eradicating the virus. It’s what’s worked so well in China, Taiwan, Vietnam, Cambodia, Laos, Mongolia, Singapore, Australia, and New Zealand.
“We can be back to a reasonably normal existence: schools, travel, job growth, safer nursing homes & other settings. And we could do it in a matter of weeks. If we want to.”
— Andy Slavitt, White House Advisor for COVID Response on a Zero COVID “elimination” strategy
In early 2020, countries around the world began using different strategies to deal with the growing pandemic. But we might not have really thought about what strategy we were using in the US, since it was just failing so badly. It was perhaps too easy to think that failure was only because of Trump’s failures.
But the suppression strategy Trump used in the US also failed to prevent infections and deaths in the UK, in most of Europe, in Canada, and elsewhere. Many countries in Asia had experience with recent similar outbreaks and were able to draw on that experience to do better. Other countries simply had governments that listened to the right scientists, the scientists who wanted to save lives above all else.
Professor of public health Michael Baker and his colleagues have written extensively about this very successful strategy used by New Zealand, Australia, and other countries which is called an “elimination” strategy. As of today Australia still has less than 1000 total deaths from the pandemic, and New Zealand has only 25. Meanwhile the UK is approaching 120,000 and the US is approaching 500,000 deaths.
If the elimination strategy was a obviously a success, the strategy used by the United States has been an equally obvious failure. The strategy the US has used and continues to use is called “suppression” and instead of aiming to stop community transmission of the virus it tries to reduce it. Instead of trying to stop infections and deaths, it tries to reduce them. And the difference in outcome is clear from the numbers. The US has more infections and deaths than any country on Earth, the UK currently has the highest rate of death.
In early 2020 Trump began the US on this course to use a suppression strategy against the pandemic. But in response, some experts who now advise the Biden administration called for an elimination strategy instead.
Michael Osterholm, a member of Biden’s COVID-19 transition team and director of the Center for Infectious Disease Research and Policy at the University of Minnesota, repeatedly called for an elimination strategy to get the pandemic under control in the US. He did so in several interviews and in a New York Times op-ed where he wrote: “There is no trade-off between health and the economy. Both require aggressively getting control of the virus. History will judge us harshly if we miss this life-and economy-saving opportunity to get it right this time.”
Andy Slavitt, Biden’s current White House Senior Advisor for COVID Response, also argued for an elimination strategy in 2020, explaining that “We can virtually eliminate the virus any time we decide to.” In a long and detailed thread on Twitter, Slavitt explains how an elimination strategy would work to stop infections and deaths in the United States, by using the examples of other countries that have successfully deployed this strategy. He ends by saying: “We will do this. There is no other way. The question is when. The question is who will convince us. The question is the leadership it takes. But there’s not much question if we should.”
In an interview with ABC News in August 2020, Biden also said he would be willing to use an elimination strategy.
Here’s a transcript:
David Muir: Would you be prepared to shut this country down again [in January 2021]?
Joe Biden: I would be prepared to do whatever it takes to save lives. Because we can not get the country moving until we control the virus. That is the fundamental flaw of [the Trump] administration’s thinking to begin with. In order to keep the country running, and moving, and the economy growing, and people employed, you have to fix the virus. You have to deal with the virus.
David Muir: So if the scientists say, shut it down?
Joe Biden: I would shut it down, I would listen to the scientists.
Despite the proven success of the elimination strategy and his own acknowledgement during the campaign that he would use it, Biden has so far resisted switching from Trump’s suppression strategy to the one he and his experts were so passionately recommending. In November of last year, after Osterholm had given several interviews pointing out the benefits of an elimination strategy and calling for a short shutdown where we would pay people to stay home, Biden said “I am not going to shut down the economy.”
As Dr. Margaret Flowers documented in November 2020, another of Biden’s own task force members took on the role of rejecting the idea as well:
“In response to Osterholm’s statement, Celine Gounder, another task force member, said: ‘A national lockdown or shutdown is not on the table. The President-elect has no intention of implementing a national lockdown.’”
That is not to say that Dr. Gounder was giving advice based on her expertise in this case, she is clearly speaking on behalf of the administration in her role as part of the transition team telling the press what Biden has “no intention” of doing. For example, in this Twitter thread about Sweden’s disastrous pandemic strategy it doesn’t appear as though she opposes lockdowns herself.
This Biden administration rejection of Osterholm’s advice is more than just a rejection of the elimination strategy. It’s a strategic response to the Trump movement’s anti-lockdown discourse. But more importantly it’s also a misunderstanding of what an elimination strategy seeks to do.
As Slavitt and Osterholm explain, an elimination strategy uses one short and strict lockdown to stop community transmission and then opens up again sooner and safer than with a suppression strategy. Despite this fact Biden repeatedly said he would not “shut down the country” but would “shut down the virus” instead. However that still implies using an elimination strategy to “shut down” the virus that he has not yet adopted.
In addition to causing many more deaths, a suppression strategy like the one Biden continues to use, has even been shown in countries around the world to be more harmful to the economy than an elimination strategy. It also continues to disproportionately harm already marginalized and vulnerable people who were suffering before the pandemic by providing no support when they are forced to stay home by pandemic conditions, and making them work non-essential jobs. Instead the suppression strategy in the US tries to get people to go back to work sooner. Even if it’s not safe.
On the other hand, the White House and Congress both already operate with a “Zero COVID” elimination strategy. The White House clearly maintains a policy of stopping community transmission. If there is a case, they test, trace, and isolate to prevent it from spreading. This allows them to stay open, keep working, and be safe. In addition they are all provided with salaries, masks, vaccinations, healthcare, paid sick leave, and safe working conditions. Unlike millions of Americans living through the pandemic, no one in Congress is threatened with eviction or hunger if they don’t go work in unsafe conditions.
When the Zero COVID policy is broken, such as during the attack on the Capitol, it is justifiably described as outrageous. But this is the kind of environment millions of Americans have been forced to live and work with every day because of the failed suppression strategy. So if an elimination strategy is the best thing to keep Congress and the White House safe during a pandemic, why isn’t it best for everyone else’s workplaces? Why isn’t it best for our city, state, and federal pandemic response?
What is the main difference between these two strategies, suppression and elimination? Both strategies use social distancing, lockdowns, masking, and other public health measures while we wait for vaccination. The key difference is the goal and the support provided to reach that goal.
While suppression aims to merely control and reduce transmission, elimination aims to stop community transmission so there are no cases we don’t know about. An elimination strategy is often called “Zero COVID” because the goal is zero cases of community transmission, not because it seeks to eradicate the disease. It’s important to know that elimination and eradication are two different ideas when talking about disease, as this is a common confusion about the idea. Using a Zero COVID strategy doesn’t mean there will be zero cases, it means you set the goal to have zero mystery cases.
This chart explains the different pandemic strategies being used around the world, and is from a paper published in December 2020:
The chart shows different “strategic choices for responding to COVID-19 and other pandemics” and the options are divided according to goal:
- no community transmission (exclusion and elimination)
- controlled transmission (suppression and mitigation)
- uncontrolled transmission
The strategy that Trump started using in 2020 was a suppression strategy that sometimes became more like mitigation, depending on how states decided to respond, and that is still the strategy that Biden continues to use today.
There is no state or territory in the US, no province or territory in Canada, and no nation in Europe currently using an elimination strategy. Some nations in Europe are using longer lockdowns as part of a suppression strategy, and those have been more effective but still result in surges when they re-open because they do not stop community transmission and do not have an elimination goal. We are all still using the same suppression strategies that failed so badly in 2020, and they continue to fail.
Almost one month into the Biden administration, CNN is now incorrectly reporting that the Biden administration is striving to “to take the opposite approach of former President Donald Trump on the coronavirus response.” CNN also says Biden is “leaving most of the details to the scientists.” But who are those scientists, which ones? Presumably the White House COVID Response Team. So, where is the public discussion in the United States about the possible strategies we could be using to stop the pandemic in Year Two?
In a Twitter Q&A I asked the White House team: “Why aren’t we paying people to stay home while we vaccinate when the science says government interventions like that are effective?” and they chose not to answer that question.
Osterholm, who served on Biden’s transition team, is pushing back against the current White House message that things are working just fine, saying “The Biden administration is going to have to address this issue and we’ve got to stop basically telling people we’ve turned the corner. At the rate we’re at right now, this is going to be a huge challenge.”
Osterholm also recently warned about the rise of variants, “If we see that happen, which my 45 years in the trenches tell us we will, we are going to see something like we have not seen yet in this country. That hurricane is coming.”
On Febuary 13th CNN quoted a health expert close to the White House who said “They’re painting way too rosy of a picture.” The CNN reporting continues: “The source, who requested anonymity to speak more frankly, added that the administration isn’t doing enough to sound the alarm about the threat of variants and the challenges that could lie ahead.”
“…we are going to see something like we have not seen yet in this country. That hurricane is coming.”
— Michael Osterholm
As the variants spread and vaccine slowly rolls out there is increasing public discussion about changing strategies for the second year of the pandemic. People want to save lives and re-open sooner.
In Ireland, the UK, Germany, and Canada, journalists, public health experts, and politicians are discussing the failures of the suppression strategy and asking: Why aren’t we trying the elimination strategy when we have so much evidence that it works?
Outside the US this rising debate about whether to continue using the failed suppression strategy or move to an elimination strategy is based on the evidence that the “Zero COVID” approach has been successful for China, Taiwan, Vietnam, Cambodia, Laos, Mongolia, Singapore, Australia, and New Zealand. This remains true despite the small numbers of new cases popping up in those countries and the short and often regionally limited lockdowns sometimes used to contain them.
Based on the experiences of those countries compared to the US, Canada, and Europe, the Zero COVID elimination strategy doesn’t mean you won’t have any lockdowns, but it does mean you will re-open sooner, safer, and have far fewer infections and deaths while you wait for vaccination.
And in a recent Lancet editorial “The COVID-19 exit strategy — why we need to aim low” experts make the case for using this elimination strategy as we vaccinate to end the pandemic, with global cooperation a key factor:
“This strategy would require a global, coordinated response — so far absent from the pandemic — but if achieved would reap benefits. WHO is well positioned to lead such as response; however, to be successful, an elimination strategy will require individual governments to look beyond their own interests and commit to zero COVID.”
Switching to an elimination strategy means continuing vaccination but our goal would change from just reducing transmission to stopping community transmission while we vaccinate. Experts say this could save hundreds of thousands of lives, be better for the economy, help us re-open sooner, reduce the emergence of variants, and reduce cases of Long COVID.
Because of patient advocacy The World Health Organization has begun talking about Long COVID, a form of the disease they are taking seriously as millions of people across the planet have been infected by COVID-19, and some are showing long-term symptoms.
Another key way an elimination strategy differs from a suppression strategy is the focus on reducing inequalities that lead to transmission. Elimination prioritizes protecting everyone from infection, illness, and death, rather than deciding some illnesses and deaths are acceptable.
A Zero COVID elimination strategy in the United States would also align with ongoing popular calls for monthly survival checks, expansion of healthcare, an enforceable eviction ban, and other social measures. It would protect BIPOC, elderly, disabled, and other high-risk people who have been disproportionately impacted by the pandemic. And adopting an elimination strategy now would prepare us to use the approach again during the inevitable next pandemic.
At the end of January, Michael Baker, professor of public health at the University of Otago in New Zealand, and Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, published an editorial piece in the Guardian laying out 16 reasons all countries should consider an elimination, or “Zero COVID,” strategy.
To conclude, here is Baker and McKee’s list in full for consideration, including the linked sources they provide in the original article:
1. It saves lives. Not surprisingly, eliminating transmission of the virus minimises Covid-19 deaths. Countries pursuing elimination have Covid-19 mortality rates that are typically below 10 per million, which is 100 times less than many countries “living” with the virus.
2. The elimination of community transmission also spares populations from “long-Covid”, which causes persistent health problems in survivors. These problems are reported by the majority of people hospitalised because of Covid-19 and can also affect those with even mild infection.
3. Elimination is pro-equity. Pandemics almost invariably cause disproportionate harm to the most disadvantage groups based on ethnicity, income and long-term illness. Eliminating Covid-19 can minimise these inequalities particularly if a suitable social “safety-net” is also provided.
4. Countries that have eliminated Covid-19 are experiencing less economic contraction than countries trying to live with the virus. Mainland China and Taiwan are possibly the only places with neutral or net positive economic growth in 2020.
5. Elimination is achievable and works in a variety of settings. Globally, multiple countries and jurisdictions are successfully pursuing elimination approaches, notably mainland China, Taiwan, Vietnam, Cambodia, Laos, Mongolia, Singapore, Australia and New Zealand. They are diverse in geography, population size, resources, and styles of government.
6. The virus can be eliminated even after intense local transmission has occurred. Mainland China demonstrated this in Wuhan. The state of Victoria in Australia was also able to eliminate Covid-19 even after a period of intense local transmission with higher rates than were being reported in the UK at the time.
7. It’s easier if more countries adopt this approach. Border controls can be relaxed, creating “green zones” and allowing quarantine-free travel with associated social and economic benefits. This opening-up is already happening among Australian states and between Pacific islands and New Zealand.
8. The rollout of effective vaccines will make Covid-19 elimination easier to achieve. Effective vaccines working in combination with other public health measures have been crucial to the successful elimination of diseases such as polio and measles in many countries.
9. Having an explicit “zero-Covid” goal provides a strong motivating and coordinating focus. Suppression does not offer a clear end point, leaving countries vulnerable to rapid resurgences, as seen recently in countries like Ireland. The resulting uncertainty makes it impossible to plan, with enormous consequences for schools, businesses, family life, and much else.
10. It is sustainable. Countries pursuing elimination have had setbacks in the form of border failures and outbreaks, but have mostly been able to contain them and regain their elimination status.
11. If the virus mutates, elimination still works. The major methods used for Covid-19 elimination (border management, physical distancing, mask wearing, testing and contact tracing) are relatively unaffected by virus mutations (though testing could theoretically be less effective if the virus changed markedly, and outbreak control would become more difficult with more infectious variants).
12. It also still works if vaccines provide only limited long-term protection. For example, if vaccines are poorly effective at preventing onward transmission then elimination methods could supplement that limitation.
13. It may reduce emergence of more dangerous virus variants. Elimination approaches result in far fewer circulating viruses. Consequently, there will be fewer opportunities for emergence of new variants that are more infectious, and that might escape the protective effects of vaccines, or even be more lethal.
14. The use of lockdowns should be less necessary. A relatively short, intense lockdown to eliminate Covid-19 transmission in an area should allow control measures to be relaxed in the absence of circulating virus. Countries such as New Zealand have had far less time under lockdown than most countries pursuing suppression which have needed to go in and out of lockdown for long periods to avoid their health services becoming overwhelmed.
15. Vigorous control of Covid-19 infection has substantial co-benefits. Elimination approaches have reduced transmission of other respiratory viruses, notably influenza, resulting in fewer hospitalisations and deaths from these respiratory pathogens.
16. It provides a good interim strategy while we identify an optimal long-term approach, which is currently uncertain. One scenario could be regional elimination or even global eradication as we saw with SARS. Another plausible option is endemic infection with the health burden being managed with vaccines, as we see with influenza.
At the beginning of this article, I asked: “As we begin Year Two of the pandemic, why are we continuing to use a failed pandemic strategy when we know it doesn’t work?” Admittedly there is an assumption built into this question, that our pandemic strategy should have the goal of saving lives.
But we should also ask: Why would we accept any strategy to deal with a global crisis like this pandemic that doesn’t put saving lives above all else? That doesn’t protect the most vulnerable? That doesn’t address structural inequalities? That doesn’t better prepare us for the next pandemic? And that doesn’t solve problems that existed in the US before the pandemic even started?