As the coronavirus pandemic drags into its seventh month, it remains an open debate whether the U.S. should aim for the elimination of COVID-19 — and whether we even can at this point.

Why it matters: This is the question underlying all of the political and medical battles over COVID-19. As both the direct effects of the pandemic and the indirect burden of the response continue to add up, we risk ending up with the worst of both worlds if we fail to commit to a course.

The big picture: It may not seem like it at a moment when the U.S. is still recording tens of thousands of new COVID-19 cases a day and approaching 200,000 deaths, but the ultimate goal of the pandemic response has been the elimination of the virus.

• From the start, however, there's been a gap between the goal of elimination and what the government and many Americans are actually willing to do.
• And we're not really on a path to the alternative either: a more targeted approach that protects vulnerable people but allows others to resume their lives.

Of note: Elimination isn't eradication, which means the global zeroing out of a disease, and which has been only accomplished at great effort with a handful of diseases like smallpox that have highly effective vaccines.

• That probably won't happen with the novel coronavirus, which spreads stealthily and is unlikely to be countered without a vaccine that offers lifelong protection — an outcome few scientists expect.
• Elimination is defined as the absence of sustained endemic community transmission in a country or geographic area. Sporadic cases may still occur, but they can be quickly snuffed out.

No country has yet successfully eliminated COVID-19, though some have come close.

• Through extremely strict border controls and social distancing measures, New Zealand achieved zero locally acquired cases for three months.
• But New Zealand's location means it is better able to seal itself off, and even there, a new outbreak caused by imported cases in August forced the country back into lockdown.
• "Is it worth it?" asked Simon Thornley, an epidemiologist at the University of Auckland who has argued against an elimination strategy. "To me it's a resounding no."

The other side: Thornley recommends measures that are strong enough to protect hospital and intensive care capability, as well as the most vulnerable people like the elderly, while also being loose enough to permit a return to work and school.

Be smart: As the direct health effects of the pandemic have compounded, so have the indirect costs of pursuing an elimination strategy.

• A recent study by the OECD found the economic loss of closures could reach $14.2 trillion over the next 80 years in the U.S. alone, growing to almost $28 trillion if the closures extend another three months.
• Add that to the other impacts that can be at least partially traced back to the response to the pandemic: a global recession, life-threatening levels of food insecurity, the resurgence of deadly diseases like tuberculosis, and ravaged mental health.

What they're saying: "Suppression to near zero should be possible in countries with reasonably strong public health systems," says Jonathan Quick, managing director for pandemic response, preparedness and prevention at the Rockefeller Foundation.

• But, he adds, "the economic and resulting health and social costs of elimination would outweigh the benefits" for most countries, including the U.S.   

Reality check: The U.S. is not on a path for either the near-zero suppression — getting cases down to a much more manageable level — of COVID-19 or the elimination of the disease.

• We missed the chance to snuff out the virus in its earliest stages when it would have been easier, something countries like China and South Korea were largely able to do.
• Political battles over mask rules and social distancing ensured that the national case count didn't drop that much during the summer, when the virus should have been in a lull — and now "we're starting to see a real buildup of transmission," says Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
• Those areas of the economy that have been most successful in returning safely to real life tend to be ones like major sports leagues, which have put in stringent rules about behavior, expensive control measures and ubiquitous testing.
• Meanwhile far more important but cash-strapped sectors like public schools have been left largely on their own.

As a result, the U.S. is reaping the results of a halfway, half-hearted approach to COVID-19, one that has left the burdens of the pandemic — both direct and indirect — falling on those least able to bear them.

• And it's not likely toend any time soon. Bill Gates recently said that in his most optimistic timeline, life doesn't return to normal in rich countries until 2022, which would mean we're not even halfway through this trial.

The bottom line: Both all-out elimination and a more laissez-faire approach come with costs. But by refusing to definitively pick a path, the U.S. is maximizing pain and minimizing benefits.