America’s messy Covid-19 vaccine rollout, explained
January 6, 2021
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America’s rollout of the Covid-19 vaccine is off to a bad start, with signs the country is repeating the same mistakes it made with coronavirus tests and protective equipment for health care workers.

President Donald Trump’s administration had projected 20 million people would be vaccinated by the end of December. The US is at 4.8 million first-dose vaccinations as of Tuesday, missing its 2020 goal by more than 75 percent.

Meanwhile, Israel has shown the world that a large vaccine campaign can go much quicker. The country became the first to vaccinate 15 percent of its population in recent days, working at about 10 times the rate as the US. While Israel has the advantage of a relatively small, densely packed population, the country’s health ministry and local agencies also seemed better prepared for the challenge: Clinics were quickly set up as necessary and supply bottlenecks addressed as they popped up.

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Experts say the US’s problems were predictable and preventable. “Personally, I’m incredibly frustrated,” Brown University School of Public Health dean Ashish Jha tweeted. “Did we not know that vaccines were coming? Is vaccine administration a surprise?”

Several factors appear to have contributed to the slow rollout. The Trump administration opted to leave much of the planning and coordination to state and local governments, which are already hammered by the strain of the pandemic. And while states have been calling on Congress for months to provide more support, federal lawmakers only last week approved the billions necessary for vaccination efforts, money that could take weeks longer to disseminate.

“We’re relying on health care systems and public health departments that are already over-taxed and stressed,” Saskia Popescu, an infectious disease epidemiologist, told me.

In short: A bunch of underfunded, overburdened state and local officials have been forced to pick up the Trump administration and Congress’s slack. This has led to a fragmented, under-resourced rollout, and a variety of problems have popped up from state to state and city to city as a result.

Of particular concern is what supply chain experts call the “last mile”: While the federal government has managed to ship tens of millions of doses of vaccines to states, getting vaccines from storage facilities to patients’ arms has proven a bigger logistical challenge than officials apparently anticipated. Sometimes it’s a truck, freezer, or other equipment that breaks down. In certain places, there aren’t enough people on staff on a specific day to meet scheduling demands. And conflicting or incomplete information about how many doses a certain facility will get at any given time can make scheduling or planning next to impossible.

There’s no single solution to all of these problems. But more federal support and guidance could help guarantee there’s at least a way to work through such problems quickly, if not avoid at least some of them altogether.

The vaccine shortfall is in many ways a repeat of the mistakes the US — and Trump — made before in its response to the coronavirus. Earlier in 2020, the country struggled to get enough personal protective equipment for health care workers and Covid-19 tests. Experts blamed those failures largely on the lack of a federal plan and national action to prepare for and address all kinds of issues along the supply chain. The same is true for vaccines today.

“As a supply chain person, you kind of see this sort of train wreck that you know is coming,” Nada Sanders, a supply chain management expert at Northeastern University, told me. “And now it’s just going to get worse and worse.”

The lack of federal guidance and support seeps through today’s vaccine problems, as state and local agencies — already dealing with strained budgets, testing, tracing, and hospitals over capacity — try to pick up the slack but often find themselves outmatched.

It’s still fairly early in the vaccination process, as the US is only weeks into a campaign that could take months or years. So things could change.

But this is a matter of life or death, with every day of unsolved problems inflicting an unnecessary toll on a country that’s already suffered so much from the coronavirus. More than 350,000 people have died from Covid-19 in the US, and America’s death rate is more than 2.5 times as high as neighboring Canada’s. With more than 2,500 people dying of Covid-19 in the US each day, every day of delay means potentially thousands more dead friends, family members, and neighbors across the country.

Addressing these issues quickly, then, could save a lot of lives. It could also get us back to normal — back to lives we took for granted before 2020 — much more quickly. But that begins with the federal government stepping up to its leadership role at a time of national crisis.

The vaccine supply chain is breaking down

Before a Covid-19 vaccine was even authorized for use in the US, experts warned that getting the shots to hundreds of millions of Americans would be a massive logistical challenge. Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security, told me, “This is going to be the largest mass vaccination campaign that the US has ever attempted.”

The challenges stretched beyond making enough vaccine doses. The doses have to be shipped in a “cold chain” — to keep doses as cool as -94 degrees Fahrenheit in some cases — that requires equipment some government agencies and health care facilities didn’t or still don’t have. And doses would have to be transported from factories to all 50 states as well as US territories, and then local facilities, from doctor’s offices to grocery store pharmacies, that would actually administer them.

This “would be particularly challenging in the best of circumstances,” Sanders said, pointing to the cold chain requirements. “Even if you were moving dairy, a cold supply chain is something that has very special ways that things are monitored.”

The problems that have popped up so far have been mixed, although they’re rooted in the lack of federal leadership and cohesive guidance.

Some of the problems are on the supply side. Reports of shortages of dry ice, small glass vials, and materials for the vaccine doses have already popped up, and more such issues are expected as different parts of the supply chain are resolved and new bottlenecks pop up in their stead. Some places haven’t received as many vaccine doses as they expected, limiting their ability to vaccinate the groups they’re supposed to be inoculating.

Then there have been a vast variety of problems in the “last mile,” in which the vaccines go from storage and distribution facilities to actual patients. In California, a hospital’s freezer broke down, forcing workers to race against time to make use of the 600 doses they had, with no real back-up plan. In West Virginia, 42 people mistakenly received an experimental Covid-19 treatment instead of vaccines. In Wisconsin, a medical center was unable to set clear plans for vaccinations as it didn’t even find out what kind of vaccine it was getting and how many doses it would get until the day the shipment arrived. In Florida, seniors — some in wheelchairs — were forced to wait in line for hours to get a shot.

And across the nation, hospitals and clinics have said they don’t have the staff — given the constant strain of the ongoing surge of Covid-19 patients — to actually administer the doses they have.

Some of these problems would happen even under cohesive leadership and planning. But such problems are less likely to be fixed in an environment in which states, counties, cities, and individual facilities are largely left to fend for themselves, with little federal support or guidance on how to address new problems.

Between the federal government, 50 states, thousands of local governments, and even more hospitals and clinics, there are a lot of different actors in charge of how a vaccine is distributed in the US. Without a single source of leadership to help coordinate such efforts, there’s bound to be miscommunication and delays along the way — on top of all the other problems a massive vaccination effort would normally entail.

Lower levels of government and private agencies in the US simply don’t have the resources to handle such a massive vaccination effort. America’s public health systems have been notoriously underfunded for years, and now they’ve been further strained by the daily demands of the pandemic and a weakened economy. That’s why state organizations argued that they’d need $8 billion more funding to set up the infrastructure needed for a vaccine rollout. The Trump administration provided $340 million.

The billions needed are now coming through Congress’s recently passed economic relief package, but that’s too late for the proactive effort experts were calling for last spring and summer. As expert after expert told me, this money was needed months ago.

In response to these kinds of problems, local and state officials, along with experts, have called on the federal government to provide more leadership. The Trump administration so far has resisted, claiming that its role is to get the vaccines to states, and it’s then up to state, local, and private entities to figure out the rest. Brett Giroir, an administration leader on Covid-19 efforts, argued, “The federal government doesn’t invade Texas or Montana and provide shots to people.”

The US needs to finally learn and adapt

If all of this sounds familiar, that’s because it is. When Covid-19 first reached the US last year, experts called for federal leadership to help build up sufficient personal protective equipment for health care workers and coronavirus testing capacity for the whole country. Back then, the Trump administration took the same approach it’s taken now: suggesting these are largely local, state, and private issues, and that the federal government’s proper role is limited. On testing, Trump’s plan explictly argued the feds were merely a “supplier of last resort.”

At the time, this led to huge supply chain problems with both protective equipment and testing. But it was also a missed opportunity: If the Trump administration took a different approach to getting enough masks and tests, it could have built the kind of infrastructure and expertise needed to deal with supply chain problems now as they pop up with the vaccines. In doing so, it could have also relieved some of the strain local and state agencies are feeling now in continuously juggling multiple tasks — giving them more room to work on getting a vaccination effort right.

“We should have learned from [personal protective equipment]. That should have been corrected and applied to the test kits,” Sanders said. “We should have learned from the testing, then applied that to [vaccines]. None of it was learned. None of it was corrected.”

But even as problems have continued popping up, the Trump administration has continued taking a limited view of the federal government’s role.

Experts say that must change. “For all this pandemic has taught us and cost us, it has demonstrated again that we are the United States and, especially in crisis, an effective federal government is essential,” Jha wrote in the Washington Post.

That’s what’s working in Israel, as the country has quickly vaccinated at 10 times the rate as the US. The health ministry in the country has worked closely with all levels of government, ensuring that doses get out to as many people as possible as quickly as possible. It’s likely not a coincidence that Israel has led much of the world in Covid-19 testing capacity as well.

President-elect Joe Biden, for his part, has promised a more hands-on approach: offering more guidance to agencies nationwide, using the Defense Production Act to make more vaccine doses, and creating mobile units to administer the vaccine in undercovered areas.

Some Republican lawmakers are demanding more action, too. “That comprehensive vaccination plans have not been developed at the federal level and sent to the states as models is as incomprehensible as it is inexcusable,” Sen. Mitt Romney (R-UT) said in a statement, further calling for a new national plan to speed up the vaccination process.

Beyond better coordination, some experts have called for more fundamental changes to how vaccines are distributed. Some have pushed for delaying the second dose that the currently approved vaccines require, so those doses can instead be administered to people who haven’t gotten any vaccine at all. Yet others point out that the evidence only supports a two-dose regimen — that’s what the clinical trials tested — and some worry not providing the full protection of two doses could make it easier for the virus to mutate and become resistant to a vaccine.

But such a change and others like it would have to begin with the kind of adaptive federal leadership and guidance that the US doesn’t have right now.

Whatever the country does, it’s a race against time. With each day, Covid-19 deaths are adding up. As the virus continues to spread and replicate, the chances it mutates into a more contagious or deadlier form increases (which the potentially more contagious B.1.1.7 variant demonstrates). As people get more fatigued with the pandemic, they’re more likely to ease up on restrictions, further speeding up the spread of the coronavirus.

America has spent much of the pandemic repeating the same mistakes, whether it’s reopening too early or failing to embrace the role of the federal government. The US now has one last chance in this pandemic to correct course — and potentially save thousands of lives in the process.

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