I’m not actually sure what Scott Gottlieb is suggesting in his Wall Street Journal op-ed:
The federal government built a Covid vaccine delivery scheme to track every dose shipped to the states. Information like location and travel history is available in a software platform developed for “Operation Warp Speed†called Tiberius, so that public-health officials can make sure the limited supply is allotted carefully and fairly.
These are important goals, but central control comes with a trade off: it slows down the process of getting shots into arms. Poor local and state planning hasn’t helped. Neither has the trickle of funds the feds have provided to stand up vaccination sites. Add it all up and you have the explanation for the sluggish pace of immunization. Fewer than 5 million people have been vaccinated so far, versus the 20 million promised. Here’s what’s needed to turn things around.
First, the government needs to ship more inventory. Right now, the feds are holding back up to 55% of doses. The idea is to make sure there is supply to give everyone a second dose, within three weeks for Pfizer and four weeks for Moderna.
Sticking to the dose schedule is essential, but supply is expanding and the production processes are proven. Some of the future supply can be given as second doses in those being vaccinated today. The very small possibility that a production snafu could delay second shots seems a reasonable risk to take.
Second, the distribution system needs improvement. Standing up vaccination sites and encouraging people to go get the shot is expensive and takes time. The best option may be to rely more on private industry. National pharmacy chains like CVS and Walgreens have an agreement with the federal government to provide vaccines to long-term care facilities. The government should expand this program to help vaccinate all Americans.
The major pharmacy chains combined can deliver up to 100 million vaccines a month. The plan had been to allow large retailers to start offering the shot when it was ready for the general public, perhaps later in the spring. Why not get started now? Public-health agencies can focus their resources on providing access to harder-to-reach communities and patients who might be homebound.
CVS and Walgreens have been part of the rollout since the beginning. Expanding the number of sites would not seem to be helpful until more supplies of the vaccine are available. Many states and localities are reporting that they haven’t been able to inoculate people fast enough which suggests that supplies of the vaccines are not presently the bottleneck although they may be shortly.
It sounds to me as though the primary bottlenecks are more related to staffing and distribution issues derived from different state and local priorities than anything else. What am I missing?
Ever get a vaccination at one of those places? I have. It took about 15 minutes and there was no one ahead of me. At that rate they wont do it very fast. They would have to hire more people to speed things up. Where would they get them? I dont know pharmacist labor availability but I am thinking there arent tons of them sitting around. Also, wont work with Pfizer vaccine.
Where this will work best is when there are no supply constraints and everyone is eligible. At that point this would help a lot more.
Steve
I agree with that. Expanding to pharmacies would be helpful when everyone is eligible. Hence my confusion.
1. One thing I noticed this weekend is that the feds had distributed vaccines unequally. West Virginia had received twice as many vaccines per capita as Illinois. I’m not sure why, might be just a temporary bug, but when people say some states are doing better than others, some of that is based upon factors not attributable to the states.
2. Illinois has done relatively better in distributing its allotment, which the Governor attributes to planning and practice. I have no idea if that’s true. I do know back in March they ran an emergency medical supply distribution drill, which had my wife’s office surrounded by police securing emergency delivery of a package. Why they would pick a mental health office for the drill was crazy.
3. You can see Illinois’ plans on their website, but mainly this is going to be local government execution. My county has distributed most of what its got and has scheduled vaccinations this week at various nursing homes and the fire department, all I believe in conjunction with Walgreens or CVS pharmacies. They’ve marked traffic patterns at the Public Health department parking lot (former Supermarket) for when they are ready for non-institutional settings. They have the required police and ambulance services lined up. I trust my public health department more than the state or feds on the ground.
4. Illinois distributed vaccines to at least nine counties that could not use them and returned them to the pool. That was poor planning; if the initial priority is health care first responders, then the distribution should have been based on geographic distribution of those, instead of where people are dying. Again my county has probably used most of its allotment because it has a lot of front line health care workers, but was not given an initial distribution, but got some redistributed from the pool.
5. Bad timing for holidays. Hospital employees put in their vacation time well in advance of the Holidays, and there are simply a lot of target rich institutions that do not have regular employee hours until January.
My main take-away is that future vaccines should proportionately go to where they are being used.
I read about what the Israeli’s are doing over the weekend, which is cutting out all the bureaucracy and just vaccinating people as fast as possible. But they also have advantages we don’t including a small population and a much more integrated system including national electronic health records and a national vaccine registry.
They also don’t seem to be worried about holding doses back to ensure there’s a second dose for those who got the first dose.
Here in the US I think it’s high time to start clearing the deck of bureaucratic and other obstacles and focus on getting as many people vaccinated with at least one dose as quickly as possible.
Let’s compare the other two countries that are slightly (UK) or significantly (Israel) ahead in actual vaccinations per capita.
Israel has
– 9 million people, comparable to NYC
– A unitary parliamentary government, so 1 cabinet is in charge of fiscal, military and health administration. There should be little coordination issues
– Universal conscription; I presume that means a higher percentage of the population has basic medical training or is available to help out
UK has
– 67 million people, comparable to California and Texas combined
– A mostly unitary parliamentary government, so 1 cabinet is in charge of fiscal, military and health administration. (90% in England NHS). Again coordination is less of a problem.
With the second dose — it may happen but I’m doubtful. Fauci said on Friday the US will not delay the second dose (unlike the UK). And Fauci is now the chief medical advisor.
https://www.theguardian.com/world/2021/jan/02/dr-anthony-fauci-says-us-will-not-delay-second-doses-of-covid-vaccine
Given the administration problems so far, I don’t see how the government could deliver second doses on time if they don’t hold the second dose.
But perhaps the UK and now the South African variant will change decision makers mind about second doses.
Complexity doesn’t increase linearly with the number of people. If you’re lucky complexity increases at n log n. If you’re not it increases at n2.
The differences between the UK, Israel, and US are definitely substantial.
I think the thing to focus on is how to get the most people vaccinated in the least amount of time. The bias should be against putting up bureaucratic requirements and any hurdles IMO. Here in the US there still seems to be this default attitude about using standard processes and procedures and a technocratic approach to vaccination with little in terms of creative or new ways to speed up the process.
We should, for example, still have priorities for who should get vaccinated first, but those priorities shouldn’t cause vaccines to sit unused waiting for people with the correct priority to show up. One reason I highlighted the Israeli example is that they are vaccinated as fast as they can possibly vaccinate. There is no sitting around and providers are spending every minute of every day giving shots. Quite unlike the US.
Also, there are tradeoffs between giving more people a first dose which may possibly result in a delayed second dose, vs ensuring that everyone who gets a first dose gets an on-time second dose. After reading the arguments and expert opinions on both sides, I think getting more people a first dose is the better option.
With Dr. Fauci now saying that we need 80%+ vaccinated for herd immunity, we need to work as fast and as efficiently as possible, but we still seem to be hung up on too much process. It’s the same thing seen with the delay in approval for rapid in-home testing.
The effective definition of “technocracy” is “leaving it to the experts”. There’s a pretty big mismatch between leaving it to the experts and expecting anything other than a “technocratic approach”.
As I’ve been saying for months I will be greatly surprised if the pandemic is not still ongoing in 3Q21. Now 4Q21 is looking pretty bad as well.
I have been hoping for flexible and innovative thinking from the Government, but a more typical example is this.
Gov Cuomo issued an executive order that individual medical providers who intentionally disregard the vaccination phase protocol will be fined up to $1 million and have their licenses revoked.
This was in response to scandals involving line skipping.
Gov Cuomo then issued an additional order that hospitals (but not individuals) will be fined $100,000 if they don’t administer the vaccines they get within a week.
This was in response to criticism that the vaccine rollout was too slow.
Think about the combined effect/incentive of the two orders.
You catch more flies with honey than with vinegar. That’s not the way I’d approach speeding up a process at all.
Just as a side comment you can’t stop the line-skipping problem that way at all. How do you stop people from bringing on temporary health care workers? They could be as temporary as one hour.
Andy- My sense is that Christmas is not that big of a holiday in Israel. They have a lot more asocial cohesion. Also, I am betting if you include the occupied territories their vaccination rate doesnt look so good. IOW, I dont think Israel is much use for comparison. Dont recall Israel having mass protestors out opposing masks, etc.
Aslo, the guy in charge of Warp Speed apologized for the inequalities in distribution.
Steve
steve,
Israel is giving 150k people a day the first dose in a country with 9 million according to the NYT (https://www.nytimes.com/2021/01/01/world/middleeast/israel-coronavirus-vaccines.html).
Meanwhile, California has over four times the population and has only given 452k doses total as of today. New York with over twice the population has only given the first dose to 275k. New Jersey has the same population as Israel and they’ve given less than 100k first doses total while Israel has given 1.25 million does.
As I said, Israel has some significant advantages in terms of size and the differences between our health care systems. And yes, they are more cohesive all of which makes them able to operate faster – scale matters. Does that – and Christmas – explain the entirety of why Israel has done so well? I’d argue the answer is no – they also have a fundamentally different philosophy and attitude regarding vaccination. From the NYT article:
The Israeli government made a big show about vaccinating the millionth Israel and grabbed a random person off the street for that vaccine and for a photo op. It turns out that person was a convicted murderer. The Israeli’s are not like Cuomo issuing conflicting political edicts.
We do, at least for now, seem to be doing better than Europe on a per-capita basis.
Data here: https://ourworldindata.org/covid-vaccinations
What’s pragmatic and gets results and what’s politically expedient are two different things. Our elected officials are nearly completely politically motivated. They’ll do what works politically at the expense of what actually works.
I don’t see any problem with line skipping as long as the early spots come with an appropriate and competitive endowment to the hospital or medical institution bestowing the jab.
Lines are so Bolshevik.
Depending on how you contort logic, a case can be made for any group or tribe, or bracket to be “saved†first.
Money, old or new, is our society’s determination of worthiness.
Forty years in a steel mill without a sick day is admirable, for a mule.
Financing a steel mill gives a man worth.
So does a well placed toss into the end zone. Sermons that make them empty their pockets,
a comedy routine that leaves them laughing, a political con that makes them believe you care, a song, a movie, a book, a winsome look.
These are what really matter, and the only path to prosperity for those people who have only ordinary talent is to serve those who have the most.
Vaccinations are one of those services.
Let the bidding begin.
Andy- There was huge argument about whether the elderly should receive the vaccine before workers. There are still strong disagreements. We just dont have the cohesion to do some things well and we certainly dont have the leadership. However, if you are going to set priorities as part of your strategy (remember that no one really knows which vaccine regimen is best) then you do need enforcement.
Size really does matter. Comparing us to Israel even if we had coherent politics was never going to work. On top of that they have a coordinated medical system. Everyone is insured and in a medical system. We think markets work to hold down prices so we have medical systems compete. Then when we need them to work together we act all surprised that they dont work together well.
Still, I would predict it starts moving much faster now.
Steve
The FDA has firmly come against the idea of giving half dose or delayed second doses.
https://www.google.com/amp/s/www.cbsnews.com/amp/news/covid-vaccine-fda-united-kingdom-pfizer-dose-timing-significant-risk-public-health/
Given the alignment of Fauci and FDA on this; that’s the end of the discussion.
I believe the Warp Speed officials will have to hold back 55% of doses to guarantee that second dose at the precise schedule.
We will find out in the next 2 weeks whether the vaccine administration is just suffering a holiday induced hiccup; or that the rollout of mRNA vaccines has issues that will take months to fix.
If it’s the latter; then speeding up vaccines in this country require the approval of non-m mRNA vaccines. And that requires approval and acceptance of less efficient vaccines by the FDA and the public.
steve,
Yes, there are arguments about priorities. The problem is when those priorities de facto become more important than other considerations. That is where Israel is different. They have priorities, but they are more like guidelines and they are not letting adherence to a priority order slow down their effort.
By contrast, it seems (and it’s hard to know for certain and every place will be different) that we are not doing that – we are preferencing adherence to the priority system above vaccinating people as quickly as possible, resulting in a slower vaccination effort.
This very well might just be my perception, but there seems to be a lack of earnestness or expeditiousness.
Today, my POC wife received her first vaccine dose at the tribal clinic, I’m not eligible.
I really can’t decide if I should be IN, or if she should be OUT.
We’re married now 47 years, we both have several co-morbidities and can easily die without this Goddamn virus.
Andy- Which is better? Vaccinating a lot of random people fast or 25% fewer but vaccinating those most likely to die and or spread the disease?
Steve
One Costco out in Seattle has 160 positives among employees. They see this as evidence Costco employees are vulnerable frontline workers and should be vaccinated early.
I’m wondering what Costco is doing wrong that their stores are a hotbed of infection.
steve,
I’m not sure there’s a knowable correct answer. But I’m in favor of faster vaccination. Again, Fauci is now saying we need 80%+ for herd immunity. With 320 million people, even marginal speed improvements can have a big impact on reaching that goal more quickly. It’s already going to be a herculean effort, so I think the bias should be to vaccinate as fast as possible even if that results in line-skipping. The Israelis are doing the right thing IMO by not letting bureaucratic and political calculations gum up the works. We seem to be doing the opposite of that.
Andy- I dont know either. I dont think anyone does. I think either approach could be right or wrong so I am not going to make accusations about the intelligence of either approach. That said, we can certainly go faster and that would help.
Steve