The editors of the Washington Post are concerned that only 10% of the number of inoculations that they expected have actually been administered:
UNLIKE WITH other botched aspects of the pandemic response this year, such as the shortages of diagnostic testing kits and personal protective equipment, the Trump administration has had months to plan for the massive rollout of a vaccine. The officials at Operation Warp Speed knew the nation required a logistics effort never before attempted. Yet instead of warp speed, the rollout has begun at a saunter. It must be accelerated.
Contrary to promises from the chief adviser to the operation, Moncef Slaoui, that 20 million Americans would be immunized in December, the month ends with only about 2 million shots given and 11 million shipped to the states. As Post contributing columnist Leana S. Wen pointed out, at this rate it will take about 10 years to reach 80 percent of Americans with two doses. Over and over again, the administration’s promises have turned out to be as reliable as President Trump’s claim the virus would just go away.
They are confident that President Joe Biden will solve the problem:
By contrast, President-elect Joe Biden reaffirmed on Tuesday his promise to deliver 100 million shots in his first 100 days, ramping up the current pace by five or six times. It is a tall order, but Mr. Biden at least has the right ambition.
The only actual suggestion they make is a dashboard for monitoring how many inoculations have been administered which as far as I can tell would do nothing to administer more inoculations but would handily solve the WaPo’s problem by making it easier to determine how many people had received inoculations. I would be interested in hearing what they think that President Biden would do.
To my ear this sounds at least in part like a “last mile problem”, something familiar to people knowledgeable about telecommunications or supply chain management. The last mile problem is the challenge of getting goods or services to the end customer. Doing that is inherently inefficient. You can only amortize the cost of a cable or wire or delivery that serves one customer over the life of that customer or, in the case or a delivery, over that single vend.
I think there’s some synergy (or actually dysergy I guess) between this point and the observation I highlighted by William Galston yesterday about the value of federal-state or federal-state-private collaborations. Last mile problems are characteristic of centralization—the more centralized a process the more likely they are to encounter last mile problems.
The Pfizer and Moderna vaccines present special challenges due to their special handling requirements. Due to those we can’t just rely on local Walgreens, CVSes, or Oscos for distribution. AFAICT the only actual solution would be to turn the entire process over the military. They’re the only institution with the necessary infrastructure, culture, logistical ability, and discipline to carry it off. I can see two approaches for doing that:
- Governors can call out the National Guard to administer the inoculations. I can see how President Trump has been remiss in not warning governors of the challenges ahead.
- President Trump can declare martial law and use the active duty military. Do the editors really want that?
The pictures of long lines of people waiting for their inoculations and stories of schedules being promulgated to tell people when their inoculations are scheduled suggest that the problem is not one of finding people to inoculate but in administering the inoculations. A little back-of-the-envelope calculation suggests to me that under a best case scenario it would take more than 5 million man-hours to perform the necessary inoculations. That’s a sizeable dedication of resources.
The following two comments were submitted in the thread of another post but I think they’re highly relevant to this one:
There should have been more advance planning.
The availability of staff is a bottleneck.
Finding people is a bit of a problem. First, I suspect you realize that long lines like that are problematic and not especially efficient. Maybe if you have enough staff working to help, meaning 5 or 6 support staff for every one person actually giving the shots, but I doubt that happens.
You need someone to decide who these people are going to be and then you need them to reach the places of vaccination and you need to document everything. Plus, since hospital networks compete, they dont help each other, as long as you have hospitals in charge they will always be trying to make sure they vaccinate their own patients and to those of a competitor.
In this situation I am less certain about the military. I am guessing they would mostly send reservists and the National Guard. Where would they come from? I preferentially hire ex-military and we have several reservists. Not sure how it would help me to have my reservists pulled to go work somewhere else. Would just make our shortages even worse. If you could find states that are well under control and pull only form those states then that might help. That leaves active duty medical troops. That would be a logistical nightmare, and you would need to cut back on medical care at active duty medical facilities. Not sure how that goes over. Not sure how many people you actually would get out of it.
Solutions- I think places are already sorting things out and it will pick up anyway, but it would help if we had a better idea to vaccinate next and also figure out a way to not fight so much about having a perfect solution, ie lets not politicize this also. Oh, and I want a unicorn too. So, this wont happen but we need political figures to go ahead an make decisions. I think DeSantis, based on the data, is making the wrong decision, but then Fl has lots of old people so it helps his electoral chances. The way they are doing it is chaotic and not managed well so it is inefficient. But, he at least made a decision and the people on the ground will gradually make it work. (This is where it pays to have been enlisted in the military. The officers come up with some stupid ass idea and then the enlisted guys figure out how to actually make it work.)
Next, and maybe I perseverate on this too much as I hate IT in general (while valuing it a lot) but I think things go way faster if they forego a lot of EMR/computer documentation. Just put it on paper and get it done. Computer entry later.
Steve
The only way we’re going to change things so that hospitals are not in competition is to have a full-on socialized system like British National Health. I don’t believe you’ll find many people to support such a system here.
I agree that politicization is part of the problem. Politicizing diseases, their treatments, and the vaccines that combat them is not constructive. Unfortunately, it also seems to be effective. Mounting a tiger.
There’s good information technology and bad IT. Unfortunately, most of what we have today is bad IT because too much is dependent on what’s easy (or preferred) by developers, many of whom have little or no understanding of the problems they’ve been tasked with solving.
I was surprised the Daily Mail had a concise summary on the reasons why vaccine rollout is so uneven.
https://www.dailymail.co.uk/news/article-9102395/Inside-vaccination-shambles-millions-doses-not-administered.html
“Why the vaccine rollout has proceeded so slowly:
– Shipping delays created chaos in the first weeks, a mistake General Gustave Perna apologized for
– Overstretched hospitals have struggled to find enough staffers to administer the shots
– Some governors have issued increasingly convoluted restrictions on who gets the jabs
– Local and state officials complain that their public health offices are underfunded
– Some healthcare workers have refused the vaccine, with a shocking 50% declining in some areas
– Cold storage requirements create logistical hurdles and tight windows for administering the vaccine”
To put things in perspective, among countries doing mass vaccinations — the Spectator has a nifty chart showing doses per capita by country.
https://data.spectator.co.uk/
The US is lagging slightly to the UK; but far behind Israel and Bahrain (and Bahrain is not using an rDNA vaccine).
Listening to UK reporters, due to the mutant strain, the UK Government is urgently trying to speed rollout of vaccines, so they are taking the following actions.
1. Draft the military to administer shots
2. Give emergency approval to the Oxford vaccine, despite its lower efficiency and confusing trial results. It doesn’t have cold storage requirements and can be given via pharmacy, football pitches, etc.
3. Change the “booster” shot schedule from 4 weeks to 12 weeks for both the Pfizer / Oxford vaccine and administering the shots that were reserved as boosters.
My guess is #1 will occur in the US, #2 and #3 seem unlikely here.
In rural areas they have lost a good number of their public health workers. It doesnt get written about much since small town newspapers are mostly dead and the major papers dont cover rural issues, but it gets ugly out in rural areas and small towns. I work at a couple of our rural places a couple of times a month. Good friends with several people there. They have gotten a lot of grief and even threats just for wearing masks out in public and defending their beliefs about masks and distancing. They have family calling them liars (so did I until my brother got sick) for claiming that there are lots of Covid pts in the hospital. The vitriol over this is pretty amazing.
https://www.npr.org/2020/12/28/950861977/toxic-individualism-pandemic-politics-driving-health-care-workers-from-small-tow
I kind of dread the military idea. If not done right will just make things worse. Not sure why everyone always thinks that calling in the military is the way to do things.
Steve
“Not sure why everyone always thinks that calling in the military is the way to do things.”
Because they have a history of large logistics operations. Its what my career military uncle did. He could tell stories. It doesn’t mean they will necessarily be crisp in execution. But unlike the chattering class, they have to leave their steak dinners at the Palm, or the Scotch and brandy at the faculty lounge, and deal with real world issues as they present themselves.
Who would you prefer, David Brooks, the staff at NPR or the Atlantic, or the polysci faculty of Harvard or, god forbid, Troy State?
The President could also federalize the National Guard. Regular reserve personnel could also be activated, but there are legal limits on that for domestic purposes. Might require involvement/authorization from Congress. While states can independently activate and command their guard units, that is extremely expensive to do without federal support given the current condition of state budgets. So you’d likely need the feds to step up and pay for the activations, even if command is retained by state Governors.
But the problem with activating the guard/reserve is it will pull medical professionals out of their civilian jobs. And there aren’t enough medical military personnel for a nation-wide problem.
As for logistics, yes, the military is great at that – but is that really the problem? Getting the vaccine to designated locations seems to not be a huge issue, the problem seems more about what happens when it gets there.
If we used the military, what would the non-medical personnel do? Sure, you can call them up, but the bulk of available military personnel (active, reserve, and guard) are not medical people. Maybe give them some basic training on how to give a shot and have them do that supervised by a medical pro? I dunno, I’ve never seen that done before.
The military effort could perhaps be focused on the rural and other areas that Steve mentioned that have limited medical capacity. But again, you’d have to be careful about the effects of pulling medical personnel out of their civilian jobs to do that.
I think that’s about right. We’ve never tried to mass-treat a pandemic, either. What I think that physicians and epidemiologists are missing in this entire matter is the meta-structure of our economic, political system, and health care system. All of those make dealing with the pandemic harder, particularly at the federal level.
“What I think that physicians and epidemiologists are missing ”
I am not really sure we missing it. Its just hard to work around. Our system is based upon competition. Now that we need to work together it doesnt work so well. We really have not had strong central direction, which in this case would probably help. Instead we have 50 states making decisions that in some places they are just dumping on to the hospitals, so we have hundreds of different approaches. To be fair we alls have hundreds of different staffing levels and capabilities. And this is all occurring at a time when lots of hospitals are already swamped. Oh, and did anyone notice that it is holiday season? The planning for this should have started in the summer.
Not sure if I said this here or elsewhere but we really do need the states, since they, it looks like, will control supplies, to make decisions. Just tell us what priorities to set and let us figure it out. At this point if we are going to make decisions based upon available data there is no clear way to prioritize. Some states are doing the elderly first. There is no data, if you actually read it, to support that choice BUT there is no data to support any other choice as better. So states with lots of old people will probably prioritize them. (Wins voters doesnt it?) That is fine with me as long as they make the decision quickly.
I think Andy answered the military question pretty well. I guess I can remind you that I deployed in an ATH to Saudi Arabia so I have some idea what the military does well when it comes to deploying medical assets. Large scale logistics that involve engineering or moving lots of material they are really good. For vaccinating you would be pulling mostly just people and just medical people at that. Our guard and reserve units arent set up to easily pull people from areas that have less Covid to send to people that have more. You can do it. They wanted to pull my reservists in April but since we were in the hard hit area we got exemptions. The process took several weeks. When you pull active duty troops you pull reservists to back fill. You likely end up with the same problems.
Steve
That’s only one part of it. It’s also based on increasing specialization, personalized services, and limiting the number of practitioners. The guiding principle of medical education in the U. S. for over a century has been “fewer, better doctors”.
Taken together those have implications. One of the implications is we don’t have the resources in place to do a mass distribution of vaccine. There’s a mismatch between individualized service and mass distribution.
Except that we do roughly 100 million flu vaccinations a year. In a competitive system, with supply constrained, time a major factor and special handling required we then have issues. Its a big task and as you calculated it takes lots of man hours and that needs to be setup and coordinated.
Steve
We may do 100 million but we don’t do 100 million flu vaccinations in a month, two months, or three. They’re spread over the year. Being able to respond to peak load problems is a specific challenge.
If the idea is to have 20% or 30% reserve capacity in health care to be able to respond to peak load situations, I don’t believe that it will prove practical to maintain the same delivery system, just 20-30% bigger. That can’t just be ordered by clicking on Amazon. I think the entire system will need to change.
It wont change for this. These are rare/uncommon events. No one will want to pay for the extra capacity. Look at PPE. In the midst of the best economy the US, or the entire world, has ever seen no one wanted to spend the money to rebuild PPE supplies and it would have cost only a few billion to do that. Having another 20% capacity for a rare event wont happen. (Note that we already did have that 20%-30% but we are using it for the Covid surge right now.
Steve
I’m unconvinced of that interpretation. I think that what actually happened is that a lot of other care was deferred.
I know that for our network for the last 2-3 months we have been having record numbers of procedures including IR, MRI, CT, nuclear medicine, GI, ORs. Of the department chairs with whom I maintain contact that was also true for several of their networks.
Steve