The Limits of Centralization

There are times that I think that people with whom I’ve corresponded over the years are still checking in here every once in a while. In a piece at Bloomberg Virginia Postrel sounds notes similar to those I did a couple of weeks ago:

Whether you’re laying fiber optic cable or delivering packages, that last mile is the tricky, labor-intensive, expensive part. To reach individuals, the system has to go from centralized operations to decentralized ones. That’s why we have retailers rather than ordering our toilet paper from Georgia-Pacific, and why they, in turn, often rely on distributors. “Cutting out the middleman” is a catchy slogan, but intermediaries make the system work.

When the federal government turned state agencies into the country’s vaccine distributors, it bypassed the usual supply chains. Doctors and hospitals couldn’t get Covid-19 vaccines the way they order other inoculations.

Distribution also became politicized in ways that slow down vaccination. Every shot comes with a ton of paperwork, and the rationing rules are hard to understand. Who exactly qualifies as a health-care worker or an essential employee? Is it OK for hospitals to give shots to janitors or billing clerks?

In Minnesota hospitals, one doctor who asked to remain anonymous noted in an interview, “there was a lot of focus on scheduling appointments and dividing up by departments to be sure they were fair” even if that meant delaying vaccines and potentially letting some supplies go to waste. It’s a widespread problem.

As he threatens fines for hospitals that don’t use all their vaccines, New York Governor Andrew Cuomo also signed an executive order requiring providers to certify that every recipient qualifies under the current rationing protocol. Letting someone jump the queue now risks a $1 million fine and the loss of a state license. “If you wanted to make sure that rapidly expiring vaccines distributed in 10-dose vials end up in the trash, this is how you’d do it,” observed commentator Mason Hartman on Twitter.

Micromanagement is impeding the rollout. In South Carolina, for instance, a medical assistant often gives injections in a doctor’s office, and the job requires no special certification. For Covid-19 vaccines, however, the state says that even someone with decades of experience can’t administer a shot unless they have an official credential.

Instead of leaving decisions up to medical practices that give shots every day and know who can do the job, “each state has different rules on what level of person can give a [Covid-19] vaccine,” says Craig Robbins, a primary-care physician with Kaiser Permanente in Colorado, who has been working on the health management organization’s vaccine rollout.

Distribution is hard enough without these roadblocks. Start with the numbers. At Kaiser Permanente facilities, a single vaccinator can give about 10 shots an hour, with much of the time spent filling out forms. To get to herd immunity, the U.S. needs to inject two doses several weeks apart to something like 240 million people. At 10 injections an hour, that’s 48 million hours of vaccinators’ time, 4.8 million hours a week over 10 weeks to get to early March. We’d need 120,000 vaccinators working 40-hour weeks. In a big country, that sounds doable.

I think she’s overestimating the number of inoculations an individual can make in an hour. I think that in practical terms it’s closer to four than to 10. That would mean something like needing several hundred thousand inoculators.

I think that most of her suggestions are impractical due to the vaccines’ ordering requirements and the special handling they need but I still think that a lot of facilities other than hospitals can provide the necessary refrigeration not to mention the trucks used to deliver the vaccines. Even at its presently very low incidence the possibility of anaphylaxis places additional requirements on inoculation sites. I also think that Florida has erred in making the vaccine available to all individuals over 65 but that’s another subject.

She concludes:

Covid-19 vaccines are a magnificent scientific and technological achievement. The challenges now are social and political. Meeting them requires flexibility, experimentation and trust.

Unfortunately, there are a lot of people including many in Europe who believe that anything worth doing is the job of the central government. That itself is an impediment to rapid distribution.