As the crushing effects of the COVID pandemic and uncertainty about its trajectory raised national anxiety to high levels, murmurs that the virus could be beaten back with a vaccine gave nations hope. The Trump administration funneled billions of dollars and untold resources toward “Operation Warp Speed,” with the goal of developing safe and effective immunizations by the end of 2020. Vaccine experts doubted the time line was realistic, but by early fall, it became apparent that both Pfizer and Moderna’s two-dose RNA models were on track to meet that goal.
Even as COVID cases, hospitalizations, and deaths began to spike once again as winter set in, political leaders welcomed the imminent vaccine rollout as the long-awaited light at the end of the tunnel and the masses living with the multi-faceted deleterious effects of the pandemic began to breathe a sign of relief.
Against the backdrop of unprecedented crisis, many expected that the only thing holding back mass vaccination would be the speed at which manufacturers could produce and distribute vaccines. Yet, more than three weeks into the public release of COVID vaccines, nearly every state had more doses sitting in the freezer than had been given to its citizens.
The two companies have been turning out up to 10 million doses per week, but in New York, as of last week, vaccines had not reached even half of its nursing home residents and, in New Jersey, only about a quarter of the 400,000 doses delivered to the state had been used.
“I am shocked at how slow everybody is going; at this rate it will take New York State until 2027 to vaccinate 80% of the population,” said Bill Hammond, senior fellow for public health policy at the Empire Center, a New York state political think tank. “It’s not just a problem with Cuomo and de Blasio. They’re not particularly behind most other states, but it seems there’s a collective breakdown in imagination and will power. It starts from the top; Trump abandoned his leadership role and left it to governors, but governors have yet to step up.”
Israel has stood out for its success as the only country to vaccinate faster than supplies could keep up. As of last week, 12% of Israelis had been vaccinated, an estimated 25% of its elderly population, outpacing its goal of 150,000 vaccinations per day.
Israel’s plan is vastly different from the tiered approach that America’s CDC laid out. As soon as vaccines became available they were opened up to all individuals over 60 and those with serious medical conditions as well as health care workers. Repackaging the vaccine storage materials also allowed for immunizations to be administered at a large number of remote sites scattered throughout the country.
Comparing a far smaller nation to the United States has its obvious limitations. Still, disappointment with how far behind America, which reached less than 1% of its citizens, is lagging on expectations is widespread. The Trump administration had projected that by the end of December, 20 million Americans would be vaccinated, but the actual number was a little over 4 million.
In New York and New Jersey, public health officials blamed end-of-year legal holidays for the lag. Others pointed to limited locations and operational hours of vaccine centers. In New York City many vaccine centers only operate from 9 to 4 and are only open on weekdays.
“In general, there does not seem to be the sense of urgency around administering vaccines that you would expect,” said Jason Schwartz, professor at the Yale School of Public Health. “We now have these highly safe, effective weapons. It would seem that in such a crisis not a moment should be wasted. The federal government is distributing 5 to 10 million doses a week nationwide. We knew that volume was coming, but it doesn’t seem the infrastructure was in place to deal with it, which will have to be examined more closely especially as this program expands beyond the first stage.”
Professor Schwartz was optimistic that the vaccine program’s efficiency would pick up and that most states would be able to move into broader phases throughout the winter. Yet he said it would likely “take a while to see the benefits” in the form of decreasing hospitalizations and deaths.
As state and local governments around the country took heat for the vaccination program’s sluggish start, NIH infectious disease expert Dr. Anthony Fauci dismissed the apparent impasses as “glitches” inherent to the beginning of any “big program,” and said that it was still realistic that the U.S. would get up to 1 million vaccinations per day shortly. The goal would be a prerequisite to President-elect Joe Biden being able to deliver on his plan to reach 100 million immunizations within his first 100 days in office.
The failure of many states to reach their goals of finishing vaccination of nursing home patients in a three-week time frame has fed skepticism over whether local governments are prepared to lead an effort on the scale that would be necessary to use vaccines to effectively curb the pandemic.
“I see the wisdom of doing nursing home residents first, but it’s scary that they are not done already,” said Mr. Hammond. “This is a very discreet population that doesn’t move around. We know where they are and they are surrounded by medical staff that give them meds every day. It’s very hard to understand why this has taken so long.”
With production continuing to outpace administration of vaccines, private industry’s role in the effort looks like the most successful piece. Who to blame for the rest has been a subject of debate.
Some voices, particularly leaders from Democratic-controlled states, have pinned blame on a failure by the Trump administration to develop a comprehensive delivery strategy and to provide more funding to aid those efforts.
Edward Haislmaier, an expert in health care policy at the Heritage Foundation, said that he felt criticism was an attempt to deflect responsibility from state and local leaders.
“The federal government’s role was to develop the vaccine and get it distributed to the states and they’ve done a good job of that,” he said. “Once boots hit the ground, this has to become a local public health issue. The federal government doesn’t regulate which providers can give vaccines and it’s local governments who are the best positioned to engage in outreach and figure out how [to do it] and who can best get these vaccines to people who are eligible.”
Professor Schwartz said that discontent with the pace of vaccination was rooted in a “disconnect” between expectations set by the administration and a failure by the same to build a system to support the mass endeavor.
“I think it’s a federal story. We have a national and global pandemic. It’s not feasible to have a 50-state approach to this kind of crisis,” he said. “They developed the vaccine and shipped it to the states, but said, ‘It’s up to you to take it the rest of the way.’ The most challenging part has been left to the states to handle as best they can. This job got handed to health officials who are already overwhelmed after working for 10 months on a once-in-a-century crisis.”
Professor Schwartz thought that the vaccination effort could be helped along by more partnering between federal and local authorities to commandeer large spaces like convention centers and closed schools for vaccine administration. He added that resources like the Army Corps of Engineers could likely play a helpful role in complex operations like coordinating generators and freezer space for the RNA doses that must be kept at extremely low temperatures.
Above all, Professor Schwartz felt that what the federal government had to provide more of was money.
“As this expands from a modest number of individuals in small concentrated groups in places like medical care environments to larger more scattered populations, this is going to take an incredible amount of logistics and planning,” he said. “Public health officials have the expertise in this, but they need resources. It’s an open question right now whether the existing infrastructure has what it takes right now to turn this into a mass vaccination campaign.”
The recently-passed coronavirus relief package contains $9 billion to aid vaccination efforts, but those funds first became available as vaccines were being approved.
Long before the pandemic began, the CDC offered grants to states for immunization. Mr. Haislmaier said that such existing programs, together with stimulus funding, would likely be the optimal route for additional federal support.
“Don’t reinvent the wheel,” he said. “There’s a system set up to deal with this. If more money is needed, put it in the pipeline.” Mr. Haislmaier was skeptical that the military would be a helpful tool for an effort that depends largely on detailed knowledge of local needs and capabilities.
In a week marked by recriminations over the lag in vaccination administration, political leaders had their own ideas of whom to blame.
New York Governor Andrew Cuomo, who faced much criticism over his state’s lackluster rollout, pointed a finger at hospital systems, which he selected as the vehicle for the vaccine operation. Responding to questions on the state’s lagging numbers from the press, he threatened to fine and take back vaccines from hospitals that failed to exhaust supply by a given deadline.
In choosing hospitals, Governor Cuomo had actually bypassed a years-old plan for mass vaccination that would put county governments in charge of administration. In an article by Albany’s Times Union newspaper, county leaders questioned why the Governor had chosen not to take advantage of a plan that had already been rehearsed in several flu shot drives.
Governor Cuomo said that his initial choice of giving the task to hospitals was an attempt to depoliticize the operation. Mr. Hammond suggested that politics might be the very reason for the Governor’s choice.
“Counties are run by elected officials and most are not run by Democrats. Even in those that are run by Democrats, [Cuomo] does not always get along with them; it’s fair to say that he does not get along very well with the Democrat that runs New York City,” he said.
True to script, New York City Mayor Bill de Blasio and Governor Cuomo traded barbs and blame last week over the vaccine issue. The Mayor avoided naming the Governor, but explicitly stated that he felt fines were counterproductive and asked for more flexibility in who could receive vaccines, saying the first phase should be opened up to the elderly immediately.
“Give them the freedom to vaccinate and they will vaccinate thousands, then tens of thousands, then hundreds of thousands, then millions,” Mayor de Blasio said at a press conference. “What they don’t need is to be shamed. What they don’t need is more bureaucracy. What they don’t need is a threat of fines.”
Eventually, the state was forced to bow to criticism and this week opened up vaccines to individuals over 75 and a much broader list of essential workers. Still, the signature sandbox tiff between Governor Cuomo and Mayor de Blasio highlighted a deeper debate over the possibly inhibiting role that the tiered eligibility system is having on America’s vaccination efforts.
Get in Line
The phased rollout plan broadly outlined by the CDC is the result of a debate over the program’s prime goal. One side argued that vaccine priority should be based on risk, i.e., given first to the elderly and medically fragile in an effort to decrease hospitalizations and deaths. A counterargument focused on slowing transmission and contended that individuals who deal with large numbers of people in the course of their jobs, and as such can serve as the most effective vectors, should be prioritized.
The guidelines are a hybrid of the two. Phase 1-A makes vaccines available to nursing home residents and frontline healthcare workers. Phase 1-B to individuals over 75 or with underlying health conditions and frontline essential workers. Phase 1-C to individuals over 65 and non-frontline essential workers. Phase two will make vaccines available to all adults in the general population.
Since the guideline’s introduction, the CDC has made modifications, and states are free to make adjustments. Florida, a state with a high elderly population, quickly opened up its program to all senior citizens.
Mr. Hammond said that while the public health reasons for the tiered system were on solid ground, he felt restrictions and convoluted details on who qualified played a role in slowing the effort to vaccinate as quickly as possible. He also criticized Governor Cuomo’s threats of harsh fines for medical centers administering vaccines to individuals who have cut the line of state guidelines.
“Cuomo’s talking about punishing people who don’t follow the guidelines or who make errors in good faith, but I think we should worry less about the right order and more about speed,” he said. “You could theoretically develop the perfect tier system of who is most vulnerable and who can spread the virus the most, but you have to weigh that against whether trying to figure it out and enforcing it is slowing everything down instead of working with a spirit of ‘where’s an arm that I can put a needle in?’”