Vaccination is going slowly because nobody is in charge

By Ashish K. Jha | Source: Washington Post

Ashish K. Jha is a physician, health policy researcher and the dean of the Brown University School of Public Health.

Vaccine development for covid-19 has occurred at a remarkable pace, thanks in large part to the careful work of the scientific community, both in the United States and around the globe. Operation Warp Speed played a key role in accelerating the creation of vaccines without cutting corners, and producing millions of doses. As a result, the two vaccines that have been authorized by the Food and Drug Administration are safe and highly effective against the disease. That’s why we want them to reach people’s immune systems as quickly as possible — and why the current delays in getting people vaccinated are so disappointing.

Let’s start with a quick recap: As recently as early October, Health and Human Services Secretary Alex Azar said we’d have 100 million doses of vaccine by the end of 2020. One month later, that was reduced to 40 million doses. As recently as Dec. 21, Vice President Pence, the head of the White House coronavirus task force, said that we were on track to vaccinate 20 million Americans by Dec. 31. Unfortunately, 20 million doses haven’t even gotten to the states. The Centers for Disease Control and Prevention is reporting that we have vaccinated about 2.6 million people. Assuming the reporting lags by a few days, we might be at 3 or 4 million total.

This is striking. We’ve known for months that vaccines were coming. We know that vaccines only work when people get vaccinated. Every dose of vaccine not given risks more illness and potential death. The failure to vaccinate more quickly is tragic given that more than 3,000 Americans are dying of covid-19 every day. At the current rate, we will surpass 400,000 deaths by Inauguration Day.

Operation Warp Speed now says it aims to vaccinate all Americans by June. But we will not get there unless we understand what is happening and what we need to do to fix it.

How did we get from 100 million promised doses to just a few million people vaccinated? It is a lesson in misunderstanding American federalism and a failure of national leadership. The federal government and Operation Warp Speed saw their role as getting vaccines to the states, without considering what supports states would need to get vaccines to the people. The Trump administration is now blaming the slow rollout on states. This is political theater and obviously untrue. States undoubtedly have a critical role to play in vaccine distribution. But states alone can’t mount one of the largest vaccination efforts in recent history. Moreover, not all 50 states are failing.

What is happening at the state level? The responsibility of vaccine distribution has fallen on state health departments. These relatively poorly funded agencies have been managing the full pandemic response for months. They oversee testing, the data collection and reporting, providing public guidance, overseeing restrictions, and so much more. They are squeezed and stretched, and to make matters worse, their leaders are receiving death threats and other forms of harassment, prompting some to quit. These agencies are in no position to take on rapid deployment of a new vaccine without a lot more resources and help.

The Trump administration gave about $340 million in Cares Act funding to states, territories and other jurisdictions for vaccine preparedness. This was a tiny portion of the amount that states and the administration acknowledged was needed. As time for distribution got closer, the administration never pushed for more funding to states, leaving them largely lacking the financial resources needed. So these already strained public health departments across the country are finding themselves in a position to stand up rapid vaccination infrastructure with little support.

If this story line sounds familiar, it is. This is the same strategy the administration used for personal protective equipment for nurses and doctors, as well as for testing. And it was never going to work. It’s also a story that fits into a larger pattern: For years, our public health infrastructure has been starved of resources, and without both money and deep, prolonged investments in these institutions, expecting them to pull off every major challenge in the middle of a global pandemic is unrealistic.

What is actually needed for large-scale vaccinations? The current strategy allows for every clinic, hospital and pharmacy to be a vaccination site, which translates into tens of thousands, if not hundreds of thousands, of sites across the nation. It would be simpler and easier to take a more streamlined approach, with the federal government working with states to focus resources on a more limited number of sites, providing more direct logistical support to each instead of leaving them to fend for themselves. Among other things, this would mean ensuring that they had the physical infrastructure, the staffing and the IT infrastructure they need to proceed. For people who are not able to go to these sites (such as some nursing home residents), local pharmacies could deliver the shots. (West Virginia took this approach, becoming the first in the nation to offer vaccines to all nursing home residents.) Some states might choose a different approach, and the federal government could work with them.

Regardless of the particular approach, this sort of planning should have happened in October and November. The administration should have gone to Congress and gotten the money needed to set this up. That didn’t happen. Instead, the administration is blaming the states. Of course, once a blame culture is set, the finger-pointing continues: In Mississippi, the health chief says it’s not the state’s job to ensure vaccines get into people’s arms and he is now blaming front-line providers for the slow rollout.

What must happen now? It’s important to know that many states are taking real responsibility. A lot of overburdened public health agencies are still setting up vaccination sites. And Congress just allocated $7 billion in the latest covid relief bill for states to vaccinate people. The federal government should be working with states to figure out what they need — and use staffing from FEMA, the National Guard or other agencies to bolster state capacity or even take over responsibilities where states feel they need help. Getting these sites up and running quickly with vaccinations happening efficiently is of the essence.

There is hope now. President-elect Joe Biden is pledging action, recognizing and preparing to meet the huge operational challenge of vaccinating a nation with the urgency demanded by these times. After a slow ramp up, states will improve their processes. 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.

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