As COVID-19 cases in the U.S. continue to surge—with 2,000 to 3,000 Americans dying every day and the situation in Los Angeles so dire that ambulance drivers are being told to leave patients with little chance of survival at home to save space at overwhelmed hospitals—millions of doses of vaccines are still sitting on shelves.
As of January 4, more than 15 million doses of COVID-19 vaccines had been distributed to the states. That’s far fewer than the government had promised: In October, both President Donald Trump and Health and Human Services Secretary Alex Azar said that there would be 100 million doses available by the end of 2020. In November, Azar revised that down to 40 million doses, enough to inoculate 20 million people. By December, the government said that it would keep half of the doses in reserve. Of the doses that did end up going to states, only 4.5 million have been administered so far. At the current pace, it would take nearly a decade to inoculate 80% of the population, the number that some experts say is needed to reach herd immunity.
“What I keep thinking about is, how can you invest billions of dollars into developing this amazing new technology that can really help turn the pandemic around, and just completely neglect the important implementation of how to pull it off?” says Janet Baseman, an epidemiology professor at the University of Washington School of Public Health. “We know how complicated implementation is of large public health programs. It’s like the military developing a missile defense system, and spending all this money, and then not ever bothering to figure out how to stand it up. That would never happen.”
The government had months to plan the vaccine rollout: By September, it was clear that it was very likely that vaccines would be approved by late November or December. But the necessary preparation didn’t happen. “The planning should have been started and done much more vigorously,” says Ashish Jha, dean of the Brown University School of Public Health. “Instead, what happened was the federal government asked states to put together plans, but they were never really tested and vetted thoroughly.” A state might have a plan to vaccinate at nursing homes, for example, but that doesn’t mean that critical details—like a timeline or who at each nursing home would be responsible for making sure that vaccinations are given—were ever finalized.
At a time when state and county public health systems are stretched to their limits providing emergency care, the federal government asked them to take on a massive vaccination effort without providing enough support, leadership, or funding. It took until December 27, in the new stimulus package, for Congress to approve $9 billion to support vaccinations. Trump has blamed states for the slow speed of vaccination, though as Jha says, “if you find that 50 states are all failing, it’s probably not the states’ fault.”
Some other countries are moving much faster. Israel, for example, gave shots to around 60,000 people per day as it began its vaccination rollout. In the U.S., moving at the same rate would mean more than 2 million shots administered per day, or 10 times faster than we’re moving now.
Even the rollout of the shots that have been given has been chaotic. In Florida, for example, when Lee County offered doses on a first-come, first-served basis to people 65 and older, hundreds of elderly residents waited in lines in sleeping bags overnight. When a vaccine clinic launched in Houston over the weekend, phone lines crashed after more than 250,000 people tried to call the city health department. States have gotten little notice from the federal government about how many doses of vaccine are arriving, making it hard to plan for storage or staffing.
In some cases, overwhelmed states are passing the responsibility for managing vaccine programs to county health departments. “They don’t have a ton of logistics expertise and information technology expertise,” Jha says, “and so counties across America are trying to figure out what to do to get these vaccines out and with very little money, very little expertise. In my mind, this is borderline insanity, that this is the strategy we’re using to vaccinate people in the middle of a pandemic.”
In other cases, companies that do have logistics expertise—CVS and Walgreens, for instance, were tapped by the Trump administration to carry out some of the vaccinations—are struggling with the challenge of carrying out vaccinations in nursing homes. “Because they don’t understand the workflow of nursing homes, they’ve been playing catchup from the beginning,” says Michael Wasserman, a geriatrician and former president of the California Association of Long Term Care Medicine, who argues that pharmacists who work inside long-term care facilities should be handling the rollout. Fewer than 15% of the doses allocated for nursing homes have been given out. Hundreds of millions of other doses are sitting in warehouses.
To fix the problem, several things need to change. The Biden administration can help by giving clear guidance to states about how many vaccines they’re getting and how long they can be stored, providing training materials for staff, and setting targets for vaccinating a certain number of people by a certain date, says the University of Washington’s Baseman. Others have also argued that the federal government should have given better guidance to states from the beginning. “That comprehensive vaccination plans have not been developed at the federal level and sent to the states as models is as incomprehensible as it is inexcusable,” Utah Senator Mitt Romney said recently.
The federal government can also help recruit staff or a volunteer corps to administer vaccines so that states and counties don’t have to spend weeks finding new employees as programs scale up. It can offer communication tools to help fight misinformation about vaccines; states and cities will need to mobilize far more to make sure that everyone who can be vaccinated is choosing to get the vaccine. The new round of funding will be critical, but the administration will also need to push Congress for more.
“What we’re dealing with is the capacity for the state and the municipalities to essentially mobilize themselves to be able to carry out this campaign, and they’re doing that without a lot of resources,” says Stephen Flynn, director of the Global Resilience Institute at Northeastern University. As underfunded public health departments simultaneously deal with the ongoing emergency, local budgets that depend on 2020 revenue are also shrinking.
Biden has said that he wants 100 million vaccine shots to be administered in his first 100 days in office. It’s possible, but it will be difficult to set up functioning systems quickly. “The thing that I worry about is just how long it’s going to take, because we’re frankly in a desperate situation in this country,” Baseman says. In the worst-case scenario, she adds, as the rollout flails now, some doses of the vaccines will be wasted as they expire on shelves. “That would be totally tragic.”