For too many people, it's a knee-jerk reaction: Blame the slow U.S. rollout of COVID-19 vaccines on too little central planning by the administration of President Donald Trump. Demand tighter control from the incoming administration of President-elect Joe Biden. Limit the number of vaccination sites! Bring in the military! Put somebody in charge!
But the problem with the rollout of COVID-19 vaccines isn't that no one is in charge.
Far from the remedy, tighter federal control would probably be a disaster. It would only amplify the problem.
By guaranteeing large purchases, the federal government gave manufacturers strong incentives to produce the vaccines. It was a smart move that worked. But now we're experiencing the downside.
Buying up the supplies and bestowing a vaccine monopoly on state governments blocked the normal distribution channels that connect producers with vaccinators.
Getting any product to its final consumer is not simple. Whether you're laying fiber optic cable or delivering packages, the 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 those retailers, 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 COVID 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 Gov. 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.
After all, the U.S. has nearly a million practicing physicians, about 4 million registered nurses, 920,000 licensed practical or vocational nurses, more than 670,000 medical assistants, plus pharmacists, paramedics and medical, dental, nursing and pharmacy students. The problem is that most of those people already have jobs or full-time coursework. Most aren't available to spend all day giving COVID-19 shots.
The last thing we need in these circumstances are special restrictions on who can administer vaccines — restrictions that send the perverse message that vaccines against this disease are somehow more questionable than those against the flu or measles.
Before we lose more time, it's worth asking what a program to get vaccines to people as quickly and effectively as possible might look like. Economist John Cochrane has made the case for selling vaccines to the highest bidder. That's not going to happen, but we could do better by abandoning the urge to control every aspect of the process.
Keep it simple. Use rationing rules people can easily understand. Worry less about queue jumping and more about getting vaccines into arms as quickly as possible. Trust medical professionals to do their jobs.
Leaving matters to the states has one big virtue: It allows some pragmatic experimentation unapproved by the Centers for Disease Control's bureaucrats. A growing number have gone to a simple age cutoff, offering vaccines to everyone over, say, 65.
States could also make it much easier for medical professionals to organize vaccination drives. Allow any practice to set up days when they offer shots to their employees, patients and the community. Leave it up to them to decide who can administer the injections and how to manage sign-ups. Just provide the vaccines.
Going a step further, allow any organization — a church, an alumni association, a sports league or any other legally incorporated group — that can round up the necessary space and qualified volunteers to offer a vaccination clinic. Hospitals and health departments can only do so much.
Community groups offer two essential resources: trust and willing hands. For people who might be skittish about getting vaccines from strangers in impersonal institutions, having someone they know as the face of the injection can offer reassurance. Cardiologists, neonatal nurses and dentists who'd never spend work hours administering vaccines might gladly take a weekend to do volunteer injections at their church — or to demonstrate that UCLA can beat USC in the number of shots given.
COVID-19 vaccines are a magnificent scientific and technological achievement. The challenges now are social and political. Meeting them requires flexibility, experimentation and trust.