The arrival of Covid-19 vaccines feels nothing short of a miracle. But ending the pandemic requires more than inventing a vaccine; first, those lifesaving medicines need to get into the arms of Americans as quickly as possible. This is why vaccine distribution — and not just vaccine development — is of utmost importance.
The initial phase of the distribution of vaccines is already repeating some of the worst mistakes America has made.
So far, the implementation of vaccine distribution is unfortunately falling far short of what is needed to quell the pandemic. Echoing many of the most distressing dimensions of our country’s uncoordinated and chaotic approach to the pandemic, the initial phase of the distribution of vaccines is already repeating some of the worst mistakes America has made. These issues must be corrected urgently as attempts to scale distribution move forward and implementation expands to the larger public.
After the promise to vaccinate 20 million Americans by the end of 2020, a little more than 4 million vaccines have been administered, largely to front-line health care workers and nursing home staff. The order of magnitude in this shortfall in vaccine distribution is characterized by inadequate leadership from the Trump administration, a lack of coordination among federal, state and local authorities, and inadequate communication.
These shortfalls include everything from prioritizing administrative staff ahead of medical residents caring for patients on the front lines to attempts by wealthy Americans to “skip the line.”
How did we end up here? The Trump administration’s lack of leadership, incoherent strategic planning and poor attention to detail have created foundational barriers to getting vaccines distributed at scale. The unfocused, patchwork approach President Donald Trump has helped foster means vaccine distribution has been functionally outsourced to individual states, creating significant discrepancies in who is prioritized for vaccine eligibility. This has also entailed major breaks from Centers for Disease Control and Prevention recommendations.
Far short of the promise to vaccinate 20 million Americans by the end of 2020, a little under 4 million vaccines have been administered.
National recommendations from the CDC’s Advisory Committee on Immunization Practices (ACIP) have outlined the following priority groups for initial vaccine distribution: first, health care personnel and residents at long-term care facilities, followed second by essential front-line workers outside of health care and people 75 and older.
However, due to the abdication of the federal government’s responsibility to oversee distribution, every state and territory have ultimately been left to develop their own approaches to vaccine distribution — including defining their own priority groups. As in so many other instances with our response to the pandemic, this is leading to significant inconsistencies in how Americans living in different parts of the country have been affected.
As with masks, many states are not following the CDC’s recommendations and are doing things differently. Texas, for example, has prioritized health care workers and then people over 65 and anyone over 16 with a chronic condition; Arkansas is prioritizing essential workers over those over the age of 65.
The lack of a clear federal approach has also meant that the actual delivery of vaccinations has cascaded down to public health departments without adequate preparedness or vitally required support. Public health agencies at the state and local levels are chronically underdeveloped and underfunded. In some counties, there is not even a local public health department, leaving much of this work to fall to the state. Such limitations have been widely characterized for years and are well known. Despite this, as the pandemic has progressed, inadequate attention has been paid to how distribution would actually get done at the local level.
This has led to a default reliance on hospitals to distribute vaccines, particularly with the nature of vaccine storage requirements. But hospitals lack the intrinsic structure and operational capacity to act as public health agents; they are simply not set up for this function.
Vaccines are also being slowly distributed to retail pharmacies, which can open up new points of access, but coordination is in many ways even more complicated in these settings. For example, information systems need to be developed and integrated between local public health agencies and retail pharmacies to verify eligibility, allocate resources and ensure compliance. Such systems are highly complex, involved, and often confusing. for stakeholders.
Every state and territory has ultimately been left to develop its own approach to vaccine distribution.
These inconsistencies and variations will likely only amplify disparities. Like much of the rest of the Covid-19 pandemic, the populations most likely to navigate or overcome these obstacles to receiving vaccine will likely not be people in Black and brown communities who are already dying at a much higher rate than the rest of the population.
The results to date are gutting, but not surprising. States all over are reporting disparities in distribution, particularly in rural areas. Social media platforms are filled with queries and tales of clinicians of all types (including doctors, nurses and emergency medicine technicians) who should have ready access to vaccinations still waiting to hear from someone — anyone — about when it will be their turn. Public health departments have been besieged with emails and calls from frantic people wondering not just when they will get their turn but also where to go, and how to ensure that a second dose will be available in three to four weeks. To clarify on a detail of concern here, discussion of the “one shot” strategy, where all shots are distributed with a potential delay of the second shot, similar to the strategy in the United Kingdom, should only be explored when we have exhausted the distribution of all currently available vaccines. There should be a clear understanding that such a strategy has not been studied in trials to date and does not conform to the current science. It is clear the Trump administration has given up. The incoming Biden-Harris administration should act quickly starting Jan. 20 to consider how to deploy resources to states, including Public Health Service personnel and Medical Reserve Corps officers to assist especially in reaching communities that have had challenges in vaccination deployment. This. And sadly its not much better in other states-Maryland and Virginia providers are still trying to obtain vaccines esp community based doctors. https://t.co/VCcOFfygkW This is what was done after Hurricane Katrina, as well as in response to the H1N1 outbreak. Consistent and frequent communication is essential. Nonprofit organizations and advocacy groups should be partners to public health and health institutions to broadly disseminate accurate and timely information about vaccine supply and status, as well as vaccination locations. In turn, public health departments should turn to primary care clinics, community health centers and pharmacies for further solutions and feedback since these locations tend to be trusted sources around vaccinations. If the recent weeks are any indication, we will need all the collaborative support we can get to reach the ultimate goal of broader immunity for all Americans.
Dr. Kavita Patel
Dr. Kavita Patel is a teaching professor of medicine, Division of Hospital Medicine, at Stanford University and a board-certified internal medicine physician. She served in the Obama administration as director of policy for the Office of Intergovernmental Affairs and Public Engagement in the White House. Her area of expertise is around the intersection of health policy, clinical medicine and innovation. She also spends time advising venture capital and is a medical contributor for NBC News. 
