The Biden administration's much-needed national strategy to end the covid-19 pandemic includes plans to remedy the chaotic vaccination effort with "more people, more places, more supply." The Federal Emergency Management Agency will open more vaccination sites, the government will buy more doses, and more people will be immunized. Still, by all estimates, the demand for vaccines will far exceed the supply for months to come.
For weeks, Americans have watched those who are well connected, wealthy or crafty "jump the line" to get a vaccine, while others are stuck, endlessly waiting on hold to get an appointment, watching sign-up websites crash or loitering outside clinics in the often-futile hope of getting a shot.
To eliminate this knock-out-your-neighbor race to score a vaccine, the administration needs to find ways to build trust in the system. It will take more than "more people, more places, more supply" to end the Darwinian competition and restore confidence and order.
That's in part because, desperate to end their own pandemic nightmare, many of our most respected institutions and politicians have behaved badly. Of course, hospitals have performed heroics during the pandemic — turning orthopedic wards into covid intensive care units, canceling elective surgeries, bringing retired health care workers back to help, all the while losing thousands of staff members to the virus. But some also have behaved selfishly during the vaccine rollout.
When the vaccine was released in December, the Centers for Disease Control and Prevention recommended that health care personnel and nursing home residents receive the first doses. It was pretty clear whom the agency had in mind for "health care personnel": those who deal directly with patients, including doctors, nurses, technicians, janitors and the people who deliver meals, along with those who might come into contact with the virus, like security guards and laundry staff, as part of their jobs.
But many hospitals interpreted the recommendation broadly, inoculating their entire staff — public relations departments, administrators, programmers, laboratory scientists and, sometimes, their boards. They offered vaccines to psychiatrists who were seeing their patients on Zoom. They vaccinated radiologists who were reading films at home. Some of those immunized were at the upper end of the medical income totem pole, people who had sat out the pandemic at country homes.
That behavior set a precedent for the national chaos that followed. "From soup to nuts, the whole thing has fallen apart," said Arthur Caplan, one of the country's leading medical ethicists. What Caplan called "unfair priority" left him "incredibly irritated"; ethics were often absent from the algorithm. "Once you've lost public confidence in the fairness of the process, it undermines willingness to follow the rules," he said.
Once random people working remotely got shots, those outside medical centers played whatever cards they had, too. Therapists who were teleworking claimed eligibility. Politicians and their spouses — sometimes former spouses — got vaccines.
People offered donations in exchange for vaccinations. Health officials and private doctors tipped off friends about when new vaccine doses would be released. On screening forms, people checked the boxes needed to get a vaccination appointment and in some places were immunized even after their duplicity was discovered.
Pity the rule-followers: Many older Americans who are not tech-savvy or lack internet access have been unable to get slots. It might be theoretically possible to sign up by phone, but by the time you get through, the newly released appointments may be gone. Those without a child or grandchild to help secure an appointment could be out of luck.
Hospitals, clinics and vaccination sites have explained away bad behavior by saying they didn't want to waste unused vaccines. Many have experienced higher-than-expected refusal rates from those expected to get a shot.
I don't blame the lucky recipients; after all, hospitals would just offer the unused vaccine to the next person on the list. But I do blame whoever it was in the hospital hierarchy or the health clinic who decided to distribute and redeploy vaccines this way.
If there were unexpected extras, couldn't hospitals have instead walked those doses to patients in the geriatric, hypertension or diabetes clinics? Or offered them to one of the many nursing homes and assisted living facilities whose workers and residents have still not been vaccinated, though they, like health care personnel, were the Centers for Disease Control and Prevention's top priority?
Gregg Gonsalves, who is 57, HIV-positive and an epidemiologist at the Yale School of Public Health, said he faced an ethical quandary when he was notified of his eligibility for the vaccine; he was unsure whether to sign up. His 86-year-old mother has not gotten one yet.
"Ethicists are saying, 'if offered, take it,' but stepping in line in front of my own mother? I know speed is of the essence in getting shots into arms, but this is entrenching gross inequities," Gonsalves said. (He declined to say what his decision was.)
The problem is that, often, people are not really being "offered" the vaccine; in some cases, they are grabbing it through position, influence or deceit. They are, in the abstract, taking it from someone perhaps more in need — a subway worker, a high-risk patient, maybe even their own mother.
Now, the new administration is coordinating with states to set up more mass vaccination sites. That's great. But the United States has allowed its public health system to become a hollowed-out underfunded mess, and many vaccination clinics are being run and staffed by contracted private companies. And the private sector has so far proved too vulnerable to private favoritism.
Until the supply is sufficient, the government needs to give the shots to the people and places that need it most, and find ways to ensure that the plan is followed; the system could prioritize ZIP codes that have high covid-19 infection rates or target low-income populations who might otherwise have a difficult time securing an appointment.
In Britain, citizens are notified, according to risk group, when it is their turn to book an appointment. They don't have to play knock-out-your-neighbor to score one. We shouldn't either.