The current COVID-19 vaccines have been developed with unprecedented efficiency and speed. Years of research, development, production, and regulatory approvals have been compressed into months. But accelerating the science is only half the puzzle. If we want to save lives right now, we need to improve the messy, inequitable implementation process of COVID-19 vaccine distribution.
As newly minted (and gratefully vaccinated) physicians who have had the privilege of contributing to our health system’s operational response to the pandemic, we have had front-row seats to how this gap between scientific advancement and implementation has disproportionately impacted historically underserved populations. Nearly a fifth of seniors — the group prioritized from the start — remain unvaccinated. Vaccination rates in people of color lag behind those in white people. Instead of learning from the costly, ineffective launch of Healthcare.gov in 2013, we launched clunky websites for vaccine sign-ups. When they didn’t crash, we still ignored the technological aptitude required to navigate the sites and that a digital divide still exists, with well-documented implications for underserved populations. We prioritized people with existing health comorbidities and disabilities, but disregarded their challenges in access, scheduling, and mobility while forcing them to wait in long lines in close proximity to each other while we worked out the operational kinks. We neglected language translation services and perpetuated challenges to health care access levied every day by health systems.
Problems posed by global pandemics are not new. Soon after the anthrax scares and deadly influenza season of 2003-2004, the Agency for Healthcare Research and Quality developed protocols for mass vaccination that quickly informed emergency preparedness training for several states. The Johns Hopkins Center for Health Security has run several pandemic operational simulations that routinely inform Congress and the executive branch. Unfortunately, challenges of staff, space, systems, and supplies derailed even the best-laid plans. But clever, creative solutions are everywhere and deserve our attention.
We’ve seen innovative repurposing of space to provide testing, clinical care, and now shots. From the use of stadiums and Central Park to a military ship and the Javits Center, we have learned that our spatial constraints can be reimagined for higher capacity and throughput. Emergency departments (EDs) are ramping up efforts to offer vaccines to their patients before being discharged.
Vaccination capacity is limited by staffing constraints. From librarians to persons who lost jobs because of this pandemic, many could help with registration, logistics, scheduling, and managing lines. Akin to the unprecedented number of individuals who worked as poll workers in last November’s election, a similar model could quickly amass staff from the general public. A large segment of our population is already trained but underutilized to assist with vaccine administration. Medical students volunteered across the nation, and former health care workers would gladly come out of retirement to contribute if simply asked. Community health workers or emergency medical personnel can meet people where they are, especially people with limited access or time. The military could easily be trained to administer vaccines from door to door, with a comprehensive approach similar to that of the US Census.
Existing systems, or lack thereof, are vital. Having hospitals and clinics own vaccine distribution accompanies the trade-off that they continue to miss the populations in greatest need. We need targeted outreach for underserved communities through partnerships with community leaders and organizations. In the absence of plans built with and for underserved communities, we build first-come, first-serve systems that are inherently inequitable. Out of frustration with the difficulty of finding vaccination appointments, a New York software developer created a website that automatically pulls all available appointments. Get Out The Vaccine leverages political campaign strategies to ensure equitable vaccine distribution. Employers are giving incentives to get vaccinated. Taking this a step further to incentivize the public to get vaccinated will go a long way to saving lives and health care costs. Integrated systems for sharing operational data have been lacking, but may hold the key to a more equitable response.
Our existing supply chains have been wholly unprepared for this pandemic’s demands for PPE and now vaccines. Public-private partnerships are essential to this discussion. At their worst, such partnerships can resemble what happened in Philadelphia, where “Philly Fighting COVID” was given control over distribution. They lacked the digital infrastructure and operational expertise necessary, leaving older and disabled people waiting in the cold while giving shots to friends of the start-up’s leadership. The national guard has since taken over the response. At their best, however, public-private partnerships may hold the key to addressing implementation challenges. Like the Cheesecake Factory’s relevance to health care, large supply chain and operations leaders (i.e., McDonald’s) could assist in designing throughput and distribution. Perhaps Coca-Cola, as a global corporation that can get a cold coke anywhere on the face of the Earth, could share their expertise or a portion of their cold chain delivery systems. As done in the past, multinational corporations’ partnerships may even allow us to shift to a global approach, helping struggling nations such as India. Equity does not exist in a vacuum; this global pandemic has shown us how one nation’s action or inaction impacts others. Perhaps corporations can think beyond meals for health care workers, instead developing sustained partnerships and systems in support of public health infrastructure.
We are now vaccinating approximately 2.87 million people each day. This is a remarkable testament to shared resilience and collaboration over the past year. None of this commentary is meant to detract from the efforts of those tired, committed people operating our country’s pandemic response. We have ourselves been part of this group and applaud those making today’s vaccinations a reality. Still, one must consider how many more could be vaccinated, and how it could have occurred more equitably. Political barriers and unclear designation of leadership will exist and persist, but implementation and health equity must be priorities, not afterthoughts. Scaling creative solutions and effective community, public, and private partnerships, could save lives in this pandemic and prepare us for the next one.
Charles Sanky is an emergency medicine resident. Usnish Majumdar is an internal medicine resident.
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