If history does indeed repeat itself — first as tragedy, then as farce — what about the third time?
As we witness the schlerotic, chaotic rollout of the Covid vaccine, we’re all going to get a front-row seat. The same crippling errors that marked the botched distributions of PPE and testing appear to be recapitulating themselves now.
“You should expect this to look just like testing,” says a grim Dr. Kim Rhoads, a UC San Francisco professor of epidemiology and biostatistics, and the director of community engagement for the cancer center.
“All the confusion and inefficiency and inequity and bizarre distribution of services: You will see the same thing with vaccines.”
Alas. If only there were a vaccine for this. There is an antidote, however — and we’ve taken it. We’ve voted Donald Trump into private life.
That’s because the disastrous rollouts of PPE, testing and, now, vaccines, all stem from an abdication of federal oversight and responsibility bordering on sabotage.
“It’s not that we’ve learned nothing,” Rhoads continues. “It’s still just coming from the top. If there was a federal response and everyone was working toward the same goal, you’d see less of this. There’s no centralized guidance.”
It’s hard to overstate how much of a mess the departing administration made, and how it continues to ripple down through the state and local levels. News broke this week that the Biden administration will be forced to craft a federal vaccine distribution plan from whole cloth, because there was literally nothing to inherit.
Last week, it was revealed that the so-called “vaccine reserve” the Trump administration pledged to release was actually nonexistent — a move Dr. Jake Scott, infectious disease physician and assistant clinical professor at Stanford University’s School of Medicine, described as “so sinister.”
Bay Area doctors we spoke with didn’t see this as garden-variety incompetence. They chalked it up as an out-and-out malicious move. California may have been elbowed aside in favor of other states — and, more sensibly, Northern California may be bypassed as a disaster unfolds in the south of the state.
So, at the risk of Manichaean simplicity, it’s a huge and consequential step to have Trump and his minions out of the picture.
“I give the Trump administration credit for one thing,” Scott continues. “Operation Warp Speed did a phenomenal job of getting us safe and highly efficacious vaccines in record time.”
“It’s one of the greatest medical developments of all time. In developing the vaccine, I give them an A-plus. But when it comes to the actual rollout, I give them an F.”
The Trump administration, says the doctor, “drove to the 5-yard-line and then spiked the football.”
That created a free-for-all. So even something as basic as establishing a centralized vaccine manufacturing and dissemination schedule — which doesn’t presently exist — would be a massive step forward for state and county health systems, says UCSF epidemiology and infectious disease specialist Dr. George Rutherford.
“We’ll have a real clear idea when the vaccine is going to arrive and how many doses,” he says. “That is a big thing right there.”
Adds Dr. John Swartzberg, a clinical professor emeritus at UC Berkeley and UCSF, “How can you plan when, one week, you get 100 percent of what you ask for, and the next, you get 10 percent?”
The obvious answer is, you can’t. Everyone read in junior high about the crippling incompatibilities among the 13 states under the Articles of Confederation, necessitating the crafting of the Constitution and its centralized authority.
Few of us thought we’d be living through it.
“With a bad administration, you know what the U.S. has accomplished. We are the worst in the world by nearly every metric. That’s what a bad administration can do,” Swartzberg says.
“Everything I have read about Biden’s plan is rational. He has great people surrounding him. You will see improvement.”
“But,” he continues, “not overnight.”
“Overnight,” incidentally, is how long many of us stayed on hold in an attempt to secure that vaccination appointment for mom or grandma.
Every state was left to follow the Centers for Disease Control guidelines as much — or as little — as it saw fit. In Florida, this led to cavalcades of elderly people sitting in folding chairs, Bernie-style, and playing canasta for hours and hours in a sick spectacle resembling a Black Friday vaccine drop.
Jokes about Soviet toilet paper lines suddenly became a lot less funny.
So the notion of future improvement is reassuring, but only so much. It’s a bit like telling a flood victim on his roof that the waters will, eventually, subside.
Dr. Rhoads, for one, is not holding her breath.
“Everyone is looking at the new administration and saying ‘oh, finally!’ But the reality is, the federal government, especially Health and Human Services and the Centers for Disease Control, where the science comes from, was under attack,” she says.
“How many agency heads have been decapitated? How many career professionals are gone? It’s very American to think ‘the leader,’ since he is good, what trickles down will be good. Leadership isn’t a title. It’s an activity. Who is doing the work? That is leading. It’s actually about all the people who are leading from the middle.”
With competent professionals driven out of government service, Rhoads it may take six months at least for the Biden administration to rebuild the institutions that have been sacked and burned — but that we needed, months ago, to be up to speed.
That’s a bitter pill. Not just for the folks who were waiting in lawn chairs or listening to incessant hold music but for people who didn’t even know enough to do that, or didn’t have the leeway to try.
“When you have a constrained supply and everyone is doing things differently, it leads to mass confusion — and, on the margins, the potential for inequitable distribution,” says Dr. Kirsten Bibbins-Domingo, the vice dean of population health and health equity at UCSF.
We saw this with PPE and, most notably, testing. Even in San Francisco, which surely must have been a national nexus for Dr. Fauci bobblehead purchases, the city has, for months, refused to put its testing resources into the communities all the data say are the most afflicted.
Should we expect vaccinations to be handled differently?
“Whenever supply is low and there’s rationing, you see a distribution of resources that favors those who have vs. those who have not,” explains Rhoads.
The key factor, then, is supply. And that’s not something that can be handled on the local or even the state level.
On Wednesday, the heads of San Francisco’s biggest health providers debriefed the Board of Supervisors at a hearing regarding vaccine distribution called by Supervisor Matt Haney.
One after the other, they offered detailed statistics on their progress — which had, as recently as Jan. 15, been opaque to even the highest public health authorities in San Francisco.
They laid down the coherent — and ambitious — timeline to vaccinate every San Franciscan by June 30. They outlined how they will cooperate with each other and the city to inject the 10,000 San Franciscans a day required to reach this goal. A mass-vaccination site at City College’s main campus may be online by Friday.
As hearings go, this was a good and positive one. Everyone was prepared. Information was freely proffered and agreements were made to cooperate and share data in the future.
But, one after the other, the healthcare giants listed the stumbling block as an erratic and dwindling supply of vaccines.
It was lost on nobody that we’ve already run aground on supply issues when we’re still struggling to vaccinate a small sliver of the population.
Vaccines from AstraZeneca and Johnson & Johnson appear to be rounding third on the regulatory process; they may soon help flood the market and ease the shortage.
Let us hope. Without that, it may be a dark winter indeed. All of the steps San Francisco is belatedly taking on the local level — centralized websites, mass-vaccination sites, centralized data-sharing — will ring hollow without the vaccine.
So we’ll need that. And we’ll need far better communication along the way. And we’ll need to keep testing. And keep distancing. And keep ensuring that all of this is done equitably.
And, not insignificantly, we’ll need scads of federal money to do all of this; the tattered and tepid response we’ve experienced thus far is due in large part to the feds releasing only about 5 percent of the estimated logistical costs to the states prior to the passage of the Covid relief bill.
“The good news is, every problem we’ve discussed is fixable,” says Swartzberg. “But it’s going to require a lot of attention from a lot of people. And a lot of money.”
And time. Always, time.