Post #968: Vaccine strategy: Maybe we should try the boats first.

Posted on January 22, 2021

Source:  Clipart




Last year, in 2020, when the Federal government called up the national guard to set up flu vaccine centers, I was a little surprised.  That, combined with the unprecedented mobilization of the United States Public Health Service to provide the needed medical personnel.  But what truly got my attention, last year, was when FEMA was tasked with retrofitting existing mass gathering venues to be used as Chinese-style mass flu vaccination centers.

Wait.  You don’t recall any of that?  Thank goodness, because neither do I.

But how on earth else could the U.S. have delivered 192 million flu vaccines in the last five months of 2020?  More than 100 million flu vaccines in the September and October alone, a span of roughly 60 days?

Was that some sort of miracle?

Nope.  It was business as usual.  It wasn’t even a particularly large number by historical U.S. standards.

Source:  U.S. CDC.  Note that this is a gee-whiz graph (the Y axis starts at 110 million, so this exaggerates the increase over time.)  Fact is, the U.S. has been routinely administering 100M+ flu doses per year for well over a decade.  You can find the 2020-2021 flu season number on on the current version of this CDC web page.)

It was just boring, routine business.  To get a thumbnail sketch of how the U.S. distributes flu vaccine each year, you can read through the CDC FAQ.  The gist of it is that it’s an almost completely decentralized, market-driven process.  Kind of like … well, just about every other good or service you buy in the U.S.  In a nutshell:

  • Drug companies make it (with CDC guidance and help, e.g., CDC provides the viruses for the year).
  • They compete to sell it to providers (clinics of all types, doctors, hospitals, the Veterans Administration, local public health agencies …)
  • Insurers pay for it (Medicare, Medicaid, private, VA/IHS/other, with some tax-funded insurer of last resort for the roughly 9% of Americans who are uninsured.)

This quaint, old-fashioned — I guess I’m required to say “patchwork” — system leads to a network of flu shot providers that is so thick on the ground you can’t display it without overlapping markers.  Note that the map below is just the public-access, no-appointment providers, and doesn’t include (e.g.) individual physician offices or hospital clinics that provide flu shots.

Source:  US CDC vaccine finder.

The reason for abandoning this approach for the COVID vaccine isn’t due to the physical characteristics of the vaccine.  The COVID vaccine is somewhat different, physically, from flu vaccine.  But only somewhat.  And only some of it.  The Pfizer vaccine needs to be kept super-cold, and so probably is restricted to being distributed through facilities that have ultra-cold freezers, until the very last step of the chain.  But the Moderna virus can be kept in a regular freezer.  As can the forthcoming Johnson and Johnson and AstraZeneca vaccines.

In any case, there’s no reason that health care providers could not determine for themselves whether or not they could safely store a particular vaccine.  So the mere fact that some of the vaccine requires either quick turnaround or an ultra-cold fridge is no reason, by itself, to abandon the existing delivery system.

The real driver behind the centralized approach to COVID vaccine distribution is that it is scarce, and so is being allocated, top-down-style, to the highest-risk groups first.  The fact is, the ultimate bottleneck isn’t distribution, it’s production.  As of right now, there just isn’t that much vaccine to distribute.  And that’s the reason for this highly constrained command-and-control style distribution system.

The Federal government guidelines (for who gets it first) aim for some sort of best-bang-for-the-buck distribution.  And that sort of targeted provision of vaccine would not be possible within the first-come-first-served vote-with-your-dollars market-based system used to distribute flu vaccine.

And so, there’s a tradeoff.  You could have, almost without a doubt, gotten all  30M available COVID-19 doses injected into people weeks ago.  But that would have been an efficient distribution, into an inefficient set of people, from a public health standpoint.  By and large, it would have vaccinated whoever was most motivated, quickest on the draw, and had the money to pay.  It wouldn’t have been those at highest risk for severe COVID or those facing highest exposure to COVID.

Trying to put the best face on it, plausibly the physical inefficiency of this top-down approach is offset by the greater efficiency of the choice of persons vaccinated.  We should arguably tolerate the inefficient command-and-control method because there’s no way to get the markets to target the “right” people.

Or, at least, no obvious way.  You have to wonder if there isn’t some clever way to get the best of both worlds.

That said, what started me on this particular tirade was news coverage, last night, of the proposed Biden administration vaccination efforts.  It started with a prelude of outright mis-information.  (The Federal government had no vaccine allocation plan?  Then what the heck is this?  Or this?  The Federal government is not collecting data on COVID?  What is this, then?)  Sure, Trump’s people had nothing to do with that.  That’s pretty much entirely the work of the professional bureaucracy.  But it’s not as if that didn’t exist.

The coverage then proceeded into some hagiography regarding the persons leading the great patriotic effort to vaccinate.  The 100 centralized vaccine centers that will be established.  And so on.

It was just a little over-the-top, is all.  They tried to make it seem like this centralized, mass-vaccination-center approach was somehow a wonderful feature.  When, in fact, it’s a bug.  A bug that we rationally tolerate, in recognition of the scarcity of the vaccine, and the overall greater impact that scarce vaccine will have if targeted in a non-market, top-down manner.

Let me sum up.  The U.S. has provided 100M+ flu vaccines annually for more than a decade.  It has done that without fuss or fanfare, in a manner that was as convenient as it could possibly be for the average user.  The COVID situation is different not because there’s something hugely unique about the vaccine.  It’s unique due to a manufacturing logjam.  It’s scarce, at present.  And so we gain some overall improvement in efficacy by allocating it in this clumsy, top-down, heavily controlled, and yet fractured, piece-meal, state-run manner.

What I’m trying to say is, that’s not something to be proud of.  It’s something to be tolerated due to the scarcity.  And it would be more prudent to see some solid results — a rate of delivery substantially in excess of recent experience — before we start patting ourselves on the back over it.

Can the Biden administration do worst than the Trump administration in delivering vaccines?  Almost certainly not.  Can they do materially better?  That remains to be seen.  But if worst comes to worst, we could always do it the way we do flu vaccines.  That will, without a doubt, get that vaccine into (somebody’s) arms in short order.  As it has done, in the U.S., for decades now.