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We Need a Better Way to Distribute Vaccines

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The current COVID-19 vaccines have been developed with unprecedented efficiency and speed. Developers have compressed years of research, production, and regulatory approvals into months. But accelerating the science has been only half the puzzle. If we want to help save more lives, we need to improve the messy, inequitable distribution of COVID-19 vaccines.

As newly minted 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 the gap between scientific advancement and implementation, and how it has disproportionately affected underserved populations. Nearly a fifth of seniors — one of the earliest groups prioritized — remain unvaccinated. In addition, vaccination rates for people of color lag behind those for white people in most states. 

We prioritized people with existing health comorbidities and disabilities, but disregarded their challenges in access, scheduling, and mobility. We neglected language translation services and perpetuated challenges to health care access levied every day by health systems. We launched clunky websites for vaccine sign-ups, and when the websites didn’t crash, we ignored the digital divide caused by their use, especially for underserved populations.

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. 

Still, 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 in New York to a military ship and the Javits Convention Center, we have learned that our spatial constraints can be reimagined for higher capacity and throughput. EDs are ramping up efforts to offer vaccines to their patients before being discharged as well.

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 also be trained to administer vaccines door to door, with a comprehensive approach similar to that used for the U.S. Census.

Existing systems, or lack thereof, are vital. Having hospitals and clinics oversee vaccine distribution comes with the trade-off that they often 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 tend to build first-come, first-serve systems that are inherently inequitable. 

Out of frustration with disorganized vaccine scheduling, a New York City software developer created a website that automatically pulls all available appointments in the city. A team of physicians and campaign staff is leveraging political campaign strategies to ensure equitable vaccine distribution. Employers are giving incentives to get vaccinated. Taking this a step further, incentivizing the public to get vaccinated will go a long way in 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 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 necessary digital infrastructure and operational expertise, leaving older and disabled people waiting in the cold while friends of the start-up’s leadership received shots. The National Guard has since taken over the response. 

At their best, however, public-private partnerships may hold the key to addressing implementation challenges. Large supply chain and operations leaders could assist in designing throughput and distribution. 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, and instead develop 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 committed people operating our country’s pandemic response. We have been a part of this group and applaud those making today’s vaccinations a reality. Still, one must consider how many more could have been vaccinated at this point, and how it could have occurred more equitably. Political barriers and unclear designation of leadership will exist and persist, but a focus on implementation and health equity must be a priority, not an afterthought. Scaling creative solutions and effective community, public, and private partnerships could save lives in this pandemic and prepare us for the next one.

What strategies do you believe may improve the distribution of health care services during the pandemic? Share your thoughts in the comment section.

Charles Sanky, MD, MPH is a resident physician in emergency medicine and co-founder of the Center for Healthcare Readiness at Mount Sinai Health System. Usnish Majumdar, MD is a resident physician in internal medicine at the University of Pittsburgh Medical Center and former product lead at Mount Sinai Health System. They both led operational components of Mount Sinai Health System’s response to the COVID-19 pandemic.

Illustration by Jennifer Bogartz

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