© Justin Tallis/Pool via Getty ImagesA phial of the Pfizer-BioNTech Covid-19 vaccine.
America's messy Covid-19 vaccination campaign should provide one overarching lesson for policymakers: Keep it simple.
In the lead-up to the vaccine, federal and state governments established priority groups for the vaccine. In the very first phase, vaccines would go to health care workers and nursing home residents. After, vaccines would go to frontline essential workers, older populations, and people with medical conditions that put them at a greater risk for Covid-19. The list of people eligible would expand from there.
It seemed simple enough, but then reality brought complications. Just giving vaccines to health care workers raised all sorts of issues: Do all health care workers get a vaccine? Does that include staff who never interact with any patients at all, or should other staff get priority? Do staff who regularly interact with Covid-19 patients get extra priority - and what does "regularly" mean?
These kinds of questions have led the feds and states down to an enormously complicated process: "Phase 1" has been broken down into phase 1a, 1b, and 1c, and each state has built out its own definitions and guidelines for every step.
The complexity has slowed things down. Out of the 30 million vaccine doses sent out by the federal government, only 11 million first doses have been administered. Even if states are holding half their supply for the second dose the current vaccines require (which the feds no longer recommend), that's still millions of vaccines going unused.
President Donald Trump's administration promised the US would vaccinate 20 million Americans by the end of 2020. The country has breached only half of that two weeks into 2021. Other countries are vaccinating much faster, eclipsing the US entirely or catching up after a later start.
California's health and human services secretary, Mark Ghaly, acknowledged the role of the state's complex rollout, saying the state's "really thoughtful" guidelines "led to some delays in getting vaccine out into our communities."
"I will say that certain states that have put a great deal of effort into coming up with their priority groups, watching how we keep a keen eye on equity, have been in the same place where California is," Ghaly added.
For some experts, the troubled rollout has led them to a piece of advice to US officials: embrace simplicity. Instead of trying to fine-tune theoretically perfect but increasingly complicated vaccine plans, US officials should give more priority to getting vaccines out as quickly as possible - even if it's less equitable in theory (though not necessarily in practice, since more complexity often enables more gaming of the system).
To put it simply: Worry less about whether the ideal population is getting vaccinated and more about actually vaccinating people.
"A massive vaccination campaign won't work with our current fussy and intricate criteria for who gets a shot and when," Peter Hotez, a vaccine expert at Baylor College of Medicine, wrote. "We learned in 2020 that our health system simply cannot do complicated things."
That doesn't mean opening the floodgates and letting everyone get the vaccine. For one, the limited supply of doses won't allow that for some time. The idea is to find another, but simpler, standard. For example, age: Provide vaccines to older populations first, then work down to younger and younger people. This would still target those at highest risk of death - older age is a big predictor of Covid-19 fatality - and it'd be much more straightforward.
Some states, like New York and California, have moved in this direction by letting people 65 and older get the vaccine. But these states aren't stratifying this process within the 65-and-up group, and there's currently not enough supply to meet the demand.
A simpler rollout that speeds things up could save thousands of lives. Daily new coronavirus cases now average around 240,000 in the US, with more than 3,300 people dying a day from the coronavirus. With every day that this continues, the US experiences a higher Covid-19 death toll in 24 hours than the number of people who died in the 9/11 attacks.
Complexity is slowing down vaccinations
The current round of Covid-19 vaccinations was supposed to be the easy part.
With the first phase of vaccination, the country has the advantage of knowing where people who should get the first doses are: in hospitals, clinics, and nursing homes. That's a sharp contrast to the later phases, in which would-be beneficiaries will come from more diverse places, jobs, and backgrounds. That's why some experts expected the first phase would go at least a little smoothly, even if not perfectly.
Then the US began rolling out its plans in the real world. Vaccine doses were sent to the states slower than expected, but a continuing problem is that localities and states aren't even using the majority of the doses they have. There are multiple reports of health care workers and facilities throwing out doses because they can't find people in priority groups in time.
Some state officials, like California's Ghaly, admit they've been slowed down by their own guidelines. Brown University School of Public Health dean Ashish Jha, who's advised state officials on Covid-19, told me he's heard similar complaints. "The recurring theme is that complexity is proving really hard for them," he said.
Some of that comes down to extra administrative work. For example, some places have tried to prioritize not just health care workers but frontline health care workers who see Covid-19 patients. That makes sense in theory, but in practice it's required more hurdles, from paperwork to verification to penalties for line-cutters.
The emphasis on complex guidelines has also led to a rigid emphasis on following the rules. Some officials made this explicit, such as New York Gov. Andrew Cuomo, who threatened health care providers that vaccinate people who don't meet the state's criteria with big fines. But it's also the implication of the guidelines - after all, states wouldn't spend so much time on these criteria if they didn't want people to follow them.
The result is a mix of slowdowns in getting vaccines out and discarded doses as people don't meet narrow guidelines. It's a big contrast to Israel, which has vaccinated at about seven times the rate as the US in part by embracing flexibility, even if that means giving a vaccine to a pizza guy because he's the only person vaccinators could find at the time.
"There's a trade-off between speed and efficacy," Kendall Hoyt, a vaccine and biosecurity expert at Dartmouth, told me. "If we're going for the perfect solution to such a degree that we have to throw out doses at the end of the day, then we're failing."
Things will likely get messier moving forward. As the vaccine starts to roll out to broader populations, it's going to become more difficult to verify who qualifies and who doesn't. Who is a frontline essential worker? How does a vaccinator verify that a person actually holds a job that qualifies? If vaccinators rely entirely on an honor system, what happens when people who really want to get vaccinated realize that they can just lie and cut the line? If vaccinators don't use the honor system and set up requirements, will people avoid getting a vaccine so they don't have to deal with cumbersome paperwork?
Further complicating this, state plans use different definitions for who is a frontline worker. Some states currently limit the category to K-12 school staff, first responders, and not much more than that, while others embrace a broader criteria that can include even journalists. As Jennifer Kates, Jennifer Tolbert, and Josh Michaud at the Kaiser Family Foundation concluded, "Because of these differences, for this next period, a person's place in the COVID-19 vaccine priority line will increasingly depend on where they live."
All of this will create more work for the vaccinators themselves, but also make it more difficult for the supposed beneficiaries of all of this - the people getting vaccinated - to even know if it's their turn. And unlike people who work in health care settings or live in nursing homes, these targeted groups won't all be under one roof. That will reduce the chances people get vaccinated quickly, further slowing down a process that's already too slow.
Meanwhile, thousands of Americans will die instead of getting the vaccine that could have saved their lives.
How to embrace simplicity with vaccines
For the feds and states, the reasoning for all the complicated guidelines was equity and public trust - showing that the process wasn't built to benefit the powerful and wealthy over everyone else.
But the current process may achieve the opposite. When there are more complicated rules, the people who have more time and resources are better able to game them. It's the powerful and wealthy who'll have an easier time finding a doctor who'll give them a note saying a medical condition qualifies them for vaccination (or have a doctor at all), or find an employer to put them on payroll so they can qualify as a frontline worker.
"They're really thoughtful plans, but they're implemented in a society with deep structural inequities," Jha said. "And the end product of that is going to be inequitable distribution."
It's not too late to fix the rollout, making it both easier to understand and harder to game. And by doing that, states could actually foster equity and public trust.
One idea: After health care workers and nursing home residents, use age as the primary guideline. So people 85 and up would get vaccines, then 75 and up, then 65 and up, then 55 and up, and so on. This would acknowledge that, while the virus can kill people in any age category, the older are more vulnerable: Victims 55 and older make up more than 90 percent of Covid-19 deaths.
Jha, with University of California, San Francisco, Department of Medicine chair Bob Wachter, suggested using a lottery system after people 55 and older get vaccinated, perhaps one that "selects a number at random every two weeks, corresponding to the month or last digit of people's birthdays." That's fairly straightforward, but also makes it hard to game the system or otherwise make it feel unfair.
Alternatively, the rollout could continue going down age bands: to 45 and up, 35 and up, and so on, all the way down to children (if approved for use in kids). That maintains a bit more simplicity, although it'd slow down when younger people, who can still spread the disease, get the vaccine.
Another idea, from Shan Soe-Lin and Robert Hecht at Yale, is to focus on coronavirus hot spots. States would look at places with the highest rates of Covid-19 cases, then saturate those areas with mass vaccination centers, mobile units, and other resources. Once those places reach 60 to 70 percent vaccination rates, the next tier could be targeted. This would require more logistical work than an age approach, but it could also slow transmission more quickly and, therefore, help save more lives.
In explaining the proposal, Soe-Lin told me, "We could see that the next phase was going to be way too complicated. Our point was to simplify it."
In keeping things simple, these plans are easier to explain and justify. Everyone can understand why older populations or people in hot spots might need vaccines more. Focusing on one of those categories instead of multiple avoids the vast considerations of current priority groups. And these categories are more difficult for individuals to game than, say, a doctor's note or place of employment.
No one claims these ideas are perfect. A notable gap is they don't offer extra priority to frontline workers who really may be exposed more to Covid-19, minority groups who've suffered more from the coronavirus, or the immunocompromised. Jha said one way to alleviate such concerns may be to target places where, say, people of color live with vaccine centers or mobile units - not to put them ahead in line, but to ensure they can get vaccines quickly when it's their turn.
But chasing the perfect - at the cost of more and more complexity - is what got us into the current mess and what's likely to make the rollout even messier going forward. It's not going to be a lot of people's ideal, but that's the point: To get vaccines out as quickly as possible, save more lives, and get America back to normal faster, the country should think less about the ideal and instead embrace simplicity - prioritizing a quicker, more efficient vaccination campaign above all else.