Appointments to receive COVID-19 vaccines have been canceled at the last minute due to lagging supply. Unexpected freezer failures that jeopardize hundreds of doses. There’s no other way to say it: COVID-19 vaccine distribution in the U.S. has been a shit show.
When President Joe Biden was sworn in in January, public health experts were excited. Though two COVID-19 vaccines had been granted Emergency Use Authorizations under the Trump administration, sources with direct knowledge of Biden's COVID work told CNN there had been next to no infrastructure in place to distribute the vaccines. The new administration, for many, represented a chance to turn distribution around.
Biden’s plan to administer 100 million doses of coronavirus vaccines within 100 days was criticized as both potentially too ambitious and not nearly ambitious enough. A month into his presidency, though, and things are starting to look up: 13 percent of adults in the U.S. have been vaccinated, with nearly 45 million doses injected since the start of Biden's term. By the end of May, the U.S. will have 345 million more vaccine doses on hand and July will add another 200 million doses.
Two vaccines—mRNA vaccines produced by Moderna and Pfizer-BioNTech, respectively—are being used to immunize people, at a pace of more than 1 million doses a day. A third, made by either Johnson & Johnson or AstraZeneca, may soon be on the way. But by many metrics, the COVID-19 pandemic is as bad as it’s been. The U.S. recently crossed the grim threshold of 500,000 deaths due to the virus, and with new, more infectious strains circulating, a delay in vaccinating people is costing lives.
What happened in the richest country on Earth, ravaged by an out-of-control virus? Experts interviewed by Motherboard pointed to problems in production and supply logistics that underscore the country’s underpreparedness, even in the face of something we knew we’d have to do.
Not long after hope for a vaccine appeared last year, there were signals that we should keep our expectations well in check. In December, The Wall Street Journal reported that issues with raw materials caused Pfizer to only be able to produce half as many doses of its vaccine as the company had projected for 2020. A Pfizer spokesperson said that as of mid-December, the company projects to produce up to 1.3 billion doses of the vaccine in 2021, but did not elaborate on which materials caused the delay.
It’s hard to know what’s to blame on the production side, because we don’t know the specific ingredients that go into producing the vaccine. Of course, we know the components of the vaccine itself—a type of genetic code called messenger RNA encapsulated in a fatty nanoparticle—and we know that it’s safe. There are two types of enzymes that may play crucial roles in vaccine production, and Scientific American reported that components for the nanoparticles are a limiting factor in the production of the Pfizer-BioNTech vaccine.
Vaccine production is a complicated negotiation between private manufacturers and the federal government, said Bruce Y. Lee, a professor at the CUNY Graduate School of Public Health and Health Policy. With COVID-19, manufacturers have been able to set their own production benchmarks because the virus has been spreading largely unchecked despite a push for mask wearing and social distancing.
“People really wanted to get the vaccine out as quickly as possible, so that means that there were probably more concessions needed to be given to the manufacturers,” he said. In negotiations that took place in late December, for example, Pfizer agreed to supply the U.S. with tens of millions more vaccine doses in exchange for access to raw materials that were not disclosed to the public.
Lee also has experience with manufacturing delays: he worked on the vaccine for the 2009 pandemic H1N1 influenza and said that sourcing raw materials repeatedly pushed back the schedule for vaccines to be distributed. He added that such limiting factors are often overlooked when planning for vaccine distribution, and basic materials like glass vials and dry ice can sometimes be the cause for these bottlenecks, especially at locations less well-equipped than a hospital. If even one of these ingredients is missing, the entire process can grind to a halt.
Another way to think about vaccines is in terms of economics: Americans are essentially consumers of a product—for better or for worse. Vaccines are developed by gigantic companies and purchased by governments due to a complex system of copyright law and a motive for profit. It’s important to keep in mind that companies' predictions about products’ supply are often noisy, Lee said, and can end up being incorrect.
“There's been anticipation of the vaccine, and I think many people can think, ‘The vaccine is available, so that means I should be able to get it,' when in actuality there are going to be delays,” he said. “There's certainly political reasons why some people might want to say the vaccine is available sooner than later.”
While there are alternatives to the consumer-based capitalistic approach the U.S. has taken in developing coronavirus vaccines, those approaches have their own downsides. Apologists say competition between companies may have provided incentives to produce better vaccines more quickly for example, although the jury is largely still out. It's worth noting here that Russia's Sputnik V vaccine was found to have 91.6 percent efficacy after two doses in a recent peer reviewed study, which would make it about as effective as Pfizer-BioNTech's vaccine with the added bonus of not requiring deep cold storage. (That vaccine came under immense scrutiny from world leaders as well as concerns about falsified Phase I and II trial data.)
Last March brought attention to retail and grocery stores’ supply chains when consumer runs caused widespread shortages for products like hand sanitizer and toilet paper. But for the most part, buying an item at a store puts into motion a well-choreographed dance that can, for example, restock a shirt made in Hong Kong onto shelves in Connecticut within 48 hours, said Jonathan Byrnes, a senior lecturer at the MIT Center for Transportation & Logistics.
One of the errors made in planning the rollout of coronavirus vaccines, Byrnes said, is excluding logistics experts from small- and large-scale conversations about vaccine distribution. There was a lack of federal planning that led to confusion and bottlenecks.
“If Apple is rolling out a new generation of iPhones, they don't say, ‘We'll ship it to Texas, and all the Apple people in Texas will figure out what to do with it,’” he said. “They have a function called sales and operations planning, S&OP.”
Vaccines are currently being distributed in a heavily fragmented supply chain, according to Byrnes—a more comprehensive approach would ramp up distribution with federal oversight via the Defense Production Act, which the Biden administration has used. This would create what’s called a pipeline inventory system, where products (in this case, doses of vaccines) flow through distributors like water through a pipeline, distribution sites should operate 24/7 and shipping should be standardized as much as possible.
Instead of trying to reinvent the wheel by creating shipping and distribution plans from scratch, Byrnes said that the U.S. should be taking a page from industry’s book.
Increasingly, state and local governments are involving major corporations for this reason. The state of Washington has partnered with brands including Microsoft, Starbucks, and Costco as part of its Vaccine Command and Coordination Center, an initiative that also includes a labor union and the National Guard. These companies will be providing support with logistics, planning, and scaling, among other tasks. While it remains to be seen whether this will pay dividends, it shows that distributing a vaccine is an all-hands effort that requires intense coordination across society.
There’s a clear need for improved coordination: the CDC's multimillion-dollar Vaccine Administration Management System is an exercise in unnecessary bureaucracy that has confused the users meant to benefit from it. What’s less clear-cut is whether we can—or should—rely on private industry to extricate us from this mess.
A combination of limited vaccine doses, a fragmented supply chain, and unequal coverage has further warped an unlevel playing field, and Black people are being left behind in the vaccine rollout. An effect of working with private industry is being doomed to repeat its shortcomings and structural inequities.
Life after a vaccine
With all this in mind, it’s obvious that developing vaccines didn’t magically end the pandemic. Even if we do figure distribution out, though, it's unlikely that things will go back to normal immediately, Lee said.
“Part of the dialogue has been, ‘The vaccines are going to come and we’ll return to normal,’ and that's not necessarily the case,” he said. “We have to keep in mind that there is a decent chance that even after people get the vaccine, you have to maintain a lot of these interventions in place [like social distancing and masking] for at least for a little while.”
But should things go back to normal? "Normal," after all, is what got us in this mess to begin with. Like so many other aspects of society right now, the challenge of distributing vaccines while a pandemic rages is an opportunity to reimagine how things work.
What if we lived in a world without copyrights on essential, lifesaving measures like vaccines? By monopolizing access to vaccine blueprints, pharma companies have increased their own leverage in negotiations with the federal government. Then, when raw materials shortages arise or manufacturing is delayed in other ways, these companies don’t have to tell us why.
At the very least, Lee said the groups distributing vaccines—state and local governments, as well as hospitals, long-term care facilities, and clinics—should engage with the communities they service more transparently when they run into supply problems.
The question is no longer “Can we dismantle these systems?” but “How should we?” We can’t afford to wait.