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COVID Vaccine Distribution Nears a Turning Point, but Equity Issues Remain

healthcare worker puts vaccine into a woman's arm
Photo: Phil Roeder

In the devastating year since COVID-19 was declared a pandemic, the world has been transformed. More than half a million Americans have died, and another two million people around the globe. Millions more are suffering from grief, depression, stress and loneliness. Schoolchildren have lost an entire year of learning and socializing during a critical time in their development. Businesses have closed their doors for good. Disparities have widened between the rich and the poor, the privileged and underprivileged. Clearly, a full recovery is going to take a long time.

Thankfully, this March looks a lot more hopeful than March 2020 did, in large part due to the record-fast development of several vaccines, and the tireless efforts of frontline workers helping to get them into people’s arms. COVID death rates are dropping in many places, and 64% of Americans aged 65 or older have already received at least one dose of the vaccine. Progress is certainly being made, but what could be done better? And what needs to happen next? Several experts from around the Earth Institute weigh in below.

How is the vaccine deployment going so far?

It’s no easy feat to set up an infrastructure to quickly vaccinate 300 million Americans. But Jeffrey Schlegelmilch, director of the National Center for Disaster Preparedness at Columbia University’s Earth Institute, says that earlier guidance from the federal government would have saved lives and helped to speed up the vaccine rollout.

“We should have been planning [the vaccine distribution] a year ago, and there should have been funding and resources to states and locals for doing this a year ago,” he says. “They really didn’t get those resources, or very much guidance at all, from the prior administration.”

In 2003, Schlegelmilch was involved in drawing up plans to rapidly distribute antibiotics in case of a bioterrorism attack with anthrax. Those plans could have been adapted for efficient vaccine distribution, but “one of the challenges we’re seeing is that a lot of those plans aren’t really being used. We’re seeing a lot of state governors just kind of ignore them and then doing their own thing, working with other supply chains. And so they’re literally reinventing the wheel.” He suspects that during the frenzied response, government leaders aren’t taking the time to learn about the years of planning that had been done beforehand.

Schlegelmilch thinks the Biden-Harris administration’s push to buy more vaccines, to increase production through the use of the Defense Production Act, and to deliver support to state and local governments have significantly accelerated the vaccine distribution process. “Biden set the goal of having 100 million vaccines administered within 100 days. It looks like we may be there in 50 days.”

Issues with equity

Unfortunately, communities with higher rates of hospitalization and death due to COVID-19 — usually low income and communities of color — haven’t typically been the ones who are getting the vaccine first.

Schlegelmilch thinks this is in part due to the rush to get the vaccine out. He says that rather than distributing the vaccines in local clinics and churches that are trusted and easily accessible in underprivileged communities, elected officials have tended to prioritize large hospitals and arenas that have the staff, refrigeration capacity, and infrastructure to move quickly. These sites are more likely to require internet and phone access in order to get an appointment, and may only be accessible in vehicles.

“Every time we do that, every time we reflexively pick speed without thinking about the tradeoffs, we maybe unintentionally perpetuate the inequities that existed before, during and continue to exist after any disaster,” says Schlegelmilch.

It doesn’t have to be that way. Social vulnerability data are available and can help elected officials identify where to put clinics. In addition, Schlegelmilch says, establishing relationships with community health centers earlier would have helped to increase efficiency and avoid tradeoffs between speed and equity.

As much as the vaccine developers deserve praise for their fast work, he says, “This is the hardest part — getting it into people’s arms, getting in their arms quickly, and getting it done equitably. We have we have the information to do it better. We’re just not using all of it.”

guardsman exchanges paperwork with a woman in line at vaccine clinic
A line of people wait to be vaccinated at Yankee Stadium in the Bronx, NY. Photo: New York National Guard

Nearing a turning point

President Biden aims to make vaccines available to all adults in the U.S. by the end of May. Such a feat may be difficult to imagine, considering how difficult it has been for many people to get a vaccination appointment through wonky portals and websites, or who show up to their appointments only to find out there are no more doses available.

“All these things are being addressed by the White House right now,” says Irwin Redlener, director of the Pandemic Resource and Response Initiative at the National Center for Disaster Preparedness. “My opinion is that we’re going to solve those issues. Once that happens, I think we have a good chance of getting there by the end of May.”

Both Redlener and Schlegelmilch think the U.S. is nearing a turning point in vaccine distribution. Until now, demand for the vaccine has far outstripped the supply. But thanks to an increase in production, there may soon be more shots to give out than people to administer them. “Once that takes place, your rate limiter is how quickly you can get it out,” says Schlegelmilch.

Once the supply catches up with demand, another challenge will be to make it convenient for people to get vaccinated. This can be done by making the vaccine available in community health centers, the local pharmacy, or even the neighborhood church or grocery store, says Schlegelmilch. “Getting vaccines in close proximity to people — meeting them where they are — is probably a more effective way to reach people, and to reach more people equitably.”

The federal government is already working out plans to get the vaccine into health deserts, to deploy mobile clinics, and to use large drug store chains to facilitate the wider-scale rollout, says Redlener. “So we have some serious and effective logistical plans in place now that make us confident we can reach that [end of May] goal.”

Looking beyond U.S. borders

President Biden’s goal to make the vaccine widely available in May is all well and good for the U.S., but what about other countries? Just as disadvantaged populations in the U.S. have had a difficult time securing access to the vaccine, so too have less wealthy countries.

“There isn’t enough supply of vaccines in the world, and most are being bought up by developed countries,” Sanya Reid Smith, a legal advisor and senior researcher with the Third World Network, said during a recent Earth Institute webinar. “Many developing countries haven’t even been able to vaccinate health care workers.”

It is estimated that in some developing countries, vaccine coverage won’t become widespread until as late as 2023. During the intervening years, those countries will continue to suffer the economic disadvantages of being unable to reopen schools and businesses. Meanwhile, Reid-Smith pointed out, “countries like Canada are taking an additional 1.9 million doses of vaccines from COVAX [a UNICEF initiative aimed at providing equitable access to COVID-19 vaccines], even though it has ordered enough vaccines to cover its population more than three times.”

Reid-Smith asserted that there are companies with the capacity to manufacture COVID vaccines, but they’re not being allowed to because of intellectual property restrictions. She would like to see the World Trade Organization waive these restrictions so that production could increase and more people around the world could have access to the vaccines. Other panelists were skeptical of this approach. Watch the webinar here:

During the webinar, Petros Mavroidis, a professor at the Columbia Law School and an affiliate with the Columbia Center on Sustainable Investment, called for an international health policy as an antidote to what has been called “vaccinationalism” and to encourage better cooperation and more equitable distribution. “There’s nothing like an international health policy,” he said. “Health policies are national, so there’s no obligation to impose export quotas.”

Another panelist, economist Michele Ruta with the World Bank Group, laid out several proposals to increase vaccine production and reduce hoarding. These proposals included avoiding trade restrictions and increasing transparency around the vaccine. “If we don’t know exactly how much production we will have tomorrow, we are more likely to restrict today,” he said. “This is one reason why governments are reluctant, even if they have supplies of a certain vaccine, to let it go.” Ruta also called for a clearinghouse to bring together companies with the knowhow to fulfill different aspects of the supply chain.

A woman gets vaccinated in São Paulo, Brazil
A woman gets vaccinated in São Paulo, Brazil. In general, less wealthy nations have had a harder time securing doses of the vaccines. Photo: Governo do Estado de São Paulo

Redlener pointed out that President Biden has allocated $4 billion for international vaccine programs, and he hopes that the U.S. won’t wait to begin distributing the vaccine in other countries. Sharing the vaccine is important not just for humanitarian reasons, he says, but also to protect the U.S.

“If we don’t eliminate SARS-CoV-2 everywhere,” says Redlener, “then nowhere is going to be safe. [Unvaccinated areas] are going to allow festering and mutating of the virus. Those mutations are dangerous for the country in which they occur, and also for the rest of the world. None of these viruses obey boundaries.”

Cautious hope ahead

As the situation in the U.S. improves, health experts are warning Americans not to let down their guard. Mask-wearing, hand-washing, and socially distancing remain critically important, says Redlener. “To the extent that we don’t have control over the spread, we will have many situations where the virus will continue to replicate and mutate, and that is what could actually undermine our efforts to get the pandemic under control. The main race now is between the vaccine and the variants.”

“We’re all desperate to get done with this,” Jeff Shaman, who studies infectious disease at Columbia University, told the Associated Press. “We’re not in a place where it’s safe as of yet.”

Speaking with BBC News Mundo, Shaman warned that it’s not yet known how long immunity to SARS-CoV-2 lasts; if other coronaviruses are any indication, it’s possible that people could get reinfected with it again and again. But with enhanced immunity from the vaccine and/or prior infections, plus more effective treatments that are becoming available and the natural evolution of the virus, it’s possible those subsequent infections would become less deadly over the long term.

“What we hope is to achieve levels of infection that are controllable and that the virus becomes less and less severe,” said Shaman. “That would be the kind of stability that would allow us to live with this virus and, at the same time, return to some kind of normalcy.”

Redlener is hopeful that the situation could dramatically improve in the coming months. “We’re at an inflection point, and if we can keep up the public health control and vaccinate all adults by the end of May, could be on our way to potentially having a reasonable fall,” he says. “We might be able to go to a few picnics on Labor Day, and maybe have a quasi-normal Thanksgiving. There’s reason to be hopeful, but alert.”

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