Medical Examiner

The Vaccine Is Here

Things are about to get real messy.

A Black man in navy scrubs and a surgical mask rolls up his sleeve as another health care worker gives him a vaccine.
Dr. Yves Duroseau receives the COVID-19 vaccine at Long Island Jewish Medical Center in Queens, New York, on Monday. Timothy A. Clary/Getty Images

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Over the weekend, as my Twitter feed filled up with footage of UPS trucks and FedEx planes chugging around the country, loaded with vaccines to fight COVID-19, I started to wonder:  Do we need to get on a list or get in line?

Sarah Owermohle, at Politico, has been covering the vaccine rollout. She says the answer to this question is Don’t call us, we’ll call you. Meaning: If you’re eligible for a vaccine, someone will let you know. But things are sure to get messy. In typical American fashion, there is not one plan to distribute COVID vaccines in the United States. There are at least 50 of them—one for each state. And some states’ plans are more comprehensive than others. But even the most comprehensive plans can’t predict everything about this unprecedented vaccine rollout. “Starting Monday, it’s when the rubber hits the road,” Owermohle said. “We’re going to find out how much this worked and what we didn’t plan for. And everyone you talk to will admit there’s going to be things that we didn’t think of.”

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I spoke with Owermohle on Monday’s episode of What Next to figure out: If no one is policing the line for the COVID vaccine, how will we know if the right people are getting it? Our conversation has been edited and condensed for clarity.

Mary Harris: So the reason why states are putting together complicated documents laying out who will be vaccinated when is simple: There isn’t enough to go around. The United States has ordered millions of doses, but even with factories working full speed ahead, it will take months for the shots to reach most Americans.

To make the states’ job easier, the Centers for Disease Control and Prevention has been convening for weeks, putting together guidance on who should be at the front of the vaccine line. For now, it’s health care workers and people who live and work in long-term care facilities. But making these kinds of calls gets complicated, fast, right?

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Sarah Owermohle: We did know for a long time that it would be a limited amount of vaccines and that we would have to give those to very high-need populations based on who is at most risk of severe illness and death and who is at most risk for spreading the virus. So you talk about people in nursing homes, they’re at most risk for dying from the virus. But then you talk about somebody who works in food or who works in a hospital—they might not die from it, but they could spread it. They could be a really important vector. So that’s the balance that we’re striking, is getting it to very high-risk people and high-exposure people.

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You could see how complicated this gets pretty clearly when the CDC Advisory Committee on Immunization Practices met up and started talking about the guidance they were going to give. They were voting on whether nursing home residents should be in this first wave of people getting the vaccine, and one doctor voted no. She had really interesting reasoning about why.

I saw that conversation too, and others did share her concerns. I remember one person saying, “What if Grandma gets this vaccine and then she dies two days later? And it wasn’t even necessarily because of the vaccine, but we don’t know that.” Perception can be people’s reality. And so there’s this really fine balance we have to strike. Yes, those people are at most need of protection. But could we actually harm the national public health interest by putting those people in the first group? It’s a very pragmatic but emotional conversation to have.

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Part of what this committee is considering isn’t just who needs the vaccine the most but how complicated it will be to deliver it to them. This first vaccine, from Pfizer, requires two doses. It’s easier to give a shot like that to health care workers and people in long-term care. The vaccine can meet them where they live or work. That’s not true for others, like workers in food service.

It’s important that this group of people gets vaccinated, but they could be anyone in a wide range from an Uber driver to a dishwasher at a restaurant to somebody who’s working undocumented to waitstaff. And then you think about the way that they work, the fact that they work hourly. So if they’re going to go and get a vaccine, that could cut into their hours. If they get sick—we know that the vaccines can cause headaches, they can even sometimes cause fever the day after if they think—

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And then they’re not getting paid.

Exactly. So they don’t want to be going. Why would they go and get a vaccine that can make them sick and make them lose money? How are we going to get those populations in the door to get vaccinated when they are a very important part of our structure and of group immunity? I think that’s going to be a massive task.

Black and brown Americans have been disproportionately affected by COVID-19, and there’s been this robust debate about whether race should be a deciding factor in terms of who has access to the vaccine and how. How is that playing out?

It’s come up in the federal conversations, like that CDC panel, about how to include approaching these disparities. It’s worth noting this is the first time a conversation like that has happened before that panel. State plans are trying to address that. Kaiser Family Foundation put together an analysis of states’ draft plans, and they found that 53 percent of them have at least one mention of incorporating racial or ethnic minorities or health equity considerations in their framework for distribution.

They are all doing that in very different ways. Some of them are incorporating racial or ethnic minorities through these job targets that we just talked about, including food workers and hospital cleaning staff in high-priority groups, because those are disproportionately people of color working in those jobs. Others are using the Social Vulnerability Index, which is a way of indirectly addressing it. For instance, Black populations have disproportionately higher rates of heart conditions or diabetes than other communities. And so if you say that we need to prioritize these groups, you’re addressing it in that way. One other really important consideration that several states are including is just how they actually do this in distribution sites. Are they going to put these sites in areas that are easier for communities of color to reach, that have good public transportation to them, maybe even in community centers that are employing community leaders that are trusted by people? These conversations are happening in all sorts of states right now.

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That Social Vulnerability Index makes me wonder, will people just be showing up saying, “Well, I’ve got diabetes. I have these other characteristics. I deserve a vaccine.” How does that work?

It’s going to come down to your relationship with the health care system, which is another difficult barrier. It comes back to the public outreach that happens on the state and local levels, telling people that if you have diabetes, it’s very important that you get this vaccine and also you can get it right now. That’s going to have to happen with health care providers, with community leaders. But it is difficult and it’s not going to be a very clean system. It’s not like we’re going to say, “OK, we did priority group one. Now we do priority group two.” It’s going to be a little bit more nuanced than that.

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My understanding is that that CDC advisory committee, they’re going to meet up again to make more recommendations about who’s next after this first round. Is that right?

Yes, they made their first recommendations on Saturday just for the Pfizer vaccine, and that was health care workers, long-term care facilities, people 60 and older. Those are the priorities. They are going to be making more recommendations for the next waves of people but also for the next wave of vaccines. The details start to get a little bit messier as you start to move down the chain. So who counts as an essential worker? What essential workers are going to go before other ones? Firefighters, EMTs, sure, they should be in the first priority group, but where do teachers go? How essential are they compared to other people? It starts to get more messy as you go down the line.

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When they hand out the vaccine, the states are supposed to be following these CDC guidelines, and they, of course, have their own individual state plans too. But does a state have to follow these guidelines?

There’s no punishment. Guidelines are guidelines. The CDC cannot watch over their shoulder and say you have to do it this way. It ultimately is up to the states because they have their own distinct populations, their own needs within their populations, and the federal government shouldn’t be making those calls for them. States are kind of more comfortable making those calls themselves, but that also means that we’re probably going to get a patchwork of realities across the country. We could feasibly see one state moving into a different population before another state gets there, or one state deciding that essential workers include teachers where another state might not put teachers very high up on their list. That might frustrate people or might even cause a little bit of distrust or sense of unfairness in the system.

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Does it concern you that at the same time the states are being given this enormous task, many of them, their state budgets are a disaster after the coronavirus?

That is a very big concern, and if you talk to state governors, they will tell you that that’s been a concern that they’ve been keeping on their plates for a long time now. One problem there is that we haven’t actually had a coronavirus package approved by Congress and sent to the president’s desk in months now. And the president hasn’t really shown much interest in the conversations that have been happening around a final plan that goes out before his term ends, because there are a lot of really sticky questions as a part of that that include all these funding questions that we’ve talked about. It’s going to be another at least trillion dollars. And who wins and who loses is not an easy thing to put together. But it is very notable that we’re having this conversation about distribution, about an unprecedented state outreach on every level starting this week, and we haven’t had a new funding package since this spring.

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The Wall Street Journal said in New York alone they’re estimating it’s going to be $1 billion, and most of that is personnel costs, not the stuff that the federal government has already agreed to pay for.

That doesn’t surprise me. The federal government has agreed to pay for the vaccines themselves. They continue to promise that there will be no charge to any American to get the vaccine. That’s an important part of people getting in the door to get it. But there’s all these other costs that go with that—administration costs, the staff that has to be at these health facilities or at these commercial pharmacies. It’s going to be another set of costs, some unforeseen, that states will bear the burden of. We’ve never actually done something like this before, so states can have 100-page plans, but when you get to the day-to-day, there isn’t a red line saying this person is priority group 1a and this person’s in 1b. That’s not how it’s going to work. It will come down to a lot of human judgment that isn’t reflected in those plans.

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