After nearly a year of social isolation and sacrifice in the long war on COVID-19, the end stage of the pandemic is finally in sight. Millions of Americans are being vaccinated each week, and the number of coronavirus-related hospitalizations in the United States has plunged by more than 40 percent in the past month.
But this final stage will still be lethal—perhaps more so than most people imagine. More Americans were reported dead of COVID-19 on Friday, February 5, than on any day in all of 2020. The U.S. is still on pace to have more than 80,000 COVID-19 fatalities a month. Meanwhile, variants of the coronavirus that emerged in the United Kingdom, Brazil, and South Africa are spreading quickly. These variants are more contagious and more deadly than the original virus, and they threaten to stall or even reverse our progress.
“If we don’t accelerate the pace of vaccinations, we’re looking at an apocalypse,” says Peter Hotez, a vaccine scientist at Baylor College of Medicine. “We’ve got to figure out a way to get ahead of the variants to avoid 1 million deaths by the end of this year.” Vaccinating 75 percent of the U.S. population by the beginning of the summer would require hundreds of millions of doses by June. That goes far beyond President Joe Biden’s initial plan to administer 1 million shots a day, and the current rate of about 1.5 million a day. We’d need more like 3 million shots a day. But we can do it; to save tens of thousands of lives, we have to.
The four main bottlenecks to accelerating vaccinations are:
- Authorization: You can’t receive a vaccine that the FDA hasn’t authorized or approved.
- Supply: Even with several vaccines authorized, you can’t get vaccinated if there’s a critical shortage of shots.
- Distribution: Even with lots of vaccines available, we still need to distribute them to states, cities, hospitals, and clinics and create eligibility rules that people can understand.
- Demand: Even if the public-health establishment does everything right, that won’t matter if Americans don’t want a vaccine.
How do we unblock these bottlenecks? Based on conversations with several experts and scientists, here are some big ideas to resolve each problem.
Individually, these proposals are bold, perhaps radical, and admittedly controversial. But together they form a coherent U.S. vaccination policy: The smartest way to vaccinate the most Americans by this summer is to try to vaccinate the most Americans we can right now. Solving the present supply crisis will also help alleviate hesitancy—the coming demand crisis—as skeptics will witness the tangible benefits of mass vaccination.
1. Authorization: Approve the AstraZeneca vaccine
“The first out-of-the-box thing I’d do right now is release the AstraZeneca vaccine,” Hotez told me.
The U.S. is sitting on tens of millions of doses of the vaccine developed by the pharmaceutical company AstraZeneca and researchers at the University of Oxford. The vaccine has been authorized for emergency use in the U.K. and the European Union. But the FDA has asked the company for more clinical-trial data to confirm the drug’s efficacy, probably because AstraZeneca’s research in Brazil and the U.K. has been infamously messy.
While stressing that he trusts the FDA’s process in normal circumstances, Hotez said that the rise of the variants justifies the immediate authorization of the AstraZeneca vaccine. He said he has faith in the decisions of our regulatory counterparts across the Atlantic. “The European Medicines Agency and the FDA are the premier regulatory agencies globally, so if the EMA has released for authorization, you have to take that seriously,” he said. “The levels of virus-neutralizing antibodies are not so high, but it’s protective enough. We should use it now.”
One major concern is that AstraZeneca’s trials have not sufficiently demonstrated efficacy among older people. But the way around that is obvious: Just don’t give the vaccine to older people. We could reserve its use for Americans under 45 (who are responsible for much of the virus’s transmission) and free up other vaccines for older populations. Authorizing a vaccine that hasn’t yet passed muster with the world’s most famous regulatory agency has some obvious risks.
Experts I spoke with agreed that the AstraZeneca data we have are sufficient to give the vaccine to young Americans. “I am really anxious about the next two months,” said Ashish Jha, the dean of the Brown University School of Public Health. “What are the risks of getting large numbers of AstraZeneca vaccines out to relatively young people? I think they’re really small, much smaller than most people think. And we don’t know how big the benefit is.” He said that the FDA, along with the National Institutes of Health, could enroll vaccinated individuals in studies to observe its effectiveness.
2. Supply: First Doses First
Even in the absence of AstraZeneca approval, stretching supply immediately could save thousands of lives.
Right now, most states are doling out vaccines in such a way to guarantee that recipients obtain two shots several weeks apart, in line with clinical trials. But some people, such as Alex Tabarrok, an economist at George Mason University, have for weeks been urging the U.S. to immediately maximize the number of first shots administered. Tabarrok calls this strategy “First Doses First.” The idea isn’t to deprive people of second shots, but to give first shots to as many people as possible right now and then trust the supply chain to replenish so that states can deliver second shots in a timely manner.
Imagine you have 100 people and 100 doses of a vaccine. You can do more in the short term by giving all 100 people one dose than by giving 50 people both doses while leaving the other half completely unprotected. The economics writer Tim Harford put it memorably: The two-shot mRNA vaccines aren’t like bicycles, which are great with two wheels but useless with one. They’re more like car headlights: Two are better, but at night you’d rather most cars on the road have one headlight than some two and some none.
The case for First Doses First goes beyond transportation metaphors. The U.K. has inched toward this strategy, as preliminary research suggests that one dose of the AstraZeneca or Pfizer-BioNTech vaccine significantly reduces transmission risk and serious infection, and that a relatively long interval between doses might provide more robust protection than a short one. For the tens of millions of people who have already survived COVID-19, a second dose might not be necessary at all.
Not everyone thinks that a First Doses First strategy is sound. Several scientists I spoke with said they weren’t impressed by the strength of data on virus-neutralizing antibodies from single shots in Pfizer’s and Moderna’s clinical trials. They’re concerned that loosening up the timeline between shots will result in people contracting the virus before they obtain a needed booster. “For Pfizer and Moderna, there just isn’t evidence of efficacy in an extended interval with one dose,” said Joshua Salomon, a medicine professor at Stanford. Vivek Murthy, a co-chair of Biden’s coronavirus task force, told The New York Times that “if you give somebody an insufficient dose of vaccine or don’t boost them in enough time, then you will lose the robustness of the immune response [and] you’ll have to re-vaccinate them, which means ultimately using more vaccine.”
While these are valid concerns, they are not universally shared in the medical community. In a Washington Post essay, Jha and Bob Wachter, the chair of the department of medicine at UC San Francisco, argued that the combination of a vaccine shortage, the rise of variants, and the death toll justifies a bold strategy like First Doses First. Unlike others, they concluded that the Pfizer and Moderna clinical-trial data on first shots were “reassuring,” with 80 to 90 percent effectiveness for at least one month. The single dose protects against disease, they argued, even if we aren’t sure how long strong protection lasts.
“The best argument against First Doses First and other strategies to stretch the supply, like administering half-doses of the vaccine, is that they go off script from what the clinical trials suggest,” Jha told me. “But one way to solve the data shortage is to get more data.” He suggested enrolling willing participants in randomized blind studies on the efficacy of first doses and half-doses. “Running these trials need not be incredibly hard, and I think enough people would be willing to get a shot in exchange for helping us understand how the vaccine works,” he said. “I know I would.”
A legal analogy may also help frame the debate. In disputes about the Constitution, strict constructionists, or originalists, base their decisions on the literal text, whereas liberals treat the Constitution as a living thing with underlying principles that can be applied to an ever-changing society. Reasonable people can demand that we interpret the clinical-trial data with studious literalness. But Jha is not a vaccine originalist. In this crisis, he is seeking to apply what we know about immunology to a dynamic emergency. “I don’t think being a loose constructionist of immunology means breaking away from science,” he said. “This is science. Science is a process, not dogma.”
3. Eligibility: ‘Simplicity, simplicity, simplicity’
Americans who are eager to get vaccinated face glitchy websites and alphanumeric gobbledygook. Across the country, thousands of vaccines are winding up in the garbage, in part because of confusion over who can get a vaccine and when. In some states, eligibility requirements read like advanced military cryptography. The state of Washington is currently in Phase 1B-Tier 1, which is not to be confused with Phase 1A-Tier 2, which, you may have guessed, followed Phase 1A-Tier 1.
“I really don’t like these 1B, 1C guidelines,” Hotez said. “They’re too fussy, too confusing, and too difficult to operationalize.” He said the national policy should be that everybody who wants a vaccine can get one—or they will be placed in a queue to receive a shot when the supply allows. On Twitter, former FDA Commissioner Scott Gottlieb argued for adopting a reservation system that keeps everybody connected to the process. “If you’re young and it’s not yet your turn, the web site doesn’t say ‘check back later,’ it sends you [a] ticket that guarantees you a slot in a future week or month,” he wrote.
Jha offers a similar cure: “Simplicity, simplicity, simplicity is key,” he said. Given the elevated fatality rate of older Americans, he said we should vaccinate everybody over 55 in stages from oldest to youngest. That group includes about 100 million Americans. After that, he’s advocated for a “national or state-based [lottery] that selects a number at random every two weeks, corresponding to the month or last digit of people’s birthdays.” The benefit of a random lottery is that it would be apolitical, and everybody would have confidence that their number would be called eventually.
What about equity? “Even operating with age-based criteria, we can still produce more equitable outcomes by concentrating efforts in areas with higher poverty and more essential workers,” Salomon said. States could, for example, open vaccine hubs in public housing. All the scientists I spoke with said that if the U.S. were to pursue a purely age-based strategy, the best way to make it more equitable would be to pair it with a ground game that targets vulnerable communities with high poverty.
4. Demand: The last bottleneck is human psychology
Through March or April, America’s vaccine emergency is mostly about supply. By June, however, the U.S. will very likely have hundreds of millions more shots available from some combination of Pfizer, Moderna, and (if they’re approved) AstraZeneca and Johnson & Johnson. At that point, our supply crisis may very quickly become a demand crisis. The final bottleneck in this story is human psychology.
One-third of Americans say they “probably” or “definitely” won’t get a vaccine. That figure includes 40 percent or more of several groups, including non-college-educated Americans, Republicans, Black Americans, and people under 45. If that number doesn’t budge in the next three months, the virus variants will likely run rampant in certain pockets of the country where those demographics are overrepresented. “I see very little attention being paid to vaccine hesitancy, which is a mistake,” Salomon said. “It’s an illusion of a period when vaccine demand outstrips supply.”
The media and the government should change the way they talk about the vaccines. Most headlines refer to their ability to prevent infection; for example, the Moderna vaccine is 94 percent effective at preventing COVID-19 illness. But what many people might not realize is that the Moderna and Pfizer vaccines are reportedly 100 percent effective at preventing serious illness and death. As The New York Times’ David Leonhardt noted, out of about 75,000 people who received one of the major vaccines in a research trial, zero died of COVID-19 and zero were hospitalized a month after getting a shot. By comparison, in a typical flu season about 100 out of 75,000 people will go to the hospital. The vaccine cheerleaders should be louder and more absolute: These drugs are sensationally effective, and severe medium-term side effects seem close to nonexistent.
Vaccines, the public-health establishment must stress, serve as reinforcement at every stage of the disease. They protect against infection; for those infected, they protect against severe symptoms; and for those exceedingly rare cases with severe symptoms, they protect against death.
Good arguments matter. Targeted messaging matters more. Hotez is a regular on MSNBC, but he also appears on conservative outlets such as Fox News to share his expertise with an audience that may be significantly more skeptical of vaccination. He needs company. Experts should go on Fox News, Fox Business, Newsmax, One America News Network, conservative radio, and podcasts to talk up the vaccine. Scientists, social-media influencers, and celebrities should also bring the message to younger and nonwhite Americans, who have good reason to be skeptical, given the discriminatory history of U.S. medicine. These vaccines can work miracles, but only if we solve the human challenge as effectively as we solved the viral problem.
“I have reasonable friends and family that are worried about long-term effects,” Jha said. “It’s important to engage them and talk them through how these vaccines are very well tested and, frankly, more closely scrutinized than many things that end up in the market.” Up to now, the development of the vaccines has existed purely in the domain of rare and elite expertise. But the pandemic endgame is a job for everyone—sons, daughters, brothers, and sisters. Science has gotten us this far. The last mile is on all of us.