Debbie Monahan, a school nurse, pulls down Charles Robbins' sleeve after giving him his second shot of the coronavirus vaccine at Surry County High School in Dendron, Virginia. Getting the coronavirus vaccine has been a challenge for rural counties in the U.S. that lack medical facilities such as a pharmacy or a well-equipped doctor's office. (AP Photo/Ben Finley)

I will admit that the American effort to vaccinate its public has been improving, and yet I know I’m not alone when I say that this effort still feels like the latest in a long series of missteps in the Covid-19 pandemic. Even a new presidential administration with a strong and serious approach to fighting the pandemic has been unable to break a patchwork system in which a patient’s likelihood of receiving a vaccine is highly dependent on his or her state and county and on his or her comfort with and access to technology. At some point in the coming months, we are told that there will be a vaccine for all eligible patients. But until that happens, and before we forget just how mediocre this vaccination effort has been, let’s consider two key questions that vaccines have raised about the pandemic. Namely, what do these missteps have in common, and what does this tell us about our government and our country?

To understand some of the challenges surrounding vaccines, it’s perhaps best to start with two perspectives, the perspective of a patient and the perspective of a primary care physician. From a patient’s perspective, the vaccine rollout has been inconsistent. There are areas such as mine in which coordination between local hospitals and pharmacies and the state government has been relatively good and in which, as a result, the percentage of received vaccines which have been administered has been high. In such places, a patient’s impression of the vaccine distribution process may range from satisfaction (if they are easily able to book an appointment at a local pharmacy or a state-run vaccine distribution site online) to downright frustration and anger (in particular for the many patients in my rural region who lack the tech savviness and/or consistent internet access that are both necessary to navigate the process).

From a primary-care physician’s perspective, the vaccine rollout has been often dumbfounding. There are various reasons for this, but perhaps the most important is that primary care offices are where about half of vaccines have traditionally been administered in the U.S. To see one’s own patients struggling to navigate an often byzantine online vaccine sign-up process is bound to be deeply frustrating for any primary-care physician. This becomes particularly frustrating with one’s most vulnerable patients, because in this pandemic the most vulnerable are often the ones least likely to be able to access a vaccine. This includes elderly patients, patients in rural areas, many minority patients and any patients living in or close to poverty. These are the patients who tend to struggle most with access to technology, and they continue to be the ones who we have failed the most in this pandemic.

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An important question that transcends vaccines and which I’ve asked before is, “Where is the clinician in the Covid-19 pandemic in the U.S.?” The sidelining of not only primary care physicians but clinicians in general (and, by extension, patients) has been a theme throughout the pandemic. It has been, in my opinion, one of the reasons behind a still weak public messaging campaign about the virus. The larger subordination of physicians and the needs of their patients to politicians can be seen in the attitudes of political leaders ranging from my own state of New York to the White House. It can also be seen, albeit in a different and more complex form, in President Biden’s geographically homogeneous Covid-19 advisory board, and it can now be seen again in our vaccine distribution effort. 

In short, leaving primary care providers out of the vaccine distribution plan was and continues to be a terrible idea. One of the chief reasons behind this flawed policy has been the cost of an ultracold freezer (for the Pfizer BioNTech vaccine series) for distributing the vaccine. But as of late February this vaccine can now be stored at conventional freezer temperatures for up to two weeks and the Moderna vaccine series never had this ultracold storage requirement. Furthermore, we now have an emergency-use authorization for a third Covid-19 vaccine that can be stored at routine refrigerator temperatures for up to three months. 

Another reason for leaving primary care providers out of the vaccine distribution plan is the complexity of the two shot schedule for the Pfizer and Moderna vaccines. These vaccines need to be logged in a national immunization database, and the second shot must be received on a strict schedule after the first. However, primary care providers are already used to working with such databases and, as many non-Covid vaccines are administered on particular schedules, primary care physicians are already used to delivering vaccines as part of a timetable.

So where are we today? We are in a place where every county within every state has its own vaccine distribution system and where every state has its own rules for receiving the Covid-19 vaccine.  We are also in a place where our own sidelined primary-care physicians are often unable to help us and where, in turn, an unspoken requirement for receiving the vaccine is a familiarity and deep patience with the internet. Even as our vaccination campaign improves, the phenomenal inefficiency and unfairness of the larger U.S. healthcare system has been very clearly shown. This must not be forgotten, and perhaps the best thing that can come out of our failed response to Covid-19 in the U.S. will be a sense of what exactly we’ve done wrong and, with this, a plan for how we will do better the next time a pandemic strikes. 

Let’s begin by acknowledging what we could have done better. For one, we should have allowed existing systems to work rather than creating new ones. This would have meant distributing a large share of vaccines through primary care physicians and then creating a system for capturing those patients who fell through the cracks. Fortunately, there is a process in place for primary-care physicians to administer the Covid-19 vaccine, but the great majority of vaccines are still administered through state and local public health agencies that in many cases have had neither the preparation nor the resources to quickly launch effective and efficient vaccination programs. 

We could also have spent years preparing state and local public health agencies for a pandemic exactly like this one. Such an approach would ideally have involved not just federal funding but also targeted and standardized pandemic training that would have developed strategies for quickly rolling out testing, contact tracing, vaccination and data management programs. This kind of preparation should have been coordinated at the federal level and should have paid particular attention to the most under-resourced health departments. In rural communities, where the post-World War II and post-Hill Burton Act era has been one of public health departments focusing more on provision of healthcare services (largely as a stopgap in rural counties with not enough physicians) and less on population health, there should have been an added focus.

We could also have tried (years ago) to change the power structure in medicine itself. Today’s medical landscape is largely one of big health systems, disempowered and often disconnected individual physicians, large and increasingly restrictive insurance companies that sometimes double as for-profit pharmacy benefit managers, and a rapidly growing biomedical research apparatus in which academic and industry leaders run the show. It is also a medical landscape in which many patients feel, for many reasons, disconnected from and often distrustful of the larger American medical system. This failed relationship between government, industry and academia is a very large subject that far exceeds the scope of this essay, but in brief it involves government leaders, pharma leaders and academic medicine leaders talking to one another but often failing to see grass roots problems. Stated another way, there are groups that talk about us but not among us. One of the results of this has been the ongoing sidelining of clinicians and, by extension, their patients in the Covid-19 pandemic. We’ve seen this at every stage of our national response to the pandemic, from basic community messaging right on down to vaccines. It feels absurd to even state a simple fact, but I will. Patients tend to trust their physicians. They don’t tend to trust politicians, they certainly don’t tend to trust pharma leaders and at least in the case of rural America they don’t even tend to trust academicians. They trust the physicians whom they know, and so to have sidelined primary-care physicians is perhaps the worst of many bad decisions that we’ve made over the past year in the U.S.

Here is a brief list of policy changes that the Biden administration should consider. They are focused both on the short and long term.

  1. Streamline processes for quickly enrolling physicians in federal vaccination programs.
  2. Develop processes for distributing public health messages through local health and community leaders (subtext – acknowledge that federal and national leaders are less trusted than local ones).
  3. Work to revamp public health departments, in particular in rural areas.
  4. Develop a task force to study the interrelationships between government, industry, and academia. Make sure that the majority of this task force is made up of people who are not tied to government, industry, or academia.

This is simply the beginning of what will need to be a much longer list. No matter how such a list takes form, any effort at building preparedness for this and future pandemics will need to start with a consideration of the two perspectives that I mentioned earlier, the perspectives of the primary care physician and the patient. These are the cornerstones of any good health system, and these are the cornerstones that have been the most neglected in both our vaccination effort and our larger response to the Covid-19 pandemic in the U.S. They are also the perspectives that can provide some answers to the questions I asked in the beginning of this essay. What do our missteps in the Covid-19 pandemic have in common? They all include an ongoing failure of larger systems to see individual patients. What does this tell us about our government and our country? We need to have a healthcare and pandemic response system that is both large and small. It must have enough federal oversight and support to ensure that the quality of one’s health care doesn’t depend on their zip code and broadband access, but it must also allow local health systems to have the resources and range to meet the needs of individual patients.

The Covid-19 vaccination failure is complex and multifaceted. It is also something that was predictable and preventable. If we start to look at the pandemic through the right lens, we may be able to learn from our mistakes and make things better both now in the future.

Eyal Kedar, M.D., is a rural rheumatologist who developed an interstitial lung disease clinic in the North Country of New York. He is a leader in the region’s medical-care response to Covid-19. One of his chief interests is in developing strategies for improving healthcare delivery to rural communities. More information is available on his website.   

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