January 19, 2021 Health Officer Statement
Please read or reread my previous statements below to get a better understanding of where we find ourselves today and actions you can take to protect yourselves and your family.
We are in the middle of a great COVID surge. Case rates are 10+ times higher than they were in September and October. Deaths are about 10 times higher as well. The virus is everywhere. Hospitals are bursting at the seams, and they are perilously close to breaking. When the health care system gets to this point, care can be compromised for everyone, irrespective of whether you are worried about COVID or not. While our hospitals are overwhelmed because of a huge number of COVID patients, currently about two thirds of the people in our hospitals are there for reasons other than COVID. We are all exhausted and numb, and complacency is growing. Your individual actions have great consequences. The ability to control this pandemic lies primarily in your hands. Please take every precaution.
What is the Status of Vaccination in the County?
This is a remarkably complex story without a coherent answer that I can currently provide. My understanding is incomplete, but I will try to get you as close to my understanding as possible. I will attempt to explain some disparate pieces that contribute to the answer but do not answer this question as a whole. Although these two things can’t be divorced from each other, I will also try to address this through a COVID perspective alone and not the in context of the considerable and concerning political upheaval that is taking place in the country at this time.
Is California behind other States?
I don’t know. I also believe that the professed medical/public health “experts” and those with more political expertise than medical expertise who are Monday morning quarterbacking these early phases of the vaccine roll out don’t know either. From what I’ve seen, their diagnoses of the issues and their treatment recommendations don’t necessarily ring true. Interpret their musings with caution. My best guess is that the biggest issues in our State are: 1) a supply issue, 2) an “ability to see” problem, which is mainly a data problem that leaves us all adrift in our basic understanding of what’s actually happening, and 3) the federal partnership’s schedule for distribution (Pipeline 1 below) is far behind its allocation.
It’s important to understand the current methodology of how vaccine is flowing into San Mateo County (SMC). There are at least 3 main pipelines. While all vaccine flows into the state from federal sources, the Feds take a cut off the top of the State’s allocation (I believe). This cut flows to the partnership with CVS/Walgreens to vaccinate congregate care facilities, like nursing homes and assisted living facilities, and other federal institutions like the VA and DOD facilities. The second major route is to what the State calls multi-county entities (MCE). These are large health care systems. For our county, these are Kaiser, Sutter, Dignity, and AHMC/Seton. The third, and apparently smallest amount, flows to and through health departments. The SMC health department is given a small weekly allocation (a weekly allocation that has ranged from 100 to a few thousand doses) with no known systematic ability to request more.
Despite what you may have heard, we do not yet have any real understanding of how vaccine is flowing into our county through these three pipelines, except for the small portion flowing to the health department. If you are confused, don’t be alarmed. We are all confused. I share your frustration of not having good, clear, understandable data on the efficiency of the vaccine roll out. There is no single entity that has a good understanding of the whole process. I also know some would like to ascribe blame for their perceptions on how the current situation is unfolding. I wouldn’t know where to correctly ascribe this blame, so unless you have deep knowledge into the underpinnings of this process, how could you? Perhaps it is just a natural outcome of all the dynamics that have led to our current situation. This is not an attempt at an excuse, but I have no evidence that everyone involved in getting the vaccine out isn’t working tirelessly and at the absolute limit of their ability to deal with the cards that have been dealt. We also do not have a good understanding of how many are (and who they are) currently getting the vaccine. This data should be reported to the State’s immunization registry. However, the State’s immunization registry, known as CAIR2, was not designed for this situation, and is not up to this task. Also, many doses just don’t seem to be getting into the system for a myriad of both known and unknown reasons. The State is working on all aspects of understanding the data better and rapidly putting in technological fixes, but this will likely take weeks.
Most of us do not like uncertainty and ambiguity. Uncertainty and ambiguity can create anxiety. But uncertainly and ambiguity are always going to accompany the implementation of an endeavor at this scale, especially in the early phases. Uncertainly and ambiguity will diminish over time, and, of course, we can still get where we’re going without perfect data.
Equity of Distribution
While I believe there was an attempt to be fair, there likely has not been an equitable distribution of vaccine by the State by geography (through the 3 pipelines) across the state. This is evidenced by different groups in different geographies offering vaccine to different tiers at different times. I have no way of knowing if any or all the entities receiving vaccine in SMC were advantaged or disadvantaged by this distribution. As noted, the health department was one of many entities allocated vaccine. Based on that allocation, the health department’s efforts are still focused on Phase 1A. The health department will move into Phase 1B when the vaccine doses it receives for its Phase 1A populations are more complete. Movement from one phase to the next can be quite subjective. Multi-county entity providers (Kaiser, Sutter, Dignity, and AHMC/Seton) may be at a different place with respect to the phases than the health department is AND they may be at a different place than each other based on their allocations. This may seem to cause inequitable access within SMC and it may seem unfair, but there is no way to rectify it in the near term. This too, will work itself out over time.
We are in a textbook rationing situation. We have more demand than supply. Ignoring this fact, or pretending that this is somehow not the case, is not useful. The Feds and the State have attempted to fairly deal with this rationing situation by creating the tiered prioritization scheme, although there is evidence these tiers are slowly being abandoned. Everyone’s experience of having lived through the last 10 months of this pandemic and the current surge has caused the demand for the vaccine to be very high. This rationing situation, in and of itself, creates more demand. Scarcity breeds demand, sometimes frantic demand. Luxury brands and other businesses use this concept to their benefit all the time. Some portion of the extraordinarily high demand is related to this phenomenon. Another dynamic that occurs in rationing situations such as this is called a zero-sum game. For one person to win, another has to lose. If I get a bigger piece of pie, you have to get a smaller piece. For every person not in the appropriate tier who “jumps the line,” it means that some 89-year-old widow may not get the lifesaving protection she needs. Please keep this is mind as you schedule your appointments. Also rationing situations give rise to all types of fraud and quackery. There are already a plethora of frauds being perpetrated on all us now from multiple sources. Be aware of all the schemes and frauds that are likely to develop around COVID testing, treatment, and vaccination. If it too good to be true, it is, indeed, too good to be true.
The Main Constraint
Despite what you may have heard, which would lead you to believe the problem is one of distribution to the vaccine recipient (patient), the actual currently insurmountable problem is that the supply is massively inadequate for the demand. We all want to go faster, but until this supply issue is ameliorated, we won’t be able to. The solution is to ramp up production. I don’t know how feasible this is.
The MCE’s (Kaiser, Sutter, Dignity, and AHMC/Seton) have a very heavy lift. The vast majority of folks here are insured. Probably around 98% of folks in SMC are insured, and somewhere between 70-80% are covered by MCEs. The MCEs need to fully step up and play a major role in this effort. I have no doubt they are, right now, putting every available resource into getting this job done and that they will do even more when they are able.
Pharmacies are also likely to play a large role. Pharmacies are well distributed throughout the county. All pharmacies need to be quickly brought on line to assist in this effort.
The County has direct responsibility for about 100,000 – 150,000 people in the county, mainly through the provision of direct medical services by the hospital and clinics division, through various other medical and social support programs, and to those who are vulnerable, disenfranchised, and have no access through any other means. I feel strongly the County needs to understand its role and fulfill its role. This means that while the County should be a good partner, it will not be the main provider of vaccines to the general population. Deviating from its main role means these folks are put further back on the bus, and I think all of us should find that intolerable.
My advice to the State is to quickly move to an “any door is the right door” strategy. That means all people who can vaccinate – MCEs, pharmacies, private doctors, private vendors, the County, the State, and others – need to be somewhat agnostic to their existing relationships. While I believe we need to move to this strategy as soon as we can, we are not even close to this yet, and even with this strategy the current massive constraints in our vaccine allocation wouldn’t allow us to vaccinate much faster anyway. But with less supply constraint, it would allow for more speed, efficiency, and probably equity. A number of regulatory and legal challenges (HR, technology, liability, etc.) will need to be overcome, but I believe it is the most efficient strategy and is the ideal future state with regards to mass vaccinations.
The Cold Hard Math
To vaccinate most of the population adequately by July, all the entities in the county need to vaccinate 40,000 people per week, or about 6,000 every day. The current supply coming to the various entities in the county from the state appears to be about one tenth this rate. Even if there were less of a vaccine supply constraint, it was always an unrealistic expectation to think everyone could be vaccinated at once. But this is demand outstripping supply, and the supply constraints won’t last forever. At some point this year, probably before the fall, the vaccine will be available to everyone who wants it. But even if supplies improve, the fact remains that some people who want their vaccine tomorrow will get them on July 31st.
Would a “free-for-all” distribution system work better? There is more talk of this in the press recently. This strategy can be considered the exact opposite of a strict prioritization schema. It puts more people in direct competition for vaccine. A “free-for-all” strategy can be considered along a continuum. I think there are some pros and cons to this strategy. The State, who would make a strategy decision such as this, seems to be moving in this general direction with the recent consolidation of Phase 1A and the current consideration to consolidate Phase 1A.
The argument for: We get to herd immunity more quickly by just getting the vaccine into any arm that’s available. From a population perspective, this does make some sense. It makes more sense with an unconstrained vaccine supply than with a constrained one.
The argument against: As I see it, this strategy doesn’t follow basic public heath principles, is intellectually lazy, is politically expedient, is a bit too Darwinian, and is ethically weak given our current constraints. The main losers in this strategy are the elderly, others who are at either higher personal risk or have higher exposure risk, and the concept of equity. There are significant trade-offs in this strategy. While appealing on its face, I am not a fan of this strategy.
Some Current Unique Cultural and Technological Issues to Consider
Our culture has undergone significant changes since the last time we attempted mass vaccinations on this scale, mainly the mass polio vaccinations in the 50s and 60s. (I don’t think the last pandemic, H1N1, is too comparable to our current situation). Some of the biggest changes are around our expectations about being able to obtain knowledge and our expectations about our ability to obtain things. The big tech companies have led us to believe we can have instantaneous gratification as to obtaining knowledge, and almost immediate gratification in obtaining things. We tend to get frustrated when these unrealistic expectations are not met. We’re losing the ability to tolerate delayed gratification. This requires an attitude adjustment from all of us. Another new issue is data entry, a very resource intensive and cumbersome endeavor that does slow things down. And, while I don’t have objective data, subjectively our culture appears to have become less collective in its orientation and much more self-centered.
Getting a vaccine will not free you from all the personal and public restrictions that will continue. It is not free pass for you to get out of our situation. Masking, social distancing and not gathering will be a way of life for us for some time to come, probably at least through most of 2021.
Two pieces of advice, neither of which fix any of the issues above but may help you get through this with a bit more ease. Attitude is key.
Please practice gratitude. That we even have vaccines this early in a pandemic is beyond amazing. Think of how much worse off we’d be without this option. We’d be in our current situation for, potentially, years. With all we’ve gone through so far, the best modeling estimate is that 80% of SMC’s population is still susceptible. Can you imagine the physical and economic carnage and death we’d experience by having to reach herd immunity through the route of natural infection?
Please practice patience. You’ve made it this far in a pretty bad year with very bad circumstances. We are getting much closer to something resembling normality (at least related to COVID). You will be able to get your vaccine this year. Hang in there.
This statement was written at a point in time when the things stated were true, but things are changing quite quickly. As this situation unfolds, if you want updated information on vaccine eligibility and distribution, I suggest you first check with your health care provider. You may also check the SMC Health COVID vaccine website at: smchealth.org/covidvaccine for regularly updated information.
Scott Morrow, MD, MPH, MBA
San Mateo County Health Officer