During the election campaign, Joe Biden promised to “move heaven and earth” to improve the distribution of coronavirus vaccines in the US, repeatedly criticising his predecessor for failing to come up with a rollout plan.
But now that he is president, Mr Biden is not promising a significant increase in the rate of vaccinations, leaving some to question whether the strategy his officials unveiled this month is radical enough.
“The Biden administration said it inherited no national distribution strategy, but if that is the case, how did we get to 1m vaccinations a day, and why are we still targeting that number?” asked Leana Wen, a public health professor at George Washington University. Ms Wen praised the administration’s new plan, but added: “We should be aiming for at least 2m doses a day, if not 3m.”
The US was the first country in the world to authorise two vaccines, but it has fallen behind in the international race to get jabs into arms.
According to figures from the US Centers for Disease Control and Prevention, the country has administered 26.2m doses, making it the fifth-fastest in the world to vaccinate people on a per capita basis. The US is ahead of every EU country, where supplies have been constrained, but trails Israel, the UAE, the UK and Bahrain.
Mr Biden has promised 100m vaccinations will be administered in his first 100 days in office. But this level would be reached even at the pace achieved during Donald Trump’s final days in office.
Some members of Mr Biden’s team have now warned that the public should not expect a step-change in the rate of vaccinations any time soon.
“We inherited 57 different distribution strategies, some of which were working and some of which weren’t, and that’s what we had to work with,” said a senior administration official, referring to the plans adopted by the different states and territories.
The centrepiece of the Biden plan is better co-ordination between the federal and state governments, after the Trump administration largely left it up to states to decide how to get vaccines from central distribution hubs to local communities. CDC data show that just over 50 per cent of vaccine doses that have been distributed to states have been administered, suggesting the problem in some places has more to do with logistics than supply.
One significant change introduced by the Biden administration is that the federal government will now guarantee a minimum level of supply to states and inform them of how much to expect three weeks in advance.
Cassie Sauer, chief executive of the Washington State Hospital Association, said: “Our biggest struggle has been predicting what is coming. Some weeks, hospitals were getting 140,000 doses, and others 80,000. Often, vaccination sites didn’t even know if they were going to get the Pfizer or Moderna vaccine.”
The Biden administration has also promised to use the federal government’s resources by involving the National Guard in logistics, as well as helping set up mass vaccination sites and supplying doses directly to pharmacies, clinics and community centres.
It is not, however, planning to use the National Guard to administer the shots. Nor is the federal government going to take over the distribution process from the states, as urged by some in Congress.
The Biden plan will continue to rely heavily on large pharmacy chains such as CVS and Walgreens, which have been criticised for the slow pace of vaccinations in nursing homes, where they were contracted to lead the distribution effort. Nursing home staff said they have struggled to make appointments for residents, while Mississippi’s state health officer described the companies’ performance as a “fiasco”.
West Virginia, which has vaccinated more doses per capita than any other state, said it had done so by bypassing pharmacy chains. “If we only opted into the federal programme [with the pharmacy chains], we felt we would be limiting our ability to distribute and administer the vaccine to the population in need,” an official said.
Another pillar of the Biden strategy is to boost vaccine supplies by invoking the Korean war-era Defense Production Act, which enables the government to take over corporate supply chains and redirect supplies.
But officials said they cannot simply force drug companies to make more vaccines. “People think we can use the DPA to march into a plant and simply take it over,” said the senior administration official. “But actually it is a much more subtle tool than that.”
Instead, the Biden administration has invoked the act to make sure the federal government is first in line for “low dead volume” syringes, which can extract six doses from each vial of Pfizer’s vaccine rather than five.
“You cannot ask Ford to make mRNA-LNP vaccines,” said Drew Weissman, professor of medicine at University of Pennsylvania, referring to the technology used in the vaccines that have been approved. “It requires manufacturing space and abilities and I suspect Moderna and Pfizer have obtained all that is available.”
Finally, Mr Biden’s team has reiterated the advice given in the final days of the Trump administration that anyone over 65 should be eligible for a vaccination. While that has triggered a jump in demand, it has also caused concerns that the most vulnerable communities, including African Americans, might miss out.
Data from 17 states suggest that black Americans contract and die from Covid-19 in disproportionately high numbers, but are receiving fewer vaccinations. “We are definitely concerned that people in the suburbs are simply driving into poorer areas to get vaccinated because their kids are clever and they have cars to take them,” said the senior administration official.
Members of Mr Biden’s team cautioned that the measures they have taken are meant to restore order to the distribution system rather than transform it overnight. Experts said even if the new administration has not yet solved all the problems it faces, simply having a federal strategy should make a difference.
Tom Frieden, a former CDC director, said: “We didn’t have a plan before, and now we do. A plan is better than no plan.”