Could the U.S. Have Saved More Lives? 5 Alternate Scenarios for the Vaccine Rollout

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About 100,000 people have died of Covid in the United States since February, after vaccine distribution was well underway.

A nurse prepared a dose of a coronavirus vaccine in West Orange, N.J., in April.
Credit...James Estrin/The New York Times

Sarah MervoshAmy Harmon

June 17, 2021

There is much to celebrate about America’s vaccine rollout.

The government bet big on vaccines, committing to buying millions of doses even before a vaccine was approved. Now, about 44 percent of the United States population has been fully vaccinated, far more than many other countries. While other nations struggle to obtain vaccines needed to stop outbreaks, the United States has a surplus, and is experiencing the fewest cases, hospitalizations and deaths since the beginning of the pandemic.

Yet for all of the American successes, 100,000 people have died from the virus since February, after vaccine distribution was well underway. Many more have been infected and could face long-term medical problems.

As the nation reopens and calls emerge to investigate lessons learned in the pandemic, The New York Times asked more than a dozen public health experts, economists and bioethicists to reflect on the vaccine rollout. Was the American approach as effective as it could have been? What, if anything, could have been done differently?

The Trump and Biden administrations debated numerous options, including ideas raised by the experts. There is by no means universal agreement about what should have been done, and no way of knowing with certainty whether different vaccination tactics would have resulted in fewer deaths.

Still, with the benefit of hindsight, experts pointed to several areas where the United States might have taken another approach. Here are five alternate scenarios:

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A mass vaccination site in Bayamón, P.R., in April.
Credit...Erika P. Rodriguez for The New York Times

By now, most people are familiar with the Pfizer and Moderna timelines: An initial dose of the vaccine, followed by a second shot three to four weeks later.

Some experts suggest that the United States could have delayed second doses of the vaccine for several weeks and instead given out first shots more widely to high risk people, in order to give some protection to more people. One dose of the Pfizer or Moderna vaccine offers 80 percent protection after two weeks, compared with 90 percent from two doses, according to a federal report on efficacy under real world conditions. (The Johnson & Johnson vaccine, which was authorized later, comes in a single shot.)

“We spent a lot of February providing a lot of second shots to people who had gotten their first shot in January, when there were a ton of high risk people getting infected and dying, for whom a single shot would have made a big difference,” said Dr. Ashish Jha, dean of the Brown University School of Public Health.

The delayed shot approach, which had not been rigorously tested, particularly over time and against virus variants, was hotly debated. Federal officials ultimately deemed it too risky, and Dr. Anthony S. Fauci, America’s top infectious disease expert, said he was opposed.

The approach, though experimental, was used in Britain, where officials delayed second shots by up to 12 weeks. (Britain also organized its rollout largely by age, starting with the oldest most likely to die from the virus and continuing in descending order.)

Deaths in Britain have plummeted — the country recently recorded a day with zero new deaths — and a recent study reported an intriguing finding: People who received the second shot 12 weeks later actually produced more antibodies than those who received their second shot after three weeks.

Still, Britain has seen a rise in cases in recent weeks and is now accelerating second doses in order to combat an outbreak of the Delta variant, which is more contagious and more likely to infect people who have had only one shot.

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Credit...Elijah Baylis for The New York Times

Some people have argued that the nation should have prioritized people who were most likely to spread the virus, rather than those most vulnerable to dying from it. (Indonesia tried vaccinating younger people first.) But the experts we spoke with generally said that the United States was wise to prioritize older people, who have died from Covid at much higher rates.

“If our goal is to save the most lives, we need to think about who is most likely to die,” said Nancy Jecker, a professor of bioethics at the University of Washington School of Medicine. “Age is a pretty reliable predictor.”

Indeed, since vaccinations began, deaths among people 75 and older have fallen substantially, with particular progress in nursing homes.

While doses were initially in short supply and many seniors faced problems accessing the vaccine, some experts said opening shots to a slightly wider group could have brought equity, arguing that higher age cutoffs benefited white Americans, who have a longer life expectancy than their Black peers. When states opened up eligibility to the general population, some began with a threshold of 75 or 80, while many went with a cutoff of 65 and older.

“Even at the beginning, we should have started at 60 and above, or 65 and above at least,” said Saad Omer, director of the Yale Institute for Global Health.

In recent months, people aged 50 to 64 have made up a growing share of Covid deaths, underscoring the remaining risk to this slightly younger group when unvaccinated.

Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics, also favored lowering the age limit to protect older people in communities of color or with lower incomes.

“It is not only how many lives,” she said, “but whose lives.”

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Credit...Lauren Justice for The New York Times

And, according to a U.S. census survey released last month, among Americans open to being vaccinated, the higher a person’s household income, the more likely the person was to have received a shot. Of 30 million “willing but not yet vaccinated’' people, more than 80 percent did not have a college degree, according to an analysis of the census data.

To address socioeconomic equity, the C.D.C. recommended prioritizing what it called “frontline essential workers,” including grocery and transit workers. But that proved too complicated for many states, and some experts said the C.D.C. should have pushed for a more direct approach, such as targeting disadvantaged areas, a tactic that was tried in a limited number of places.

“We could have been more intentional about planning to avoid those disparities,” said Dr. Jewel Mullen, associate dean for health equity at Dell Medical School. “The maps we had last spring and summer showed where people were dying and that could have been good enough to say, ‘We know where we need to go with vaccines.’”

One data analysis by researchers at the University of Texas at Austin suggests that it would have been possible to save lives simply by targeting vaccines early on to the ZIP codes hardest-hit by Covid-19. In Austin, as in many places, those same ZIP codes are also the poorest. Such a strategy might not have been politically tenable, but Lauren Ancel Meyers, the epidemic modeler who conducted the study, said it likely would have prevented some hospitalizations and deaths across the whole city.

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Credit...Brett Carlsen for The New York Times

After swiftly passing more than $2 trillion in three separate bills in March 2020, Congress haggled for months over the details of more legislation to address the pandemic and needs across the country. A final package, including billions of dollars for vaccine distribution, did not become law until just after Christmas — after the Pfizer and Moderna vaccines had already been authorized for emergency use.

“Had that money come earlier, yes, health departments could have scaled up operations earlier and that could have made a difference,” said Dr. Adam Gaffney, an assistant professor at Harvard Medical School and a pulmonary specialist.

At the same time, the early rollout was chaotic at a critical moment, when more than 2,000 people were dying every day.

Logistical bottlenecks meant that available shots were not immediately delivered into people’s arms, said Dr. Nathaniel Hupert, a physician and public health researcher at Weill Cornell Medicine. Such delays were tantamount to losing the benefits of compound interest in your savings account, he said.

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Credit...James Estrin/The New York Times

When a polio vaccine became available in the United States in the 1950s, the March of Dimes, an organization that had been affiliated with President Franklin D. Roosevelt, made a major advertising push, with posters featuring young children who were most at risk of being infected, recalled René Najera, editor of the History of Vaccines project at the College of Physicians of Philadelphia. To boost public interest in the vaccine, Elvis Presley got vaccinated backstage at “The Ed Sullivan Show.”

“It was seen as a patriotic thing,” Dr. Najera said.

Today, the government has planned public education efforts, but the issue has remained fragmented and divisive.

Former President Donald J. Trump, whose administration had arguably its biggest success of the pandemic in quickly producing vaccines, did not use his political stardom to convince skeptical members of his base. He got vaccinated in private before leaving the White House, and today, Republicans remain less likely than Democrats to get vaccinated.

The Biden administration has been vocal in its support for vaccines, but has also been unable to overcome hesitancy on the part of many Americans, including some who are skeptical of government authority, and others who are suspicious of a medical establishment because of its record of racial inequity. The country appears likely to fall just short of President Biden’s goal of having 70 percent of adults at least partly vaccinated by July 4.

Debra Furr-Holden, associate dean for public health integration at Michigan State University, attributed at least some of the resistance to communications failures, starting with the branding of Operation Warp Speed, the federal effort to develop a coronavirus vaccine quickly. “When people heard ‘warp speed,’ you know what they heard? Corner cutting, skipped steps, missed steps, quick and dirty,” she said.

She said the United States should have launched a mass literacy campaign on vaccines long before they were produced and made it far easier to get vaccinated once shots were available. “We should be vaccinating people on their front doorsteps,” she said.

Basic information about vaccine delivery, like the fact that the federal government was footing the bill, was also often in short supply, said Dr. Rebecca Weintraub, a vaccinator and assistant professor at Harvard Medical School.

“People would be constantly coming up bringing piles of identification and cash,” Dr. Weintraub said. “We should have had massive billboards from the beginning: ‘THE VACCINE IS FREE, YOU DON’T NEED AN I.D.’’’

And then there is the cool factor. Not everyone will be convinced by health facts and testimony from experts like Dr. Fauci, said Stacy Wood, a marketing professor at North Carolina State University, who has examined how to market to people who are disinterested, but not opposed, to the vaccine.

“Instead of top experts, you might give them celebrities,” she said — and a variety of celebrities at that. “Even Elvis Presley didn’t convince everyone.”

Emily Cochrane, Danielle Ivory Benjamin Mueller and Sheryl Gay Stolberg contributed reporting.

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