Operation Warp Speed – the Last Mile Problem

I’ve spent the last month as a Peace Corps volunteer deployed to support a mobile vaccination clinic in rural Maine. The mission is to reach underserved communities to make it as convenient as possible for everyone to get the shot.

“About one third of U.S. ‘customers’ are unsure that they want the product and are worried that vaccination might be made mandatory”, according to research by Thomas Lee and Alice Chen.* In Maine 65.2% of the people have been vaccinated with at least one dose at this writing. We hear a lot of stories about the other 34.8%. They are holding out or reluctant or Trump people or conspiracy theory adherents or anti-vaxers.

Well, here are a few of those stories.

  • The 97-year-old woman who told us, “I could have gotten the vaccine in January but I needed my daughter to take me so I had to wait for her to get the shot. I’m happy now. In two weeks, I can see my grandkids again.”
  • The construction guy who told me, “I’m the last in my family to get it. I’m in the building trades and we have been just so busy there was never an easy time. I heard about your clinic at the beach on the radio – J&J one and done, no appointment needed, no waiting. That was for me.”
  • The young guy that worked in the paper mill in Madawaska who complained that, “my foreman told me I had to keep wearing this damn mask unless I got the shot. It is 98o in the mill and I can’t stand this mask any longer.”

Then there was Jason my Uber driver one day in Portland. As I explained to him why I was in Maine he remarked, “You’re never going to get me!” He had studied the problem. He knew the vaccine was still an experimental drug. He discussed the numbers on Homeland Securities’ VAERS (Vaccine Adverse Event Reporting System) database. He was as fully informed as anyone I’ve met and yet he made a different choice. He said he might consider it when the FDA approves the vaccines beyond emergency use.

On one level the problem seems simple. We know who we vaccinated (unless they deceived us as no ID is required here) and the state must have some notion of who is here from voter rolls, the census and other databases. Compare the two and you find the last mile target market and a relatively simple process to reach out to them directly.

Maine Center for Disease Control Director Dr. Nirav Shah, explained that the state would never take that action. It was more likely that they would push the information to local health care providers. This makes sense as surveys show twice as many people trust their doctor over the government (67% vs. 37%).

But, therein lies a different problem. Many of the customers I met over the last month have not had any interactions with the healthcare system in years. “We all went to Dr. Johnson when we were kids but he died about 20 years ago and there hasn’t been a doc in town since then.”

From a marketing perspective it should be an easy sale. I have a product that can save your life and it is free. You can even get a coupon for 50% off your beer at the microbrewery next door, or a free hunting license or $10 gift card at the local super market. Even better, Maine just announced a lottery where you can win up to $1 million if you get vaccinated.

Yet, it is still a battle.

With all the worry about mutations, the mutations no one paid enough attention to were those in public perception. Accordingly to a recent Gallup poll only 9% of Americans have a “great deal of trust and confidence in the mass media.”  Having lost so much credibility over the last five years, the press is no longer seen as a reliable source of information.

The medical and scientific community struggled to understand the disease and was rarely willing to admit what they didn’t know. Studies are published in learned journals like the Lancet then retracted because the data was fraudulent. Similarly peer reviewed studies contradict the ones we read a few months ago.

The bobbing and weaving about masks and assorted treatments did not enhance public confidence.

Layered on top of all this chaos was the inept curating by the media of every shift in the story. They could not get their arms around some basic concepts in epidemiology preferring to view every aspect through a political lens. When the conversation shifted to the notion of herd immunity, the lack of numeracy in the fourth estate became apparent.

The percentage of the population required for herd immunity depends on the nature of the population, their behavior and the replication rate of the disease, known as R0 (“R naught”). The current estimate of the R0 for COVID-19 is between 2.5 and 3.0, meaning each infected person will infect 2.5 to 3.0 others in an unprotected population. As people get sick and recover or get vaccinated, the size of the susceptible population decreases and the “effective” R0 goes down. Once it is under one, the disease will eventually die out due to a lack of hosts to infect.

The formula for herd immunity is simple: the protected population must be greater than: 1 – (1/ R0) or 67% for an R0 of 3.0. For example, the R0 for measles is about 18 meaning the herd needs to be 94% protected.

Clearly the level of protection now varies widely in the U.S. In Portland, Maine, it may be 70% + but upstate in Calais the situation could be very different. Based on what I experienced and the medical journals I’ve read it seems pockets of under-protected populations will exist in the U.S. possibly for years.

While we struggle to complete the last mile, each un-vaccinated individual remains like a mini-Wuhan Virology Lab cooking up new and potentially more dangerous mutations of the virus.

The resources needed to combat these outbreaks are rapid testing and genetic analysis, as well as, effective contact tracing. In short, all the tools we wished we had in place when the virus first turned up here in late 2019. At that time, of course, the WHO and others were not conceeding that the virus was a problem.

Still after hundreds of thousands of deaths and appearing to have the worst system in the world, there is light at the end of this dark tunnel for the U.S. The rapid vaccine development project coordinated and bankrolled by the prior administration as implemented by President Biden’s team has so far left the U.S. as one of the leaders in recovery after COVID-19.

-Jim Anderson

*Last-Mile Logistics of Covid Vaccination — The Role of Health Care Organizations

List of authors: Thomas H. Lee, M.D., and Alice H. Chen, M.D., M.P.H.

 

 

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