Why America's vaccine rollout was a total disaster - and what it means for the next few months

• The US developed coronavirus vaccines in record time last year.
• But the process of getting those shots into people's arms is going horrendously slow, just as more Americans are dying from the virus than ever before.
• The blame lies with a president who either forgot — or didn't care enough — to finish off the country's vaccination plan, setting the US on the back foot.
• There are promising signs that this vaccine drive is going to accelerate soon.
• But the delay has already caused thousands of deaths, and it will be a challenge to come back from.

On a hot and swampy day last May, President Donald Trump strode out to the lawn of the White House to make a dramatic announcement.

The world, at that moment, was more than four months into a pandemic. Some 80,000 Americans had been killed by COVID-19, and another 1.5 million had tested positive for the virus.

But now, Trump declared, the end was in sight. His administration would not only marshal scientists and researchers to develop a vaccine in record time, it would also roll out the vaccine at an unprecedented pace.

"It's called Operation Warp Speed," the president said. "That means big, and it means fast. A massive scientific, industrial, and logistical endeavor unlike anything our country has seen since the Manhattan Project."

Like the "wartime president" he had recently proclaimed himself to be, Trump announced he was putting a four-star general in charge of the entire operation - to "manufacture and distribute a proven coronavirus vaccine as fast as possible."

"That means the full power and strength of the military," the president vowed. "That means the logistics, getting it out, so that everybody can take it."

To his credit, the president made good on his promise to produce a vaccine before the end of 2020. But so far, what should have been the simplest part of the operation - the rollout of the vaccine - has been a deadly and uncoordinated disaster.

There has been no show of military force against the virus, no marshaling of troops to deliver vaccines and save lives. Instead, the work of vaccinating the entire country has been left to overburdened hospitals, understaffed health departments, and mom-and-pop pharmacies.

Operation Warp Speed, which promised to inoculate 100 million Americans in 100 days, vaccinated fewer than 12 million people in the first month. Most Americans remain confused about if, when, and how they may get vaccinated. All while the death toll from COVID-19 has soared to record levels.

Never before, when presented with a national crisis of this scale - not during World War II, not after the terror attacks on 9/11, not even the last time there was a pandemic, in 2009 - has the federal government failed to coordinate a national response.

There is only one person to blame, and Americans will be paying for the mess he created for months to come.

"This is a failure of the president," Scott McNabb, a professor of public health at Emory University who served as an epidemiologist with the Centers for Disease Control and Prevention, told Insider. "The United States was supposed to be the most prepared country for a pandemic. And we are doing the worst - that is shocking."

The lack of federal coordination was no accident. It was a calculated decision on the part of the Trump administration to leave each state to develop its own plan for the rollout, with little guidance and few resources from Washington. The result has been a catastrophe that has unfolded in slow motion, as state and local authorities have scrambled to implement what Trump promised would be a military-style campaign to save lives.

"You know, it's the Wild West out there," said Dr. Camara Jones, past president of the American Public Health Association. "It's sort of the opposite of an equitable distribution plan, if there were a plan. But there's no plan! No plan."

States were left on their own to figure this out, and now there is no quick fix for the resulting mess

The US Constitution gives primary responsibility for public health to the states, not the federal government. But that doesn't mean that Washington can't step in during a national emergency to protect American lives.

The Trump administration could have formulated a cohesive vaccination plan for the entire country, or at least a framework that states could opt to follow voluntarily. Instead, it asked each state to independently develop and submit its own COVID-19 vaccination agenda. By taking what amounted to a "states rights" position to confront a public health crisis of unprecedented proportions, the administration effectively abdicated any responsibility for delivering the vaccine it had rushed to manufacture.

"There's no federal response," said Dr. Peter Hotez, a professor of pediatrics, molecular virology, and microbiology at Baylor College of Medicine. "The 'philosophy,' if you can call it that, was the states have to be in the lead, and the federal government will provide backup support. But the states never had the intellectual horsepower and ability to manage something this ambitious. There are times when you need federal intervention."

The rollout could have been coordinated by well-established mechanisms within the federal government. The Department of Health and Human Services is empowered to issue recommendations and protocols, and the CDC has long offered guidance to local authorities about how to handle deadly diseases in their jurisdictions. But the vaccination "playbook" that the CDC provided to states last fall is little more than a laundry list of generalities.

"State governance structures vary from centralized to decentralized," the playbook reads. "Regardless of the jurisdiction's governance structure, it is imperative that state and local authorities combine and coordinate efforts."

The CDC, according to the Washington Post, did press the administration to give it the green light for a nationwide campaign to promote vaccine awareness. Given that millions of Americans remain skeptical of the vaccines, such a campaign was essential to ensure a worried public that the vaccines are safe, and to let people know where and how they could receive a shot.

"That's where the federal support could come - giving local leaders guidance on how to do this," McNabb said. "Normally it should happen smoothly, quickly, without any controversy, and with an intent to try to get as many people vaccinated as possible."

A hodgepodge of different approaches by states, with most moving far too slowly

But that national campaign never happened, because the top brass in Washington would not endorse it. Local health departments, which were already stretched to the breaking point by the pandemic, were ultimately provided no blueprint to follow for how to move quickly and save lives.

As a result, the vaccine rollout has descended into chaos. States adopted a hodgepodge of approaches to distributing the vaccine, many of which made the process needlessly complicated and inefficient.

New York enacted strict rules and million-dollar fines to ensure the vaccine was distributed fairly, on the basis of need. But the sanctions, meant to prioritize healthcare workers and nursing home residents, ended up being too burdensome once the multi-dose vials were popped open and needed to be used up quickly. Vaccines that many New Yorkers gladly would have taken ended up going straight into the trash.

Some states proved unable to administer all the vaccines they were given. In Texas, there were so many unused doses that panicked health officials sent out a letter on Christmas Eve urging providers to "push forward aggressively with administering all the vaccine." Other states didn't receive the supplies they were promised: Oregon, which expected to get more than 40,000 doses on Christmas week, ended up with only 25,000.

A lack of reliable information sowed panic and distrust. When word spread on Facebook in mid-January that there were 400 doses available at a 24-hour distribution center in Brooklyn, hundreds of residents made a wild dash to the distribution center - only to be told that the report was "bogus." At the same time, about a third of healthcare workers in the city - front-line responders who had struggled for months to get proper protective gear and pandemic support - refused to take the vaccine, citing concerns about its safety.

"The message shouldn't be: Here's the vaccine, you better take it," Jones said. "It should be: Here's the vaccine, we know there are questions, we will answer your questions."

In Florida, where everyone over 65 has been eligible for vaccination for weeks, international tourists and elite snowbirds have been flying in for their shots, even though some elderly residents are still waiting at home for their turn. And because each county in the Sunshine State is taking its own approach to the rollout, the availability varies wildly.

Nancy Goldstein, who recently got her first shot of the Moderna vaccine at a drive-thru site in Manatee County, says her good fortune was all happenstance. "It was only by dumb luck that my spouse and I managed to get an appointment," she wrote Insider in an email. "I saw a headline in a random email from a local newspaper to which I don't subscribe."

Meanwhile, seniors elsewhere in the state are spending hours waiting in line - some even camping out overnight - only to be sent home without a shot. Other counties, swamped with hundreds of calls every second, have resorted to using Eventbrite to sign people up for vaccinations. Only the tech-savvy make it to the head of those lines.

The federal government's Operation Warp Speed has shipped nearly 30 million doses of vaccines to the states. But so far, only about a third of those shipments, 12.2 million doses, have made it into people's arms. On a per capita basis, Alabama has done the worst job of rolling out the vaccine: just 2% of its residents have been vaccinated, even though the state has received nearly enough doses to begin protecting 10% of all residents.

A few states - and other countries - are getting it right

In the midst of all the chaos and confusion, a few states have figured out ways to get the vaccine out on their own.

West Virginia, which is currently leading the country when it comes to per capita vaccination, spent $260,000 in December on a statewide media campaign - not to push people to get vaccinated, but rather to provide them with a reliable source of information about how the vaccines were developed and how to get them. The state also leveraged its network of local pharmacies, which already had existing partnerships with nursing homes and healthcare providers, to administer the shots. As a result, West Virginia has administered more than seven doses per 100 residents - compared to the nationwide average of only 3.6 doses.

Other states with high vaccination rates also relied on proven networks to administer the vaccines. North Dakota, like West Virginia, used local pharmacies to quickly vaccinate nursing home residents and healthcare providers. South Dakota utilized its statewide system of 32 public "points of dispensing" to quickly pop up and efficiently coordinate vaccine sites and drive-thrus, while Connecticut hired a consultant from McKinsey to organize its statewide vaccine distribution and "ensure access to COVID vaccine for every person living in Connecticut."

Other countries have also surpassed the United States in getting the vaccine into the arms of their citizens. Israel, the world leader in per capita coronavirus vaccinations, is on track to vaccinate its entire population by the end of March, thanks to a well-coordinated health system, a prime minister willing to pay a premium for fast access to vaccines, and a flexible distribution plan that almost never wastes an extra dose. The United Kingdom, where the National Health Service has set up a system to notify residents when it's their turn to be vaccinated, has already vaccinated 5% of its population, compared to only 3% in the US.

Pharmacists can't vaccinate the entire country on their own

Public health experts, hospitals, and pharmacists have all warned the federal government that it needs to vaccine far more Americans, and quickly, if the country is to have any hope of achieving herd immunity.

"Our only hope now, given how much this virus is accelerating, and causing deaths of 4,000 a day, is we need to vaccinate the American people at the rate of 1 million to 2 million per day for every day from now until the end of August," Hotez said, a calculation which aligns with estimates from the American Hospital Association.

The National Association of Chain Drug Stores estimated this week that working together, the nation's pharmacies could distribute 100 million doses of per month. But experts stress that won't be enough of a push, on its own. And it isn't happening yet.

"The private pharmacies, and the hospital chains, that's just the start - that can't be the whole enchilada," Hotez said. "We're going to need another big piece on top of that."

Some states, including New York and New Jersey, are beginning to undertake a massive effort to use sports stadiums and other big, open-air venues as mega-sites for vaccine distribution. In Arizona, the state has opened a 24-hour vaccine site at State Farm Stadium outside Phoenix.

But larger venues will require more people to administer the vaccine - something most states just don't have.

"You've got to hire people," said Dr. Ashish Jha, dean of Brown University's school of public health. "That's the kind of thing where FEMA and the US Public Health Service can bring people to bear - if the federal government were willing to partner with states to do that."

Help appears to be on the way.

President-elect Joe Biden has announced plans for a full-scale vaccination blitz. The incoming administration is vowing to triple America's public health workforce, stand up FEMA-supported "community vaccination centers" nationwide, and reimburse states that use their National Guard troops to administer shots. All of this, Biden says, should enable America to vaccinate 100 million people during his first 100 days in office.

But even if the Biden plan is successful, the dramatic acceleration of transmission over the past month - and the introduction of a new, faster-spreading variant of the virus - will make it even harder for public health officials to bring COVID-19 under control. As a result, untold numbers of Americans will continue to die simply because the Trump administration failed to deliver the vaccines it manufactured in record time.

"It's not like nobody knew vaccines were coming," said Jha. "Everybody knew what was coming. So the idea that we're developing the playbook in January, when we knew in September that vaccines were coming? It's atrocious."