Distribute the vaccines NOW!

My last post about covid vaccines felt like shouting uselessly into the void … at least until Patrick Collison, the cofounder of Stripe and a wonderful friend, massively signal-boosted the post by tweeting it. This business is of such life-and-death urgency right now, and a shift in attitude or a hardening of resolve by just a few people reading could have such an outsized effect, that with apologies to anyone wanting me to return to my math/CS/physics lane, I feel like a second post on the same topic is called for.

Here’s my main point for today (as you might have noticed, I’ve changed the tagline of this entire blog accordingly):

Reasonable people can disagree about whether vaccination could have, or should have, started much earlier. But now that we in the US have painstakingly approved two vaccines, we should all agree about the urgent need to get millions of doses into people’s arms before they spoil! Sure, better the elderly than the young, better essential than inessential workers—but much more importantly, better today than tomorrow, and better anyone than no one!

Israel, which didn’t do especially well in earlier stages of the pandemic, is now putting the rest of the planet to shame with vaccinations. What Dana and I hear from our friends and relatives there confirms what you can read here, here, and elsewhere. Rabin Square in Tel Aviv is now a huge vaccination field site. Vaccinations are now proceeding 24/7, even on Shabbat—something the ultra-Orthodox rabbis are grudgingly tolerating under the doctrine of “pikuach nefesh” (i.e., saving a life overrides almost every other religious obligation). Israelis are receiving texts at all hours telling them when it’s their turn and where to go. Apparently, after the nurses are finished with everyone who had appointments, rather than waste whatever already-thawed supply is left, they simply go into the street and offer the extra doses to anyone passing by.

Contrast that with the historic fiasco—yes, another historic fiasco—now unfolding in the US. The Trump administration had pledged to administer 20 million vaccines (well, Trump originally said 100 million) by the end of 2020. Instead, fewer than three million were administered, with the already-glacial pace slowing even further over the holidays. Unbelievably, millions of doses are on track to spoil this month, before they can be administered. The bottleneck is now not manufacturing, it’s not supply, it’s just pure bureaucratic dysfunction and chaos, lack of funding and staff, and a stone-faced unwillingness by governors to deviate from harebrained “plans” and “guidelines” even with their populations’ survival at stake.

Famously, the CDC urged that essential workers get vaccinated before the elderly, since even though their own modeling predicted that many more people from all ethnic groups would die that way, at least the deaths would be more equitably distributed. While there are some good arguments to prioritize essential workers, an outcry then led to the CDC partially backtracking, and to many states just making up their own guidelines. But we’re now, for real, headed for a scenario where none of these moral-philosophy debates turn out to matter, since the vaccines will simply spoil in freezers (!!!) while the medical system struggles to comply with the Byzantine rules about who gets them first.

While I’d obviously never advocate such a thing, one wonders whether there’s an idealistic medical worker, somewhere in the US, who’s willing to risk jail for vaccinating people without approval, using supply that would otherwise be wasted. If anything could galvanize this sad and declining nation to move faster, maybe it’s that.

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In my last post, I invited people to explain to me where I went wrong in my naïve, simplistic, doofus belief that, were our civilization still capable of “WWII” levels of competence, flexibility, and calculated risk-tolerance, most of the world could have already been vaccinated by now. In the rest of this post, I’d like to list the eight most important counterarguments to that position that commenters offered (at least, those that I hadn’t already anticipated in the post itself), together with my brief responses to them.

1. Faster approval wouldn’t have helped, since the limiting factor was just the time needed to ramp up the supply. As the first part of this post discussed, ironically supply is not now the limiting factor, and approval even a month or two earlier could’ve provided precious time to iron out the massive problems in distribution. More broadly, though, what’s becoming obvious is that we needed faster everything: testing, approval, manufacturing, and distribution.
2. The real risk, with vaccines, is long-term side effects, ones that might manifest only after years. What I don’t get is, if people genuinely believe this, then why are they OK with having approved the vaccines last month? Why shouldn’t we have waited until 2024, or maybe 2040? By that point, those of us who were still alive could take the covid vaccine with real confidence, at least that the dreaded side effects would be unlikely to manifest before 2060.
3. Much like with Amdahl’s Law, there are limits to how much more money could’ve sped up vaccine manufacturing. My problem is that, while this is undoubtedly true, I see no indication that we were anywhere close to those limits—or indeed, that the paltry ~$9 billion the US spent on covid vaccines was the output of any rational cost/benefit calculation. It’s like: suppose an enemy army had invaded the US mainland, slaughtered 330,000 people, and shut down much of the economy. Can you imagine Congress responding by giving the Pentagon a 1.3% budget increase to fight back, reasoning that any more would run up against Amdahl’s Law? That’s how much $9 billion is.
4. The old, inactivated-virus vaccines often took years to develop, so spending years to test them as well made a lot more sense. This is undoubtedly true, but is not a counterargument. It’s time to rethink the whole vaccine approval process for the era of programmable mRNA, which is also the era of pandemics that can spread around the world in months.
5. Human challenge trials wouldn’t have provided much information, because you can’t do challenge trials with old or sick people, and because covid spread so widely that normal Phase III trials were perfectly informative. Actually, 1DaySooner had plenty of elderly volunteers and volunteers with preexisting conditions. It bothers me how the impossibility of using those volunteers is treated like a law of physics, rather than what it is: another non-obvious moral tradeoff. Also, compared to Phase III trials, it looks like challenge trials would’ve bought us at least a couple months and maybe a half-million lives.
6. Doctors can’t think like utilitarians—e.g., risking hundreds of lives in challenge trials in order to save millions of lives with a vaccine—because it’s a slippery slope from there to cutting up one person in order to save ten with their organs. Well, I think the informed consent of the challenge trial participants is a pretty important factor here! As is their >99% chance of survival. Look, anyone who works in public health makes utilitarian tradeoffs; the question is whether they’re good or bad ones. As someone who lost most of his extended family in the Holocaust, my rule of thumb is that, if you’re worrying every second about whether you might become Dr. Mengele, that’s a pretty good sign that you won’t become Dr. Mengele.
7. If a hastily-approved vaccine turned out to be ineffective or dangerous, it could diminish the public’s trust in all future vaccines. Yes, of course there’s such a tradeoff, but I want you to notice the immense irony: this argument effectively says we can condemn millions to die right now, out of concern for hypothetical other millions in the future. And yet some of the people making this argument will then turn around and call me a callous utilitarian!
8. I’m suffering from hindsight bias: it might be clear now that vaccine approval and distribution should’ve happened a lot faster, but experts had no way of knowing that in the spring. Here’s my post from May 1, entitled “Vaccine challenge trials NOW!” I was encouraged by the many others who said similar things still earlier. Was it just a lucky gamble? Had we been allowed to get vaccinated then, at least we could’ve put our bloodstreams where our mouths were, and profited from the gamble! More seriously, I sympathize with the decision-makers who’d be on the hook had an early vaccine rollout proved disastrous. But if we don’t learn a lesson from this, and ready ourselves for the next pandemic with an mRNA platform that can be customized, tested, and injected into people’s arms within at most 2-3 months, we’ll really have no excuse.