The U.S.' vaccine rollout is world-beating

That doesn't mean it's good enough. But let's take a moment to appreciate it.

"Microemulsion could allow vaccines to be stockpiled long-term" by Army Medicine, CC BY 2.0

The U.S. vaccine rollout is not going fast enough. Currently, about 1.7 million shots are being put into arms per day:

At that rate, according to the Bloomberg Vaccine Tracker, it will take 8 months to vaccinate 75% of the population (or essentially the entire adult population) with a two-dose vaccine. That’s not nearly fast enough, as more transmissible and antibody-resistant virus strains are spreading fast. Meanwhile we’re firing doctors for giving out vaccine doses out of order to prevent them from expiring, and we don’t even know how many doses the country is wasting. We need faster production and faster distribution. And we need a massive long-lasting upgrade of supply chains and distribution systems so we can quickly get booster shots into arms if and when a fully resistant strain emerges.

But. That said, it’s time to acknowledge a fact that few people seem to be acknowledging: The U.S. vaccine rollout, for all its faults, is ahead of almost every other country in the entire world. For those of us who were only recently wringing our hands about American decline, the fact of U.S. vaccine leadership provides a bracing counterexample and a reason to hope that the American system still retains a bit of the magic we were once taught to expect.

The U.S. is ahead of almost every other country

In terms of doses administered as a percent of the population, the U.S. is ahead of all but four other countries — Israel, Seychelles, UAE, and the UK:

In absolute terms, the U.S. has given out more total shots than China, which had a head start on vaccine development and has 4 times the U.S. population.

Israel is the clear global winner, and we should definitely study their amazing vaccination campaign and the institutions that made it possible. And let us not deny respect to Seychelles or UAE. But in terms of big countries, the only one ahead of the U.S. is the UK.

But are they really ahead? In terms of total shots and first doses, yes. But in terms of people who have received both vaccine shots, the U.S. is way out in front of the UK, which has chosen to delay second doses in order to stretch vaccine supply. In terms of full double-dose vaccination, the U.S. is in third place:

That could end up being very important. A very recent, not-yet-published study shows that the Pfizer vaccine generates a substantial immune response against the very scary South Africa variant, but only after two doses does the antibody response become sufficient to neutralize the virus. That means that by forgoing second doses, the UK might leave itself vulnerable to some degree of infection by the South Africa strain.

Biden seemed to flirt with a UK-style “first doses first” policy, but his administration now insists that second doses will be given on time. That’s a tough call, given that just one dose of Moderna or Pfizer shows fairly substantial protection against basic COVID after two or three weeks. But so far, the administration seems to be striking a good balance, releasing first doses en masse but keeping production and distribution rising so that second doses are available by the time they’re needed.

Importantly, though the U.S. has had early problems with distribution, those problems seem to be roughly keeping pace with supply bottlenecks. The U.S. has currently used 76.8% of its vaccine supply, which suggests that neither distribution nor manufacturing is holding up the vaccination effort by much more than the other one. Though production may turn into a bottleneck soon, for now we’re managing to do something roughly approximating an efficient, just-in-time supply chain.

Why have almost all other countries faltered?

Why did European countries, with their vaunted national health insurance systems, and Asian countries, with their vaunted public health systems, fall behind the U.S. on vaccination?

For Europe, one big obstacle was that the EU decided to bargain for vaccines as a group, which made the process of securing shots very cumbersome. As a result, the region got cheaper vaccine prices but delayed delivery. The EU regulatory state has also reportedly gotten in the way of rapid approval. And the EU member states seem to have spent some time fighting over who gets how many vaccines — not the first time that dissension within the multinational federation has caused problems at a moment of crisis.

As for Asian countries, their success in suppressing the virus with public health measures has reportedly made them more cautious about mass vaccination, and more focused on getting vaccines cheaply. Japan wasn’t as good at suppression as many of its neighbors, but its approval process has been slow; the government also hasn’t shown as much urgency as others. And in some Asian countries, reluctance to get vaccinated may also be a factor.

U.S. manufacturers have also been better at rolling out large numbers of vaccine doses. One reason Canada has fallen far behind its neighbor to the south is that it ordered lots of doses from European factories that have struggled to meet production quotas. Japan may lose out on millions of doses because it doesn’t have enough of a specialized syringe. As for China, the reasons why it hasn’t come close to meeting its vaccination goals are as yet unclear, but it appears to also be having supply chain issues. U.S. manufacturing capacity and competence appears to have been underestimated!

So there are a whole lot of different explanations for why other countries have been slow. The upshot seems to be that the deep and comprehensive strength of the U.S. system — regulatory approval, manufacturing supply chains, distribution, government negotiation, and general urgency — has been enormously underestimated. The U.S. fumbled a lot of things during this pandemic, but compared to almost every other peer nation, it is handling vaccination well. That’s highly encouraging news for those of us who took those early stumbles to be the signs of a nation in rapid decline.

And in fact its advantage is even greater, because the U.S. has truly world-beating vaccine technology.

U.S. vaccine technology is the best

The U.S. is primarily relying on two mRNA vaccines, the Pfizer/BioNTech vaccine and the Moderna vaccine. Both of these have shown very high efficacy against standard COVID variants in large-scale trials — 95% for Pfizer and 94% for Moderna. In Israel, the Pfizer vaccine is showing a 94% reduction of symptomatic disease in the population, despite the fact that the South Africa variant is spreading in the country.

No other vaccine in the world has so clearly and consistently shown such high efficacy. Novavax, also an American company, is the closest at 89%. The Johnson & Johnson vaccine comes in at 66%.

Data for some other countries’ vaccines, meanwhile, has been all over the map. The Oxford/AstraZeneca vaccine, which is the main one being used in the UK, officially has an efficacy of 63% according to the WHO. One dosing regimen — which was actually a dosing mistake that the experimenters just ran with — was reported to show 90% efficacy, though it was a small sample and didn’t include people over 55 (for whom vaccines are generally somewhat less effective). Another trial showed 75% efficacy. Because of this odd data, Germany has only approved the vaccine for people under 55, other countries have delayed approval, and South Africa, concerned that the vaccine seemed far less effective against its resistant variant, halted use of Oxford/AZ entirely. Remember, this is a two-dose vaccine that the UK is giving its people only one shot of right now.

China, meanwhile, has a bunch of vaccines, showing various levels of efficacy, ranging between 50% and 79%. Data for these vaccines has been patchy and opaque, though, with some worrying reports from trials outside China.

In fact, the only vaccine that seems to approach the U.S.’ mRNA platforms in efficacy is Russia’s Gamaleya (“Sputnik”) vaccine, which came in at 91%. Россия, вперед!

But the U.S. mRNA vaccines are clearly the leaders. Though more data is needed, their higher baseline efficacy leads some scientists to predict that they’ll be more effective against the semi-resistant South Africa variant. That seems to be supported by the recent data on the Pfizer vaccine. Their disadvantage is that they’re somewhat more expensive to manufacture and difficult to store.

But the mRNA vaccines have one more very important property that likely make them MUCH better than any rival platforms — they can be quickly modified to fight resistant strains. The vaccines all act against the coronavirus’ spike protein, so resistant variants have differences in their spike proteins that allow them to evade the antibodies produced by the vaccine — to vaccinate against a resistant strain, you need to modify the vaccine to attack a different spike protein. For the Oxford/AstraZeneca vaccine that could take six to nine months, but for mRNA vaccines the process is much faster; modifying them is sometimes referred to as a “plug and play” process. That means that if even more resistant strains arrive, it will be the American mRNA vaccines that will be the front line of defense against them.

MRNA vaccines are truly a marvel of modern science. But it wasn’t just dumb luck that the U.S. and Germany (BioNTech is a German company) developed these vaccines — a combination of far-sighted government research and bold corporate bets had been advancing the technology for decades. For a long time, scientists struggled to make mRNA vaccines useful for anything — now, not only are they at the forefront of the fight against COVID-19, they’re being mooted for a number of other battles, including, incredibly, the fight against cancer.

In other words, the U.S. system of public-private partnership has proven its worth once again, when it mattered most.

Who gets the credit for this success?

Other than the far-sighted research and investment apparatus that brought us the mRNA vaccine technology, who do we have to thank for the U.S.’ world-beating vaccine rollout?

Some Republican voters will surely respond with a hearty “Thanks, Trump!” In fact, Trump’s Operation Warp Speed — which provided research funding, advance purchase orders, manufacturing funding, and help with regulatory approval — does deserve a significant share of the credit.

It’s worth noting that I was incredibly pessimistic about OWS, given that Jared Kushner was supposed to be in charge of it, and Kushner tends to be a terminal screw-up. But it appears that Kushner actually did the smart thing — he stood back and let military leaders handle it. But Trump appointee Alex Azar and Kushner ally Adam Boehler appear to have been helpful to the process. Yes, there was infighting and ideological resistance, but ultimately the thing got us a bunch of really good vaccines in record time. It’s worth noting that rapid FDA approval, which involved a dramatic, unprecedented shortening of clinical trials, was absolutely key — a victory for libertarians who have been urging the regulatory agency to adopt a lighter touch. Ultimately, the reason OWS succeeded was that Trump himself stood back and didn’t interfere, allowing competent people to handle things for once.

But OWS and Trump stumbled badly when it came time to actually distribute the vaccines it had created. There was no real federal plan in place for actually putting the shots into arms; instead they were basically dumped on state public health agencies, who were already severely overstretched by the pandemic itself. Obsessed with trying to overturn his 2020 election loss, Trump steadfastly refused to develop a national distribution plan, declaring that he was leaving it up to the states. Trump administration officials even tried to deny states extra money for vaccinations!

Despite this failure, state governments, health care providers, and pharmacies strove mightily to remedy the situation. After three weeks or so, shots started going into arms at a substantial rate.

Now Biden is accelerating the process further. The new President has secured a deal for hundreds of millions more vaccine doses by the end of July. He has used the Defense Production Act, which basically gave the administration an excuse to work with manufacturers to increase supply. The administration has been pushing to set up lots of additional vaccination centers. Biden has released more vaccine shots, confident that production can keep up, and has used FEMA to dish out some much-needed federal funding to cash-strapped states. He has also helped turn retail pharmacies like CVS and Walgreens into vaccination centers.

So Trump was successful in getting vaccines created and approved quickly, while Biden looks like he’ll be effective at ramping up distribution. But far beyond the contributions of either President or their administrations, the American system deserves the credit for the vaccination drive’s relative success. From national science funding agencies to biotechnology and pharma corporations and their financiers, from hardworking state public health employees to community volunteers, everyone pitched in. And somehow the system worked.

The obvious comparison here is the space race. The U.S. was famously backfooted by Sputnik, and the Soviets were the first to put a human in space. But when the massive engine of U.S. science, industry, and government ramped up, there was no stopping it, and here’s how the space race ended:

"Apollo 11 Video Restoration Press Conference / Newseum" by NASA Goddard Photo and Video, CC BY 2.0

The other obvious comparison is World War 2. At the beginning of the war, America’s navy was outclassed by Japan’s, especially in naval aviation. But by the end of the war, Japan had produced only 17 new aircraft carriers, while America built 141.

The COVID-vaccination drive provides some reassurance that America still operates on that general model — starting slow, fumbling around for a bit, falling behind, freaking out, but finally setting its shoulder to the wheel, and ultimately becoming an irresistible force. There is deep, fundamental strength remaining in this country and its institutions — we can still summon some of the old magic when we need to.

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