Say Hello to Last-Mile problems.
I have desisted from writing on Covid related information on the blog. Personal reasons aside, there are a number of reliable writers on the internet who speak to this issue well. I am an ardent admirer of the efforts of Tinglong Dai at Johns Hopkins on clarifying many issues in vaccine operations, and health care supply chains in general. Anyway, I break this hiatus on covid-posts to talk about last-mile problems in vaccination delivery.
It is clear now that the United States has millions of excess doses and is struggling to meet the criterion set by the federal government: To vaccinate 70% of the American adult population with a single dose by July 4th.
Contrast this problem to the world covid situation, lest we forget that we share the planet. According to the Economist, World Health Organization’s vaccine-sharing program, Covas, is out of supply after delivering 90m doses to 131 countries. More than half of eligible countries do not have sufficient supplies. In Africa, less than 2% of people have been vaccinated.
Back to the United States vaccine issues. After the initial speedy progress when it seemed like the Biden administration, which made vaccination a priority, would blow past the target. But, in the recent slowdown, it is increasingly clear that the target may not be reached.
So what can we do to solve the last-mile problems?
Hesitancy was always there.
One frustrating thing for me as an Operations Prof, was to watch educated people on TV and media blame it all vaccine skepticism and politics. To be sure, politics is a big factor — but when has it not been a factor? If no one was hesitant, will the problems disappear? I think not.
Here is an example of vaccine skepticism during the “progressive era” in the aftermath of the Spanish flu in 1918, from a paper by Hausman and others:
Concerns about contamination were widespread and expressed in several ways in the early 20th century. Some news reporting suggested that vaccines were dirty, contaminated with pus or bacteria. Others suggested that vaccines contaminated the blood of those vaccinated: “The fact is that many, even among physicians, regard vaccination as a pollution of the blood, which not only doesn’t prevent smallpox, but makes the victim of the virus susceptible to numerous other ailments” [14]. Vaccines were linked to septicemia [15] and described as loathsome: “I was vaccinated in 1878. ‘It took,’ settled in my eyes, and I have been a sufferer from the poisonous, filthy, loathsome, damnable stuff ever since” [16]. Many advertisements for physicians or pharmacies emphasized how “pure, fresh, and clean” vaccines were, clearly providing a direct counterargument to contamination concerns [17–23]. A common method of getting these views into newspapers was to purchase advertising space. One such ad published in The Commoner (Nebraska) in 1919 invoked religious views as a way to articulate a concern with the contents of vaccines: “What profiteth your babies if their God-made blood is periodically tainted with pus vaccine?” [24]. Other concerns about altering the composition of blood, injecting someone with an actual disease, or causing discomfort through vaccination are apparent [25]. Some writers invoked conspiracy theories about vaccination measures in tandem with arguments about contamination: a brief report with a Memphis byline suggests “a nation-wide plot to kill soldiers by poisoning vaccine serum with tetanus germs is believed to have been uncovered by five deaths traceable to vaccinations here” [26].
My overarching view is that blaming the difficulty of vaccinating everyone on vaccine skepticism and politics offers a convenient escape hatch. Governments and mega-hospitals should be concertedly striving to deliver vaccines to the doorstep of everyone who needs it. There is still a lot of work to be done. What should be done?
Lotteries and Monetary Rewards.
Initially, some of the academic crowd was against monetary rewards for vaccinations, because lotteries are often viewed as a detestable addiction problem. Fortunately, we have come around to change our view on lotteries for getting vaccinated. At least six states including California and West Virginia began offering vaccine lotteries. (It all started with Ohio’s Republican Governor Mike DeWine incidentally). West Virginia is now even offering hunting rifles as lottery prizes for those vaccinated. Even Philadelphia is in. A colleague of mine, Katy Milkman, is running an amazing large-scale lottery experiment together with the Philadelphia city government. Like the Dutch postal lottery, everyone is automatically entered in the Philadelphia lottery, but “winners” do not get the money if they are not vaccinated. This is great, as it emphasizes loss aversion to increase vaccination, because the last thing people want to learn after they won, is that they will lose the price if they had not gotten vaccinated.
Ohio drive has provided an exciting lift in the numbers of the vaccinated, with more than 3 million Ohioans entered to win $1 million in the lottery. My favorite lottery prize offer is the full-ride scholarship to college for children ages 12 to 17. Here is Ohio Gov Mike De Wine with the first winner.
Congrats, Joseph! You just won a full-ride college scholarship! If you’re between 12 and 17 years-old and had at least one dose of the vaccine, you could be next! Sign up at https://t.co/ZmJ8iKoSlV! pic.twitter.com/StHlWewhW5
— Mike DeWine (@MikeDeWine) May 27, 2021
Lotteries are great first-order instruments. But when you want to reach specific unvaccinated folks, it becomes harder without pushing against conceptual fairness. (Philadelphia lottery, for instance, allocates higher win-probability to some zip codes with low vaccinations).
How do we increase the vaccinations further?
Bear the Costs.
As I have often emphasized on the blog, last-mile problems have natural diseconomies of scale, and the successful actions demand tremendous costs and even unprofitable investments. “Easy” actions such as texting people reminders to tax vaccines are useful, but not enough for solving these problems. Think about it. The smartphone penetration in the United States is about 75%. Which population has more unvaccinated people: Smartphone owners or people without smartphones?
My point is actually quite simple — the marginal costs of vaccinating every additional adult increase. But what is in the “marginal cost”: the cost of efforts that overcome skepticism, lack of access, and availability. While the availability issue has been (mostly) taken care of, access to vaccines still a problem.
For instance, a New York Times article reports that the vaccine takeup rates vary between the worst affected counties — but in general vaccination rates are low.
For instance,
In Greenville County, S.C., where at least one in 508 residents has died, about 40 percent of those eligible have been fully vaccinated. In East Feliciana Parish, La., where one in 168 has died, about 29 percent of the eligible population is fully inoculated. And in the county of San Bernardino in California, where one in 455 has died, just 43 percent of eligible residents are fully vaccinated.
Compare this with:
In Hidalgo County, where one in 308 residents has died from the coronavirus, and nearby Cameron County, where one in 252 residents has died, about 60 percent of those who qualify have been fully vaccinated […]
But, we should note that even 60 percent is a low number and well below the target.
The main problem is that free uber rides to the vaccine center or text message reminders, or even vaccine lotteries are not going to be enough to reach all the remaining folks. Many of the people who are unvaccinated people are workers who can’t take a day off to go take the vaccine without losing pay, or coverage for their children.
The effort needs to be done in an old-fashioned, costly way like registering voters and census form taking: personnel reaching out to doorstep, through mobile vaccine vans. Many churches and local organizations have pitched in to help hospitals and the government. Delivery by mobile vaccine vans — like Amazon Prime type delivery trucks — is what we need. The science (due to the fact the mRNA vaccines can stay in a refrigerator for 30 days) is no longer a bigger constraint. We need to increase the willingness of some hospitals, universities, and firms to reduce the access problem — the real constraint that is holding us back.