Once the FDA gave a green light to the Pfizer and Moderna vaccines, Bhatia and his team had to navigate overlapping, often conflicting messaging from federal and state resources, while gearing up to vaccinate as many people as quickly as possible—especially among its frontline care providers.
Bhatia sat down with Achal Bassamboo, a professor of operations at the Kellogg School, to discuss the supply chain questions—as well as some of the ethical and cultural implications—of a project as ambitious and complex as the COVID-19 vaccine distribution.
This interview has been edited for length and clarity.
Achal BASSAMBOO: Let’s start with the nuances of the COVID-19 vaccine process.
Dr. Ashwani BHATIA: When it’s all said and done, I think just getting this vaccine into people’s arms in less than a year is going to be one of the greatest achievements ever for healthcare science. All the world dedicated the resources, great minds came together and made it happen. So I don’t think there should be skepticism about how fast this vaccine was mass produced.
But vaccine distribution? Maybe that has not been such a great achievement. We’ll see.
Remember, we have a very decentralized form of healthcare in the U.S., which works to make the system efficient—except when there is a national crisis like we have seen. You’re not talking about agencies that are very regimented in terms of communicating well with each other. I think that’s where we have seen some roadblocks with vaccine distribution.
BASSAMBOO: Can we draw distinctions between the rollout of the COVID-19 vaccine and other vaccines?
BHATIA: Vaccines like tetanus or measles-mumps-rubella don’t have such stringent storage requirements. Add the fact that other vaccines don’t need a booster within a few weeks in adult populations—this adds a different layer of complexity. And because it was something that had to be done quickly, that brings another wrinkle to the picture.
Now remember, there were distribution guidelines from the federal government. Then state departments of health services decided to have their own guidelines. In Wisconsin, they decided that they are going to give it to the frontline healthcare workers, and they would also give it to the long-term care residents of assisted living facilities and nursing homes, which makes sense.
But what happened with the long-term care residents was that providers needed to have X number of reserved vaccines in-hand before they could start vaccinating anyone, because the second shot has to be administered within a particular period of time. So that’s an additional supply chain wrinkle.
BASSAMBOO: Let’s talk about the various constraints on the COVID-19 vaccine supply chain. Now, the first reason we couldn’t start vaccination immediately is that the vaccine did not exist. So, manufacturing was the constraint on the system. Then we learned the vaccine would have a stringent cold storage requirement. Did you find the transportation piece of the supply chain became a constraining factor? I know UPS and other players invested in cold storage.
BHATIA: I think they did a great job. I think UPS and FedEx did a fantastic job, as did the manufacturers. As they were manufacturing this vaccine, they had all the experts on board—physicians, scientists, and their own supply chain experts.
Where the breakdown started appearing was in the criteria for putting it into the arms of people after the initial category of healthcare workers.
Early on, the federal government was telling states what allotments they were going to get only a few days in advance, which left the state little time to figure out who was getting how much vaccine and how to open up eligibility.
BASSAMBOO: And once you open the vials you have to use it within a few hours or you have to throw it away. If you have a mandate to follow the list precisely, vaccines will go waste. So, this become a tradeoff issue.
BHATIA: Yes, so then you have an ethical dilemma.
This put vaccinators and administrators like me under immense pressure. Should we waste the vaccine, or administer it even if we can’t find the appropriate person based on the guidelines? If it was a universal health care government system, then somebody could take charge and say, “Yeah, this is correct.” In our decentralized system, a lot of people took upon themselves to decide: “I won’t let the vaccine go to waste. I’m going to jab anybody I can get.” But you might be thinking, “You know what? I will let a few doses go to waste rather than be unethical.” There’s no perfect answer.
We had the moral responsibility of giving it to the frontline healthcare workers first, and we did. As a chief medical officer, I did not take the vaccine in the first three, four weeks, although I was working in the COVID-19 unit, because I felt an ethical responsibility to make sure that I vaccinated everybody who is actually in the frontline. I might work the weekends, but hey, these are the people working day in and day out.
BASSAMBOO: Can you talk about how you reconciled federal guidelines, state guidelines, and your decisions as an organization in the rollout? Do you think those layered messages complicated the trust and understanding picture, especially with what people were hearing on the internet?
BHATIA: That is a problem. And I think it is kind of the elephant in the room. A decentralized healthcare system works great until we hit a crisis like this. Because in crisis, we want everything to be uniform: one mandate coming out, one guideline coming out, that everybody follows. But America doesn’t work that way. Here’s an example: the CDC says that we are going to expand to 65-and-older as of today, but we don’t know whether we have the supplies to do that. A patient hears the CDC guideline and calls our healthcare institution, and says, “Where is my vaccine? They just approved it.”
In this age of the news traveling so fast, they feel like, “If CDC has approved it, I should get the shot tomorrow.” And if you can’t, then you will have people saying, “Well, they’re trying to give it to somebody else,” or “maybe somebody’s skipping the line.” There’s some paranoia.
BASSAMBOO: How did you decide on the facilities that you’re using for vaccination?
BHATIA: We were starting in December in Wisconsin, so we needed a very large indoor place. We have a sports center adjoining our hospital, so we used that. We engaged administrators who have led projects before like these—mass vaccinations, flu clinics, occupational health or employee health. We prepared for two weeks before the vaccinations started how it was going to flow. We did mock drills. We had to plan to vaccinate from 7:00 in the morning till 6:00 in the evening because the healthcare workers—who were our first category—would have to go back and work. We were prepared for anyone who may have had an allergic reaction by having medical supplies for treating such reaction readily available and having a physician onsite. We also offered the ability to conveniently schedule the second shot upon receiving the first.
We also had to take their history and add everything in the electronic health record. We created a registry to communicate with Wisconsin’s immunization registry. There were little hiccups there. All those things had to be worked out very quickly.
BASSAMBOO: How is the situation now in your view? I know initially we had vaccine go to waste, but now we’re in the middle somewhat. Right? Would you say that the tough part is behind us? Or would you say that there are still challenges that are going to come in the coming months? Because now it’s much more open and people are getting vaccinated.
BHATIA: I would definitely say with any new process, we go through the initial growing-pains stages. And then we change the way we look at things. I still see issues getting vaccines to minority communities. Some of the ways this vaccine communication happened has largely excluded underserved populations: people who don’t have access to transportation, who don’t have access to internet, who don’t have access to apps, who don’t have a primary care provider.
BASSAMBOO: Can you talk about what your health system has done to try to bridge that gap?
BHATIA: For our healthcare system, BayCare Clinic, I did a Facebook Live on vaccination. I went through the history of vaccination, how it came about and why this vaccine is different. It’s safe. We just talked about how it’s one of the greatest things to happen to science. And then I started taking questions individually, from the Facebook Live viewers.
We received numerous questions among all age groups such as, “Should I take it? What are the side effects?” These are valid questions.
What we have done as a healthcare system to avoid people jumping the line is to make sure that we are vaccinating our own patients first. We started calling people manually, telling them, “Yes, you are eligible, you can come today.” And that requires a lot of work.
BASSAMBOO: You made this decision in your own system to centralize vaccine distribution into a larger facility. Do you feel like that had an effect on access for underserved populations? If you’re centralizing it in fewer spots, are you exacerbating an issue that you’re also trying to solve at the same time? Sort of an unintended consequence.
BHATIA: The nature of this dilemma is such that you’ve got the vaccine, you want to get as many people as possible as fast as possible. I think decentralizing will help to get the vaccines to remote places. But the other scientific way to look at this that we also want to vaccinate the community as fast as we can. If we vaccinate 70 percent, that’s the golden number to try to provide some herd immunity.
When you’re vaccinating category by category, that’s a whole different ballgame, because you have to identify those high-risk patients, healthcare workers, and others and make sure that those who need to, get it. But now we are ready to mass vaccinate. This works as a decentralized thing, because we have enough vaccine and we have figured out the supply chain.
As I mentioned before, we still are faced with the barrier of communicating with certain high-risk and minority communities that have less access to technology or apps. How can we do better? Should we be responsible for getting the vaccination to those communities rather than getting them to our facility? Some members of those communities don’t have trust in the healthcare system, because I think we have not been able to create that. And I think the onus is on us.
BASSAMBOO: What’s your opinion about pharmacy chains coming on board the effort? Should they have been involved from get go? Should they have waited a little bit longer?
BHATIA: I feel personally that they came at the right time. As soon as we decided that after the healthcare workers and the nursing homes we would vaccinate people who are 65 and above, the government started giving it to the pharmacies. That helped, because then you have less pressure on healthcare institutions, which are also taking care of patients and battling COVID-19. I think it helped to push some of those mass vaccinations elsewhere.
Remember that when we started, we started with small groups. And if those healthcare systems then have to mass vaccinate, they’ll get overwhelmed just vaccinating. We cannot have that. Opening up locations will help.
BayCare Clinic, LLP, is the largest physician-owned specialty-care clinic in northeastern Wisconsin and Michigan’s Upper Peninsula. It is based in Green Bay, Wisconsin. BayCare Clinic offers expertise in more than 20 specialties, with more than 100 physicians serving in 16 area communities. BayCare Clinic is a joint partner in Aurora BayCare Medical Center, a 167-bed, full-service hospital.