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Opening vaccine eligibility up, and allowing walk-ins if doses will expire, is part of how Israel was so successful at distribution. Multiple priority queues are nice in computer science, but managing them with time-sensitive vaccine doses is hard. Simple, imperfect and fast is better than perfect, complicated, and slow.

Getting a large swath of people vaccinated is more valuable than perfectly getting prioritization right. Prior to this change, NY was attempting to perfect prioritization, and was discarding many doses as they expired.

> and allowing walk-ins if doses will expire

Exactly. Any person getting a dose is better than vaccine expiring

We should also open up expired vaccines to whoever wants them. Expiry dates are usually quite pessimistic and medicines often have efficacy long after they're officially expired.

This is a different model of expiration. This isn't "two-year shelf life can be extended to five years w/ stable temperature and humidity and only a 10% loss of efficacy."

This is "once this vaccine is pulled out of the super-cold freezer, it starts breaking down, and you have X hours before it's worthless at best."

Worse than "worthless" is the idea that people might get a useless expired vaccine anyway, think they're protected, and then be a vector for future transmission.

This reminds me of how the Israeli military supposedly works. Top level goals and being flexible and creative at the operational level.

See https://www.jstor.org/stable/4531385?seq=1

In my opinion, the US’s top level goals were wrong (over focus on equity versus utility) and the US bureaucracy is neither flexible nor creative as evidenced by its refusal to buck top level orders and it’s continuing slowness. These are signs of a decaying system.

> the US bureaucracy is neither flexible nor creative as evidenced by its refusal to buck top level orders and it’s continuing slowness. These are signs of a decaying system.

Yes, and it’s because the priorities rank as follows for each individual:

1) personal liability

2) organizational liability

3) utility

Where liability includes both legal and public relations consequences. It’s exhausting to constantly think about open ended and unintended consequences that you might be held accountable for, with no recourse.

Yeah and I think it is on a negative feedback loop. Look at Cuomo and his complete flip flop except for the punitive and controlling attitude.

Are you sure 3) is on that list?

I completely agree with you about the US over-focus on equity with the vaccination effort. By all means attempt a best effort at vaccinating at-risk populations first... But at the end of the day, even the at-risk-but-vaccinated folks are still at risk as long as herd immunity isn't reached (the vaccines are 95% effective, not 100%). Lots of shots in arms, quickly, is more important than being extremely particular about whose arms the shots are in and in what order they are inserted. Israel will eliminate COVID as a serious concern by March; is it more "equitable" that Americans will likely continue dying through the summer, but at least they're dying in the right order?

Well, at the begining it caused a lot of mess. And then it was much more controlled. I wouldn't say this is what help us in the efficient distribution.

What really helped is a very centralized healthcare system with a very long history of managing public emergencies.

This is because Israel was founded as a socialist welfare state, and the impressive healthcare system is one of the leftovers.

What is the current system is designed to let those who are connected get in first? Could the answer to “why does it suck” simply be corruption?

Also, they paid a lot to have early access to a lot of vaccine.

Michigan (my state) is doing about 35,000 doses on weekdays at this point, which is frustratingly slow. But if they had spun up twice as fast, we wouldn't be doing 70,000 doses a day, we'd be out of vaccine.

The most recent shipments have been ~120,000 vaccines/week for 2 weeks and then none for a third week. So if the tempo of Federal allotments is 120,000 a week, the 35,000 a day is not a bottleneck. They should of course be building capacity anyway, with the idea that deliveries will increase (and making a plan for what to do if/when the adenovirus vaccines are approved in the US; fortunately it looks like that can be "send it everywhere").

Anyway, wasting vaccines is obviously stupid, I'm not trying to argue about that.

I'd be less concerned about people over 65 "sneaking in" over people more than 75 than systems that end up being a free for all anyone to get vaccinations because they're in the right place at the right time (and presumably getting second vaccinations as well).

A lot is really about overall volume. Even a million vaccinations a day means you're looking at well into the summer until you even approach 50% vaccinated.

There are 260 million American adults. Already 12 million receiving a vaccine. Approaching 1,000,000 per day receiving first dose. At that rate we’ll need 118 days to have half the population vaccinated with a first dose in mid-May and the second dose in early/mid-June.

OK. So early summer. And that's 50% which some would say is not nearly high enough for people to get on with their lives (but may, or may not, be a reasonable target--especially given that a fair number of people will hold off).

Also unknown is the number protected by prior infection. Anywhere from 10-30%.

I think we’ll see R’ start to plunge during summer due to weather and never climb back up from increase in immunity. But “back to normal”. January earliest.

Most events people I know are betting on things being normal-ish by the fall. Doesn't mean they're right of course although they were right enough to shut things down at a time when many people were still thinking it wasn't that big a deal.

There are also gradations of normal although once you fully open up restaurants, have indoor concerts, packed auditoriums, etc. most things you could do to reduce spread are pretty much theater at that point (other than possibly requiring vaccinations to fly, enter venues, workplaces).

Make sure to take a screenshot of whatever confirmation you get. Because servers are overloaded, some people in my area did not get confirmation texts or emails.

If somebody is elderly, the chances of them getting an appointment is extremely low without the help (and extreme vigilance) of their tech savvy children/nieces/nephews.

Some states have also opened up their registrations to people 16+ with serious chronic health conditions that put them at high risk of severe COVID-19. In a handful of these states, many of these people have received a vaccine. But, it is first come first serve, which is an absolute disaster along with being inequitable.

Why are healthcare servers still getting overloaded when HIPAA compliant "infinitely scalable for a price" cloud systems like AWS exist.

And why now? I'm sure it would be much easier than normal to get AWS and some relevantly skilled professionals to donate enough time to make a workable reservation system.

>"infinitely scalable for a price" cloud systems like AWS exist.

That only applies if your application is programmed for it. Good luck scaling even if you had aws if your server had database locks everywhere, for instance.

Or maybe, the developers need to go back to school to learn about horizontal and auto scaling.

Which school would that be? My cs program was all math and data structures. I learned everything I know about software development on my own.

Yeah, the college I went to back in '09 _just_ started teaching version control. All we learned were concepts and common languages from each of the major domains of programming, and math. That's it. (Think like SQL for DB, Java / Python for application development, c and c++ for embedded systems and operating systems, etc.)

Software engineering can be studied at University and is a different degree and I think even falls under a different department to cs.

I mean, it’s not like we knew this was coming or had any time to prepare for it...

The point of the vaccine is to keep the health system from being overloaded. Over 75s are already being triaged out of intensive care in many countries, so it matters little on a society-wide scale whether they get the vaccine or not. In fact, somewhere in the news today I read an official claiming that it is 60-75 year old people who are the most important vaccination target to begin lifting lockdowns.

The point of the vaccine is to end the pandemic. An early benefit of the vaccine is reduced load on the health system.

As has been often emphasized, the reason that COVID-19 is considered a pandemic of such dangerous degree to require a rapid development of vaccine, is because it overloads hospitals and can deny many others (not just COVID sufferers) access to urgent treatment. Without that factor, the most vulnerable demographic for COVID-19 in terms of mortality rate is e.g. elderly people in care homes who are ordinarily a low priority for innovative medical treatments, and it is hard to imagine a vaccine would have been rushed just for their sake.

It wasn't rushed, the science was ready to go early last year and all they did was accelerate the first trial phases, the Phase 3 trials went quickly because infections were so widespread.

That there are multiple candidate vaccines targeting the spike protein without using the virus directly is strong evidence that the science was ready (using mRNA, viral vector and other technologies).

The missteps suck, but I really dont think it is on the local health departments very much. The federal government shouldve really been taking a lot of the load themselves. My local health department has a dozen workers and has had to handle the pandemic basically on their own the whole way through. The outbreak was so bad in October/November that they literally couldnt finish counting all the cases in a day multiple times. Now, in addition to trying to handle the outbreak, theyre also being tasked with distributing a vaccine in record times. And through all this, theyve been underpaid and harassed by a significant portion of the population

What about your state? They are the ones who are supposed to handle stuff like this.

To me it is a cop-out to blame the feds. There is nothing to stop any state in our union from addressing this pandemic as they see fit. The states making up the Euro aren't blaming Brussels for their problems.

The converse would be to have one world government make decisions for everybody, right? That would work if we all agreed on everything, but we don't. So it is good to have different states try different solutions, and copy what works. Better then having a bad federal solution imposed on everyone.

> There is nothing to stop any state in our union from addressing this pandemic as they see fit

Except for zero funding...

My state is definitely to blame too, our new governor is an absolute disaster. But, we also have no serious funding left to handle the pandemic. Our last governor started a rainy day fund years ago and exhausted that last year, along with part of our wildfire fund. There is nothing left for us without federal assistance.

There is absolutely a middle ground between putting everything on the state and having one government rule the entire world. The federal government is the best equipped entity in the United States for handling the pandemic. It has the funding, personnel, and logistics management to efficiently distribute vaccines.

It is my understanding that it is the states' responsibility to handle situations like this.

The fact that some states are not doing a good job doesn't incline me to want to gamble on the federal government doing better. They don't have a good track record in emergencies.

You might end up punishing the states who are doing ok, and possibly causing a lot of problems forcing everyone into one solution.

At some point politicians need to be held accountable. Passing the buck for everything is not a great answer.

> It is my understanding that it is the states' responsibility to handle situations like this.

Its only the state's responsibility now because the federal government fumbled hard initially and had to pass blame because it was an election year. When is the last time states had to handle disaster relief on this scale with little to no assistance from the Federal government? A strong central force is crucial to handling crises like this, ours just blew it.

You can have input from local officials on setting up locations and timelines for clinics, but the 12 people making 20$/hr working in my local health department shouldnt have to deal with some of the most complex logistics the country has ever seen.

This is absolutely the best time to mobilize the massive military logistics chain in order to distribute and use vaccines as fast as possible.

If states are truly doing a great job (not many are), they can always decline assistance, but it isnt even being offered in the first place at this point.

> At some point politicians need to be held accountable. Passing the buck for everything is not a great answer.

Are you not just passing the blame onto local politicians and off of the federal level ones that hold most of the power?

Handling disasters has always been the states' responsibility. They are the ones with the power to address this. That part of the constitution is still intact. This is why Biden can suggest wearing masks, but is powerless to mandate them, amongst other things.

I think that it is wishful thinking to believe the military could be re-purposed to make a significant difference. Their job is to blow things up and kill people. It seems the field hospitals deployed were a drop in the bucket, and I assume that all doctors and nurses are already busy. What else would you expect from them, or the rest of the federal government? I'd be afraid of a single bad solution being forced on everyone. The feds have a pretty bad record of moving fast.

Perhaps this is just a difficult situation and is not going to go as smooth as you'd wish? There's no magic bullet here. It's a pandemic. Covid has killed as many people per-capita as the low end of the estimated 1-4 million deaths from the 1968 Hong Kong flu. These things happen.

Also there is no widespread disagreement on what the response should be. i.e. Would our national response follow the NY model or the Florida model?

Yes, I would blame states for local problems. If your state setup a system leaving twelve local $20/hr employees in a bad situation I would say that is your state's fault. What makes you think the feds could do a more effective job?

Not all states are doing a bad job.

Yeah, a lot of the states that are top in distributing their reserves of vaccines deal with really bad disasters on a regular basis.

I do not know if there is correlation though, based on looking at Bloomberg vaccine tracker. However, it appears so.

It’s a Byzantine Generals problem.