Friday, February 12, 2021

A Huge Potential for Chaos”: How the COVID-19 Vaccine Rollout Was Hobbled by Turf Wars and Magical Thinking

 

“A Huge Potential for Chaos”: How the COVID-19 Vaccine Rollout Was Hobbled by Turf Wars and Magical Thinking

Inside the Trump administration, sensible ideas for how to manage a massive, unprecedented distribution of vaccinations were no match for bureaucratic knife fighting, gung ho hubris, and a knee-jerk aversion to strong federal action.

BY KATHERINE EBAN

FEBRUARY 5, 2021

One Pandemic, Two Task Forces

On January 5, 2021, the day before an angry mob invaded the U.S. Capitol and called for him to be hanged for disloyalty to the president, Vice President Mike Pence convened his long-suffering COVID-19 task force at the White House to address a vaccine rollout that had devolved into chaos. On the agenda was a long list of concerns, from expanding eligibility for the shots to releasing second doses, which until then had been held back.

Among those in attendance were the task force’s coordinator, Dr. Deborah Birx, and the director of the Centers for Disease Control and Prevention, Dr. Robert Redfield. But the person most responsible for the rollout, the secretary of health and human services, Alex Azar, was missing. Azar, along with the secretary of defense, was in charge of Operation Warp Speed, the federal government’s vaccine development and rollout program. So where was he?

Sixty miles away, it turned out, inside a secure situation room at Camp David. There, Azar and a small group of top aides and military members of Operation Warp Speed were busy conducting their own analysis of the rollout’s problems. At least one blindsided White House task force member was “shocked” upon learning of the separate meeting.

The bureaucratic brinkmanship of the dueling meetings would be laughable if the stakes weren’t so high. Three weeks after the first vaccines rolled out of warehouses, the distribution effort was failing to live up to the Trump administration’s extravagant promises. Too few people were getting the shots, and states were ending each day with unadministered doses that had to be discarded, owing to the onerous refrigeration requirements.

The Camp David group determined that the states were adhering too religiously to the CDC’s guidelines for who was eligible to be vaccinated first, according to one person present. The solution the group arrived at was to tap pharmacy chains to order and administer the vaccine. As part of this effort, the military performed a “geospatial analysis” to identify the 19,000 pharmacies that were the closest to population centers.

Weeks later President Joe Biden’s incoming administration began phone calls with those pharmacies and discovered that they had little understanding of how patients would flow through their systems. “They were begging us for answers,” said one member of Biden’s White House COVID-19 team. “There was a concept to use pharmacies. There wasn’t any plan to exercise against that concept.” That revelation, among others, led Biden to declare former president Donald Trump’s vaccine rollout plan a “dismal failure.” Administration officials vowed to start from scratch in redesigning it.

As officials from the Trump and Biden administrations point fingers, a Vanity Fair investigation, encompassing interviews with more than 20 people with knowledge of Operation Warp Speed’s activities and a review of dozens of internal emails and documents, indicates that the rollout was plagued by turf wars and infighting, Trumpian overpromises, a culture clash between military and public health officials, and a blinkered military focus on delivering vaccines to states instead of vaccinations to individual citizens. The failure to plan for the “last mile” has left Americans desperately navigating a chaotic online wilderness to score elusive vaccination slots in a maddeningly uneven rollout that changes from hour to hour and county to county.

“They had a theory of the case. They had press releases,” as the Biden team member put it. “They did not have a plan to deliver 600 million shots in record time.”

Paul Mango called that characterization a “bunch of bullshit.” Mango, the former HHS deputy chief of staff for policy under Azar, played a central role in coordinating Operation Warp Speed. He also defended the program’s handling of the pharmacies. “We reviewed their business plans. We visited their CEOs.”

But Mango also embodies the laissez-faire ideology that infused the vaccination effort, just as it had the Trump administration’s decision to scrap a proposed national testing plan. “We’ve inoculated more citizens than any country in the world,” Mango told Vanity Fair. “For the Biden team to say, ‘We have to start from scratch,’ their task should be to avoid creating a mess with their authoritarian impulses.”

Unlike many of the career health officials they worked with or oversaw, some political appointees within Operation Warp Speed held an ideological belief that the federal government should limit its role to empowering the private sector, handing off responsibility for actual vaccinations to the states. The program’s mantra—“federally assisted, state managed, locally executed”—was adhered to so slavishly that urgent requests for direct federal assistance to states for vaccinations, from increased funding to additional manpower, were rebuffed, Vanity Fair has learned.

General Gustave Perna, who headed Operation Warp Speed’s logistics, prioritized two key metrics for success, say two people involved in the program: to ship out vaccines within 24 hours of the Food and Drug Administration authorization and to develop a regular cadence for vaccine deliveries to the states. But his definition of mission accomplished didn’t seem to involve actually getting people vaccinated. In one tense meeting between Perna and the CDC, Perna’s staff had to explain to the four-star general that the CDC defined success by two entirely different metrics: the uptake of the vaccine and the elimination of the pandemic, said someone present at the meeting.

Perna retained laser-like focus on what was called the N-hour sequence: the plan to move out the vaccine within 24 hours of its being authorized by the Food and Drug Administration. Perna “talked about how it would look” on TV, said one CDC official. “He really thought that would be the most important thing to build vaccine confidence.” The emphasis on the N-hour sequence led to days of phone calls and tabletop exercises. “It took up tons of staff time,” said the CDC official.

General Perna declined to be interviewed, but an HHS official said, “General Perna and OWS leaders contend that the unparalleled expertise of the health care community and scientists, military planning and logistics capability, American industrial ingenuity, and academic innovation enabled success and strengthened every step” of what continues to be a “complex, unprecedented, and herculean operation.”

Inside the CDC the prevailing wisdom on vaccine administration, built from hard-earned experience, was to underpromise, given everything that could go wrong, and then hopefully over-deliver. Redfield urged the White House and Secretary Azar to promise a more modest and achievable vaccination goal of 4 million doses by year-end, Vanity Fair has learned. He was rebuked by both Azar and Trump himself, who claimed to have better information and told him he didn’t know what he was talking about, said someone familiar with the exchanges. The number they insisted on was 100 million. In the end Redfield’s instincts proved accurate. By January 2, U.S. states had administered 4.2 million doses.

Azar declined to be interviewed for this story, but a former senior administration official said he never heard any point of difference between Redfield’s numbers and Azar’s, and that Azar was “meticulous” about getting accurate numbers from Operation Warp Speed planners and conveying them to the public.

By almost all accounts the Warp Speed program succeeded phenomenally in its central goal: to fund and support the development of COVID-19 vaccines, a process that usually takes years but was accomplished within 10 months of the pandemic’s onset. The program’s officials held weekly phone calls with state governors and sent out strike teams to states that were struggling with their rollout planning. But Operation Warp Speed’s failure to prioritize the administration of vaccines became a growing topic of concern at White House task force meetings, said several people familiar with the discussions.

Based on past experience, public health officials expected distribution planning to take up a significant amount of their time. But officials at the CDC said they were restricted from discussing distribution plans with the states until very late in the game, and were told by Operation Warp Speed officials that any operational details were “close hold.” And from the program’s formal launch on May 15 to the start of the vaccine rollout seven months later, just one of the roughly dozen Operation Warp Speed board meetings addressed distribution, according to two participants.

In response, a former senior administration official said, “The only role that the board played was to get barriers out of the way for the scientists and logisticians, to make sure they get what they need to be successful.”

To Ashish Jha, dean of the Brown University School of Public Health, the insistence on offloading responsibility to the states looks less like a reasoned plan than a deliberate evasion tactic. “It’s very clear that the feds really didn’t know or care whether states were going to be able to do this or not. If states can’t do it, we can always blame them. And that has been the strategy from the very beginning.”

In retrospect the FedEx trucks rolling to the rescue out of vaccine warehouses, duly captured by news cameras in accordance with General Perna’s wishes, call to mind U.S. tanks rolling into Baghdad in 2003—a declaration of victory, followed by mayhem.

All of the Credit, None of the Blame

In late April, HHS Secretary Alex Azar had a telling encounter in the West Wing with President Trump’s chief of staff, Mark Meadows. The two men had just left a COVID task force meeting in which the fledgling Operation Warp Speed program was discussed, and Azar was feeling bullish.

“This vaccine program is the way we need to do it,” he said.

Meadows, who had seen his share of reputations rise and fall in Trump’s orbit, wasn’t so sure. “You’re not going to get the credit for this, and you’re going to get the blame,” he told Azar, according to a former senior administration official. Azar responded, “I am completely fine with that.” To which Meadows, wearing a frown, said, “This may not be a good gamble on your part.” (Meadows did not respond to a request for comment.)

As it happened, according to several people who worked on the vaccine rollout, Azar’s gamble was that he could achieve the opposite effect: all of the credit, with none of the blame.

A lawyer by training, who had previously served at Health and Human Services under President George W. Bush, Azar was feared by subordinates as a formidable bureaucratic infighter. He surrounded himself with loyalists and was skilled at leaving paper trails against those who crossed him, according to a former HHS official, who described his leadership style as “ultra paranoid.”

A former senior administration official said of Azar, “It wasn’t about getting the credit. It was: Americans are dying every day. That was his guiding light.” Regarding his leadership, the official added, “He built a very strong team. That’s what any good executive would do.”

On January 29, Azar was put in charge of the White House COVID-19 task force, but within a month, control was turned over to Vice President Pence. The memory of that reversal shaped Operation Warp Speed, as Azar worked to design a program that could not be wrested from his grasp, said several people involved in the program.

As the secretive $15 billion program rumbled to life, with a central goal of developing a COVID-19 vaccine in record time, Azar moved swiftly to consolidate control, holding meetings that excluded the leaders of the agencies under the Health and Human Services umbrella, from the CDC to the Centers for Medicare & Medicaid Services. “He owned Warp Speed. He shoved everyone out of this,” said one former senior HHS official, adding, “He was the one who said [the states] didn’t need money to do this.”

Operation Warp Speed was supposed to be jointly run between the Defense Department and HHS, with an advisory board that included the CDC director, Dr. Redfield, and Dr. Deborah Birx, the coordinator of the White House COVID-19 task force. But most major decisions were made without any input from the board, said several program participants. “It’s part of the positioning the secretary has prioritized,” said one participant, “to get the credit for it, and anything else that goes wrong he can Teflon it off.”

“Rapidly Mashing Together Two Cultures”

Azar exhibited a tendency to side with the program’s military members against health officials from his own agencies. As military officials flooded into the Hubert H. Humphrey Building, where HHS is headquartered, the offices there began to look “like an armed camp,” said one Trump administration official who worked on the program. Top officials traded copies of a book called Freedom’s Forge: How American Business Produced Victory in World War II, which celebrated collaborations between the Pentagon and private companies.

At an early meeting Perna directed the participants—drawn from different backgrounds and from different agencies—to look at their government badges, which bore different logos. “We’re now one team,” he said, according to a meeting attendee, who added, “The CDC never bought into it.”

In a May 27 email to Operation Warp Speed officials, Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, acknowledged the tensions between military and public health officials: “Part of the struggle here is rapidly mashing together two cultures. I am hoping that a joint work plan will go a long way to setting up swim lanes, timelines and deliverables.”

But the culture clash wasn’t so easily resolved, in part because it stemmed from a fundamental disagreement over the core mission. Were they trying to deliver vaccines to states or inject them into arms?

To officials at the CDC, creating a credible last-mile plan was an obvious imperative. Such a plan would have given the states detailed instructions on how to reach eligible vaccine recipients, how to formulate and deploy effective messaging, and how to enlist and assemble a force of vaccinators. It would be up to each state to tweak those instructions based on individual circumstances, but a clear blueprint needed to be in place, along with ample financial support.

More than a month before Operation Warp Speed was formally announced, CDC officials worked through Easter weekend to assemble a preliminary last-mile plan. But it soon became clear that their belief in its importance was not shared by Azar and his Pentagon allies. Dr. Messonnier, who had previously incurred the president’s wrath in late February when she warned Americans at a press conference that the COVID-19 virus would soon disrupt everyday life, was again sounding the alarm. She “warned and warned and warned” about the difficulties of forming a credible rollout strategy, said Dr. Rick Bright, then the head of the Biomedical Advanced Research and Development Authority, the government’s central incubator of new therapeutics. Others heard from Dr. Messonnier that the CDC was getting little support and being kept out of discussions and meetings.

To the political appointees and their Pentagon allies, these complaints from career officials sounded like unimaginative bellyaching. The CDC “strongly preferred public sector input over private,” said Paul Mango. As one Operation Warp Speed team member told him, “This is their Super Bowl. They’re not acting like it.”

 

In May, Dr. Redfield asked Operation Warp Speed officials for $5.35 billion for states to build their last-mile capacity. It wouldn’t be his last request. He asked again repeatedly through September, each time running up against the same obstacle: Secretary Azar’s office didn’t think that the states needed the money.

On June 5, a CDC team traveled from its headquarters in Atlanta, Georgia, to Washington, D.C., to brief Operation Warp Speed officials on their view of the essential components of a successful vaccination plan. What they heard back was dismaying. “They told [us] their task was to pick up the vaccine and put it in the trucks and drive it to state health departments and drop it off,” said one of the CDC team members.

When Dr. Birx asked the officials leading Operation Warp Speed more granular questions about the distribution and administration of vaccinations, she was rebuked, said someone familiar with the exchanges. “If you’re questioning my judgment, maybe you should do this,” one told her.

“A Vaccine World and a Vaccination World”

By June, concern was growing in the larger vaccination community that no credible plan to distribute vaccinations had been established. On June 27, Dr. Bruce Gellin, the president of global immunization for the Sabin Vaccine Institute, urgently emailed Paul Mango, requesting a meeting with Secretary Azar. “My mantra when I ran the National Vaccine Program Office was that there was a vaccine world and a vaccination world—and there wasn’t an arrow that connected the two,” he wrote. “From what I can tell, OWS is mostly focused on the vaccine part but has little insight into our national immunization program. I worry that there is a huge potential for chaos if, as it seems, the wheel is going to be reinvented on the fly.”

Before long Gellin scored an invitation. On July 15, he was invited to join a vaccine consultation panel that HHS established to presumably get expert input and loop in key experts who could help disseminate critical information. “Producing a vaccine is one piece of the task—but another equally critical component is ensuring public understanding, acceptance, and participation in any eventual vaccine campaign,” the invitation stated.

But Gellin soon came to believe that the panel’s principal function was to create a facade of “famous people” in the vaccine world, who would serve as “external validators” for any Operation Warp Speed vaccine. In biweekly Zoom calls that allowed for limited discussion, the group was briefed by various Warp Speed officials. “It was a seminar series,” said Gellin.

As states began work on their individual rollout plans, military officials headed down to CDC headquarters in Atlanta and took over a conference room. They brought their mission-driven culture with them, erecting a poster outside the conference room that read, “Winning Matters,” and touted “300 Million Doses of Vaccine January 2021.” The expectations were “unrealistic,” said one CDC official. “We counseled Perna that we should be planning a much slower rollout. These vaccines are complicated. It’s intimidating. States were likely going to want to start slow.”

But the warning fell on deaf ears. On October 8, at a discussion sponsored by Goldman Sachs, Azar dangled the idea that it was possible to have 100 million doses of the vaccine by year-end, a number that the White House supported. Said one former HHS official of Azar: “He just lies. The biggest lie is that he had it under control. He oversold it.”

A former senior administration official said that Azar’s projections related to doses produced, not administered, adding, “Whatever he said had been vetted by the Warp Speed team because he strived for transparency and accuracy.”

As late as December, shortly before the Pfizer vaccine was authorized by the FDA on an emergency basis, one participant recalled an Operation Warp Speed planning meeting where the distribution plan was outlined. “They showed how the vaccines were going to leave the warehouse, have a military escort. We’re going to add vaccines, kits, gloves. Then we’ll ship it wherever the states tell us,” said the former HHS official. “That’s where the presentation ended. You can’t say, ‘My job ends here.’ When you’re running an operation this large, you want to get shots in arms.”

Paul Mango defended the planning, saying that it was “all based on the fundamental belief that local leaders are best positioned to execute. It guided our whole process. We’re going to provide you the vaccine for free, all the accoutrements; we are going to distribute to precisely the place you want it; and all you need to do is tell us where.”

But by mid-December, as vaccines landed in hospitals and storage depots, the majority of states faced an almost immediate tangle of problems: too few vaccinators; in some cases, too few interested patients; threadbare public health departments, depleted by months of pandemic crisis; I.T. systems that were crashing in real time. Though several states—notably West Virginia and Connecticut—pulled off efficient and well-organized rollouts, they were the exceptions.

The Biden administration has moved swiftly to get more shots into arms. This week it announced that the Federal Emergency Management Agency would provide $1.7 billion and 600 workers to 27 states and territories, support the deployment of thousands of National Guard troops to help with vaccinations, and build new community vaccination centers that would be substantially staffed and funded by the Department of Defense.

Meanwhile, Dr. Redfield, who departed as CDC director on January 20 and returned home to Maryland, still has not been able to get a vaccination appointment for himself or his wife, who, like him, is 69 years old. He chose not to jump the line when the vaccine was offered to him as part of his federal job. “We’ve tried,” he told Vanity Fair. “Maryland is in the second week of 65 and over, [and there is] nothing available to sign up for.”

With more than a thousand Americans dying each day from COVID-19, the frozen sign-ups and stuttering rollout have life-and-death consequences. “When you have a policy where only a few states can succeed,” said Dr. Jha, “the problem is not that you have 47 failing states. It’s that you have a failing federal government.”

 

Total Pageviews

GOOGLE ANALYTICS

Blog Archive