“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.
FEBRUARY 5, 2021
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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.”