How the US vaccine effort derailed and why we shouldn’t be surprised

Dr Claudia Fegan’s patient was a congenial, articulate and unvaccinated 27-year-old deli worker who contracted Covid-19 and became so ill he required at-home oxygen treatments.

Now recuperating, he told his doctor his 64-year-old boss had been vaccinated, and she too was sickened with a “breakthrough” case. However, she only had mild symptoms.

“He said, ‘Wow, I really should have done that,’” said Fegan, about getting vaccinated. Instead, he was sickened in the Delta-driven fourth wave of the pandemic, as he waited to see “how it played out”.

The story is one example of how the United States purchased enough vaccines to inoculate its entire population, and even potentially embark on a round of booster shots, but health professionals found lacking another essential element essential to a successful vaccination campaign: trust.

That lack of confidence garnered the United States an unenviable distinction – in mid-September it became the least vaccinated member of the world’s seven most populous and wealthy democracies, or “G7,” which includes Britain, Canada, France, Germany, Italy and Japan.

Now, a surge of the Delta Covid-19 variant has killed on average more than 2,000 Americans per day and forced the US death toll past the symbolic milestone of 675,000 deaths, the estimated number of Americans who perished in the 1918 influenza pandemic, even as hospitalization and death from Covid-19 is largely preventable.

The cause of flagging vaccine uptake in the United States has flummoxed national health authorities, who in May loosened mask guidance in hopes it would encourage more people to get vaccinated, in July again recommended masks because of the Delta variant, and hoped August’s full FDA approval of the Pfizer Covid-19 vaccine would increase vaccine mandates.

In a September speech, just days before the US slipped behind Japan, Joe Biden channeled national exasperation: “Many of us are frustrated with the nearly 80 million Americans who are still not vaccinated even though the vaccine is safe, effective and free.” He called for vaccine mandates impacting 100 million Americans, two-thirds of US workers.

However, all these strategies have failed to encourage more than 900,000 Americans per day to get vaccinated in recent weeks, far lower than nearly 3m doses administered per day in April, the height of the vaccination push. Finally, in mid-September, the country’s slow progress allowed Japan to surpass the US both in terms of vaccination rate per 100,000 people and percentage of the total population with one or both shots.

There are very specific, well-documented reasons that Americans are hesitant to take vaccines. They vary from the troubling way the medical system treats people of color, to vaccine misinformation campaigns overwhelmingly popular in conservative circles, to logistical challenges.

But population health researchers, whose work considers how society as a whole is fairing, said low vaccine uptake may be looked at another way: as the predictable outcome of a campaign subject to entrenched social forces that have diminished American health and life expectancy since the 1980s.

“When I look at this I do see a very familiar pattern,” said Dr Steven Woolf, a prominent population health researcher at Virginia Commonwealth University. “When Operation Warp Speed came out I thought I was just seeing a modern example of this old problem where the scientific community developed the vaccine at ‘warp speed,’ but the implementation system for getting it out into the community was inadequate”.

Woolf calls this “breakthrough without follow-through”. In that light, the plodding vaccination campaign could be seen as one more aspect of the American “health disadvantage”.

The phrase describes a paradox: the US houses among the most advanced medical and research centers in the world, but performs poorly in basic health metrics such as maternal mortality and infant mortality; accidental injury, death and disability; and chronic and infectious disease.

“So much of the whole issue of social determinants of health and the US ‘health disadvantage’ is rooted in a lack of trust and a lack of trustworthiness in many parts of our society,” said Laudan Y Aron, a senior fellow at the Urban Institute’s health policy center.

A key piece of research in this area is a 2013 report by a panel chaired by Woolf, directed by Aron, and funded by the National Institutes of Health. Called US Health in International Perspective: Shorter Lives, Poorer Health, the report describes how Americans spend more than double per person on healthcare compared to 17 peer nations, but rank near the bottom in health outcomes.

The phenomenon is described as “pervasive”, impacting all age groups up to 75, with life expectancy declining especially for women. In just a few examples, Americans have the highest infant mortality, children are less likely to live to age five, and the US has the worst rates of Aids among peer nations.

The US also has the highest or among the highest rates of cardiovascular disease, obesity, chronic lung disease and disability. Together, these risk factors culminate in Americans having the worst or second worst probability of living to age 50.

Americans know intuitively that their healthcare is expensive, frustrating and often unfair. Remarkably, even amid the pandemic, roughly 30 million Americans went without health insurance, exposing them to potentially ruinous medical debt.

“It’s also really interesting how often the messaging is: talk to your doctor, talk to someone you trust,” said Aron. “Yet, we don’t really acknowledge how many people don’t have a doctor, or a doctor they have a trust-based relationship with them”.

“Even the term ‘vaccine hesitancy’ kind of rubs me the wrong way,” she said. “It’s a term that really puts the onus on the individual and the choices he or she is making,” as opposed to focusing on the systemic issues driving poor vaccine uptake.

But researchers such as Woolf have found healthcare alone is not to blame for Americans’ poorer health relative to peer nations. Rather, as with the vaccination drive, disparities are driven by a diverse range of forces, from the built environment to a faltering education system to racism and inequality. Even people relatively well insulated from societal ills, live shorter, sicker lives than counterparts in Europe.

“That is, Americans with healthy behaviors or those who are white, insured, college-educated, or in upper-income groups appear to be in worse health than similar groups in comparison countries,” the 2013 report found.

Research since this report has elaborated on these findings, notably including recent research on how American life expectancy has declined while peer nations saw continued gains.

“To some extent, we feel that reflects the tendency of Americans to reflect the role of government, and insist on their freedoms,” said Woolf. However, it is an attitude that can be taken to extremes, “and there’s no better example than Covid-19”.

These societal forces transcend vaccine messaging, resulting in lower overall vaccination rates in the US, and a population whose hesitancy appears to have hardened.

“People want to have the freedom not only to allow themselves to die from a disease, but increase the risk of their relatives and friends to die from the disease,” he concluded.

Nevertheless, public health workers across the country are not giving up. Fegan and counterparts at Cook County Health are involved in time-consuming outreach, literally going door-to-door to vaccinate people and having “kitchen table conversations” where there is space to ask – What are you afraid of?

“The way you build trust comes over time,” said Fegan, who is national coordinator for Physicians for a National Health Program, which advocates for the US to enact single-payer healthcare like other developed countries.

“The people who want to get vaccinated are vaccinated,” said Fegan. Now, the long campaign ahead “is, again, meeting patients where they are”.

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