I spent a few months in 2019 studying vaccine distribution logistics in Vanuatu and as we close out 2020 far short of the goal of vaccination 20m people in the US, let me tell you, I'm pissed. 1/ https://www.reuters.com/article/us-health-coronavirus-usa-vaccinations/u-s-vaccinations-in-2020-falling-far-short-of-target-of-20-million-people-idUSKBN29512W

Vanuatu is an archipelago with more than 80 inhabited islands. It's supremely hilly, full of jungles and the most gorgeous beaches you've ever seen, with a dispersed, linguistically diverse population, and very little reliable electricity. A vaccine logistics nightmare. 2/

We worked in Shefa province, the easier part of the country to think about this problem in. It's home to the capital Port Vila and at least four airports. Here's a picture of the one on Emae island. Yes, I took this standing on the runway, a meticulously mowed field. 3/

To travel between islands and between clinics, vaccines are placed in cooler packs, like the ones below, with ice packs, and placed on planes, buses, cargo boats, motorbikes, bicycles, or just plain walked miles around islands by dedicated health workers to get to clinics. 4/

Up 4wd hills, over channels and reefs, around jungles, these clinics are placed to best serve the rural, disperse populations, but folks still often walk miles to get there, and it is no easy feat to get supplies to them (though I admit the journey is often quite beautiful). 5/

Vaccines are kept mostly in solar-powered freezers, unless a clinic is lucky enough to get hooked up to the grid. These freezers are medical grade, but have freeze/thaw cycles, have their solar panels ripped out by typhoons, and are rarely serviced due to communication delays 6/

Vaccines freeze and thaw, too, and some are lost, or expire or get opened and cannot be used entirely, so there is wastage. Any good vaccine distribution plans accounts for some wastage and leakage. It's part of the deal. 7/

Notably, we were focused on pediatric vaccinations. Some of these are given at birth, like BCG, and some have to be given to children later on. 8/

The vaccination schedule requires parents to bring their children back to clinic for routine care on maternal and child health clinic days (often 1x/week), or to an outreach day, where the health workers go set up a tent in a community without a clinic and give out vaccines 9/

When folks started talking about how we would get 360m people vaccinated against COVID, I pictured an outreach day to mass vaccinate folks. Colorado has drive-up testing sites. Repurpose those, I said.

Surely, someone is thinking about a plan, I said. 10/

Only, it appears they weren't. We have vaccines languishing in freezers that were specifically built to keep this vaccine super cold because we didn't account for the fact that people would feel sick after vaccination and we can't hollow out hospital staff for a week. 11/

We have high-risk folks refusing vaccines because of the maddening disinformation campaign that has been waged across this country for the past five years, and especially the last year. 12/

We have vaccines expiring & being left out too long because of inadequate planning & infighting about prioritization

And now we have a more transmissible variant circulating in a semi-vaccinated population that we don't actually know whether the vaccine is effective against 13/

So, I'm mad. And I tell you about Vanuatu for a couple of reasons. First, because vaccine logistics distribution is hard. It's hard in the best of situations, but especially when you are starting from zero and need fancy new freezers. 14/

But it's also doable. Despite all their challenges, every new baby born in Vanuatu gets a BCG vaccine, even if a health worker has to walk that vaccine in a cooler around an island after traveling on a cargo ship and a plane and a bus. 15/

It's also really hard to get people to come back. One shot regimens are tough enough, two-shot regimens have pretty severe drop-offs. Though BCG coverage is very high in Vanuatu, vaccine coverage for later childhood vaccinations is lower 16/

So, I'm mad. In the richest country in the world, in a country that prides itself on two-day or even same-day delivery of groceries and toilet paper, that arguably excels at consumer logistics, we couldn't figure out vaccine distribution logistics. 17/

We couldn't figure out how to get even 20m people vaccinated, let alone 360m, at a quick enough rate to slow virus transmission, to use the resources we have, to allow a quick return to the social, safe interactions we've all been missing. 18/

What good is a vaccine if only healthworkers get it? The answer is not much. We need herd immunity to protect folks who can't get vaccines, or for whom the vaccine doesn't work, to reduce transmission, to keep it from mutating too fast to keep track of it. 19/

The world knows how to get people mass vaccinated. We did with polio. We do it every day with any number of infectious diseases. But we're failing. And meanwhile, people are dying, essential workers are suffering tremendous trauma, and some of us stay home. And I'm mad. 20/