The excellent Patrick McKenzie tells the story of VaccineCA, the ragtag group of volunteers that quickly became Google’s and then the US Government’s best source on where to find vaccines during the pandemic.

Wait. The US Government was giving out the vaccines. How could they not know where the vaccines were? It’s complicated. Operation Warp Speed delivered the vaccines to the pharmacy programs and to the states but after that they dissappeared into a morass of incompatible systems.

[L]et’s oversimplify: Vials were allocated by the federal government to states, which allocated them to counties, which allocated them to healthcare providers and community groups. The allocators of vials within each supply chain had sharply limited ability to see true systemic supply levels. The recipients of the vials in many cases had limited organizational ability to communicate to potential patients that they actually had them available.

Patients then asked the federal government, states, counties, healthcare providers and community groups, ‘Do you have the vaccine?’ And in most cases the only answer available to the person who picked up the phone was ‘I don’t have it. I don’t know if we have it. Plausibly someone has it. Maybe you should call someone else.’ Technologists will see the analogy to a distributed denial of service incident, and as if the overwhelming demand was not enough of a problem, the rerouting of calls between institutions amplified the burden on the healthcare system. Vaccine seekers were routinely making dozens of calls.

This caused a standing wave of inquiries to hit all levels of US healthcare infrastructure in the early months of the vaccination effort. Very few of those inquiries went well for any party. It is widely believed, and was widely believed at the time, that this was primarily because supply was lacking, but it was often the case that supply was frequently not being used as quickly as it was produced because demand could not find it.

It turned out that the best way to get visibility into this mess was not to trace the vaccines but to call the endpoints on the phone and then create a database that people could access which is what VaccinateCA did but in addition to finding the doses they had to deal with the issue of who was allowed access.

A key consideration for us, from the first day of the effort, was recording not just which pharmacist had vials but who they thought they could provide care to. This was dependent on prevailing regulations in their state and county, interpretations of those regulations by the pharmacy chain, and (frequently!) ad hoc decision-making by individual medical providers. Individual providers routinely made decisions that the relevant policy makers did not agree comported with their understanding of the rules.

VaccinateCA saw the policy sausage made in real time in California while keeping an eye on it nationwide. It continues to give me nightmares.

California, not to mince words, prioritized the appearance of equity over saving lives, over and over and over again, as part of an explicitly documented strategy, at all levels of the government. You can read the sanitized version of the rationale, by putative medical ethics experts, in numerous official documents. The less sanitized version came out frequently in meetings.

This was the official strategy.

The unofficial strategy, the result the system actually obtained, was that early access to the vaccine was preferentially awarded based on proximity to power and to the professional-managerial class.

… The essential workers list heavily informed the vaccination prioritization schedule. Lobbyists used it as procedural leverage to prioritize their clients for vaccines. The veterinary lobby was unusually candid, in writing, about how it achieved maximum priority (1A) for veterinarians due to them being ‘healthcare workers’.

Teachers’ unions worked tirelessly and landed teachers a 1B. They were ahead of 1C, which included (among others) non-elderly people for whom preexisting severe disability meant that ‘a covid-19 infection is likely to result in severe life-threatening illness or death’. The public rationale was that teachers were at elevated risk of exposure through their occupation. Schools were, of course, mostly closed at the time, and teachers were Zooming along with the rest of the professional-managerial class, but teachers’ unions have power and so 1B it was. Young, healthy teachers quarantining at home were offered the vaccine before people who doctors thought would probably die if they caught Covid.

Now repeat this exercise up and down the social structure and economy of the United States.

…Healthcare providers were fired for administering doses that were destined to expire uselessly. The public health sector devoted substantial attention to the problem of vaccinating too many people during a pandemic. Administration of the formal spoils system became farcically complicated and frequently outcompeted administration of the vaccine as a goal.

The process of registering for the vaccine inherited the complexity of the negotiation over the prioritization, and so vulnerable people were asked to parse rules that routinely befuddled healthy professional software engineers and healthcare administrators – the state of New York subjected senior citizens to a ‘51 step online questionnaire that include[d] uploading multiple attachments’!

That isn’t hyperbole! New York meant to do that! On purpose!

Lives were sacrificed by the thousands and tens of thousands for political reasons. Many more were lost because institutions failed to execute with the competence and vigor the United States is abundantly capable of.

…The State of California instituted a policy of redlining in the provision of medical care in a pandemic to thunderous applause from its activist class and medical ethics experts….Residency restrictions were pervasively enforced at the county level and frequently finer-grained than that. A pop-up clinic, for example, might have been restricted to residents of a single zip code or small group of zip codes.

All people are equal in the eyes of the law in California, but some people are . . . let’s politely say ‘administratively disfavored’.

The theory was, and you could write down this part of it, disfavored potential patients might use social advantages like better access to information and transportation to present themselves for treatment at locations that had doses allocated for favored potential patients. This part of the theory was extremely well-founded. Many people were willing to drive the length and breadth of California for their dose and did so.

What many wanted to do, and this is the part that they couldn’t write down, is deny healthcare to disfavored patients. Since healthcare providers are public accommodations in the state of California, they are legally forbidden from discriminating on the basis of characteristics that some people wanted to discriminate on. So that was laundered through residency restrictions.

Many more items of interest. I didn’t know this incredibly fact about the Biden adminsitratins Vaccines.gov for example:

Pharmacies through the FRPP had roughly half of the doses; states and counties had roughly the other half (sometimes administered at pharmacies, because clearly this isn’t complicated enough yet). You would hope that state and county doses were findable on Vaccines.gov. It was going to be the centerpiece of the Biden administration’s effort to fix the vaccine finding problem and take credit for doing so.

…Since the optics would be terrible if America appeared to serve some states much better than others on the official website that everyone would assume must show all the doses, no state doses, not even from states that would opt in, would be shown on it, at least not at the moment of maximum publicity. Got that?

A good point about America.

We also benefited from another major strength of America: You cannot get arrested, jailed, or shot for publishing true facts, even if those facts happen to embarrass people in positions of power. Many funders wanted us to expand the model to a particular nation. In early talks with contacts there in civil society, it was explained repeatedly and at length that a local team that embarrassed the government’s vaccination rollout would be arrested and beaten by people carrying guns. This made it ethically challenging to take charitable donations and try to recruit that team.

Many more points of interest about the process of running a medical startup during a pandemic. Read the whole thing.