What’s ailing the COVID vaccine rollout? A number of things, from operational issues to vaccine hesitancy to the inadequacy of our nation’s healthcare system in scaling up a mass vaccination effort. 

So when President-elect Joe Biden announced last Friday his plans to tweak the vaccine distribution scheme by opening up the national stockpile, the move drew more than its share of reactions, not only from the Trump administration but from members of the scientific community as well.

Whether you agree with his plan, intended to increase the availability of COVID vaccines – and maybe even boost the flagging rollout – no change to the distribution plan should come at the expense of equitable distribution. In other words, jumpstart the rollout, but don’t jump the line. That was the message from Richard Besser, M.D., president and CEO of the Robert Wood Johnson Foundation and former acting director of the Centers for Disease Control and Prevention.

“I would be very concerned about moving away from a system that lays out clear priorities to groups and works to overcome the barriers to that,” said Besser, speaking as part of a recent panel, which took place a day before Biden’s announcement, organized by the USC-Brookings Schaeffer Initiative for Health Policy and the USC Behavioral Science and Well-Being Policy Initiative.

The panel featured Besser alongside a number of behavioral-science experts who suggested ways to encourage COVID vaccination. He was responding to a question on whether the country’s vaccine strategy needs to shift gears by waiving the CDC’s tiered system. The system is designed to preserve equity, as opposed to one in which shots are made available to those who want them as quickly as possible.

Especially nowadays, given the high degree of vaccine hesitancy, why not simply bypass those who are seemingly on the fence? 

“If we go to a system where those who want it [can] get it first, we’re going to play into the same… system we currently have, a system which is just rife with structural racism,” Besser warned. “I’m really worried about that. It would ensure those with money or social connections are most likely to get vaccinated quickly.”

Besser pointed out that those who are most at risk from COVID – essential and frontline workers – are not yet getting the protections they need. For instance, the vast majority lack sick time or personal time off.

Similarly, many states haven’t been able to set up the systems designed to meet the needs of these workers. Instead, governments are working around the needs of clinics or public health departments. The resources have not been there to staff clinics 24/7 or to make it as easy as possible for those who want to get vaccinated to get vaccinated. 

It’s but one symptom plaguing the rollout. A month after the first of the two available coronavirus vaccines received emergency approval, the national vaccination effort is off to a shaky start. 

The Pfizer/BioNTech vaccine was approved by the Food and Drug Administration on an emergency basis Dec. 11, followed a week later by Moderna’s shot. Both are two-dose vaccines with efficacy in the neighborhood of 95%. Operation Warp Speed had promised 20 million shots would be administered by the end of 2020.

Heading into the second weekend of the New Year, only about seven million first doses had reached arms. That’s out of more than 22 million distributed, per the CDC, and a number that’s well below the administration’s goal (although Moncef Slaoui, the outgoing head of the government’s vaccine accelerator, said the fed’s commitment has been met because the doses have been made available).

A mere 2.4% of the U.S. population has been vaccinated. Not only has the pace of the rollout lagged, but the distribution of vaccines has been inequitable. Most of the initial shots are going to white people, even though Black people and other racial and ethnic minorities have been hit harder by the virus. Meanwhile, hundreds of thousands of people are being infected and thousands are dying every day. 

That means we’re making slow, uneven progress toward herd immunity – that level of community protection at which those at greatest risk can be protected. To get there, about 75% of people may need to be jabbed with both doses of the vaccine, says the nation’s top infectious-disease doctor, Anthony Fauci. 

So what’s causing the bottleneck? Myriad logistical issues have been cited for hampering administration, from reduced holiday hours at hospitals and other healthcare settings to lack of funding for local facilities or lack of health insurance for people. The more than $2 trillion aid package signed into law by President Donald Trump on Dec. 28 set aside $9 billion for the vaccine rollout, but it will take weeks for states to allocate it for mass vaccination sites and inoculation campaigns, among other potential balms. 

Second, the hospital workers responsible for giving the shots, depending on the state they’re in, were swamped and exhausted even before the holidays exacerbated the outbreak. And one can add to that the aforementioned lack of after-hours staffing for clinics, which would accommodate frontline workers. As it stands, the overburdened U.S. healthcare system is ill-suited to launching a mass vaccination effort in the midst of a pandemic. 

Third, the people most in need must be both able and willing to receive the vaccine, and that’s simply not the case yet. The vaccination effort started mostly with healthcare workers and nursing home residents, but not every eligible healthcare provider wants to get the shot. Almost a third of HCPs probably or definitely would refuse it, according to a recent Kaiser Family Foundation poll, along with 35% of Black adults, even if cost were not an issue. Much of that hesitancy is based on minority groups’ deep-rooted mistrust of vaccinations and other large-scale healthcare programs. 

To be sure, political ideology also plays a role: 42% of Republicans fall into the aforementioned hesitant category, per KFF. It will be very difficult for public health officials to contain the pandemic if a substantial percentage of the country harbors concerns that keep them on the fence. Skeptics fear side effects, rushed science in the vaccines’ development and political involvement. There is also a segment of the population who simply don’t buy into vaccines, regardless of circumstance. 

A million Americans per day need to be vaccinated in order to end the pandemic by September, and Dr. Fauci thinks that’s within reach. But we won’t reach those numbers with the current distribution plan. Behavioral scientists stress that the diversity of views dictates a targeted, digital messaging strategy, rather than standard PSAs on television. 

“We can’t have one singular message that will appeal to all these groups,” explained Jason Doctor, director of health informatics at the USC Schaeffer Center. “Clinicals will need to tailor messages and tailor the interventions.” That may include, within the Black community for instance, encouraging more Black doctors to talk to Black patients about their vaccine hesitancy. 

One resource, the COVID-19 Vaccine Communication Handbook, includes tips for addressing community concerns. According to the handbook, a recommendation from a healthcare provider is one of the strongest determinants of vaccine acceptance. However, providers often underestimate the importance of their recommendations. A strong recommendation from the HCP to get vaccinated – assuming the person is willing to hear it – has been shown to increase uptake, the handbook notes.

Clinicians can also impede vaccination. If a patient’s clinic doesn’t know her or his vaccine status or if the doctor delays vaccination, it may fall by the wayside. Urging same-day vaccination has had a big effect in prior incolulation research, Doctor explained. 

Indeed, forging connections with people is crucial. “We know a lot of forms of vaccine hesitancy are rooted in decades, if not centuries, of medical exploitation and mistreatment,” said Alison Buttenheim, associate professor at the University of Pennsylvania and a leading expert in the application of behavioral economics to infectious disease prevention. “We need to be really savvy about asking questions of people to find out what they need.”

Sometimes that might entail having a conversation with a trusted peer. “There’s been lots of offers within PennMed for people to serve as vaccine ambassadors or champions or peer buddies within their departments,” she said. “And that often works well if it’s within the same occupational group. So if our security team or environmental services team is having some reluctance or hesitancy, who can they talk to in their department?”

Much like in traditional pharma marketing, each person’s “vaccine journey” looks different based on their priority stage and level of motivation, she added.

Another behavior-based intervention is to meet people where they are. “At PennMed, we’re thinking about how to structure the emails that are going out to different tranches of HCPs. We need to make sure it’s not just ‘click on this link to make an appointment’ but also ‘can we help you through this email journey, to make sure you get to your appointment, or so you tell us if you’re not ready yet?’” Buttenheim explained.

Notwithstanding cold-chain challenges with the Pfizer/BioNtech and Moderna shots, efforts are underway in Philadelphia to get people vaccinated in community locations like churches and food distribution sites. “If you think ‘stroll to the polls,’ we need ‘stroll to get your shot,’” Buttenheim added. 

Distributing the vaccine where people spend significant amounts of time is very important, agreed Wändi Bruine de Bruin, a University of Southern California provost professor of public policy, psychology and behavioral science. “Then people will see their peers getting vaccinated, which is an effective way of overcoming trust issues,” she said. 

There’s also an opportunity, Buttenheim added, to make the process fun and exciting — “to take advantage of the fact that the vaccine-development process has been extraordinary and in our interventions to really think about how we can delight people.” 

That may include competitions, stickers, two-part bracelets or keeping lists of folks who have said, “If you have doses left at the end of the day, text me and I’ll be there in five minutes,” Such methods “infuse this with a sense of delight that matches the extraordinary moment we are in,” Buttenheim said.