At the beginning of 2020, Maj. Gen. Jim Hoyer was ready to retire. He was turning 60, the usual age limit for leading the National Guard in West Virginia. He’d led responses to every major disaster in the last decade, from the massive snowstorm during Superstorm Sandy to the one-in-1,000-year flood in 2016. “Some people would say I was bad luck,” he joked, because of the number of emergencies he oversaw.
Then the pandemic hit. The governor put Hoyer in charge of an interagency task force of doctors, officials, researchers, emergency responders, and others, managing everything from testing to ordering medical gear to crunching the numbers on who is getting sick and dying, and where. Hoyer wound up retiring from the National Guard to focus on pandemic response. He feels good about that decision: West Virginia, led by this task force, has ranked among the top U.S. states for quickly and efficiently administering Covid-19 vaccinations.
The states nailing their vaccination drives aren’t necessarily the ones you might expect—the states with the highest number of hospitals or medical staff, for instance. Alaska, North Dakota, and New Mexico have also claimed top spots. And while some critics of sluggish vaccination rates in, say, New York or California have suggested these patterns are an argument for jettisoning equity-based vaccine plans in the name of efficiency, experts say the lessons from successful vaccination plans, including from countries topping the international leaderboard, such as the United Kingdom and Israel, are more basic. The common theme from these states and countries isn’t that they abandon efforts to vaccinate the at-risk and elderly, experts told me. It’s that they’re top-down, data-driven efforts with centralized, easy-to-access registration systems.
The U.S. rollout “is all over the place, because every state is doing it differently,” Dr. Jen Kates, senior vice president at the Kaiser Family Foundation, told me. Fifty states, five territories, and the District of Columbia all have different plans—and sometimes, there are different systems even within those places. “Every state is making different decisions on a whole range of things,” she said. Normally, when it comes to immunizations or routine public health planning, that’s OK—but not in a crisis, she said.
The U.K. and Israel, in marked contrast, have had smoother, faster vaccine rollouts. Part of the reason why is that both countries have universal health coverage. But they also have a centralized vaccination process. In the U.K., you’re notified when it’s time to register for a vaccine, and it’s clear when and where you should go to get the shots. You don’t have to search through local, state, or federal registration systems, or try to figure out where the shots are even being offered. “It’s just much more streamlined,” Kates said.
West Virginia had a leg up by getting organized early. “From the day they started talking about Operation Warp Speed,” Hoyer said, “we started planning for vaccinations.” Governor Jim Justice assembled the task force early on with Dr. Clay Marsh as leading medical expert, and Hoyer credits the governor with “running interference” for them, keeping politics away from the science and data. “We want to make sure we make this efficient, effective, and fair,” Hoyer said.
Focusing on specific epidemiological patterns in West Virginia has been another key to the state’s success. “We’ve driven this thing by data from the beginning,” Hoyer said. For instance, the task force knew that 97 percent of Covid-19 deaths were happening in people above the age of 50. But it also knew the exact figures within those age ranges. Hoyer rattled them off from memory when we spoke: 77.5 percent in those aged 70 and above; 14.5 percent for people aged 60 to 70, and 5 percent for people 50 to 60. In December, when the vaccines were being authorized for emergency use, more than half of the West Virginians dying of Covid-19 were in nursing homes. When it came time to vaccinate those most at risk of dying from the virus, the task force knew exactly the approach it needed to take: prioritize by age and by residence. It started with those over the age of 80, then 70, then 65, and it also focused on vaccinating health workers and employees at care facilities who might bring the virus to residents.
West Virginia also crunched numbers to make an unusual decision that put it ahead of the pack on vaccinating quickly: Because half of the state’s pharmacies are independent, and most of its care facilities have relationships with those independent stores, it chose not to participate in the national pharmacy vaccination program. In that program, CVS and Walgreens partnered with the federal government to vaccinate workers and residents of care facilities across the country. But the plan was plagued with bureaucratic inefficiencies and bottlenecks, worsened by the fact that the two chains don’t have locations everywhere, and it made several states lag behind in distributing doses. “North Dakota, as I understand, similarly made the decision to partner with local pharmacies right off the bat, and many other community health sites,” Kates said. “Both states, in addition to having smaller populations, really did an all-hands-on-deck, upfront, proactive way to try to get as many people into vaccination” as quickly as possible.
In West Virginia, decisions like these were easy to make because of another advantage in planning: the state set up the 10,000-square-foot National Guard armory as a socially distanced, well-ventilated headquarters for the task force, with 60 in-person workstations and remote conferencing. If they needed to discuss the pharmacy rollout decisions, for instance, they could simply walk over to the pharmacy representative and chat about their options. This kind of coordination has been difficult for other states, Kates said, “especially some of the hard-hit ones [that] were still dealing with the immediate effects of Covid and struggling even to deal with the testing needs, the contact-tracing needs, the hospital capacity issues.” Different states were in very different places, she said. But those with a good precedent for working together in crises, that began planning early, were able to move quickly on the vaccine rollout.
Making sign-ups easy is another major factor. New Mexico was among the first to create a centralized registration system, which allowed the state to “manage the situation much more easily—and for the consumer, it’s one place to go,” Kates said. Otherwise, confusion can reign: “Where do I sign up, when do I sign up, how do I sign up? It’s different all over the country; it’s different if you live in this county or that county. That is a cumbersome and not efficient or transparent way to organize this.” In New York, for instance, you can sign up at pharmacies, hospitals, local health departments, and state-run distribution sites—and they all have different systems. In New Jersey, on the other hand, you can register through the state, but you can also comb through appointments at each vaccination site—each with its own link. Some states, like California and Florida, allow preregistration, but in others, residents must snag vaccine slots as they appear. Complicated sign-up systems also reinforce patterns of inequity, bringing those who have good internet connections, technical savvy, or assistance from relatives to the front of the line, instead of those who need it the most. West Virginia also offers a phone registration system, so those without good internet connections or technological know-how can still book appointments.
Prioritization has also varied in each state, and those priorities have been subject to change, often leaving both vaccinators and the public confused. “So that has created a challenging, confusing, and complicated rollout across the country,” Kates said. But narrow prioritization isn’t holding the United States back now—about 150 million people, or around half of the population, are eligible for vaccines. And more importantly, Kates said, pitting speed against prioritizing the vulnerable is a false dichotomy. “The juxtaposition has been speed versus equity, and I don’t think they have to be at odds with each other. I think that you can really focus on getting shots in arms and equity at the same time,” she said. “Equity has to be at the forefront of all these approaches across the country, but you can still do a speedy approach. We can do both.”
Perhaps the most important lesson is to be flexible and adapt as the situation evolves. When Hoyer heard about cases in other states where vaccinators discarded doses instead of giving them to people outside of the priority group, he laughed in disbelief: “If somebody throws one away here, they’re gonna get a personal visit—probably from me followed by the governor.” Identifying backup appointments among priority groups, and then making rare exceptions when there are a few leftover doses, can help stretch each vial. “Every shot you get in an arm potentially saves a life,” Hoyer remembers the governor telling him.
In any fast-moving, high-stakes operation like this, there are sure to be mistakes, and no system will be right for everyone. “What we did right in West Virginia—I would not be doing a service [in] trying to impose the exact West Virginia model on somebody else,” said Hoyer. Even within the state, the task force has helped counties develop what each vaccination plan would look like, depending on their needs and capabilities: Those with bigger populations created mass vaccination sites, while those with harder-to-reach residents even went door to door to vaccinate. But successful campaigns all started with strong, top-level collaboration to make the process as easy as possible while focusing on those at particular risk. And that can be the difference between life and death.