In the months leading up to the first COVID-19 vaccine shipments, Washington state health officials agonized over which residents should be vaccinated before others. They surveyed 18,000 people and convened focus groups, debating race, age and essential occupations.
But unlike some other states, the state Department of Health (DOH) neglected to plan for basic logistics that would have allowed for quick vaccination of those most vulnerable to the disease.
They didn't enlist the National Guard. They didn't centralize vaccine appointments. Key scheduling and reporting software arrived late. Providers were given vials but no strategy to process patients.
Then, despite a constrained federal supply, the state opened up vaccines to everyone 65 and older. Chaos ensued. Some wealthy hospital donors and those able to navigate a labyrinth of websites have secured shots. Trust in the system frayed.
After two months and more than a million doses administered, the state has struggled to vaccinate some of the people at highest risk for disease, including home care workers, Hispanic residents and homeless people eligible for vaccine.
"It was a much heavier lift than I think we anticipated, and we should have had more resources there from the beginning," said Michele Roberts, the DOH acting assistant secretary in charge of the vaccine rollout. "We should have been paying more attention to those logistical details."
A Seattle Times review of the state's vaccination plans, internal emails and other reports, along with vaccine provider interviews, reveals missteps that confounded one of the largest and most difficult government undertaking in generations.
Washington has increased its pace and now exceeds the national average for the percentage of doses that have been administered. While the DOH is still ironing out distribution and data, it has begun reaching underserved communities with a recently deployed National Guard team and targeted shipments.
How quickly the state can immunize the most susceptible now depends on rebuilding trust.
National Guard sidelined
It was the picture of efficiency.
Throughout Wednesday morning, the seniors living at Lakewood Meadows arrived at the makeshift vaccination clinic operated by the National Guard at a steady clip, some leaning on canes or walkers. The Pierce County apartment complex serves a diverse group and includes low-income residents.
A uniformed Guard member greeted and directed them to one of four stations, where another Guard member reviewed paperwork, discussed any concerns and then asked residents to roll up their sleeves.
Within minutes, the newly-immunized seniors joined their neighbors with goody bags filled with snacks and water. Dozens passed through the clinic each hour.
The mobile vaccine clinic, which has been operated jointly by the DOH and the National Guard since Jan. 27, is one step the state is taking toward a more centralized approach. It has also opened four mass-vaccination sites with the Guard's support. Washington is playing catch-up with other states, though, that started centralizing from the beginning.
By late November at least 22 other states had enlisted their emergency management agencies — the state equivalent of FEMA — to help with logistics or other aspects of vaccination efforts, according to an informal survey conducted by the National Emergency Management Association obtained by The Seattle Times through a public records request.
West Virginia, among the states leading the nation for its pace of vaccinations, placed the National Guard at the center of its vaccine effort. The Guard there hosts the state command center, coordinates distribution from five hubs, repackages vials into refrigerated containers, and assembles kits with extra syringes.
But in Washington, health officials went their own way.
The DOH "has been running all things vaccine without input or support from us," Robert Ezelle, director of the Washington Military Department's Emergency Management Division, wrote in an internal email Dec. 4 — just 10 days before the first doses arrived.
As they developed a vaccine plan in the fall, DOH leaders expected the state's hospital systems and its existing network of vaccine providers — doctors offices, pharmacies and the like — could handle COVID-19 vaccinations, so it didn't originally plan to enlist the state Military Department.
"We were thinking that was the best way to go, but it was a time when our health care sector was already very taxed with COVID disease," said Roberts. Her team overestimated the industry's capacity, she said.
Imelda Delgado, 88, saw that firsthand. One of the seniors at the Lakewood mobile clinic, she had previously tried calling her pharmacy and her doctor, inquiring about the vaccine, but had no luck. They'd promised to call back, but she never heard anything.
When she learned Guard members would be coming to her, she was ecstatic. "I said, I'm going for it!" Delgado said. "It's so hard to get it."
Jill Piasecki, the administrator of a Gig Harbor plastic surgery center, has spent hours emailing and calling the Department of Health for help navigating its vaccine reporting systems. Piasecki on Thursday finally got login credentials for one of the four separate data systems vaccine providers are required to use.
Despite following all the steps, she's learned the state has temporarily stopped giving first doses to many providers, while prioritizing second doses.
"I have a list of 900 people who I would love to give doses to tomorrow," she said. "The bureaucratic nightmare that's been created is forcing us to shut down."
Washington planned to offer vaccine providers a seamless online tool to register patients, schedule their vaccines, and — importantly — report the data back to the state, according to the state's 72-page vaccine plan. The portal would be centralized, so any resident across the state could find an available appointment. But because of development delays, the website, PrepMod, wasn't ready until Jan. 15. Instead, many providers had to develop their own system.
Microsoft, in partnership with the state, is now working to consolidate all the disparate scheduling tools into a statewide website that will simplify the search for an appointment.
On the back-end, many providers' tech systems don't automatically connect to the state's immunization registry, so they have been hand-entering data, resulting in it often being incomplete and late. After the state threatened to cut off vaccine shipments for tardy data entry, reporting improved.
The data stumbles clouded state officials' view of where the vaccine was actually being administered, and led to more than a month of guesswork. When available data showed only a third of doses had been used a month into the rollout, the public wondered who was getting the shots, and why it appeared they were sitting on shelves.
"Quite frankly, the biggest challenge is the information system," Kevin Brooks, chief operating officer for Swedish Health Services, said in late January, after starting a vaccination clinic with Seattle University. "It's registering patients, tracking doses, scheduling second doses, syncing with the state information system."
At first, hospitals thought they would be vaccinating their own staff and medical workers, Brooks said, but he was stunned when the state told them to keep going with the general public as well. The infrastructure for taking millions of public appointments simply didn't exist.
People flooded vaccine provider websites after the state opened eligibility to all residents 65 and older, among others, on Jan. 18. More than 2 million people qualified under the guidelines at that point, but the state had received just 700,000 doses. Phase Finder, the state's online eligibility tool, crashed.
Complicating things, some local health departments limited access to older age groups, hoping to stem the demand. In King County, for instance, the health department allowed access to its mass-vaccination sites only for those 75 and up, even as the state had lowered the age to 65.
"If you have expectations that were raised higher than they should have been, if you have a flow of information that is incomplete and changing, and if you have policies that are changing from one jurisdiction to another, then you have people that are going to be discontented and suspicious," said William Galston, a senior fellow at the left-leaning Brookings Institution. "The results were a mad scramble and a resultant loss of trust."
That piled onto generations of government mistrust among some groups, Galston said, and vaccine hesitancy runs high. He pointed to African Americans, who have been historically underserved by public and private health care systems.
Amid the disarray, some people got special access. The tech-savvy and those with connections to large health systems — which still had the bulk of doses — scored appointments.
At least three Puget Sound-area hospitals gave early access to foundation board members or donors who'd contributed upward of $10,000. The Seattle Times revealed the privileged access, sparking outrage. Calls for reform reached the U.S. House of Representatives last week.
By the beginning of February, the Downtown Emergency Service Center (DESC), one of the largest homeless shelter and supportive housing providers in Seattle, had only been able to vaccinate two clients.
DESC's nursing director, Alix Van Hollebeke, said she had applied for 400 doses, but had only received 100, most of which went to vaccinating front-line workers. The organization's weekly orders since have all been denied, she said, as the state directed doses to mass-vaccination sites.
In another high-risk group — home care workers — only a third have been vaccinated, estimated Adam Glickman, secretary-treasurer of SEIU 775, a union representing 45,000 Washington home care workers.
"There's a huge gap between those who want to and are willing to get vaccinated and those who are able," Glickman said of these workers, who often care for the sick and elderly and have been eligible for vaccines from the start.
Many don't speak English or have limited access to the internet, and "there's not, as far as we can tell, good systems in place for limited English speakers to actually access vaccines and communicate with vaccine providers and schedule appointments," Glickman said.
The state Department of Social and Health Services (DSHS) didn't contact these workers about vaccinations until the week of Jan. 11, offering letters to prove eligibility. Letters in languages other than English were made available Jan. 15.
Bea Rector, director of home and community services for DSHS, said the agency was waiting for supply to increase, for hospitals to move beyond vaccinating their own workers, and for the health department to launch technology to help workers find and schedule doses.
"We did not feel it was the right thing to communicate they were eligible until we could also tell them where to find the vaccine," Rector said. "If the technologies had been available earlier we certainly would have communicated earlier."
Less than a week later, the state announced it was expanding access to anyone 65 and older, adding more than a million more people trying to schedule appointments. Many home care workers were squeezed out.
Reaching racial and ethnic groups disproportionally at risk for the disease, a focus of the DOH, has also faltered. Last week the department released its first data on race and ethnicity of vaccine recipients, and it highlighted inequities. About 5% of people who have received at least one dose were Hispanic, while about 13% of the state population is Hispanic. Black and multiracial groups were also underrepresented, the report found.
Some local health departments have positioned themselves to fill equity gaps, but supply remains hard to come by. In early February, the state was routing just 19% of doses to county health departments, community health centers, federally qualified health centers and private practitioners.
DOH officials, taking stock of the rollout so far, have pledged to do more to reach underserved residents. The state is now setting aside 20% of its mass-vaccination slots for those making appointments by phone. It's also using a data tool to prioritize allocation in communities particularly vulnerable to COVID-19 and contracting with dozens of community groups for vaccine outreach efforts.
But the crushing demand over the past month, since the state opened the vaccine to all older residents, has left officials grappling with their original goals for equity.
"Was some of that at the cost of who has access to the vaccine?" said Roberts, the DOH assistant secretary. "That is a tension where we are all trying to figure out — what the right balance is."