California's muddled county-based coronavirus vaccine distribution system has stoked confusion, frustration and angst for citizens across America's most populous state.

California, the deadly epicenter of the nation's winter coronavirus surge, has consistently ranked in the very bottom tier of states in vaccinations administered per capita. State officials say missing vaccination data and collection snafus are partly to blame. But in the face of ongoing criticism that high-tech California can't seem to efficiently administer the vaccine at scale, state leaders have announced a major do-over.

The in-progress revamp includes the launch of next month and bringing in a third-party administrator to help fix a jumbled system that basically has each of the state's 58 counties running its own vaccine program. State public health leaders say the moves, which follow the lifting of regional stay-at-home orders, will centralize delivery and streamline appointments while bolstering data collection, equity and accountability.

But Californians have heard these pledges before. Skeptics say Gov. Gavin Newsom is once again over-promising as he faces criticism, lawsuits and a nascent, yet growing, recall movement.

NPR's Eric Westervelt spoke with the woman helping to lead the revamp effort, California's Surgeon General Dr. Nadine Burke Harris, about vaccine equity, transparency, and the distribution makeover underway. Dr. Burke Harris took the helm of the newly created office less than a year before the pandemic struck.

Interview Highlights

Eric Westervelt: The vaccine distribution in California has not gone perfectly, to say the least. What have you learned from the rollout of this phase 1A to health care workers and nursing home residents? And how have those lessons changed your vaccine planning going forward?

Dr. Nadine Burke Harris: Well, we've learned a tremendous amount, as you can imagine. Ramping up this type of vaccine distribution process, particularly in a state as large and diverse as California, is certainly a challenge. And you're absolutely right. We started off, it was a bit rocky, and the governor gave us a challenge, what we call the 10-day vaccine challenge. And we were able in 10 days to triple the number of folks that we had vaccinated in the previous 10 days. So we did a rapid ramp-up.

And we recognize that it's really important for us to have, you know, a simple and straightforward strategy, to have a very clear statewide strategy. We do a lot with our our counties, which I think is a strength in California. But in this case, it was a challenge for administering the vaccine as quickly as we possibly could. And we also want to be clear with the public about a simple, straightforward way for them to understand when it's their turn and how they can get vaccinated. And these are all things that we are now really doubling down on improving.

Now a third-party administrator will allocate and distribute vaccines directly to providers to maximize distribution efficiency. Do I have that right? Who is this third-party administrator and what role will they play? How will they work with counties?

Yeah, so that's exactly right: A third-party administrator will allocate vaccines directly to providers. And to your question of who is the third-party administrator, that is currently being negotiated. So unfortunately, I don't have a name for you on that. But what I can tell you is that the goal is to really simplify and streamline, you know, really matching capacity and capability with vaccine supply so that we can most efficiently vaccinate as many Californians as possible.

But what kind of administrator are you looking at, what kind of skillset?

Certainly we're looking for an entity that has very, very strong logistics and tracking and data tracking capacity.

So basically UPS meets Google?

(Laughs) You won't get me to say more than that, unfortunately.

[Late Wednesday after this interview a state official confirmed that a contract is pending with Blue Shield of California, the large nonprofit insurer. Contractual details and an implementation timeline are still being worked out]

But all of these things are still a work in progress: hiring a third-party administrator; getting theand getting better data to operationalize equity and distribution. And it's all still contingent on getting more vaccine doses from the federal government. What do you say to Californians who are frustrated and say, "You know, this is all sounds good, but it's still all aspirational?" Are we going to be waiting months before we actually get the shot in the arm?

I want to acknowledge very plainly: There is a constraint on supply of vaccine, so there are many people who will have to wait until they get a shot in the arm. We recognize there were some challenges, there were some bumps. That said, we are working around-the-clock to make sure that the only constraint is the supply. And when [the federal government] is able to ramp up supply, we're able to get those shots in arms.

The state announced it hopes to simplify eligibility and that future groups will become eligible for the vaccine based on age, and that this will allow the state to scale capacity while ensuring equity. Could you clarify the balance on age and equity? So will an older Latino farm worker in Imperial County get precedence over, say, an elderly person in Berkeley?

We are moving to an age-based system because what the data tells [sic] us is that age is, by far, the strongest predictor of risk of hospitalization and death. We had started out with a system based on our occupational sectors. We started with our health care workers. We also identified that individuals who were in senior residential care facilities were at dramatically disproportionate risk.

And we had included our 65-plus ages in tier one of phase 1B, and we also had occupational sectors based on occupational exposure. That included our agricultural workers, it included our educators, child care workers. Now, when that tier is completed, California will move to a straight age-based system. And as we look at an age based system, we are holding equity at the center of that.

And there are a couple of levers that we can pull to operationalize equity. That includes doing the outreach, working with community-based organization and partners to really leverage and mobilize trusted messengers within the community to make sure that we are focusing some on vulnerable communities, such as those who are lower income, those who are facing occupational exposure.

In terms of your question, a farm worker versus someone in Berkeley, what we do in that situation, I wouldn't call it prioritization, but if the data is [sic] telling us that in our Central Valley, where we have a high density of farm workers, we have a very high density of cases, we might allocate more doses to those places where we are seeing a high numbers of cases.

So you will be able to put the vaccine fire hose maybe more focused on where you're seeing the greatest need?

That's right, that's exactly part of the intent of what we're trying to do.

When do you think the state will be able to release better and more granular data about vaccine distribution by county, by age, by race and the share of health care workers who've been vaccinated so far? Many other states, as you know, are doing this. California is not. This is key to the sort of equity, transparency issues the governor talks about a lot. But, you know, talk is one thing, let's see the data.

Well, that's part of the reason for transitioning to a third-party administrator, right, is to have that level of transparency, data collection, accountability. Those are exactly the challenges that we will be solving with this approach.

The Biden administration has said there's this need to balance speedy vaccine distribution and delivery with equity. Why are speed and equity, necessarily, opposing forces? What is the right balance, in your view? And how, specifically, in California do you hope to achieve that balance?

I want to clarify that myth: I don't think that speed and equity are opposing forces. But I think that if we think only about speed and we don't do it thoughtfully, we can undermine equity. But speed and equity absolutely can be achieved at the same time.

You can achieve equity through means of allocation, through means of outreach, identifying what are the barriers and supporting those communities here in California. We've been looking at using a tool called the Healthy Places Index, which helps to identify which communities are at greater risk of contracting COVID-19. It looks at things like transportation, housing, access to health care, access to services. And no surprise, the areas in the lowest quartile, the neighborhoods that have the lowest availability of these community resources that help to ensure health, they are seeing the highest rates of COVID-19. And not only the highest rates, but also the highest hospitalizations and death rates. And so when we talk about equity, we are talking about using data to drive a smart way for allocating our supports to communities to prevent the pandemic from boiling over in the areas that are most vulnerable.

The CDC vaccine tracker shows doses distributed and doses administered. It's basically a measure for speed. What kind of specific metrics do we need to measure equity in California, in your view?

I'm looking at things like social vulnerability, looking at which communities are most likely to be have occupational exposures, more likely to contract COVID-19 and more likely to have poorer outcomes. Do they have access to health care or are we looking at situations where, when folks begin to feel symptomatic, they don't have a regular health care provider that they can go to. And it takes longer to identify a case of COVID-19 and there's increased risk of spread as a result. So these are some of the data points that we are looking at here in California to make sure that we can be as aggressive and effective as possible at curbing this pandemic by targeting the places where we see the spread is the fastest.

So in California, one example is among our farm worker community. We see very high rates of spread, disproportionate contraction of COVID-19, as well as hospitalization and death among our Latino population, which is the vast majority of farm workers in California.

Thank you for your time. I know Californians are wishing you and all your colleagues Godspeed on this important work.

Thank you. If you know a public health official right now, maybe send them some flowers (laughs) because we are all working triple overtime to make sure that we have a really solid vaccine allocation framework for the state of California and that our only limitation is supply.

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