I spent a lot of time last year thinking about how things went wrong. You can understand why. For a physician like me, the many failures of our public health and medical systems have been especially stinging. Now we’re faced with the great, dashed hope of 2021: a plague of “vaccine chaos,” where distribution chains get knotted up with disastrous delays. I expect to read much more about this in the coming months—about every dose that’s been delivered too slowly, every one that expires unused, and every Covid-denying US senator who gets their shots before your grandmother.
It’s curious that medical and scientific advances are so easily described in superlatives—miracles, breakthroughs, game changers—but their real-world implementation often ends up seeming like a catastrophe. The reason it’s so hard to put science into practice is as banal as it is complex. It’s the lesson you were taught in every history, literature, or social science class you ever took: Humans are unpredictable; society is not a controlled laboratory experiment. (Shakespeare was admittedly more poetic when he said this.) If the system does work, little credit is given. Frederick Banting and John Macleod won a Nobel Prize for their discovery of insulin, but there is no Nobel Prize for the many private companies and government regulators who ensure the cold chain actually delivers insulin to those in need. Maybe there should be, for the field of logistics.
I wonder how we got to this point, where any public institution not achieving immediate perfection is deemed a failure. Is it just an extension of the old news saying that “if it bleeds, it leads”—that we love reading about things going horribly wrong? I remember the bad press that followed the disastrous start of Healthcare.gov, the health insurance exchange set up by the Affordable Care Act. The technical problems were substantial. After achieving what was once considered an American impossibility—meaningful health care reform—the botched online rollout brought the law back to earth. In retrospect, the improvements gained through the expansion of health insurance have been so real that all the ink spilled over early site outages seems trifling now, even a tad offensive. Obamacare made authentic progress against entrenched social inequality. Eventually, they fixed the website.
It seems likely that the vaccine rollout will look much the same after the fact. Once we are all immunized, we will celebrate the unprecedented scientific advances and administrative efforts that crushed the pandemic. In the meantime, we hear about all of the ways the vaccination campaign is going wrong. I’ve already read complaints that health care workers are being prioritized over high-risk community members, and that people in the community are being prioritized over strained health care workers. I’ve seen pundits criticize the government’s reliance on private companies for distribution and economists suggest that we should hand the reins over to private companies for distribution. We didn’t like it when Florida asked us to sign up in person for the vaccine or when they asked us to sign up online instead. American doctors have praised the UK’s decision to stretch supplies by giving only one dose to each person, while doctors in the UK decry the same thing.
I don’t mean to sound too dismissive or overly optimistic. One reason we care about institutional failures is because the consequences are real. The Covid crisis dwarfs even health care reform in its urgency and impact. Every delay in vaccination means more social disruption, more death. Glacial, unforgiving government bureaucracies can devastate lives. If we expect only mediocrity, that’s what we’ll achieve.
Practicing medicine means being intimately aware of the consequences of failure. Individual and systemic perfection is the expectation in my line of work, even when it seems amazing that our byzantine health care system works at all. There’s always a new catchphrase in health care (high reliability, six sigma, never events, zero error) that basically means the same thing: no mistakes should ever be made. That’s my personal goal, as well. Every mistake is truly calamitous for patients and providers. It’s part of what makes being a doctor so stressful. While you may have heard that doctors and nurses are suffering from burnout, the problem stems from more than overwork. Much of our stress comes from “moral injury”—that disconcerting feeling of being trapped in flawed institutions that nevertheless demand the impossible. Imagine Office Space in an ICU.