By Dave Northfield
When the Oregon Health Authority needed someone to lead the effort to distribute the COVID-19 vaccine across the state, they turned to Dave Baden. The OHA chief financial officer, Baden came to Oregon from the Centers for Disease Control, where he was deputy CFO and helped develop a $7 billion budget presented to Congress.
In managing the vaccine rollout, Baden oversees a program that has administered over four million doses. We spoke to Baden as Oregon moved closer to Governor Brown’s target of vaccinating 70 percent of those 18 and older.
What have been the biggest challenges for the rollout?
It’s amazing to think we are six months since the first vaccines have arrived into the state, and to the amazing feat of science and engineering to get to this point. As we all talked about how long it usually takes for a vaccine to be developed in the normal process, and the eggs it takes to develop a flu vaccine, and you can see the power of technology and the power of engineering and ingenuity to get the vaccines to this point, with a lot more money than normally gets put into developing a vaccine. The biggest challenges of the rollout probably have changed throughout the rollout, having a product that has extraordinarily high demand while supply is scarce is difficult to manage for all of us. And for our health care system partners, for the Oregon Health Authority, for those that wanted it, I would have loved to open up the full vaccine spigot on January 1st, we weren’t able to do that. We weren’t able to do that on February 1st, we haven’t been able to do that really until now (early June) where the supply and demand quotient has shifted. And that has been a really big challenge of the rollout. I think at the beginning, especially for our hospital partners that really stepped up, understanding the storage and the pharmacy and the administration of this product, of a two-dose vaccine, was underappreciated going into this. Having something that needed ultra-cold storage, how to turn that on a daily basis, that was not something a hospital normally deals with. I think just getting used to that was definitely a challenge in the rollout. And looking back at the last six months, I think the piece that we would have thought about and done differently and been better prepared for was a better equitable distribution of the vaccine that got to all Oregonians regardless of economic status, regardless of whether they were a Black or a Brown Oregonian, the impact of the pandemic on communities of color and where the pandemic raged most in Oregon and across the country were in those communities. And we did not do a good enough job to assure that there was access from the very beginning to those communities.
How were the allocation decisions made?
This definitely is one that evolved over the first few months of the response. At first, where vaccines were initially headed to was health care settings and hospitals to vaccinate frontline heroes in the healthcare infrastructure of the state. There were surveys done on which to base that data. I think from there is where it got more complicated, because hospitals and health systems that pivoted from vaccinating their own staff – which may be challenging, but is way less challenging than operating a large, very high through-put mass vaccination site – that pivot changed how the weekly allocations were done. It started with our weekly allocations with where we could get doses in arms. That led to doses not going in a consistent fashion in January and February across the state, it really went to places that had the capacity to move doses in arms quickly. So when we got into February, we all knew that we had to fix that, and we moved a little bit more into assuring that we had doses moving across the state. Because as we got into February, more and more places figured out how to give this vaccine. It was a little slower than all of maybe had wanted, but as we got into February, we were able to turn on a little more consistent spigot, now it was a spigot that was slow, it was not big enough to meet the demand in the Oregon Convention Center or at the Salem Fairgrounds, but we wanted to assure that someone in Morrow County had basically a per capita equal chance of getting a vaccination appointment than someone in Portland. That meant basically everybody was mad, but at least I could go back on a consistent formula that said hey, I get that that may mean only 100 doses go to Morrow County, but that is what your per capita demands with how much vaccine that we were getting. If I had double the vaccine, I would be able to send double the doses. It took a little bit for that to get through, but that allowed for a bit more data driven policy of where vaccine doses were sent every week. And as we got into the next three months, we were able to use more inventory data and other things to manage allocations. And now we are into a model where a vaccine provider is able to get the vaccine that they need when they need it. So now we are past the point of a weekly allocation process, and more of if you’re a vaccine provider and you have some vaccine in your fridge, when it looks like you’re running out, you order more and it should be there in two or three days. It’s a very different place than where we were but it gets back to some more normalcy in how medical supplies typically are ordered period.
Has there been a difference in dealing with the current administration versus the previous one?
I do think that there’s a little bit better collaboration with the states, listening to some concerns about the rollout, I think you that having more doses available as we got through the end of January, February and into March led to a little bit of rising tide lifts all boats. There were definitely still some concerns that based on data Oregon’s share of doses per capita in February, March and April still weren’t adequate. We ended up being for a while the 49th state in per capita doses that we were getting at one point, so we brought up those concerns and got an explanation, nothing changed, we didn’t get magically more doses, but really at that time we were starting to switch into everybody was eligible and that allowed us to change how things were done. But having more vaccine, having a Federal Emergency Management Agency site in Jackson County for a while I think was helpful and FEMA has been supportive of sites throughout the state.
Here we are with well over half the state vaccinated, how does that feel?
It does feel good to get to where we are, knocking on the door of 70 percent of 18 and older at least receiving dose, I would love to see demand not slow down as rapidly as it did. That’s really where we’re at, is going from people seeking vaccine to now we are seeking people out to get vaccinated. And that’s just such a change. Generally, with partnerships with the health care industry, with local public health agencies, Oregon, as bad as the pandemic has been, Oregon has been one of the better places to be in the United States. We’ve had a lower infection rate generally, our death rate is much lower than most other states, and we are 18th in our vaccination rate now overall. So I think generally you have more chance to be alive if you are in Oregon in this pandemic than in other places, which is a testament to the hard work of everyone out there, and to all Oregonians who did put on a mask when asked, who did social distance, who quarantined when they were sick and who did not spread the virus as much as other places.
As you mentioned, now the work is harder getting those doses to targeted groups. How do you do that and overcome some of the hesitancy that is out there?
It’s multi fold. There are so many reasons why people have made a choice not to get vaccinated. The piece that I’ve been reflecting on is every COVID death is a tragedy, but the COVID deaths in the last few weeks are even more of a tragedy because the 92 percent of those that have died were unvaccinated or were not fully vaccinated. It just points to where we are in the pandemic, vaccines save lives, but there are a lot of people for a lot of different reasons who don’t trust the messenger, don’t trust the government, don’t believe their doctor, don’t believe their county commissioner, don’t believe the Governor, don’t believe the President. So the switch from the messenger to really figuring out more opportunities where someone may get their news from a source that doesn’t believe in the vaccine or sees social media posts that aren’t true about side effects, that person may also go see the doctor and although they may not trust their doctor either, I think over the next weeks and months, that’s where we can build an opportunity to have those conversations with their provider I think that’s an important part of this. That will be slow and painful in some areas, and I think Dave you hit it, bringing more access points for people who are busy, have two jobs, have a very family life, or who can’t take off work to go get vaccinated or be ready for the side effects, which could mean they would miss another day of work. Those opportunities could be at the market, it could be at a game, it could be lots of different places, where it’s like they have an extra day and so I’m going to get vaccinated now. Opening up more of those opportunities, one of the successes in Jackson County at the FEMA site which brought mobile capacity was they went and set up at a market that serves largely Latino-Latinx-Hispanic community, and watching the rate there every Sunday, of when people got vaccinated, it’s when people were having their day off. So having that vaccine available, it was 10-15 people, and then 100 people…10 or 15 people, and then 100 people. So that’s what’s going to happen. Reassurance messages, having trusted messengers, makes a lot of sense, and then it will be the slog in doctor’s offices and the people that are really vaccine obstinate, what will it take to convince them? I’m not sure. The country is grappling with people saying I will not get vaccinated under any circumstances, maybe their doctor will convince them, maybe it will take one of their friends getting sick, who is also not vaccinated, I would really love for that not to be the reason for someone to get the vaccine, I think that has been the trigger in some of the new cases, especially in some of the rural Oregon counties people saying I saw this community member get sick or I heard about a pastor that got sick. That drove them to get vaccinated. Unfortunately, that may still happen in some areas where the vaccine rate is really low.
There are some really smart targeted efforts in a lot of places, working with employers for example. How important are some of these partners, hospitals and other organizations, in this effort?
They’ve been super important and a lynchpin of the vaccination effort in Oregon. I see it as a three-legged stool going forward. We’ve got community partners that have either a trusted voice or a group they work with providing funding to community based organizations to get out there to partner with the second leg of the stool which is the vaccinator, whether it’s a hospital employee or a pharmacist or doctor, you have to find somebody to put the needle into arms, and we’ve broadened eligibility for who can do it, but having people connected there, and the third part is where people work or where people play or go to shop, that third leg of how to get people vaccinated it’s getting all parties to play a role going forward. The roles that hospitals played in stepping up in vaccinating beyond just their employees in their local communities, to say you know what the state needs us now and we are going to take a risk, and set up these things that we don’t know how we’re going to get paid for, we don’t know exactly how they’re going to happen, but they have been really successful in keeping the state going in this vaccination effort.
There were so many unknowns at the beginning, so your job was very difficult, there were questions about supply and efficacy, how did that affect where you sent doses?
The beginning was really tough, people figuring out how to manage a new product, the setup, how the filling the vials would work, all that goes into managing a new vaccine or a new drug, there was just so much pressure right at the very beginning, that was as difficult thing to manage. The pieces of trying to not only manage the supply but managing the demand, in the different eligibility categories, was really difficult. And looking back there will be a lot of medical ethicists who look at how we did the rollout even according to the CDC categories 1a, and 1b, and of course trying to get health care workers vaccinated, but I think there is a lot of thinking and questions about where to go. And I think some of us wish that we would have had more community guidance and the Vaccine Advisory Committee should have started earlier than it did. Looking back, we should have had that going in the fall and really ready to go and having thoughtful guidance about getting vaccine to all Oregonians and all populations of Oregonians. I think all states suffered from some of the same concerns but it is one thing that we definitely could have done better.
You may have also thought it would be great to have a connected, well-funded public health infrastructure and I can just get the supply and plug it in. But that’s not how we set up public health in this country.
I think you’ve hit on the disjointed nature of the public health system, the pandemic has shown where there are very very strong disconnects. There were thoughtful plans and preparedness exercises done between hospitals and health systems and local public health and you saw where those were strong you saw some benefit in how the pandemic response rolled out in a certain county. But even if you take a step back that there’s not a national system that we have are all part of that is able to say who and who isn’t vaccinated, is pretty absurd when you think about it. It comes to me that some of the hard ways that impacted the vaccine rollout is that insurers have records, the state has records, coordinated care organizations have records, but not all together. So that interconnectedness of someone’s health record is definitely one of the challenges.
How do you manage declining demand now that there is plenty of supply? Moving forward, what is the strategy?
I think first and foremost it’s creating more and more access spots. One assuring that every primary care physician or doctor’s office, hospital mode, urgent care, some dental offices have access and have vaccine there, basically the health care industry and pharmacies all have vaccine. I think we’re pretty close to that spot. But that’s not enough. So it’s working on events, continuing them, moving to a campaign ground game, which is boots on the ground, knocking on doors, figuring out where there is lower uptake, and just creating opportunities where people can receive a vaccine. That’s hard, slow work. We’re not going to get back to where we hit 50,000 doses a day a couple of times. That’s not going to happen again. It may when we need a booster, or if we need a booster, but for now keeping a continued push on getting people vaccinated, we still have a long way to go in the state, eventually children under 12 will be eligible, so we’re definitely done, we’ve come a long way, and I think hopefully we have a different kind of summer to look forward to with cases that are really going down in Oregon and in the country. So hopefully more and more people will get vaccinated so we won’t have a resurgence in the fall or a resurgence with the new variant. But only time will tell.
Thanks Dave, we appreciate it, you have a really hard job, and people are grateful for the incredible amount of effort you’ve put into it.
Thanks Dave, and thanks to the hospitals and health systems who have been such important partners in this vaccine effort.