How is the person at Walgreens or CVS going to verify that someone is a bus driver, or a grocery store clerk, or a preschool teacher? A note from HR? The honor system? Really?

And preexisting conditions are even harder. Will you need a note from your doctor? What if.... (5/15)
...you don't have a primary care MD? And what's a pre-existing condition? Diabetes, sure. How about diet-controlled diabetes? Pre-diabetes? Cancer, of course. I had a fairly benign type of thyroid cancer in my 20s. 40 yrs later, I'm pretty sure I'm cured. Does that count? (6/15)
In the end, @ashishkjha & I felt that – in a well-intended effort to promote equity thru distribution – we had built a system so complex that it would actually be inequitable. Why? Who figures out how to get ahead in complex systems? The privileged. Exhibit A: the tax code (7/15)
How would our suggested system work? After finishing the current groups, we'd turn to age next. First >75, then 65-74, then 55-64. When that's done, we'll have vaccinated 29% of the population, but a group that accounts for 92% of all Covid deaths. A great start. (8/15)
Then the lottery would kick in, run either by feds or states. A random number is selected, let's say it's a "3". Everybody whose last digit of their birth year is 3 is eligible for vaccination for the next 1-2 weeks. And so on. Fair, transparent, equitable, & non-gameable. (9/15)
In the last few weeks, we've watched the roll-out at several large academic health centers (Stanford, MGH, several NYC hospitals) devolve into rancor, with protests, line jumping, computer crashes, and cheating. Not good.

And I was influenced by watching... (10/15)
... our roll-out @UCSF, which – though not perfect – has gone smoothly and been perceived as fair. How'd we do it? Divided our people into four big groups based on amount of job-related Covid exposure. And then...a lottery. Once your group was up, you knew you would get...(11/15)
... an email inviting you to make an appointment in the next week or so. But your place on that line was chosen randomly, with no special advantage for any one group. It worked.

Ditto the experience in the 1970s, where the nation used a odd-even system ... (12/15)
...during the oil crisis. There, too, one could have argued for various groups to go first (poorer, longer commute, bigger family, more important work...). But the decision was to do it randomly, via license #. If your license ended with an odd number, you gassed up on... (13/15)
... an odd-number day. Ditto even. Transparent, equitable, feasible, & non-gameable. And it worked.

To paraphrase Churchill, a lottery is the worst system... except for all the others.

These vaccines are a miracle, but we could screw it up with a chaotic, unfair,... (14/15)
... and unworkable roll out. We look forward to the debate our proposal is likely to generate. It's not like there's anything else to talk about in the news 😉

Again, our piece is here: tinyurl.com/y24vncws

Stay safe and, when you can, get vaccinated. (15/end)

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More from @Bob_Wachter

7 Jan
Today @nytimes, @ashishkjha & I make the case for a more straightforward, less-gameable & (we think) more equitable way to roll out vaccines: older people first, then use a lottery. tinyurl.com/y24vncws. Here's our reasoning: (1/15)
(It's worth noting that ours is part of a set of 4 interesting articles, the others on targeting hot spots, not pressuring the vaccine-hesitant, and a better way of thinking about distribution algorithms. All worth your time.) (2/15)
Our thinking: after we finish healthcare workers & people in nursing homes, question is: who goes next? Efforts to prioritize groups like "essential workers" & people with pre-existing conditions seem reasonable, but we fear that they are devolving into an unworkable mess. (3/15)
Read 15 tweets
6 Jan
1/ Covid (@UCSF) Chronicles, Day 294

Lots to talk about, so today I’ll do an update on things @UCSFHospitals (now adding vaccine rollout), SF and CA. Then quick takes on a bunch of issues, mostly vaccine-related. The news is coming fast and furious – too much of it bad.
2/ Let’s start @UCSFHospitals, now having our biggest surge yet: 83 pts, 14 on vents (Fig L). It’s busy but it's not yet stressing our capacity in both hospital & ICU. Test positivity rate 5.1% overall – 16% (highest yet) in symptomatic pts; 2% (stable) in asymptomatics (Fig R).
3/ Interesting that our hospital cases keep rising despite fewer new cases in SF – down to 237/day from peak of 290 (Fig L). But a worrisome new uptick – might be holiday/New Year’s effect. Test positivity rate pretty close to @UCSF’s: 4.49%. SF hospitalizations=218 (Fig R), w/…
Read 24 tweets
4 Jan
As expected, our @washingtonpost editorial today on the delayed second dose vaccine strategy has generated a vigorous and interesting dialogue. tinyurl.com/y7c6v9hz Here are my takeaways (a thread): 1/18
The debate is healthy. There are pros and cons to the current strategy and the alternative we present, and there are real uncertainties associated with them both. They should debated thoughtful and studied to the degree possible. 2/18
Many people seem focused on the source of the delays in vaccination, as if it matters whether the bottleneck is from vaccine production or distribution/injection. I don’t think it does. Starting soon, there will be doses available and people to inject them – and... 3/18
Read 18 tweets
31 Dec 20
U.S. is now considering idea of a single vaccination shot, delaying shot #2 until months later. Last wk, I thought that was a bad idea – the trials that found 95% efficacy were 2 shots; why add extra complexity & a new curveball. But facts on the ground demand a rethink. (1/7)
The two main changes are the slower-than-expected vaccine rollout and the new variant virus being found in the U.S. Both demand that we turbocharge the process of getting a large chunk of the population at least partly protected. (2/7)
Here's my back-of-the-envelope math:
- Single shot seems to be about 80% protective after a month
- 2nd shot adds some efficacy (up to 95% protective), and maybe (tho not yet proven) some durability.
- New variant is here, and undoubtedly far more widespread than we know. (3/7)
Read 7 tweets
30 Dec 20
1/ Covid (@UCSF) Chronicles, Day 287

Today, a brief update on the local situation in SF & CA, and then a few reflections on a series of new failures in the U.S. that, sadly, make clear how difficult it is for our country to get execution right in the fight against Covid-19.
2/ First, a brief update on the local scene. Bottom line: not much change, which is either good or bad news, depending on how you feel about half-filled (or empty) glasses. Personally, I don’t feel great about it, since we’re just starting to see the impact of holiday mingling.
3/ TSA reported 1.3 million people screened at airports Sunday, a 60% decrease from last year but still an awful lot of travel for a country that should be staying home. After 10 months, the urge to be with friends & family is understandable, but the cost will be very high.
Read 25 tweets
25 Dec 20
1/ Covid (@UCSF) Chronicles, Day 282

Holiday greetings – hope you’re getting a little R&R. I’m on clinical svc @ucsfhospitals – welcome break from a Life of Zoom, leavened by a little Netflix. Today, update on Covid in SF/CA, & lessons from first 2 wks of vaccine distribution.
2/ @UCSFHospitals, 60 pts in hospital, 12 on vents (Fig on L). Curve shows we may have plateaued – at a pretty high # but one that isn’t overly stressing system. Our test positivity rates (Fig R) have inched down a bit in the past week. Maybe things are starting to turn around.
3/ SF cases up to 288/d (Fig L) – low when compared to many regions (incl. SoCal), but 10x SF's Oct cases. Test positivity still inching up, now 4.3%. 176 Covid pts in SF hospitals; perhaps hint of a plateau? (Fig R). Cumulative deaths=178, w/ only 12 in past 30d – amazingly low.
Read 25 tweets

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