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I spent a a lot of time last year thinking about how things went wrong. You can understand why. As a physician, the many failures of our public health and medical systems have been particularly harsh. We are now faced with the great disappointed hope of 2021: a scourge of “vaccine chaos,” or distribution chains to have tied with disastrous delays. I expect to read a lot more about it in the coming months – about every dose given too slowly, every dose expiring unused, and every Covid-denying US Senator who gets her injections before your grandmother does.
It’s curious that medical and scientific advances are so easily described in superlatives – miracles, breakthroughs, game changers – but their implementation in the real world often ends up appearing like a disaster. The reason why it is so difficult to put science into practice is as trivial as it is complex. This is the lesson you have been taught in every history, literature or social science class you have taken: humans are unpredictable; the company is not a controlled laboratory experiment. (Shakespeare was admittedly more poetic when he said this.) If the system works, 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 The cold chain actually provides insulin to those who need it. Maybe there should be, for logistics.
I wonder how we got to this point, where any public institution that does not achieve immediate perfection is seen as a failure. Is this just an extension of the old news saying that “if it bleeds, it leads” – which we love to read about things that go terribly wrong? I remember the bad press which followed the disastrous start of Healthcare.gov, the health insurance exchange established by the Affordable Care Act. the technical issues were substantial. After achieving what was once seen as an American impossibility – meaningful healthcare reform – the failed online rollout brought the law back to earth. In retrospect, the improvements won thanks to the expansion of health insurance have been so real that all the ink spilled during the first site outages seem insignificant now, even a little offensive. Obamacare has made genuine progress against entrenched social inequalities. Finally, they fixed the website.
It seems likely that the vaccine rollout will be very similar after the fact. Once we are all vaccinated, we will celebrate the scientific advancements and unprecedented administrative efforts that crushed the pandemic. In the meantime, we hear about all the ways the vaccination campaign is going wrong. I’ve already read complaints that healthcare workers take priority over high-risk community members and that community members are priority overworked health care workers. I saw experts criticize government dependence on private companies for distribution and economists to suggest that we should hand over the reins to private companies for distribution. We didn’t like it when Florida asked us to join in person for the vaccine or when they asked us to register online instead of. American doctors have rented UK decision to stretch supply by giving just one dose to each person, while UK doctors decry the same thing.
I don’t want to sound too dismissive or too optimistic. One of the reasons we care about institutional failures is that the consequences are real. The Covid crisis even eclipses healthcare reform in its urgency and impact. Every delay in vaccination means more social disruption, more deaths. Frozen and ruthless government bureaucracies can devastate lives. If we only expect mediocrity, this is what we will achieve.
To practice medicine is to be intimately aware of the consequences of failure. Individual and systemic perfection is the expectation in my line of work, even when it seems astonishing that our Byzantine health system is functioning at all. There is always a new slogan in healthcare (high reliability, six sigma, never events, zero errors) which basically means the same thing: no mistakes should already be done. It is also my personal goal. Every mistake is truly disastrous for patients and providers. This is part of what makes the job of a doctor so stressful. While you may have heard that doctors and nurses suffer from burnout, there is more to the problem than overwork. Much of our stress comes from “moral damage– that disconcerting feeling of being trapped in faulty institutions that nevertheless demand the impossible. Imagine Office space in an intensive care unit.
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