Rae Woods: From Advisory Board, we're bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. Rae Woods: We've talked a lot about the logistic and operational barriers of COVID-19 vaccines on this pod, but the latest dilemma isn't about syringes or nursing capacity; it's about the lengths that some people are willing to go in the pursuit of vaccination. And that creates a whole host of real challenges for health officials, especially when it comes to enabling equitable access. Rae Woods: To talk about the ever-changing landscape of vaccines, I've brought back coronavirus vaccine expert, Brandi Greenberg. Hey Brandi. Brandi Greenberg: Hey Rae. Rae Woods: I feel like we finally crested the date. It has been a year plus of quarantine, of lockdown of, staying home. How do you feel one year later? Brandi Greenberg: Not surprisingly, Rae, I am quite optimistic. For us, there's a little bit of sentiment right now because in my family we mark the date when things shut down as March 13th of last year, which was also my son's 13th birthday. So we will be honoring his 14th birthday by also looking forward to things starting to open up over the next few weeks. Rae Woods: It wouldn't be a conversation with you and me, if you weren't playing the optimist and I wasn't maybe playing a bit of a pessimist role. Brandi Greenberg: Very true, but if you read more articles, you will see the optimists are winning. Rae Woods: Well, Brandi it's been a couple of weeks since we've done a full vaccine update on the pod. So do me a favor and just get me up to speed. Where do things stand in the middle of March? Brandi Greenberg: Right now there's a lot to be quite optimistic about. We have not two, but now three authorized vaccines moving through the United States. We have the two mRNA vaccines from Pfizer-BioNTech and Moderna, and now as of a few weeks ago, we have a single shot option from Johnson and Johnson. And through their partnership with Merck, they are quickly ramping up supply, and as of a few days ago, we were steadily injecting over two million shots a day in people's arms, with a lot of folks, including Jeff Zients, saying that they are pretty confident they're going to get to about three million shots a day within a few weeks. Rae Woods: Wow. Okay, so that is great news. And supply is clearly continuing to go up, but it hasn't yet matched demand. There's still this vast number of people who are eager to get their hands on vaccines. They're waiting in lines, they're getting on to registration websites, crossing their fingers hoping for immunization. What are you seeing folks do when it comes to getting their hands on a dose? Brandi Greenberg: I think there's been a fair bit of coverage and hype around some of the extreme actions people are taking, including people dressing up as old ladies, people posing as an elderly person's caregiver. But I think there are also a lot of folks who are not doing anything wrong or what might be considered unethical, but they are just all bombarding these registration sites at the same time and navigating multiple sites in some cases to try and figure out where to get that appointment, what to do, long lines for those handful of extra doses that could be available. So clearly demand is still outstripping supply. Rae Woods: Those are the crazy stories. That's what the media has labeled vaccine hunting. Those extreme cases that hit headlines or, I mean, let's be honest, make it into SNL skits, which makes you know this is a problem. But when it comes to vaccine hunting, I'm not sure that the kind of ethical line is so black and white. I think that there's a lot of vaccine hunting that isn't really shady or unethical. Is that right? Brandi Greenberg: I would have to agree since I would put myself in the category of an ethical vaccine hunter. What I will tell you though, is it doesn't mean that I wasn't very aware of my privilege in doing so, that I was working within a system as many others are that's just right for arbitrage. You have states with very different guidelines. You have certain hubs that were known and word was spreading quickly that they were having hundreds of leftover vaccines at the end of the day, and that information was getting out there. Brandi Greenberg: So I think we created ... it's that law of unintended consequences that a lot of the vaccine hunters who were successful, but staying with what I would argue, the bounds of ethics, just working within the system, they were taking advantage of the fact that they had time, technology, transportation, and a lot of flexibility. They can navigate all those different sites. They can refresh the appointments. They can dedicate time. I've heard of people literally blocking out a day on their calendar and just saying, "I'm going to go." I was able to drop a meeting when I found out that within 20 minutes, there was a place with hundreds of leftover shots. So I think that flexibility that lends itself to more white collar jobs is one of the underlying things going on here. Rae Woods: We'll talk about the kind of downstream effects of that, but I really liked that you said, "Working within the bounds of the system," because that is what this is. Crazy headlines aside, this is not a problem of individual misbehavior; the behavior that we are seeing is a result of the system that's been created to match people to doses. Especially to doses that are extra or leftover or God forbid would be thrown out. Right? Brandi Greenberg: Absolutely. This is one where we have to remember the CDC, Dr. Fauci, many other public health leaders have said, "A shot in any arm is still better than a shot that is thrown away." So within that system, people are figuring out how to take advantage of it if they really want a shot, they can get a shot. Rae Woods: I think we're starting to see new systems entering the market to try to make this matching hunters to supply a little bit easier. Brandi Greenberg: Yeah. I've definitely seen in a few different markets now and one national player, which the New York Times covered, this site called "Dr. B". But these tech companies are trying to aggregate information from different community health centers, different hubs, different provider organizations that are vaccinating so that they can centralize how they communicate that they may have available doses. And then on the demand side, people are able to enter their information, not just their availability, but again, the information that could affect prioritization. This is where I think you start to see a little bit more efficiency in the market to the extent that part of our goal is equal access. Rae Woods: All of what we've talked about thus far is a good thing. Again, matching up demand to supply of doses that would be tossed, still making sure that we're prioritizing risk and vulnerability, but and I think you've started to get to it earlier, what's the downside? What's potentially the unintended consequence of some of these digital first systems? Brandi Greenberg: Well, the big one is simply that they are digital first. You have a lot of people who either don't have access to that technology, maybe aren't necessarily as technologically literate in terms of understanding how to navigate it, or even just that older population that may not quite understand how a particular app works. So I think for both age and probably just economic class, I would say simply by being a technology is still going to prioritize certain populations or at least disadvantage the vulnerable who may have less access to technology. Rae Woods: Or even some of the other things you talked about; the ability to block your calendar to take a day off. If you think about essential workers, maybe people who aren't the VP of a company, Brandi, and able to say, "Nope, I'm not going to this meeting; I'm hitting the road," it starts to piece together this puzzle where, like you said, more affluent members of the community tend to have the ability to do these digital first solutions, which ultimately is going to have an impact on disparities. Brandi Greenberg: Yeah unquestionably. And I think you bring up a huge point that even if everybody was given an iPad in the United States, and even if you equalized for technology, you cannot necessarily equalize for flexibility. So a lot of these essential workers that are in hourly jobs or have committed to being in a certain place at a certain time for a certain set of hours, even if they got the alert on their iPhone that doses were available 20 minutes away, only a subset of the population could drop everything and be able to get there. Rae Woods: So then what's the role of the incumbents? I'm thinking the providers, the public health agencies, what can they be doing to sort of level the playing field a little bit? Brandi Greenberg: I think the onus is a bit on those health systems and the public health leaders to be aware of those inequities and the advantages or disadvantages that come from technology, and they need to be deliberate about trying to rebalance the scale. They need to be leaning in to the zip codes where they know they have historically marginalized communities, underserved communities, and they need to lean in in ways that both take advantage of the data they have so that they know where those at-risk populations are, but then they need to do some old fashioned human to human outreach. We've heard of people knocking on doors to get people signed up, old-school by hand, on a piece of paper. We have heard of even mobile clinics driving around in Baltimore and in Connecticut, I think, really literally pulling up to people's homes and offering them vaccines. That kind of physical outreach I think about it a little bit as kind of that vaccination last mile. Rae Woods: Okay. Yeah. This is a big part of our conversation with Parkland last week, about the same kind of topic where they fully admitted that doing digital only registration and sign up, led to a very specific type of community to show up at their vaccination sites. And just like you said, they started going door to door, they started doing in-person registration, because even entering in the information to be able to prioritize, it tends to be done online. So being really creative and scrappy with all of the different ways that you're getting that information and then connecting real people to vaccines. Brandi Greenberg: I love the word scrappy. It's actually one of my favorite words in terms of how I think people need to behave in times of crisis. It's about trying things, learning from them, seeing what works, trying something else. Yeah, I was so impressed with the Parkland leadership on that recent pod and their ability to keep learning from their environment. Rae Woods: We've been talking about vaccine hunters, but I'll admit, this is been a problem for the last several weeks again, because there's a mismatch between supply and demand. But like you said, we're hitting two million doses, we're getting close to three million doses administered every day. So we're starting to see, or at least the light is at the end of the tunnel for supply and demand to get closer together. When that happens is there a different problem that we should be worried about? Brandi Greenberg: I think so. I think we are moving from a world of vaccine hunters to what I would call vaccine shoppers. Rae Woods: What is a vaccine shopper? Brandi Greenberg: I would define a vaccine shopper as somebody who isn't just looking for a vaccine, but they are looking for a particular vaccine that they either believe is superior or believe is better for them. Rae Woods: Okay this is where the pessimism in me starts to come out because we know, and I want to be clear that Advisory Board, the CDC, public health agencies say, "No vaccine is better than the other. You should get whatever dose you can," again, channeling Dr. Fauci for a moment here. But how common is it right now for somebody to say, "No, I'm not going to get that one. I'm going to wait for J and J, or I really want to go for Moderna." Brandi Greenberg: Fortunately right now, from what I'm picking up in the media and from conversations that I'm having with peers who are also talking about relatives, I don't actually think it's that common yet, but I think a lot of people in a good way are worried about it and trying to get ahead of it. Rae Woods: I wonder as we're planning for this new behavior to come, are there legitimate reasons that leaders should be aware of where, you know what, it's actually okay for a patient, a member of the community to show up and say, "I really want this vaccine over the other?" Are there legitimate reasons for that? Brandi Greenberg: I think there are, and I think we need to be open and honest about that. I was just talking to somebody who has a friend who is absolutely terrified of needles and they didn't think they could get two shots, and that was going to almost cause PTSD, and you could get them over the hump with the one-shot option. I also know that there's reported allergic reactions to the vaccines. And just about any vaccine, any medication says, "Don't take it if you're allergic to any of these ingredients." Now we've got multiple options in different formulations. So people who might be sensitive, there very well could be one of the vaccines that is less likely to cause an allergic reaction. Rae Woods: We'll be right back with more Radio Advisory after this short break. Rae Woods: What you're getting at is the benefit of having multiple types of products on the market. And this is where I want to channel the clinical leader for a moment, because if patients come in with vaccine shopping in mind, I feel like the sort of opposite of that, the provider perspective of that is vaccine prioritization, not prioritizing people, we know that that has been happening since the beginning, but I'm talking about prioritizing the specific characteristics of one vaccine to the specific needs of a community. Now, Parkland told us they were just starting to consider that. What have you been hearing? Brandi Greenberg: I've definitely been hearing a lot about where we should prioritize or where it makes sense to prioritize Johnson and Johnson's vaccine relative to others. Importantly, it's not a prioritization that has anything at all to do with relative efficacy. This is a prioritization that is about single shot versus two shots. So where is it going to be easier or where maybe will be more successful reaching out to people who might be hard to track down for that second shot? And because it does not require the same level of cold chain storage and transport as the mRNA vaccines, there are certain hard to access rural communities that might be less likely to have the kinds of freezers needed. Brandi Greenberg: I'm in love with Alaska and I've been reading everything that there is about Alaska. Some of the lengths that they have gone to to reach these rural communities only accessible by plane, and then to think that they may have to go back in three to four weeks, which they're doing, this is where you can start to see a single shot refrigerated-only vaccine actually has real benefits if we are looking holistically at vaccinating our entire adult population. Rae Woods: Again, I think those are the more obvious examples. The one that Parkland brought up is the homeless population. Talk about difficult to track down, that was where a one-and-done kind of vaccine is really going to be beneficial. But I'm thinking back to those essential workers, the people who have transportation issues, frankly, the communities that tend to have access issues with the medical system anyways, and those communities tend to be less affluent and it tends to impact more people of color, this is where I start to get really worried. Are you at all concerned or are you hearing from folks any concern of what might happen if those communities think even for a second that they're getting the short end of the stick? Brandi Greenberg: Yeah, this is my single biggest up at night issue right now is that all of our vaccinations, all of our efforts to educate and communicate have to be taken in the context of over 200 years in some cases of medical choices, certain kinds of trials that have quite frankly prioritized white lives. In that context where you have a lot of good reasons for mistrust of the medical system, what are you not telling me? Am I getting the inferior one? That context, you have to understand it as you think about how you communicate, why you are bringing one vaccine or another to a particular community. And if for any reason at all, if there are public officials, if it's running across social media platforms that one vaccine is seen as less effective either in total or potentially against some of the variants, and then that is the vaccine that seems to be going into certain communities of color, I can understand a lot of caution and hesitancy, which is going to make our goal of getting to herd immunity that much harder. Rae Woods: And it makes the role of the provider that much harder too, because I feel like there's this trade-off. There is, I know that the quickest way to immunization is the one-and-done vaccine and I want to target that towards these communities. But it's a slippery slope if that same community, either A, isn't going to take it, or they are going to maybe not even interact with the medical system entirely because of this again, very valid perception. The other side of the trade-off is even though it's harder, we might have to do the two dose vaccine. How do you recommend leaders think about that trade-off? Brandi Greenberg: One of the things that I'm hoping for is that no one community gets just one option. I was thinking about this a little bit last night. Right now, it seems to be that a lot of communities ... I live in LA ... and the LA market I'm hearing people getting Pfizer, I'm hearing of people getting Moderna and I'm hearing pretty quickly of J and J starting to come into our market. So I think the more that we can educate people that all three are available at least in the community and that there wasn't a steerage going on, that may help, even if in fact, we are for good reason trying to get the single dose refrigerated option to those harder to access communities. Rae Woods: Like you said, in the background, every single healthcare leader and every single public official needs to continue to reinforce the message that no vaccine is superior to the other. All protect against severe disease, hospitalization and death. Brandi Greenberg: I just want to echo that last point, because as you know from some of the other articles that I've written about the vaccines each time one is authorized, I'm getting a lot of questions from friends and relatives and digging into the data, and I really stress that- Rae Woods: Oh your friends are asking which one they should get? Brandi Greenberg: Oh yes. Oh yes. I am reinforcing the same message I am telling you on this podcast. I don't have one story for the pod and a different thing I'm telling my friends. That the consistent ability of all these vaccines to reduce severe disease, hospitalization, and death, and the new data that is coming out from Israel about the vaccines' abilities to reduce transmission in some cases, the data that's coming out about them being more effective against the variants, even in South Africa, even in Brazil, people aren't dying and getting hospitalized if they have been vaccinated with any of these vaccines. That is really important to just keep emphasizing and make sure that that is the larger message that is going on. Rae Woods: Vaccine hunting is something that happens when there is more demand than supply. Vaccine shopping is something that we'll see more and more of as supply and demand get closer together. I'm curious, is there a third scenario that maybe hasn't happened yet that you're watching for? Brandi Greenberg: Yeah, I would say it's a scenario that has happened, we just aren't paying attention to it as much yet, which is the folks that aren't interested in getting a vaccine. We can call them the vaccine avoiders. We've been talking about it in the sense of vaccine hesitancy, but it hasn't affected our ability to vaccinate our society yet because there are enough people at this point who want the vaccine, that how we encourage those who are hesitant or unwilling to move in the direction of getting a shot, that hasn't yet surfaced as the next most important need yet. Rae Woods: So you're saying with vaccine avoiders, there might be plenty of supply but not enough demand, not enough people actually offering up their arm to get immunization? Brandi Greenberg: Yeah. Actually, I was doing a little bit of a modeling exercise because I was curious. When the Biden administration came out a week or two ago with the announcement that they anticipate having enough supply to vaccinate every American by end of May. They've been clear that that doesn't mean everybody will be vaccinated by May, but the supply will be available, then it'll start to work its way through the system. But what they didn't talk about was the fact that as of the end of February, Kaiser Family Foundation is still showing that up to 44% of adult Americans aren't ready to get a vaccine yet. Rae Woods: So what's the outcome? If we haven't reached herd immunity yet, and again, we have enough supply to vaccinate American adults as the Biden administration has predicted, but there are still a good chunk of people that don't want to be vaccinated, what's the outcome there? Brandi Greenberg: The outcome is that by our estimates sometime in late May we think there's going to be more supply than there is demand Rae Woods: Yeah, and still no herd immunity? Brandi Greenberg: Correct, because again, if 44% of the US population doesn't want it yet and not all of them have already had it, you're getting in the 50, 60% range of potentially people with antibodies, but most estimates say we need to be at least at 70 to 80% of the population having antibodies before we can feel like we have herd immunity. Rae Woods: So maybe there's a moment where providers, public health agencies, et cetera, are going to have to actually start generating their own demand for COVID vaccines. Brandi Greenberg: And I think that moment is now. At the point where we actually still have demand exceeds supply. We actually need to start months in advance. It probably should have started, and in many communities it did start months ago, because for all the reasons that we were talking about, about legacy mistrust and some of the root cause reasons that people aren't ready yet to get a vaccine. Rae Woods: And that probably combined with just like rampant misinformation out there. Brandi Greenberg: Absolutely, but for all the different reasons that people may be hesitant, some of which are based in misinformation, some of which may be based in their understanding of legitimate science, some of which may be based on again, just fear and anxiety or legacy mistrust. But unless we are out there in the community talking about this, not just running public service campaigns, not just having an educational flyer when you go to your doctor's office or a section of the website that's your basic facts about the vaccine, but really out there, human to human, talking to people, answering their questions, getting them to open up about why they're still hesitant, until we start having those conversations on a regular basis and breaking down those barriers and building that trust then I think we run the risk of a supply demand disequilibrium of the worst possible kind. Rae Woods: So aside from the fact that I cannot believe that you are still an optimist, I do want to give you that moment to speak directly to our listeners. What is the one thing that you want listeners to Radio Advisory to focus on right now? Brandi Greenberg: For me, it is about empathetic listening and trust building. That right now I think the focus is on logistics and operations, and that we are doing a lot of things right, to have the necessary number and location of vaccine sites, people who can vaccinate, logistics seem to be running smoothly, but that if we don't start now to be building those networks of trust building and empathetic listening and storytelling ... again, don't forget the power of story. Very often with anti-vaccination campaigns, we have people that get caught up in the single worst case scenario story. There is so much power in the positive storytelling of somebody who was hesitant, who then made the choice to get vaccinated and what that experience was like. I think that we need to be doing more of that power of narrative, power of listening to build trust so that we have plenty of demand to work us through to the point of herd immunity hopefully sometime this summer. Rae Woods: Yeah. And that's the light at the end of the tunnel that I'm waiting for. Rae Woods: Well Brandi, thanks so much for coming on Radio Advisory. Brandi Greenberg: Thanks for having me, Rae. Rae Woods: Stay tuned for an update on what our research team is watching. Rae Woods: On Thursday, Biden signed into law the $1.9 trillion COVID relief package, and there's a lot included in it. I'm talking billions to assist state and local governments, reopen schools, strengthen public health, increase testing and vaccinations. And there's the expansion of premium tax credits on the Obamacare exchanges. The bill does not allocate more money to the Provider Relief Fund or extend the current moratorium on Medicare sequester cuts, but it will direct 8.5 billion to rural hospitals. Rae Woods: Biden also made key announcements on the vaccine supply. The Biden administration is now directing all states to make all adults eligible for COVID-19 vaccination by May 1st. But remember, they're still not predicting that we'll have enough supply to vaccinate those Americans until later that same month. Rae Woods: You probably also heard that the administration announced they'll be buying an additional hundred million doses of the Johnson and Johnson vaccine, but those doses likely won't be available in time to speed up the timeline for adults getting vaccinated this spring. And by the way, this is probably a good time to remind you that my partner works for Johnson and Johnson. Rae Woods: While we wait to get those shots in arms, there's good news for the thousands of people contracting COVID each day. There's new data on antibody treatments that have demonstrated that we can reduce deaths and hospitalizations by about 85%. There's new treatments from Eli Lilly and GlaxoSmithKline, and then Merck also released some early data showing that they have an antiviral pill that can safely reduce the amount of time patients test positive for COVID. Rae Woods: What all of this means is that our ability to mitigate the severity of this disease continues to improve, saving lives and reducing the burden on providers. It also probably means that Brandi is right, the optimists really are winning. Rae Woods: So remember, as always, we're here to help.