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.
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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.
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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.
As a laboratory medicine specialist, I’ve gotten a preview of what vaccine administrators will endure. Every day I open up the news to read about all of the ways Covid testing is falling short. Then I open up social media to see endless disinformation about how “false positive” results and greedy hospitals are creating a fake pandemic. The fact that there’s a caring doctor behind every Covid test doesn’t seem to register. I don’t even try to explain anymore that. despite all of our Covid testing failures, most have not been unique to the US. It’s fine to chide the federal government for a lack of over-the-counter home testing, for instance, but we actually authorized a prescription-free home test before Canada, Germany, and many other countries did. Some perspective is in order.
What would the public discourse look like if we treated our institutions with the same mercy with which we treat each other? We should hold leaders accountable, but behind every politician are thousands of government employees just doing their jobs. The Trump era made that especially clear. Instead of the deep state, we might call it the human state. Cheering on postal workers was a nice start, even if they did lose one of my packages.
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So you’ll have to indulge me if I sound too forgiving of the many bureaucrats executing our major human endeavors. This isn’t just personal compassion—an easy enough virtue to defend. How we talk about our institutions defines them. Whether they seem trustworthy or dishonest, efficient or sluggish, powerful or impotent has as much to do with the public narrative as their actual results. Some states, for example, have reduced the negative connotations associated with Medicaid and CHIP—the government health insurance programs for poor adults and kids—simply by changing their names. Signing up your kid for Georgia’s PeachCare feels less like taking the kind of government handout that’s been demonized by politicians. What are the knock-on effects of sowing casual doubt about our public institutions?
It’s possible to take forgiveness too far. There is a risk of becoming Panglossian—deciding that we already live in the best of all possible worlds as an excuse for not changing it. Given the enormous amount of money and power we bestow on governments and health care systems, it’s only right to ask for something in return. It’s even fair game to criticize us “health care heroes” when we deserve it.
So let’s instead make 2021 a year of reasonable expectations. Setting these in the face of intense, justified emotion is hard. But here’s where we might start: by valuing transparency over perfection, improvement over denial, iteration over omnipotence, and access over perfect equity. We will not administer the vaccine in the exact order that everyone just now personally decided was most fair. Our institutions will fail us this year—like they fail us every year—in ways large and small, incompetent and corrupt. But they will also accomplish tiny miracles. We can declare “the system” an irredeemable failure; or we can start to recognize, and nurture, all its strengths.