When Covid-19 first appeared in New York in March of this year, the state, like other locations, faced a novel disease against which there were few defenses. New York faced a dire situation in March – hospitals in the New York Metropolitan area were overwhelmed. With cases and hospitalizations skyrocketing, the State imposed a lockdown, requiring that all but essential workers work off-site. The restrictions worked, and by June, when many of the restrictions had been relaxed, the rate of infection had dropped to very low levels.
Over the Summer, Governor Cuomo frequently took credit for the low level of infections in New York State, arguing that the state’s relatively strict controls on in person business interactions were responsible. But, today, New York has more COVID-19 infections per hundred thousand residents than most states. And, the State’s roll-out of the most important infection control tool has been marred by confusion and an interface that is likely to frustrate many users. What should be done to improve the state’s response?
The COVID-19 Explosion in New York
In September, New York was seeing only four new cases per hundred thousand residents per day. Only five states- Massachusetts, Vermont, Maine, New Hampshire and Connecticut had fewer cases per resident. Hospitalizations were very low as well – only two residents per hundred thousand were identified as “currently hospitalized” for the seven day rolling average ending September 7th. Only Connecticut, Vermont, Maine, and Connecticut had lower rates. Rates were low nationally as well. The nation averaged 12 new cases per hundred thousand residents, and 11 current hospitalizations in September.
By January, rates had skyrocketed nationally but grew even more in New York State. New York’s daily rate of new positive cases per hundred thousand residents, based on a seven-day rolling average, increased from four to eighty-four. Nationally, the rate increased from 11 to 75. Hospitalizations increased as well. In New York, the rate of current hospitalizations increased from two to 44 per hundred thousand, while the national rate increased to 40.
New York’s Response to the Increase in Infections and Hospitalizations
Responses to the COVID-19 Pandemic have evolved since the initial surge in March and April. Rather than completely prohibiting in-person non-essential business activity, a variety of tools are being employed to mitigate risk. Mask wearing and social distancing continue to be the basic elements of the response, but activities like shopping, dining, church-attending, and the like are restricted to varying degrees to ensure distancing in most places.
Although New York was slower to relax restrictions than most places, over the Summer, the state again allowed the resumption of many activities with restrictions. But, the State rules continued to be more restrictive in New York City than elsewhere. For example, indoor dining was not allowed until September 30th in the City. Because the State’s rules were more restrictive than in many other states, New York’s infection rates were consistently among the lowest in the nation.
But, the weather also was a factor. Places like Arizona and Florida, which saw infection peaks in the Summer, suffered from the fact that excessive heat drove social activities indoors along with relatively lax COVID related restrictions. As temperatures dropped in the Northeast, social interactions were driven inside, where they are riskier. By January, New York, Massachusetts, and Rhode Island all had rates of positive infections and hospitalizations that were higher than the national average. Governor Cuomo has imposed more restrictions on positivity clusters – small areas where rates of positive tests rates are high and has threatened to impose lockdowns where high hospital utilization levels threaten to overwhelm available resources.
New York’s Flawed Vaccine Rollout
With two COVID-19 vaccines available, vaccine manufacturers and the state and federal governments face a huge challenge in ensuring that as many people get vaccinated in as short a period of time as is possible. With manufacturers beginning to scale up production, initial supplies have been limited. At the federal level, guidelines developed by the advisory committees for the Centers for Disease Control were intended to ensure that high-risk groups, like health care workers and those living in congregate settings, received the vaccine first.
New York’s implementation process has suffered from poor communication, which left counties that have developed mass inoculation plans out of the loop. Instead, the state initially assigned responsibility for vaccine distribution to regional hospital centers. While hospital centers would have been one element of a rational approach to ensuring that health care workers get vaccinated, they are already under severe stress because of the need to manage increasing caseloads of COVID patients. Hospital centers had to develop implementation plans from scratch, even though county health departments have been required by the Federal Government to have mass vaccination distribution plans since the early 2000s.
The confusion that resulted from the state’s policy can been seen in an Albany Times-Union report from January 11th. “County leaders and other local officials on Monday accused Gov. Andrew M. Cuomo’s vaccination team of fueling “chaos” and “bedlam” as phone banks are being overwhelmed and much of the general public remains confused about when they can receive the shots.
The State’s COVID response has suffered from the fact that the Cuomo Administration has been reluctant to include outside stakeholders, like county governments and New York City, in the vaccine distribution planning process. Instead, policies have often been presented as a fait accompli, announced at the last minute.
Counties were not given a significant role in vaccine distribution by the state until distribution by hospitals faltered. The Governor’s staff member responsible for leading the vaccine rollout, Larry Schwarz suggested ignorance of the role of counties by saying that the rollout has “been a little helter-skelter; I apologize for that, but this is a massive undertaking and it’s something unprecedented that we’re doing here.“ .
The state’s ad-hoc and poorly communicated response to the need to rollout COVID vaccines can also be seen in the way it has informed eligible individuals of vaccine eligibility. The state has established a phone bank that has been overwhelmed with calls and a website that provides a confusing process for finding a location and making an appointment for vaccination. {Note: After the following section was written, the State vaccine portal (https://am-i-eligible.covid19vaccine.health.ny.gov/) was modified to show only sites run by New York State.}Website users will find that few locations are actually offering vaccinations. Several of the locations that are shown on the State website aren’t actually offering vaccine. Others are only reachable by telephone. The state’s mass inoculation site in the Albany area, at SUNY-Albany, quickly filled all its available slots, which ran through part of April.
New York City residents face even more confusion, with two portals – one from the City and the other from the State – with differing information about where to get vaccine. The New York Times reports, “Buggy websites, multiple sign-up systems that act in parallel but do not link together and a lack of outreach are causing exasperation and exhaustion among older New Yorkers and others trying to set up vaccination appointments.”
To be sure, the greatest constraints on vaccine supply for those eligible result from limited manufacturing capacity and the federal government’s overly optimistic projections of vaccine availability. In May, when Operation Warp Speed was announced, the administration planned to manufacture “hundreds of million doses by the end of 2018.“ In fact, as of mid-January, just 29 million doses had been distributed to states, and only about one-third of those actually administered to people.
New York’s problems are not unique. Because the United States has a fragmented health care delivery system, the resulting complexity impedes the creation of an effective national response. For the state, the creation of an effective, simple to use web portal for users was made more difficult because the independent health care providers each have their own systems of managing inventory and booking appointments. The detailed CDC rules for vaccine eligibility slowed initial distribution.
The lack of coordination between the State, counties and New York City is an impediment to an effective response to the COVID pandemic. Governor Cuomo’s administration should move away from its insular style of policy development and implementation to a more open model in which state and local participants share information and execute vaccine delivery in ways that make more effective use of existing resources.