 The COVID vaccines made by Moderna and Pfizer were developed and brought to market at a blistering pace. The fastest vaccine development in Western history. But their distribution has been hobbled by poor planning and rigid eligibility rules. Vaccine distribution is going very, very badly. Nationwide, the initial vaccine rollout has been rocky. Doses are being thawed and they're not being administered. Because the vaccine ships in batches and expires quickly once thawed, precious doses have been pitched when eligible recipients weren't readily available or missed their appointments. New York Governor Andrew Cuomo threatened fines of a million dollars for healthcare providers who vaccinate people out of turn. The most recent CDC data shows that of the more than 30 million doses shipped, only about 11 million have been used. And those are mostly first doses. The Pfizer and Moderna vaccines are both given as two identical shots, three and four weeks apart respectively. Although the Trump administration has since reversed course, it initially stockpiled one dose for everyone shipped. Doctors and epidemiologists worry that we're losing the race against surging infections and new strains that spread more easily and may be more likely to cause reinfection. The problem with the vaccine rollout is that it was centrally planned in a way that didn't give local officials and healthcare workers enough flexibility to adjust to the realities on the ground. And to make trade-offs between treating as many people as possible and strictly adhering to the rules. The idea of keeping the second doses in reserve was really nuts. We ought to trust the supply chain, give out as many first doses as you can, even if you're still going to try and give out the second dose at 21 or 28 days, just trust the supply chain to do that. Alex Taberock is an economist at George Mason University who consulted with the Trump administration, the World Bank, and foreign governments on optimal ways to incentivize rapid development of a COVID vaccine. He says that the decision to hold half the vaccine supply in reserve is an example of a failure to think in terms of trade-offs. The first dose's first approach, which the UK recently adopted, would allocate all available vaccines to be used as first doses while pushing off second doses for weeks or even months until production can catch up. That means you can give twice as many first doses. If you, instead of giving a second dose, you give a first dose of somebody else, you can have two people who are protected at an 80% efficacy rate as opposed to one person who's protected at a 95% efficacy rate. But there are additional advantages. When you push out the first dose as faster, you get to herd immunity faster. You push down R, so the more you spread out the first doses, the slower the transmission rate of the virus is, because now fewer people are getting the disease, and it looks like then fewer people will be transmitting the disease. The current approach of giving boosters at three and four weeks is based on what Pfizer and Moderna evaluated in their clinical trials. But waiting longer likely won't significantly reduce the vaccine's effectiveness. At 21 or 28 days, that is not a magical number. That is not a number which is set in stone by, you know, the vaccine gods. A lot of vaccines, you get the booster months later, even years later. It's still good. One of the reasons the companies chose that, very short time, they wanted quite rightly to get the clinical trials done. So for the AstraZeneca vaccine, we actually know the longer booster is more effective, and that could be true for some of these other vaccines as well. From the UK, this more contagious version of the virus. The new variant of coronavirus is out of control. Critics of this approach argue that partial immunity from a single dose might create dangerous strains under a process known as selection pressure, where random mutations create new strains that can evade the antibodies generated by the current vaccines. I am a little bit puzzled when some of the vaccine people make this argument, because the FDA was willing to accept a vaccine with a efficacy rate of 50 percent, much lower than we're getting now. Nobody at that time was saying, oh, no, no, no, no, we can't do that. If we have a vaccine with 50 percent efficacy will get viral mutation. It'll be worse than having no vaccine at all. Nobody made that argument back then. Proponents of first doses first say that dangerous strains have already emerged in the absence of selection pressure, and that the priority right now should be ending the pandemic as quickly as possible, even if that means trying an untested, low risk gamble. If you switch to first doses first, you have the option of switching back. You learn whether it works or not. If it does work, you've made the right decision. If it doesn't work, you can go back to second doses. If you stick with second doses, you never learn whether you might have been wrong. We will learn something from the British trials. We'll learn something from what's happening in Quebec. We will learn something in the United States if we go to first doses first. United States is in a relatively good position because of Operation Warp Speed. The rest of the world is going to have a much bigger shortage than the United States. So the world really needs to maximize the value of these vaccines. The vaccines are extremely valuable. The UK is also running trials on fractional dosing, which would extend supply by giving doses as small as one half the prescribed amount. In the past, with yellow fever and with polio in an emergency situation where supplies were really scarce, the WHO went to fractional dosing. And that can also work extremely well. So what we learned from the Moderna trials is that at least for adults between 20 and 55, a half dose appears to work just as well as a full dose. We just heard from the UK that they're just trying to hit as many people at once. Why not do something like that and space out the time between doses? But there are no plans to follow the UK's approach of vaccinating more widely by pushing off the second dose. For the Moderna vaccine, two doses, half the dose, immunizing double the number of people with the doses we have. We know it induces identical immune response. Montsef Slouy, who headed up Operation Warp Speed, expressed interest in stretching the Moderna vaccine through fractional dosing. Of course, ultimately it will be an FDA decision. And what's been extremely frustrating is that the FDA has a medical mindset and not a public health mindset. What economists are good at is making decisions under uncertainty and scarcity. And it's being hard-nosed and thinking about probabilities, thinking about risk, expected value. Economists are very good at saying, let's do the thing which saves the most lives. In Israel, they're just pulling people off the street and giving them a vaccination right there on the spot. In New York, that will get you arrested and that will get you fined. It might be better, particularly at this stage, just to say go, go, go and vaccinate as many people as you can. And certainly it's a terrible idea to penalize people when they take actions which are in favor of the public health.