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The US was the world leader in vaccination. What went wrong?

Five months ago, the US overtook almost every country except Israel in vaccinating their population against Covid-19. Almost 1 in 5 Americans were already fully vaccinated; Hungary stood out as a success among European countries, yet by April 6, only 1 in 10 people had received a full vaccination. Most of Europe was in the single digits.

The speed of adoption, combined with the United States' role in developing and manufacturing the vaccines, seemed to make vaccination a modern example of American exceptionalism that dealt a decisive blow to the virus that is living around the world had turned the past year upside down.

But over the summer, the American Covid-19 vaccine success story turned into a story of mediocrity and missed opportunities – as countries in Western Europe and Scandinavia caught up with and then outperformed the United States in their vaccination campaigns.

Portugal is currently setting the pace in Europe, with almost 80 percent of its population fully vaccinated. Spain and Belgium have reached over 70 percent of their population. France, Germany, Great Britain, the Netherlands and Norway are all above 60 percent.

Meanwhile, America looks consistently mediocre among affluent nations, at 52.3 percent of its total population as of September 7th. The U.S. now ranks 57th in the world for percentage of the population vaccinated, according to Bloomberg's vaccine tracker.

Only a handful of Western European countries – Switzerland in particular – currently rank behind the USA in their vaccination campaigns. In poorer parts of the world, many people are still waiting for a vaccination due to a lack of care.

President Joe Biden is currently trying to get more Americans to get vaccinated as the Delta variant is driving deaths to levels not seen since early February. The government reportedly announced Thursday that the vast majority of federal employees and contractors will have to receive the vaccine. Biden is also urging private companies and schools to impose their own vaccine requirements.

"We took the lead and then fell behind," said Celine Gounder, an infectious disease epidemiologist. "We quickly vaccinated half of the population who wanted to be vaccinated but then hit a plateau."

Our world in data

Israel, once considered a role model for efficient vaccinations, is also stagnating: The vaccination coverage has only increased marginally in recent months from 56 percent in April to 63 percent at the beginning of September.

The US is paying a heavy price for failing to maintain its strong start in vaccinating people against Covid-19. The number of cases has increased dramatically in the past two months, making this the second worst wave in the pandemic. The average number of daily deaths in the US has increased from less than 200 in early July to about 1,500 now. When you factor in population, America is seeing more than twice as many Covid-19 deaths every day as countries like France, Germany and Italy, which have been more successful in vaccinating people against the virus.

Our world in data

Why America's Covid-19 vaccination campaign lags behind much of Europe

The US started its vaccination campaign with a structural advantage. It, along with Israel, had the most generous supply of Covid vaccines thanks to investments made to source doses before the vaccines were approved for emergency use by the U.S. Food and Drug Administration.

Europe, meanwhile, had difficulties obtaining and distributing vaccine doses in advance, as Politico Europe reported in an investigation in January. This gave the US and Israel a hot start while the EU caught up as vaccine supplies improved in the spring and summer. (That also meant the latter had more room to grow than the United States, which had already tossed shots into the arms of its most willing citizens.)

Demographics can also hold the US back to some extent. There are more young people in America than in most Western European countries: around 16 percent of the German population is under 18 compared to around 22 percent of the US population, for example. Children under the age of 12 are still not eligible for vaccines in the US (or elsewhere), which can partially depress the vaccination percentage.

But there is more to the story than just supply quirks or demographic trends.

Compared to a country like Portugal, which is now the world leader in Covid vaccination, the United States' vaccination rates are not particularly high for the eligible population either. In Portugal, 99 percent of people over 65 are fully vaccinated; in the USA the proportion is closer to 80 percent. These differences persist in the younger age groups: 85 percent of Portuguese between the ages of 25 and 49 are fully vaccinated, compared with less than 70 percent of Americans in the same age group.

Another big difference that explains that the divergence is one of culture and politics. Covid vaccinations, like so much in America's pandemic response, are polarized along political lines. According to a survey by the Kaiser Family Foundation in July, 86 percent of Democrats said they were vaccinated, while only 54 percent of Republicans said the same. One in five Republicans said they "definitely won't" get the vaccine.

"This political divide over vaccines has caused the US to lag behind European countries in terms of coverage," said Josh Michaud, assistant director of global health at the Kaiser Family Foundation.

There is hesitant vaccination in Europe, especially in Germany and France, but nothing to the extent that we have seen in the United States. In Portugal, skeptics have a very low public profile, which is reflected in the exemplary vaccination rate.

"We don't have to convince people to get vaccinated," Gonçalo Figueiredo Augusto, who studies public health at the NOVA University of Lisbon, told me about Zoom. "The people want."

How Portugal became the world leader in vaccinations

Strangely enough, a difficult history brought Portugal to success, said Augusto. The country lived under dictatorship from 1933 to 1974, and public health efforts stagnated during that time. Driven by preventable deaths from infectious diseases, the infant mortality rate remained significantly higher in Portugal than in wealthier European countries such as France, Germany and the UK. It was only in the last few years of the regime in the early 1970s that a serious vaccination campaign began.

“People were very willing to get the vaccines because infectious diseases were a huge problem,” Augusto told me. "We were a poor country back then and have learned how important vaccines are."

As Portuguese democracy was restored and economic conditions improved, so did public health. Child mortality fell in the 1990s at the same rate as in other countries.

But some residents still remember a time when routine vaccinations were not yet a matter of course. More than 97 percent of Portuguese children are now vaccinated against measles, Augusto said. But in the US the percentage is lower, closer to 90 percent, as a small but sizable segment of the population continues to oppose this vaccination.

Portugal also carries recent memories of a devastating winter wave of Covid-19, as do many countries, including the US. After the worst waves of last spring and summer were largely dodged, social distancing restrictions were eased. The country's heads of state and government wanted to make the Christmas holidays in 2020 as normal as possible.

The number of cases rose rapidly until the beginning of January and deaths soon followed. Portugal had the worst Covid death rate in the world at times. "The idea that the virus was very close was really felt in January," said Augusto. "It was traumatizing for the country."

In Portugal, vaccinations were seen as the best way out of the crisis. Initially, the country was hampered by the same supply shortages as across Europe. But as more and more doses became available, vaccination rates rose. As the elderly, those with compromised immune systems, and key workers were vaccinated, death rates began to decline. That built more confidence in the vaccines.

The US has had its own fatal winter surge, and the recent delta wave appears to coincide with a surge in vaccinations. But the proportion of Americans vaccinated is still lagging behind the Portuguese, even if you just look at the populations in question.

Portugal has also adapted spontaneously to a changing pandemic. When the Delta variant arrived there in May, the national government decided to speed up the dosing schedule for the vaccines. The interval between the first and second doses of the AstraZeneca, Pfizer, and Moderna vaccines was shortened by a week or more.

“The idea was to vaccinate the population with two doses as soon as possible,” said Augusto. The country was supported through a highly centralized approach, with the national government taking responsibility for the acquisition, distribution and administration of the vaccines. The military also played a practical logistical role.

The aggressive rollout paid off. Portugal saw a small delta-driven wave of Covid cases and deaths in July and August, but it was much less severe than what the US is now suffering.

Our world in data

The country has also explicitly linked its vaccination rates to its reopening plans. Bars and nightclubs have been closed there for months, and the government has announced that they will be allowed to reopen once 85 percent of the population is vaccinated. It is expected that this benchmark will be reached in a few weeks.

“You don't want any rules? Get the vaccine, help the country, ”said Augusto, describing the Prime Minister's message to the Portuguese people.

Some US politicians and corporations feel comfortable with the same type of idea by either mandating vaccinations outright or requiring them for certain activities. The Biden government is now aggressively pushing vaccine requirements, with the president himself due to make more announcements in a speech on Thursday. Democratically led states and cities are taking similar steps. More and more private companies are adopting the vaccine requirements as well.

"In the US, we are almost all vaccinated who want to be vaccinated voluntarily," said Michaud. "So any further progress in vaccinating many adults will likely depend on vaccine requirements and regulations."

But these efforts are met with opposition from Republican politicians and voters who portray them as un-American.

It's a microcosm why the United States has lagged behind in trying to vaccinate people against Covid-19 and get the pandemic under control. The toll of this failure continues to grow.

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