Defying all expectations, the US developed two surprisingly effective COVID-19 vaccines in record-shattering time, spurring hopes of the pandemic’s eventual end. Vaccine rollout began in December, but getting those shots into people’s arms nationwide has so far been plagued by chaos.

Right now, the US is averaging around 970,000 COVID-19 vaccine shots a day, according to the CDC. At that rate, the country’s 330 million people will see nearly two more years pass before everyone gets their second shot of the authorized vaccines.

“It feels like we’re being punched in the mouth,” said Bob Wachter, chair of the Department of Medicine at the University of California, San Francisco, speaking at a recent briefing held by the JAMA medical journal, where he called for a lottery to provide people with shots as a way to speed up immunizations. “The rollout has been extraordinarily slow and sluggish.”

In the first five weeks of the nationwide rollout, the Trump administration’s $18 billion Operation Warp Speed effort delivered 36 million vaccines nationwide, far short of its initial goal of distributing 300 million doses by the end of 2020. And only 17 million of those have actually been given to people — a consequence of a patchwork of state plans that have proven slow to administer shots. As some states face dire shortages, OWS officials last week said other states are leaving shots unused and sitting on shelves.

“The vaccine rollout in the United States has been a dismal failure thus far,” said President Joe Biden last week ahead of the announcement of his plan. “We’ll have to move heaven and earth to get more people vaccinated.”

In contrast to former president Donald Trump’s state-led approach, Biden has committed to a federalized vaccination campaign nationwide, repeating a campaign promise to have 100 million shots administered in his first 100 days in office. But — with reports of no expanded vaccine supply to tap into and many states still grappling with a deadly third surge of COVID-19 cases — it’s unclear how quickly he’ll be able to make this happen.

In the month leading up to Biden’s inauguration, about 83,000 Americans died of COVID-19 amid the worst surge of a pandemic. So far, more than 400,000 people in the US have died of COVID-19, filling hospitals with patients and stretching public health department capabilities to test and trace for the virus.

The slow rollout of a nationwide vaccination campaign was in many ways expected, experts told BuzzFeed News — but grave errors in the last few months have made things much worse. Here’s what went wrong and how we may be able to fix it:

COVID-19 shots aren’t flu shots.

On May 15, 2020, Trump announced the start of Operation Warp Speed, aimed at delivering “substantial amounts of a safe and effective vaccine available for Americans by January 2021.” The public-private partnership supported the development and manufacturing of five vaccines, in addition to a $1.95 billion contract with Pfizer announced in July for 100 million doses.

OWS radically shortened the timelines for vaccine development by sliding together clinical trials and building factories to manufacture doses before they even proved to be effective. In combination with a second surge of the virus in the fall, which quickly led to enough COVID-19 cases among the placebo arms of the trials to show that the vaccines worked, the plan shortened a process that typically takes seven years into less than one. In November, both Pfizer and Moderna’s vaccines were shown to reduce COVID-19 cases by about 95% — a surprise to many experts who were expecting lower rates of protection — leading to their emergency authorizations in December.

“The focus was on getting vaccines available and getting manufacturing ramped up, less about getting vaccines into people’s arms,” Courtney Gidengil, a public health physician with the RAND Corporation, told BuzzFeed News.

What OWS didn’t do was build out the capacity for mass vaccinations. Instead, the partnership and the CDC decided to pump out COVID-19 vaccines through the agency’s long-running Vaccines for Children Program, expanding its contract with McKesson Corporation, which distributes 150 million flu shots to public health clinics, hospitals, doctors’ offices, nursing homes, pharmacies, and other medical facilities every year. Rather than re-create a mass vaccination system, OWS officials explained in September that the partnership would leverage the infrastructure of the CDC’s existing flu shot program through “microplans” with 64 separate states, territories, and jurisdictions.

Unfortunately, administering the new vaccines is far more complicated than even the rushed introduction of the H1N1 flu vaccine in 2009, an experience that McKesson touted in announcing its expanded contract with the CDC. That rollout had a disappointing outcome — marked by shortages, long lines, and factory shortfalls — concluding by only immunizing around 23% of the adult population.

“These are two new vaccines, not a single flu vaccine,” said Emory University’s Walt Orenstein, former director of the US National Immunization Program. “They are brand new and have very particular handling requirements. They require two doses, given at very particular times apart. This is a lot more complex. Certainly like nothing I’ve seen before.”

There also weren’t going to be enough shots of the Pfizer and Moderna vaccines to go around right away, so they required prioritization of who should get them first, something the CDC’s Advisory Committee on Immunization Practices, a panel of outside experts, debated over the summer and fall. Complicating the situation further, the Pfizer vaccine needs to be stored in ultracold temperatures of around -94 degrees and has to be distributed in dry ice–lined boxes of 975 doses. This informed the committee’s recommendation for the first shots to be given in settings like hospitals and nursing homes, rather than doctors’ offices and pharmacies, where most flu shots are injected. By October, the CDC was warning that the first six weeks of the vaccine rollout in the US would be slow and aimed at healthcare workers in order to protect hospitals against further surges.

In the end, ACIP also prioritized long-term care facilities and nursing homes, where some 3 million staffers and older people live. To reach this population outside of a hospital setting, OWS turned to Walgreens and CVS, which would together partner with some 75,000 nursing homes and facilities. After a slow start, pharmacists have administered more than 1.9 million doses in these settings. Walgreens said it would wrap up its shots by Jan. 25.

Unfortunately for the 21 million healthcare personnel also in ACIP’s first tranche of recipients, hospitals proved to be very busy in December, making them difficult places to launch a mass vaccination campaign, Gidengil said.

Public health departments are already overtaxed with increased testing amid the winter surge, Julie Vaishampayan, chair of the public health committee of the Infectious Diseases Society of America, said at a news briefing last week. Starting a mass vaccination program in hospitals already buckling under the biggest surge in COVID-19 cases, she suggested, was doomed.

Federal coordination just did not happen.

In December, ACIP tried to determine what was effective, practical, and fair in how it recommended who gets shots first, said infectious disease expert Andrew Pavia of the University of Utah School of Medicine. “On the practicality side, they tried to have groups that were about the size of the vaccine [doses] available,” he said.

But prioritizing specific people to get the limited COVID-19 shots also complicated planning, Orenstein noted. Anyone can walk up to a pharmacist and ask for a flu shot, after all.

“Most of our work in our planning is trying to get the right people to be vaccinated,” Vaishampayan said. Because OWS left the final say in priority groups to governors, “vaccine tourism” is now a thing, with people flying to Florida to get a shot after Gov. Ron DeSantis opened vaccinations up to people older than 65.

OWS’s practice of allocating doses on a weekly basis has made things even harder for states, which are only told how many they will receive a week in advance. Pfizer and Moderna are making 12 million to 18 million doses of vaccine each week, with the goal of shipping 100 million doses each by mid-March.

Alex Azar, former health and human services secretary, made this even more confusing last week at his final OWS briefing by announcing that the partnership would no longer hold back second doses, instead shipping its entire stockpile to serve as first shots. Azar said he was confident that manufacturers would produce enough excess to guarantee second shots roughly on schedule, delivered 21 days later for Pfizer’s and 28 days later for Moderna’s. He blamed states for being slow in administering the doses and said future allotments would penalize states that are not giving shots quickly enough, a step later rejected by Biden officials.

To speed things up, Azar called for disregarding the CDC’s recommendations by lowering the priority age to 65 and including people with high-risk conditions, an expansion of almost 110 million people who would be eligible for shots — a third of the US population. Some states went ahead, only to later learn OWS had already been shipping its entire allotment and not holding back a reserve, leaving no extra doses for those who were now eligible. New York Gov. Andrew Cuomo grew so frustrated that he asked Pfizer to sell doses directly to his state.

As a result, there have been shortages in California, Ohio, Florida, and other states, as well as canceled appointments for shots in places like New York City, even as CDC data suggests that 19 million doses are sitting on shelves, still awaiting injection.

“There is a constant tension in any kind of vaccination getting doses to the right people, and shortages and surpluses are almost inevitable,” Gidengil said. “But here in the US, there is a tremendous amount of federal coordination that just did not happen.”

Even the advertising campaign for vaccinations was botched, only starting in December, months after ACIP members called for it to start. One of the largest drivers of public hesitancy over the vaccine was the perception that Trump, no fan of scientific caution, was hurrying the vaccines without regard for safety in a bid to deliver an “October surprise” before the November election. Public willingness to get the shots fell below 50% in September but rebounded to 63% after the election, according to Gallup polls.

States need more money to vaccinate people.

Cash has been a crucial final hurdle. Former Senate majority leader Mitch McConnell bottled up federal money for strapped states to administer vaccinations in a $900 billion coronavirus relief bill until just before Christmas, even after former CDC director Robert Redfield had testified in September that states needed another $6 billion to give out shots. The mistake may have cost McConnell the Republican-controlled Senate (when the relief bill’s $600 checks became an issue in Georgia’s runoff races), and it also hobbled states’ vaccination efforts. States only received $3 billion for vaccinations when the bill passed — half of what Redfield had suggested — piped into the CDC’s Vaccines for Children Program.

“We have done mass vaccination campaigns before, and we do have partners we have worked with on them,” Vaishampayan said. “But at the end of the day, we have to have money to pay them.”

This led to some states having more vaccines than they had vaccinators to give them to people. In Indiana and elsewhere, physicians are being called out of retirement to help inject shots. Rosalind Webb, a retired radiologist from outside Indianapolis who began volunteering to give injections last week, told BuzzFeed News that she thinks she has given more shots for the COVID vaccine than she has in her entire medical career.

Inadequate funding has hindered setting up volunteer efforts like Webb’s. States and cities need to ensure that volunteer vaccinators have valid credentials and the training to give the shots, which have specific handling instructions. Webb was only able to volunteer after a friend at the hospital let her know about the program. She had volunteered with a state program in December and hasn’t heard anything back, which is a typical experience for retiree volunteers.

“It shouldn’t be this hard,” one retired dermatologist in Portland, Oregon, told BuzzFeed News, speaking anonymously because she is only halfway through the complicated certification needed to become a state public health worker just to give vaccinations. “I’ve given a kajillion shots in my life. I think I can help here.”

Biden is aiming to administer 100 million doses in 100 days — but some say that’s not enough.

The centerpiece of Biden’s plan is a pledge to give 100 million vaccine shots in his first 100 days in office, built around added federal support from the CDC and the Federal Emergency Management Agency, which will help build mass vaccination centers. The strategy includes $160 billion from a $1.9 trillion pandemic recovery plan that would directly move the federal government into the vaccine administration arena neglected by OWS. The money would hire 100,000 public health workers and pay for community health centers and mobile vaccination centers to reach disadvantaged communities hit hardest by the pandemic. (There are only about 136,000 local public health workers who are employed full time right now nationwide.)

On Thursday, Biden’s first full day in office, Jeff Zients, the newly installed pandemic czar, complained that “what we’re inheriting is so much worse than we could have imagined.” The new administration, he explained, would need to build a pandemic plan from the ground up. After the previous administration tried to get people vaccinated on the cheap, a wartime strategy is now needed to stop the pandemic. Biden has projected that another 100,000 Americans will die in the next month.

Just like in the H1N1 flu outbreak, federal observers will be installed in factories to monitor vaccine output. Through the Defense Production Act, the administration hopes to overcome shortages of raw materials at those factories and manufacture specialized needles that can add extra doses of vaccine to reserves. Medicaid will cover 100% of the costs of shots for its members and allow states to seek reimbursement for vaccination drives through disaster relief funds. The plan will also enroll far more retirees like Webb as volunteer vaccinators.

Public health groups have applauded Biden’s plan. But some experts say that 100 million doses in that time frame is still not enough, though it’s unclear how many more doses will be made available in the manufacturing supply. Political opponents, such as Rep. Steve Scalise of Louisiana, the second-ranking Republican in the House, said Biden should aim higher, targeting 200 million shots in 100 days.

“C’mon, give me a break, man. It’s a good start, 100 million,” said Biden, when questioned about his goal.

White House press secretary Jen Psaki argued that since the Trump administration had only averaged 500,000 vaccine shots a day over 38 days, the Biden administration’s goal of 1 million shots a day was ambitious. Others disagreed, pointing to the country’s average of more than 970,000 daily shots given in the last week.

Not everything has been a mess — so there’s reason to be hopeful.

As usual, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, punctured some presidential posturing on Thursday, only this time from the new administration.

“We certainly are not starting from scratch,” Fauci said from the White House press room, pointing to the success Operation Warp Speed has had in shipping effective vaccines developed in record time. By building vaccination centers, spurring syringe production, and accelerating a pharmacy program that OWS embraced in the last month, the Biden plan is “taking what’s gone on but amplifying it in a big way,” Fauci said.

The big question even Fauci could not answer is how some states have so many unused vaccines while others are reporting shortages. The CDC did not reply to a request to explain this discrepancy from BuzzFeed News.

The number of vaccinators and places to give shots appears to be part of the bottleneck right now, Gidengil suggested.

While Biden has called the vaccination rollout a “failure,” some small rural states, like West Virginia and North Dakota, have done better, administering more than 60% of the shots they have received. West Virginia has eschewed chain pharmacies, turning to 250 local ones to give shots. Connecticut has also earned praise for running a well-coordinated system.

Outside the US, the most successful vaccination campaign has taken place in Israel, where more than a quarter of the population is already vaccinated. The country set up mobile sites and mass vaccination centers throughout the country ahead of time, and it benefits from a universal healthcare system where everyone is enrolled in one of four nonprofit health plans or the military, Yoel Har-Even of the Sheba Medical Center in Israel told BuzzFeed News.

“There has been no politics around this. Everyone has seen this as a serious wartime-level matter,” Har-Even added. “It helps that we are a smaller country. We have about the population of New Jersey.”

Jim Blumenstock of the Association of State and Territorial Health Officers has pointed out that most mass vaccination efforts start out slowly before taking off. The CDC’s flu shot campaign this year went from inoculating 200,000 adults in its first week to giving 8 million or more weekly doses a few months later. More patience might simply be required to get a nation of 330 million people immunized.

“If we get 70% to 85% of the country vaccinated by the end of [or] middle of the summer, I believe by the time we get to the fall we will be approaching a degree of normality,” Fauci said in his Thursday remarks. “It’s not going to be perfectly normal, but one that I think will take a lot of pressure off the American people.”

Some help may come later this month, when a third vaccine, made by Johnson & Johnson and consisting of just one shot, is expected to report its clinical trial results in time for a February rollout. Although it has hit manufacturing delays, promising only millions of doses instead of tens of millions in February, an effective single-shot vaccine would eliminate the need to schedule people for boosters. And the only benefit of a shortage is that it may drive up demand, experts said, combatting hesitancy about getting a shot.

“I think pretty soon we’re going to get to a point where it is truly a supply problem rather than a last-mile getting-it-into-arms problem,” UCSF’s Bob Wachter said.

Opening the vaccinator bottleneck seems to depend on the fate of Biden’s $1.9 trillion recovery plan, which is once again bound up in a fight in the Senate.

“We do need Congress to act, and act quickly,” Zients, Biden’s COVID-19 czar, said on Wednesday. “This is a national emergency, and we need to treat it accordingly.”

Nidhi Prakash contributed reporting to this story.