Reread Patrick McKenzie (patio11)’s inspirational oral history of VaccinateCA and thought to pull out a few quotes for my own edification. (Patrick posted about this on the forum awhile back, that’s worth reading too.)
The following is what it looks like to bake in triage into org decision-making from the top down:
We had an internal culture of counting the passage of time from Day 0, the day (in California) we started working on the project. We made the first calls and published our first vaccine availability on Day 1. I instituted this little meme mostly to keep up the perception of urgency among everyone.
We repeated a mantra: Every day matters. Every dose matters.
Where other orgs would say, ‘Yeah I think we can have a meeting about that this coming Monday,’ I would say, ‘It is Day 4. On what day do you expect this to ship?’ and if told you would have your first meeting on Day 8, would ask, ‘Is there a reason that meeting could not be on Day 4 so that this could ship no later than Day 5?’
I started every meeting and status report to the team by reminding them what Day it was. Our internal stats dashboard had a counter of what Day it was. I had a whiteboard in my apartment showing what Day it was. I wrote that every morning as soon as I woke up, and updated the other two numbers right before I went to sleep. Those were: the number of locations we had published to Californians where they could currently get the vaccine, and the number we knew about elsewhere across the United States with the vaccine.
The latter was zero at this point, of course. I brushed my teeth, wrote my emails, ate my meals, did media interviews, called my family, negotiated with funders, and said my prayers with the zero where I could see it.
A photo of the non-computer version of VaccinateCA’s dashboard, taken on Day 39. It shows VaccinateCA’s then-current understanding of where to find the vaccine: 1,025 sites in California and 0 sites outside of California. Image by Patrick McKenzie.
I think in absolute terms plenty of orgs do this, Patrick just so happens to be a good writer. But in relative terms it’s quite rare, and very meaningful to see, especially for folks like me with a bit of mission orientation. Also this:
After the workday was over and pharmacies stopped answering their phones, the workday began again immediately, as much of our engineering team turned off their day job computers and logged on to Discord to digest what we had learned. We worked into the night, and not infrequently through it, to be ready for 9:30am the next morning.
It was often a brutal crunch. I told the team to take care of themselves and keep an eye on one another. The mission wouldn’t be served by anyone ending up in the hospital. But subject to that constraint, we worked like men and women possessed, because people were dying.
On entrepreneurship:
Part of entrepreneurship is having a vision of something that is possible and figuring out what is necessary to bring it into the world. A cynic would say that the world has a secret: Building things is not actually possible, because different organizations have different timelines allowing access to different resources, and it is impossible to correctly sequence things to satisfy all the requirements in order to build anything. An entrepreneur would tell the cynic a secret in return: You can carefully titrate the amount of truth to various parties to dissolve these deadlocks.
Your donor-advised fund won’t let you donate unless we’re a 501(c)(3)? Well, you’d donate if we were a 501(c)(3), right? Great. We’re applying for approval as a 501(c)(3) from the IRS. Can I put you down for $25,000? Dear IRS examiners: I have a written commitment from a charitable allocator for a $25,000 donation contingent on 501(c)(3) status. As you are aware, IRS procedure says that this qualifies for expedited processing. Oh, yes, government actor whose cooperation we need, we’re a nonprofit. Look at this official paperwork from Delaware. It says that the State of Delaware is officially aware that I say we’re a nonprofit. Not good enough? Our 501(c)(3) status? The IRS is busy approving it, on an expedited basis.
This is somewhat reminiscent of what Scott Alexander wrote about a very different person, although what Patrick calls “carefully titrating the amount of truth to various parties” Scott outright labeled “blatant lies”; my takeaway is that it’s possible to do a more ethical version of the description below:
I started the book with the question: what exactly do real estate developers do? They don’t design buildings; they hire an architect for that part. They don’t construct the buildings; they hire a construction company for that part. They don’t manage the buildings; they hire a management company for that part. They’re not even the capitalist who funds the whole thing; they get a loan from a bank for that. So what do they do? Why don’t you or I take out a $100 million loan from a bank, hire a company to build a $100 million skyscraper, and then rent it out for somewhat more than $100 million and become rich?
As best I can tell, the developer’s job is coordination. This often means blatant lies. The usual process goes like this: the bank would be happy to lend you the money as long as you have guaranteed renters. The renters would be happy to sign up as long as you show them a design. The architect would be happy to design the building as long as you tell them what the government’s allowing. The government would be happy to give you your permit as long as you have a construction company lined up. And the construction company would be happy to sign on with you as long as you have the money from the bank in your pocket. Or some kind of complicated multi-step catch-22 like that. The solution – or at least Trump’s solution – is to tell everybody that all the other players have agreed and the deal is completely done except for their signature. The trick is to lie to the right people in the right order, so that by the time somebody checks to see whether they’ve been conned, you actually do have the signatures you told them that you had. The whole thing sounds very stressful.
But I digress. Relatedly:
That’s life in a start-up: trying to create enough impact very quickly to convince people to give you more resources, while understanding that the default case is running out of resources, and, by the way, everything is broken all the time.
On do-gooder precocity:
We saw peer projects sprout up in many states, with varying levels of effort and success. Many credited us as an inspiration. One peer project was ILVaccine.org, a project of Eli Coustan. We were working with him for a while before I learned he was in middle school. When I later blanked on his name and asked someone about the public health infrastructure coordinator who was a middle school student I was asked to be more specific.
On ownership and accountability, a case study:
Our scripts instructed callers to take down notes from pharmacists as to how to get an appointment for doses they had, when they had them. A Rite Aid pharmacy in San Bernardino asked our caller to sign up for an appointment at the county health department’s website. Our caller, who had been calling into San Bernardino frequently and had seen that website frequently, remarked that he had seen no Rite Aid listed as a possible vaccination location.
The pharmacist then swore into the telephone, hung up, and immediately called the county health department.
I want you to visualize the operations of county health offices during the middle of the pandemic. A stressed staff are busy coordinating a logistical challenge larger than any they’ve faced in their careers. Their phones are ringing off the hook. The consultancy that won the bid finally delivered the freaking appointment website, thank god. It is crappy and barely works but at least it is finally here. You just have to download all of the email attachments from the pharmacy chain corporate offices, maybe fix a few in Excel because those jokers can’t read clear instructions, then upload them into the administrative side of the portal, and finally people can register for appointments to get the doses sitting in pharmacy freezers.
Rite Aid’s data never made it into the system. Maybe Rite Aid forgot to send it and nobody followed up. Maybe it got eaten by the county’s spam filter. Maybe a public health worker with a million things to do did 999,999.
There were 13 Rite-Aids in San Bernardino county. None of them, despite being in possession of the most desirable object in the world, had received a single appointment. No pharmacist, with years of training in healthcare, noticed this before we told them.
Why would they? Every pharmacy has lots of tiny glass vials and bottles of pills and satchels of powder. Patients were coming in and getting healthcare. It was no one’s job to check that any particular vials got distributed quickly. Pharmacists are not pharmaceutical sales representatives; they do not generate demand. Pharmacists service appointments and prescriptions, deliver healthcare, and go on to the next patient. If you walked up to the counter or called in and asked about Covid appointments, they’d tell you to book one with the county and move on to the next customer. Just another day at the pharmacy.
You might object and say that it must have been someone’s job to actually get those doses injected. Someone who worked . . . at the White House? Okay, no, but at the CDC? Okay, no, but at the California Office of the Governor? Okay, no, but at the county health department? Okay, no, county health departments do not track individual SKU inventory levels at individual pharmacies, that’s actually not a thing. OK, then, Rite Aid – some logistics manager at Rite Aid should have opened a spreadsheet, seen an SKU like #DJFKJDF3285325 with 50 doses available out of 50 shipped at a location in San Bernardino, and immediately said, ‘Oh, #$*#(%. That drug being in supply is equivalent to a life-threatening medical emergency. I will now get out my emergency procedures binder.’ Nope, that is also not a reasonable expectation.
Each of these organizations wants someone else to be responsible for catching errors like this, and they want them to be effective at doing so. They want, and the nation wants, an organization to be accountable for delivering the vaccine.
VaccinateCA considered this bug, and anything else that kept vaccines in freezers while patients were still waiting, to be our problem.
This problem was fixed because a caller from VaccinateCA thought to say, ‘Wait, I notice that I am confused’. It was fixed within about half an hour of being noticed. We estimate more than 500 doses were quickly taken out of freezers, thawed, and injected into waiting arms. Those arms were often attached to people who had been refreshing the county website every few minutes hoping new appointments would finally open up.
This was early and dramatic evidence to me that California was benefiting from having an organization that felt itself accountable for delivering the vaccine.
On how much of Patrick’s job in the early days as CEO was bringing in funding:
VaccinateCA had an extremely effective team, as good as any I have ever had the privilege of working with. They were instrumental in almost everything I did and probably could have done almost all of it without me. The main thing I uniquely brought to the table, and spent a lot of my cycles on, was finding the money.
Our earliest funding source was a prepaid debit card I spun up and posted in our public Discord, with $20,000 of my own savings on it. That would cover servers and software and similar for a while. That was not going to be sufficient to get a proper nonprofit with a paid staff off the ground, and I knew we would both need that and need to be read as that to get cooperation from some quarters.
I called in favors and plead our case up and down the tech industry, and scraped together about $1.2 million in funding.
This was below what I initially thought I could reasonably raise, and below what I thought we likely needed. For better or worse, it would have been a lot easier if I had pitched it as: ‘Just make a small angel investment in a promising technology company whose CEO thinks his job is burning through investor dollars as quickly as possible while driving the total addressable market to zero. You won’t make any money on it, but think of the story.’
But while that tech company would probably have been well funded, it would have smelled like a tech company to potential partners. To accelerate shots in arms we urgently needed the cooperation of people who, if confronted with the proposition ‘Big Tech is bringing about the end of constitutional democracy so that it can gather more of your data to sell’, would like that tweet from their iPhone. I have a different point of view, but debating would not have put shots in arms.
We were approximately the most privileged nascent nonprofit imaginable in terms of access to funding, and given that it directly unlocked our ability to help people find the vaccine, I don’t want to complain too much about the process of getting it. I will record, for the benefit of future charitable founders, that probably half of my time from Day 8 to Day 160 was spent chasing funding, dealing with funders and the nonprofit industrial complex, pitching (and pitching and pitching and pitching) large pots of tech money earmarked for pandemic response, filing required reports with funders and the government, and diligently accounting for every penny spent.
It was a bit of a culture shock coming from the technology industry. Tech isn’t exactly profligate, but it certainly empowers twentysomething engineers to spend thousands of dollars by typing a command into their terminals. An engineer who fumble-fingers a command and spends ten times what they expected to is told to type more carefully next time.
On the advantages private individuals and organizations have over official initiatives:
The government of the United States is an intrinsically political entity. We were formally nonpartisan (and even better, as a 501(c)(3) nonprofit, had to be). Informally, to quote a memo I wrote early on, we would do a deal with the devil himself if it got one more patient one more dose. We didn’t need to worry about compromising anyone’s reelection chances by being too maniacally focused on shots in arms to consider the big picture. We had no responsibilities to allies in our party, like not overshadowing their efforts, because we had no party and, for that matter, no shadow.
I knew that many political actors wanted to hoard the facts of their operations so that they could claim credit for them. I just didn’t particularly care. If an actor had a dose available to the public, it was going to be publicized anywhere we could cause it to be.
(It’s hard to convey how much I like and appreciate that last paragraph.)
On funder-nonprofit misalignment:
Some potential funders were in after an emailed discussion that could fit in a tweet. Some were in after a single call.
Some potential funders had expectations that were misaligned with us. VaccinateCA was always designed as a rapid-response project that would spin up, cover for an urgent gap in US infrastructure, and then spin down once the work was done. We explained this at length while emphasizing that we wanted to work with funders who could reach a decision quickly. Every day mattered. Every dose matters.
We had some interactions where we were put through weeks or months of grant writing, which sounds like ‘turn in a paper and wait for it to be graded’ and is more ‘schedule sufficient meetings with sufficient backing documentation to buy a company for $20 million’. The funder eventually passed on us, saying they worried we would create no institution with enduring value after the pandemic.
I don’t begrudge anyone’s choices of how to spend their money, particularly charitably earmarked money. I will point out that the gap in expectations between a grant-reviewing team keen on institution building and a nonprofit with an urgent unmet need is a very, very common story in nonprofit fundraising.
Many pots of money have preferences with regard to how they allocate, and those preferences change with the seasons. Have I mentioned that health equity was all the rage in California in 2021? I put on my best face to funders, explained that the system of siloing vaccine information benefited only people who were professionally competent at navigating the American healthcare bureaucracy. I suggested that publishing vaccine locations to a website and Google and every other place we could think of was an improvement over that status quo. I didn’t engage with debates about how, and this was made absolutely explicit in some conversations – perhaps saving lives but failing to save lives in preferred demographic ratios would be considered worse than not engaging in the project at all.
(I’ll be upfront that despite having spent a couple of my formative years in California, my bias leans so far in Patrick’s direction that it’d probably be useful for me to hear out the strongest counterargument, especially in the context of triage.)
Reread Patrick McKenzie (patio11)’s inspirational oral history of VaccinateCA and thought to pull out a few quotes for my own edification. (Patrick posted about this on the forum awhile back, that’s worth reading too.)
The following is what it looks like to bake in triage into org decision-making from the top down:
I think in absolute terms plenty of orgs do this, Patrick just so happens to be a good writer. But in relative terms it’s quite rare, and very meaningful to see, especially for folks like me with a bit of mission orientation. Also this:
On entrepreneurship:
This is somewhat reminiscent of what Scott Alexander wrote about a very different person, although what Patrick calls “carefully titrating the amount of truth to various parties” Scott outright labeled “blatant lies”; my takeaway is that it’s possible to do a more ethical version of the description below:
But I digress. Relatedly:
On do-gooder precocity:
On ownership and accountability, a case study:
On how much of Patrick’s job in the early days as CEO was bringing in funding:
On the advantages private individuals and organizations have over official initiatives:
(It’s hard to convey how much I like and appreciate that last paragraph.)
On funder-nonprofit misalignment:
(I’ll be upfront that despite having spent a couple of my formative years in California, my bias leans so far in Patrick’s direction that it’d probably be useful for me to hear out the strongest counterargument, especially in the context of triage.)
Thanks for the relevant quotes, Mo!