Over Valentine’s Day weekend, the halls of Steinmetz College Prep were teeming with activity. The high school, located on the Northwest Side of Chicago in Belmont Cragin, a largely Latino neighborhood, was where the city had launched an initiative like few in the country: Here, more than five dozen volunteers — many of them members of local community-based organizations, major health networks, and small providers — filed into the building each morning to execute an equitable vaccine rollout.
Local organizations had spent weeks planning and reaching out to members to sign up for their first shot. The result looked much like an assembly line snaking through the school. At the entrance, patients were screened to make sure they had a vaccination appointment and promptly given their CDC card and another card with the date for their second shot. They were then ushered to the cafeteria, set up with 18 socially distanced vaccination stations. After receiving the vaccination, they were monitored for side effects in the school’s auditorium; 20 minutes later, they were free to leave.
By Sunday evening, volunteers vaccinated nearly 2,000 residents who lived directly in the community. The initiative, which prioritized Belmont Cragin since it has one of the highest Covid-19 death rates of any neighborhood in the city, changed the face of the people being vaccinated in Chicago: That week, 50 percent of all vaccine doses went to Black or Latinx residents, which is reflective of their combined populations in Chicago, a shift from the city’s initial results of just 30 percent.
This weekend, I visited @ChiPublicHealth's Protect Chicago Plus #COVID19 vaccination event in Belmont Cragin and witnessed the valuable work of @oakstreethealth and @IMPACT4HC. This is aimed at increasing #vaccine access and uptake in priority areas heavily impacted by COVID-19. pic.twitter.com/B1nLwj1cKM— Helene Gayle (@helenegayle) February 16, 2021
In late January, Mayor Lori Lightfoot and the Chicago Department of Public Health launched the Protect Chicago Plus plan, an effort to target Chicago’s 15 high-need neighborhoods as designated by the city’s Covid-19 Community Vulnerability Index, which rates neighborhoods according to Covid-19 cases and deaths; poverty level; and the percentage of residents with preexisting conditions, occupational risk factors, and who are uninsured. For eight weeks, the city is dedicating 2,000 vaccines per week to each of these neighborhoods, forgoing previous phase restrictions. As long as someone lives in the designated zip code, irrespective of their job, age, or health status, they can get vaccinated.
“This is one of the boldest strategies out there,” Ali Khan, the executive medical director of Oak Street Health, a clinic administering vaccines in Belmont Cragin, told Vox. “We asked ourselves if we could change the game by working with communities, CBOs, partners, providers, and leaders to identify the silent majority that’s ready to receive the vaccine even though they might automatically be labeled ‘vaccine hesitant’ because they are Black and brown.”
When the city began vaccinating residents on December 15, it gave priority to those in group 1a — health care workers and long-term care facility residents and staff — and then moved to phase 1b at the end of January, targeting Chicagoans age 65 and older, people in homeless shelters and correctional settings, and essential workers. In addition to recognizing that some of the most vulnerable people had been shut out of this process, the city noticed that the most impacted neighborhoods lagged far behind those in and around downtown and on the Near North Side, areas with predominantly white and affluent neighborhoods.
That’s when, after weeks of talks with local stakeholders, the mayor devised a plan to try to protect its most vulnerable residents by making equity a bigger focus.
Chicago’s earlier vaccination outcomes mirror what is happening across the country: White people are being vaccinated at higher rates than their Black and brown peers. Moreover, much of the country is still failing to record vaccination data by race, a form of negligence that further harms communities that have already been hard hit by the virus.
While every city and state faces its own set of challenges, there are lessons state and local leaders can learn from Chicago: start with data and transparency, and create targeted plans built on equity — specifically, dedicating a set number of vaccines to people in areas most heavily affected and distributing those shots at easy-to-access locations. But leaders have to want to make the effort.
“I don’t know that people are ready to make equity a blatant agenda item,” Khan told Vox. “When it comes to the data, for example, transparency is the first part of dismantling structural racism, but it’s not the only part.”
To do better, we first need better data
Looking at the big-picture numbers, the country’s vaccine rollout has improved since distribution started in December. As Vox’s German Lopez reported, the US first met the weekly average of 1 million doses a day on January 23, then hit 1.6 million a day three weeks later, which is in line with the goals President Joe Biden has outlined.
Yet while experts urge speed in an effort to beat the emerging variants, they may be sacrificing equity. The country still does not have a complete picture about who’s been vaccinated due to the wide variety of data collection measures that haven’t been consolidated or aligned nationwide. In fact, racial and ethnic demographic information in data has lagged from the beginning of the pandemic, with states and the federal government only making a slow effort to release the information after public outcry.
As of February 21, national data from the Centers for Disease Control and Prevention (CDC) shows that race and ethnicity were known for just over 54 percent of the 43 million people who got at least one dose of the vaccine. Of those, 63 percent were white, 9 percent were Hispanic, 6 percent were Black, 5 percent were Asian, 2 percent were Native American or Alaska Native, and fewer than 1 percent were Native Hawaiian or other Pacific Islander.
According to the CDC, Black, Native American, and Hispanic people are dying at three times the rate of white people, amid a pandemic that has claimed half a million lives nationwide, with about 80 million confirmed cases of illness.
The CDC is not currently providing this data on the state level, but a February 18 report from the Kaiser Family Foundation collected race and ethnicity information for the 34 states that were reporting such information. The report’s key finding is the “consistent pattern of Black and Hispanic people receiving smaller shares of vaccination compared to their shares of cases and deaths and compared to their shares of the population.”
The report highlighted two states where the disparity is glaring: Texas and Mississippi. In Texas, 20 percent of vaccinations went to Hispanic people, while they make up 42 percent of cases, 47 percent of deaths, and 40 percent of the state’s total population. In Mississippi, Black people have gotten 22 percent of vaccinations, while they make up 38 percent of cases, 40 percent of deaths, and 38 percent of the population statewide.
White people received a higher share of vaccinations compared to their share of cases and deaths and compared to their share of the total population in most states, according to the report, while the share of vaccinations among Asian people was on par with or higher than their share of cases and deaths in most states.
The Kaiser report’s summation was unsurprising: The data remains inadequate, with 18 states and the District of Columbia not yet reporting information by race and ethnicity. Conclusions couldn’t be drawn about Native American people, for example, due to the lack of information. Though the country is still early in its vaccine rollout, the authors wrote, “these data raise concerns about disparities in vaccination but are also subject to gaps, limitations, and inconsistencies” that don’t allow researchers to form “strong conclusions.”
The emerging disparities in the vaccine rollout only amplify the same inequities laid bare throughout the coronavirus pandemic as the world approaches the anniversary of lockdown measures.
Gathering data by race was not prioritized, even though by late March it was clear that the virus was ravaging Black, Latino, and Native American communities at a disproportionate rate — and within the months following, the death rate only underscored the disparity. Coronavirus testing wasn’t as readily accessible for these groups as it was for white people. An estimated 118,000 Black and Hispanic people died from the coronavirus in the US in 2020.
“What we knew at the start of the pandemic was that there was this call to make sure that we collect race-based data around the outcomes of Covid-19 for the same exact reasons that we need race-based data attached to who is getting the vaccine,” Melissa S. Creary, assistant professor of health management and policy at the University of Michigan, told Vox. “And we need that information to be able to see the gaps and address the disparities.”
To help fill in the racial data gaps, Reps. Ayanna Pressley (D-MA) and Barbara Lee (D-CA) and Sen. Elizabeth Warren (D-MA) reintroduced a bill in February that would establish anti-racism centers within the CDC and would, among other efforts, collect race-based data. This would be helpful for the current moment, but just as importantly, it would set the country up to take proactive steps in the event of another health crisis.
“To confront and dismantle the racist systems and practices that create these inequities, we need robust, comprehensive research on the public health impacts of structural racism and policy solutions to bring an end to these disparities once and for all,” Pressley said in reintroducing the bill.
In the meantime, local leaders say the more doses they administer, the clearer the data will become. But for now, they have to make do with the data they have and strategize from there.
Khan said starting with the data allows leaders to “own their own failings.”
“When Chicago was doing 1a only, we were able to look at the data and see that a lot of Asian people like me and white people were getting vaccinated at higher rates,” he said. “Looking at the data allowed us to correct the imbalance.”
Vaccine rollouts have to confront the root of inequity
With the demographic data so far available about vaccine dissemination, it’s clear that disparities exist. Understanding why they persist should be the foundation of any plan for redress.
For one, systemic racism has historically undermined America’s health care system, preventing Black and brown communities from receiving the kind of care — and living circumstances — that would help prevent the compounding health factors that led to their heightened vulnerability to the virus.
Relatedly, policymakers failed to create strategies that would address these communities’ unique fragility from the outset. As the AP analysis concluded, many states pushed to open vaccinations to a wider group of older people and essential workers, ignoring the fact that “the nation’s over-65 population is more heavily white than other age groups.”
A Brookings Institution report from June 2020 found that Black people who die of Covid-19 are typically 10 years younger than white people who succumb to the disease. This means that older white people — some of whom aren’t as high risk as younger Black people — have been receiving priority. A CNN analysis found that at least 83 percent of Alabama’s Black population lives in counties where life expectancy for Black people (less than 75 years) did not meet the age requirement — over 75 years — for vaccine eligibility. And CDC data shows that the life expectancy gap between white and Black people has only grown in the pandemic.
While vaccinations of health care workers and the elderly have left many to wait, phase 1b in many localities may encompass more Black and Latino essential workers. According to a report from the Center for Economic and Policy Research think tank, about four in 10 front-line workers are Black, Hispanic, Asian American, or Pacific Islander.
Still, leaders have failed to treat these vulnerable populations as groups deserving of protection during a time when unemployment is tearing down families yet the rent is still due. Countless reports have documented how some white people swooped into Black and brown neighborhoods miles away from their own in the hunt to get immunized. According to Khan, his team specifically checked registration information to ensure that people outside of the zip code weren’t sneaking in, and even turned away residents from the wealthy Loop area of Chicago who caught wind of the event. Any leftover vaccines at the end of the day went to people from the neighborhood, not just to anyone who showed up.
Khan says communities can’t simply put up a website and wait for sign-ups. The digital divide, in addition to language barriers and internet literacy gaps, has slowed and deterred would-be vaccination candidates.
As @Eugenia_South underscores, #HealthEquity isn’t hard, but it does take intentional work to overcome the inequitable inertia of the status quo.— Ali Khan, MD, MPP (@alikhan28) February 16, 2021
This weekend in Chicago, our @OakStreetHealth team vaccinated 2000 Latinx people in Belmont-Cragin. Here's how we made it work. pic.twitter.com/Sa5K5vwKYX
“We can’t just hand out vaccines in a colorblind fashion,” Creary told Vox. “We need a systemic solution that addresses the fact that Black and brown communities are likelier to be in crowded living conditions, be unable to access PPE, be unable to work from home, and likelier to work jobs in which it is difficult to social distance — all conditions created by systemic racism.”
Vaccine hesitancy remains a challenge in fostering a more equitable vaccine rollout, but it’s not an insurmountable one, according to experts. Some people in Black and brown communities have grown hesitant over decades of experiencing medical bias and mistreatment — sometimes deliberately — at the hands of health care professionals and local and federal governments.
Even Black doctors, like University of Pennsylvania assistant professor of emergency medicine Eugenia South, felt hesitant about the vaccine, questioning whether she could trust a vaccine developed under a racist president. South argues that we need to normalize vaccine hesitancy around Covid-19, to give people time to get more information, like learning about the role of Black scientists like Kizzmekia Corbett in developing one of the vaccines.
Instead of state and local leaders planning how to create trust and access, much of the narrative around hesitancy has placed blame and shame with the already vulnerable communities.
“Now they’re telling us ‘all you have to do is take the vaccine, but you don’t want to take the vaccine,’ ignoring how systemic racism creates hesitancy,” Creary said. “My question now is, how can the people who have never experienced equity in any other format be trusting of a supposed new urgent call for equity when it comes to the vaccine?”
Change has to be intentional and close to home
Trust, many experts say, starts with action.
Local leaders must devise targeted plans to get vaccines to people in vulnerable communities. Often, that’s through campaigning hand in hand with community stakeholders to reach these populations and bringing the vaccines to trusted and accessible locations.
When Khan and his peers showed up at Steinmetz College Prep, they didn’t come with a half-baked plan. The team thought through all angles with the goal of using up all 2,000 vaccines they had on site.
The preparation took weeks, including connecting with community organizations and local leaders — like the HUD-certified Northwest Side Housing Center, the local alderman, and a state representative — who were already embedded in the neighborhood. Khan’s Oak Street Health team had an advantage because they had already been serving the neighborhoods hit hardest by Covid-19, administering tests throughout 2020 and vaccines more recently.
Within 36 hours, beginning the Tuesday before the weekend, about 50 participating organizations made phone calls to sign up local residents for their appointments. IDs were not required, in an effort to help undocumented populations feel comfortable and confident. When the team recognized that there was a no-show rate of about 8 to 10 percent by the early afternoon, they made a round of more than 100 calls to get more people in that day. In addition, they built a separate waitlist based on referrals. If someone with an appointment brought in their brother who didn’t have an appointment, they’d work to accommodate the brother later that day.
“We built an almost intentionally analog strategy to registration. It couldn’t just be a website,” Khan said. “It had to be a multi-layered and multi-channel effort that involved web, text, telephone, and shoe leather. And leveraging the people and places the neighborhood trusts.”
Across the country, other groups and networks, and some states, are stepping up to promote models that promote equity, but it may still be too soon to tell their impact. In Tennessee, the government and health department have set aside allotments for Black communities hardest hit but the pandemic with little access to hospitals and other health centers. In Philadelphia, a group led by local Black physicians hosted a 24-hour vax-a-thon last Friday. Attendees didn’t need to register, but they had to live in the 15 hardest-hit zip codes and be part of the city’s first vaccination groups.
The Black Doctors “vax-a-thon” will target people who qualify for the vaccine in the city’s Phase 1B or who are over 75 years old. Individuals must reside in the city ZIP codes that have been identified by the consortium as having the highest incidence of COVID-19 and deaths. 2/ pic.twitter.com/OeAH3kGEuk— Kenyatta Johnson (@CouncilmemberKJ) February 19, 2021
And across Indian Country, tribes are distributing the vaccine quicker than US averages, NPR reported, due to vaccination drives via the Indian Health Service as opposed to state systems. The Rosebud Sioux Tribe, having suffered the loss of more than two dozen tribal members due to Covid-19, has managed to vaccinate its community at “near double the rate of South Dakota.” This is despite tribes having to go the extra mile to overcome challenges like securing ultra-cold storage units, distributing leftover vials, and combatting vaccine hesitancy that stems from the US government’s failure to honor its promises to Indian Country.
These examples show that an equitable vaccine rollout takes a combination of factors. It requires pinpointing those most vulnerable to the disease and those being left behind in vaccine distribution, community-led campaigns to disseminate vaccine information with compassion toward hesitancy, and no-fuss ways for these vulnerable populations to get the shots.
As some leaders begin to shift strategy, time will tell how much they’ll impact the current trends. More worrisome, though, is that the success of these plans is only temporary and predicated on a vaccine supply that remains inadequate. Officials in Chicago wrote at the time the city unveiled its new initiative that supply is a “significant concern” since they’re not receiving “nearly enough doses from the federal government” to inoculate everyone in the first vaccination groups.
For Khan, the eight weeks the initiative is set up in the Belmont Cragin neighborhood — with four weeks of first doses and four weeks of second doses — isn’t enough: “If we can do more, we will.”