Equity push, but shots missed mark
How did early doses go to people from affluent suburbs and Chicagoans in low-risk areas?
In the early weeks of the COVID19 vaccine’s release, a joke made the rounds among people hunting for appointments in Chicago:
What’s the best way to find a shot in the city?
Live in Glencoe.
While the punchline was meant to be facetious, it wasn’t far off the mark. A Tribune analysis of federal vaccination data shows that in Glencoe’s predominant ZIP code, roughly 1 in every 6 residents was given their first dose from Chicago’s vaccine supply during the rollout’s earliest phases.
Residents of other affluent suburbs also had luck finding shots in the city between December 2020 and mid-April, a period when eligibility rules were still in play, people were desperate to find appointments and city officials were promising to steer doses to the hardest-hit neighborhoods. At least 1 in 8 of all residents in ZIP codes covering Oak Park, Kenilworth, Wilmette, Winnetka and River Forest received their first dose in Chicago, the data shows. When looking only at those residents who got vaccinated, the numbers are even more stark: At least 1 in 4 found shots in the city.
In fact, more Northbrook residents received first doses from the city’s supply than people living in Englewood’s primary ZIP code.
Chicago’s vaccination rollout serves as yet another example of the longtime health care inequities laid bare by the pandemic. An analysis of more than 1 million first doses given in Chicago found nearly 60% of shots went to suburbanites and residents of neighborhoods deemed to have the lowest risk of COVID-19.
The Tribune obtained the vaccination data from the Centers for Disease Control and Prevention
through a public records request. That data was compared with a list of ZIP codes categorized by city officials as having low-, medium- or high-vulnerability to COVID-19, based on demographic, occupational and epidemiological factors.
The Tribune’s analysis found less than 40% of Chicago’s shots were given to residents in highor medium-risk communities, though nearly 60% of Chicago residents live in those neighborhoods. These communities, which were among the hardest hit by COVID-19 infections and death over the past year, are predominantly Black and Latino neighborhoods on the West and South sides.
“This is not a surprise to anyone in the Black community because this is the norm,” said 20th Ward Ald. Jeanette Taylor, who represents a large swath of Englewood. “And it won’t be easily fixed until we give Black and brown communities the same access to health care and a healthy lifestyle as we do people on the North Side and the suburbs.”
Chicago health officials said the Tribune’s findings reflect both the concerted effort the city made to bring vaccines to harder-hit communities and the realities of an inequitable health care system that has plagued the city for generations.
“When we talk about root causes and real societal structures within public health, this is what we are talking about,” said Dr. Allison Arwady, commissioner of the Chicago Department of Public Health. “We’re not just talking about health care, we’re talking about things that allow people to lead healthy lives: housing, education, neighborhood safety and security, food access. … It’s more broadly a reflection of the inequities that we have here in Chicago, many of which are built around race. And in a city as racially segregated as Chicago is, we are able to see those patterns show up in our geography as well.”
Yet even among widespread evidence of inequity, the analysis revealed some medical providers delivered significant numbers of doses to those living in hardhit pockets of the city. That includes several community health centers and a safety-net hospital whose early efforts could offer a road map to reach those in underserved areas who may work long hours, be uneasy about getting vaccinated or find the scheduling process intimidating. In a reflection of the yeoman’s job done by providers such as Esperanza Health Centers and St. Anthony Hospital, Arwady said the city prioritized their vaccine orders ahead of the big medical centers to make it easier for vulnerable populations to receive shots as part of its Protect Chicago Plus initiative.
The CDC data does not provide enough detail to determine whether the recipients met the eligibility rules established by the city for the various phases. The Chicago Department of Public Health repeatedly said shots should go to people who lived, worked or received medical care in the city, as long as they met criteria that included age, occupation and underlying conditions in a phased rollout.
While the city saw a sizable influx of suburbanites coming for shots, the data show some Chicagoans, particularly those from low-risk areas, traveled outside the city to get shots in other parts of Illinois and Indiana.
“There is a lot of fluidity across the region,” said Arwady, who added that the vast majority of people who traveled for shots had the luxury of transportation and time to do so.
Still, the findings help add context to the debate about the rollout’s effectiveness. City health officials touted targeted efforts early into vaccination that they credit for helping lessen racial and ethnic inequities, including the use of safety-net hospitals. But Block Club Chicago reported embarrassing details about how one of those facilities, Loretto Hospital, held vaccination events at places tied to its executives, including Trump Tower, a suburban church and a Gold Coast jeweler.
The Tribune analysis found that only 36% of Loretto’s doses went to residents in medium- and highrisk ZIP codes, while 37% went to people who didn’t live in Chicago. Naperville, Oak Brook, Bolingbrook and Aurora all had more than 100 residents vaccinated by the hospital, which gained a reputation among vaccine hunters as a go-to place for leftover doses available to anyone regardless of residency.
The city now oversees vaccine administration at the hospital to ensure the doses are more equitably given.
But for all the attention Loretto received, it wasn’t the only provider to contribute to the inequity gap. Walgreens, Jewel-Osco and the larger hospital systems all gave most of their first shots in Chicago to suburbanites and residents of wealthier city neighborhoods with lower infection and death rates.
That dynamic unfolded amid heavy demand for doses in vaccine-starved collar counties and the state proportionally sending more of its federal allocation of doses Downstate. That left some suburban residents who were eligible under state guidelines scrambling to find doses anywhere they could, with some willing to drive hours to get vaccinated, or cross into Chicago, which got its own supply from federal officials.
Hospitals say they reached out to members of vulnerable communities early on while facing challenges including limited supply, high demand and an imperative to vaccinate people quickly without wasting doses. Public health officials also encouraged them to offer shots to patients because it’s considered best practice for people to be inoculated by their own medical care provider.
Northwestern Medicine leaders, for example, say they prioritized people from high-risk neighborhoods throughout the rollout.
But the data show Northwestern administered 54% of its shots in the city to people who live in Chicago’s low-risk areas, while another 29% went to non-Chicago residents. Less than 5% of its 46,344 shots went to residents who live in neighborhoods with the highest vulnerability rating, a group that makes up nearly 30% of the city’s total population.
The findings also highlight challenges in connecting the most vulnerable to the earliest doses available.
With the majority of appointments hinging upon computer skills or an existing relationship with a big hospital system, the rollout favored the more affluent in those early months. While those scheduling platforms were intended to put people on an equal playing field, they became an obstacle for residents without access to regular health care or the ability to sit in front of a computer for hours and hitting refresh.
“They were just trying to get as many shots into arms as possible. They were counting numbers,” said Dr. Marina Del Rios, the social emergency medicine director at the University of Illinois Hospital. “This is what happens when you measure success in terms of numbers instead of people. The most vulnerable are left out.”
Chain pharmacies
Walgreens was the second-largest provider of first doses in the city, but only about 26% of those shots went to people in highor medium-risk Chicago ZIP codes. About 30%, meanwhile, went to suburbanites who struggled to find appointments closer to home.
The pharmacy chain says it wasn’t told it had to confirm that patients lived or worked in the city until late March, though city officials said they had been clear about the eligibility guidelines from the start and noted their public directives. Public health officials, who had been monitoring ZIP code data since the beginning of the rollout, said that in late March they asked Walgreens to do a better job.
“The goal was immunize and protect as many patients as we can,” said Rina Shah, Walgreens group vice president of pharmacy operations. “When the city came and said we really want to focus on our Chicago residents, then we updated our policies and procedures to do that.”
Shah noted that in the last couple of months, Walgreens has held nearly 60 clinics in higher-risk communities, where it’s administered about 30,000 doses. She said Walgreens didn’t have enough vaccine supply to hold those kinds of clinics earlier in the rollout.
Jewel-Osco saw about 28% of its first doses in the city go to people from highand medium-risk ZIP codes. Company spokeswoman Mary Frances Trucco said in a statement that Jewel has worked with county health departments to make vaccines available based on supply and demand.
Big hospitals
The city’s big five hospital systems were among the next largest providers of shots, after Walgreens, delivering nearly 250,000 first doses, according to CDC data.
Among the city’s 19 largest vaccine providers, Northwestern Medicine ranked sixth for the most shots given, but last when it came to vaccinating people from high- and medium-risk areas of Chicago. About 15% of its first doses went to people from those neighborhoods between December and mid-April.
A Northwestern spokesman contended the system did better vaccinating people in high-risk areas during the early months of the rollout before the vaccine became more widely available at pharmacies and community clinics. He also said that when the numbers were expanded to include the health system’s suburban locations, Northwestern’s success in vulnerable ZIP codes increased.
Northwestern officials said that throughout the rollout, they prioritized residents from high-hardship ZIP codes, as defined by Sen. Dick Durbin’s Chicago HEAL Initiative, a project involving 10 health systems that aims to reduce violence and improve health equity. Their efforts included reaching out to patients in vulnerable ZIP codes through phone calls and postcards, as well as a vaccine clinic in Humboldt Park that drew about 3,000 people.
“If you lived in a HEAL ZIP code, we were really focused on connecting with you and getting you in,” said Posh Charles, Northwestern senior vice president of administration.
Rush and University of Chicago said they, too, prioritized patients from high-risk areas within each phase, reaching out to them before others. University of Illinois Hospital called those patients beginning in February, setting aside a certain number of appointments for them, and noted that it’s one of the top providers in Protect Chicago Plus, the city’s vaccine equity program.
All three hospital systems held clinics in high-risk neighborhoods and called patients in high-risk areas to set up appointments.
To date, Rush has offered 120,000 appointments to people in high-risk neighborhoods, though only about 20,000 people snapped up those slots, said Dr. Paul Casey, chief medical officer at Rush. It’s unclear whether that’s because they got vaccinated elsewhere or didn’t want shots at all, he said.
Rush and University of Chicago Medicine began by vaccinating patients who had visited their systems in recent years, even if it was only for an emergency room visit. UI Health never limited vaccinations to just its own patients.
“We have, from the beginning, opened it up to the community because we know some people don’t have established care,” said Dr. Susan Bleasdale, an infectious disease physician and associate professor at the UIC College of Medicine.
Still, the hospitals faced limitations when it came to vaccinating more people in vulnerable neighborhoods — barriers that reflect the long-standing inequities in health care, said Dr. William Parker, assistant director of the MacLean Center for Clinical Medical Ethics at University of Chicago Medicine.
For one, not everyone in those high-risk neighborhoods was connected to a large health system before the pandemic. The University of Chicago, which borders some of the hardest-hit ZIP codes on the South Side, administered 8.4% of its 48,855 first doses to people living in high-risk communities.
“We only had so many names of people who lived in high- and medium-risk ZIP codes, those that had come through our health system’s doors, and obviously there were thousands of others we didn’t have access to,” Parker said.
Also, the big academic medical centers in the city serve many suburban patients because of the specialty and complex care they provide. Though the hospitals didn’t necessarily prioritize those people for vaccines early on, they did ultimately invite many of them to get their shots in the city. The hospitals also vaccinated their own employees, some of whom lived outside the city and would be included in the CDC data.
Roughly one-third of the people who received first doses at UI Health, Rush and University of Chicago didn’t live in the city, according to the Tribune analysis. Parker said he would have liked to have seen the state health department send more vaccine doses to Chicago early on to make up for all the suburbanites who were getting vaccinated in the city.
“Health care access for the well-off is so gratuitous compared to the disadvantaged in society,” Parker said. “If we weren’t careful, if we didn’t have this equity focus, it would have been very easy for our patients who are more privileged, who have better insurance, to end up at the front of the line. That’s the default in the American health care system.”
Many advocates believe hospitals didn’t do better in the hardest-hit areas in part because they didn’t have the credibility or the foundation to make connections in those communities. Health experts said significant numbers of residents don’t have primary care physicians, so the mass vaccination events materialized before some of them had even had a conversation with a medical professional about the benefits of the vaccine and low risk of side effects.
“You can’t just set up a pop-up clinic and think people are going to show up,” said Del Rios, a health equity advocate who became the first Illinois resident to be vaccinated. “No matter how well-intentioned those efforts are, they aren’t going to work. You have to invest the time and energy to create relationships with people, to gain their trust.”
“This is not a surprise to anyone in the Black community because this is the norm.” — 20th Ward Ald. Jeanette Taylor, who represents a large swath of Englewood
Successes
Few medical providers rose to the occasion more than Esperanza Health Centers and St. Anthony Hospital, both of which serve the Southwest Side. Both organizations hired dozens of people and sent them out into the neighborhoods to answer questions and help book appointments.
Those efforts paid off: Esperanza gave 91% of its first doses to people in high- to medium-risk ZIP codes, while nearly 70% of St. Anthony’s shots went to residents of the city’s harder-hit neighborhoods.
At St. Anthony, the determination to vaccinate its surrounding neighborhoods was born at the height of the pandemic, when the hospital grappled with positivity rates 30 points higher than the citywide population. Its frequently filled intensive care unit often was one of the busiest in the city, said Dr. Romeen Lavani, the hospital’s chief medical officer.
“We had seen the sick
est of the sickest, so knew the vaccine could have a big impact in the community,” Lavani said. “And we knew we had to reach out to the population as soon as the vaccine became available. We could not delay.”
The hospital, which had almost run out of money at the pandemic’s peak, hired 80 people from the community to be part of its vaccination effort. The goal was to make the process, from booking to injection, as easy and encouraging as possible.
Partnering with local community groups, the hospital sent fully vaccinated health educators — speaking English, Spanish, Mandarin and Cantonese — into supermercados, laundromats and churches to talk to people about getting shots. If someone expressed interest, the educator called the hospital and immediately booked an appointment. No fighting the internet, no spending hours trying to get through jammed telephone lines.
The hospital also used multilingual “navigators” to escort people through the process once they arrived. An emphasis was placed on being friendly, informative and enthusiastic problem solvers and not helpless cogs in an ambitious vaccination plan.
When a pastor called to say his younger congregants were afraid to come to the hospital because it meant crossing gang lines, the staff created a pop-up site to alleviate the concern.
“We were meeting people where they were at,” said Jim Sifuentes, the hospital’s senior vice president of mission and community development.
From December to mid-April, the hospital vaccinated a bigger percentage of residents from highrisk neighborhoods than any other Chicago hospital. It also vaccinated a lower proportion of residents — 19% — outside the city than any other medical center.
Lavani acknowledges that they tried to find shots for anyone who came to them for help, particularly those with underlying conditions, because its mission as a safety-net hospital is to provide assistance to anyone who needs it. But the staff ’s efforts within the community meant there weren’t many open appointments or unused vaccines to scoop up.
Esperanza took a similar approach as it worked with five community organizations to hire 90 people to help the vaccination effort. The health center, meanwhile, plastered its number throughout the South and Southwest sides, urging people to text them to schedule an appoint. They also proactively texted anyone already in their system to book shots.
Staff members replied to texts within 72 hours, calling residents to schedule an appointment and offering to vaccinate their entire family at the same time. Each night, officials audited their daily appointments to ensure that only people from eligible ZIP codes were slated for doses.
“We had to be pretty firm with that,” said Carmen Vergara, Esperanza’s chief operations officer and a registered nurse. “At one point, we did have people from Naperville and from Schaumburg reaching out and trying to get appointments with us. But we had to say ‘no.’ … That’s what we needed to do to ensure equitable distribution.”
The vast majority of Esperanza’s 33,000 first shots went to the hardest-hit neighborhoods, and less than 7% of went to people who lived outside Chicago — the strongest numbers among any provider in the Tribune analysis.
Like St. Anthony, Esperanza officials say the health center’s success largely was dependent upon their work with community-based organizations and the city’s willingness to give them doses. Vergara hopes it offers a road map to other providers as everyone looks toward vaccinating younger people and adults who still haven’t scheduled their first shot.
Without a change in approach, the citywide numbers will continue to show an inequitable distribution, she said.
“Imagine what the map would look like without us,” Vergara said.