During the first week of February, a winter storm blew through Chicago, leaving piles of snow before subzero temperatures set in. Eve Bloomgarden, an endocrinologist at Northwestern Memorial Hospital, got a call from a worried patient who was scheduled to receive a covid-19 vaccine that week. She was preparing to brave the weather—and drive for the first time since the start of the pandemic—because she was concerned that this would be her only chance to get a shot.

“I’m seeing immense frustration and fear that they’re going to be left behind,” Bloomgarden says. 

Chicago, like many parts of the US, has found the distribution of covid-19 vaccines slower than anyone hoped. Just 6% of the city’s 2.7 million residents have been vaccinated so far, and people have said the process is “like the Hunger Games,” requiring them to stay up late to refresh multiple websites in the hope that an open slot will pop up. Making things worse, official sign-up websites are clunky and hard to navigate. 

In early February, the Department of Public Health announced a plan to help ease some of those technical problems: a partnership with Zocdoc, the popular online health-care scheduling company. Zocdoc is acting as a unified portal for multiple providers, so that people can sign up with a single, more user-friendly tool rather than wrestle with several different systems at once. While Chicago is the first city to make this specific agreement with Zocdoc, other health agencies are launching similar partnerships with private startups.

Before the pandemic, Zocdoc acted as a one-stop shop where patients could check out different doctors, compare medical providers, and make appointments. The company’s CEO, Oliver Kharraz, says the years spent bridging a fragmented health-care system unknowingly prepared it for taking on covid-19 vaccination appointments. After the idea was tested with the Mount Sinai Health System in New York, Zocdoc says, Chicago reached out about a partnership—and the system was up and running within a few weeks. Zocdoc connects with 1,400 different scheduling systems: doctors’ workflows remain unchanged, but patients all see the same simple interface no matter which provider they’re using.

“If you’re not plugged into the right system, then how are you going to get access?”

“You don’t have to register 10 times, and you know when the next available shot is for you,” Kharraz says.

Bloomgarden, the doctor at Northwestern Memorial, says the new Zocdoc tool will be a “great addition” to Chicago’s vaccine drive, but that it addresses only one of the issues with the rollout. After all, it’s still a version of the same first-come, first-served approach, which means it’s not solving the most critical problem: vaccines aren’t reaching the people who need them most.

Christina Anderson, deputy commissioner of the Chicago Department of Public Health and chief of operations for covid-19 response, says that while Zocdoc may not be the solution needed to reach and vaccinate elderly Chicagoans, it has the potential to help others who are struggling to get vaccinated, such as those without a primary care provider. 

But Bloomgarden says truly making vaccines accessible will require targeted outreach—much of it offline.

Who you know matters

Local and federal officials in the US seem to be coming to the same conclusion. On February 9, President Joe Biden announced a new program that will provide vaccines directly to community health centers serving 30 million people across the US, two-thirds of whom are at or below the federal poverty line. Federally qualified community health centers receive federal funding to provide care to underserved populations.

Keon L. Gilbert, an associate professor in behavioral science and health education at Saint Louis University, says the approaches to serving particularly vulnerable populations have varied widely from state to state. Some states have moved adults over 65 up the priority list regardless of their other risk factors. Other strategies have come up against obstacles: when Dallas attempted to prioritize vaccinations for eligible people living in hard-hit zip codes—who tend to be people of color—the state threatened to reduce the county’s allotment of doses. 

Chicago, meanwhile, recently announced a program aimed at vaccinating people in high-need neighborhoods.

“Equity is not a static target or goal that one can reach. It’s something that has to be … defined by context,” Gilbert says. Overburdened public health departments may be more focused on absolute numbers than on assessing where the greatest need is.

Bloomgarden and her colleagues in the Illinois Medical Professionals Action Collaborative Team (IMPACT), a grassroots group formed in response to covid-19, think a lottery system would work best. Patients could register for a slot—either online or with someone who comes to their home—and then wait to be picked for an appointment. 

A weighted lottery would allow officials to make sure vaccines were reaching patients in hard-hit zip codes—especially important in Chicago, where wealthier, whiter parts of the city show higher levels of vaccination and lower death rates, while working-class, Black, and Latino areas are faring worst. 

Deputy health commissioner Anderson disagrees about whether lotteries are useful, saying the city is pushing to improve equity through community partnerships and outreach instead. City officials also attribute some of the existing racial disparity to the fact that health-care workers who have opted to be vaccinated are more likely to be white. 

Access issues are not limited to race and income. Residents may also be left out if they’re not linked to a big institution, says Ali Khan, executive medical director of Oak Street Health, a national chain of clinics serving low-income seniors. Mom-and-pop providers, solo practices, home health aides, and others across the city have struggled to obtain and administer vaccines without the resources of major operators, Khan says. When Oak Street opened its doors to vaccinate front-line medical workers no matter where they worked, the waitlist was almost immediately in the thousands. An app won’t necessarily fix that. 

“If you’re not plugged into the right system, then how are you going to get access?” Khan says.

Anderson says the city does plan to make the system work better for people who aren’t associated with a major provider. One federally qualified community health center is already enrolled in the Zocdoc system, and she expects more to follow. This will be important as vaccine supply increases, she says.

Building “connective tissue” 

Another issue that can’t be solved with an app is overcoming vaccine hesitancy. Khan thinks of community outreach as the key here. Meanwhile, Anderson says city officials are hosting town halls to answer questions about the vaccine for those who may be “slow yeses.” 

Despite the challenges, Khan believes a combination of different systems and networks can do the hard work of vaccinating everybody. His focus is on the “connective tissue” where people live, work, and gather: grocery stores, places of worship, community centers, pharmacies. What he calls the “slow work” of such network-building goes far beyond sending out a link for sign-up. Like Zocdoc, it’s about centralizing information and sharing it across organizations—except it happens mostly offline.

“There should not be 90-year-olds sitting around wondering if anyone’s going to remember they exist and give them a vaccine.”

Bloomgarden stresses just how important it is to get this right, and fast.

“There’s just no way to keep this as a first-come, first-served internet online sign-up,” she says. “There should not be 90-year-olds sitting around wondering if anyone’s going to remember they exist and give them a vaccine.”

For now, like places all across the US and the world, Chicago and its citizens are desperately waiting to receive more doses. Anderson says that when it announced the Zocdoc partnership, the city added nearly 3,000 appointment slots to the system. They were filled before the press conference was over.

This story is part of the Pandemic Technology Project, supported by The Rockefeller Foundation.

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