PHILADELPHIA — Chidinma Nwakanma walked out the doors of the emergency room into the stillness of a Saturday morning. Her overnight shift had been a swirl of activity, but rest would have to wait as there was one more task at hand for the physician: a community vaccination clinic set to start in about 60 minutes.
In the hours before at Penn Presbyterian Medical Center, she'd encountered the trauma and travails that are the currency of the ER: A patient had abruptly stopped talking and slumped over, cancer blocking her nasal passages. There was a man struggling to breathe, a problem that had persisted for nearly two months. A 25-year-old with fever and chills. An 81-year-old who passed out in front of her family. And because it has become part of Nwakanma's routine when gathering information about a patient's presenting illness, the same as questions about abdominal and chest pain, she asked them: Have you received the coronavirus vaccine?
As always, the answers were mixed, the reasons varied.
The 81-year-old, who was hypertensive and previously suffered a stroke, happily reported she had been inoculated. But her grandson, in his 30s and in the room with her, laughed at the thought, explaining that he didn't want to suffer the aches and pains common after injection like his grandmother did. Nwakanma told him that when his grandmother got the shot, her fever and chills disappeared a day later.
"So, I should get it?" he asked.
The United States is awash in coronavirus vaccines, with free beer, plane tickets and million-dollar prizes dangled as inducements to persuade the reluctant to get a shot. Philadelphia is doling out $400,000 in giveaways. Despite that, a racial divide persists in the nation's vaccination campaign, with federal figures showing counties with higher percentages of Black residents having some of the lowest vaccination rates in the country.
An examination of city and federal vaccination data and interviews with more than 20 researchers, doctors, health officials and residents in the nation's sixth-largest city opens a window onto the missteps and misunderstandings, the legacy and loss that have fostered the disproportionate pain of death and disease in communities of color. Coronavirus immunizations are the latest iteration of the pandemic's unequal burden.
The city of Philadelphia is the nation's largest predominantly Black county, and it has one of the higher vaccination rates among counties with a preponderance of Black residents. But that doesn't mean Black people are getting vaccinated at a high rate. The city's data shows that while 52 percent of White people have received at least one dose of vaccine, just 34 percent of Black people have. Nationally, 54 percent of the population has received at least one dose.
"I get mad when I see the numbers," said Ala Stanford, a surgeon and founder of the Black Doctors COVID-19 Consortium, whose organization, according to the group's figures, had administered nearly 50,000 vaccinations as of June 11, about 75 percent of which went to African Americans.
It's like the city "just decided we are everybody Black in Philly's answer," Stanford said recently, pausing a phone interview to encourage - and then schedule - the custodian emptying the trash in her office to get vaccinated at the end of his shift. "It just can't be me. What are the rest of y'all doing?"
To help gain a deeper understanding of vaccination efforts in Philadelphia, Nwakanma, at the request of The Washington Post, recorded an audio journal documenting her experiences in the emergency room in the days leading up to the final mass community vaccination clinic run by the world-renowned academic medical center in late May. The accounts sketch a portrait of how environmental, economic and political factors entwine, putting Black people at higher risk of chronic conditions that leave immune systems vulnerable while fueling the misinformation, mistrust and fear that leave them unprotected.
Emergency rooms treat everything from stubborn splinters to gunshot wounds regardless of whether the person is insured, and Nwakanma said two to three new patients need her attention every hour. That's in addition to those already under her care and not including trauma patients who burst through the doors and phone calls from EMTs out in the field. So the time it takes Nwakanma to have COVID conversations with ER patients - most of whom are Black or Latino - runs counter to the "treat 'em and street 'em" culture of emergency medicine, and medicine more broadly.
City health officials said they considered the barriers that fuel disparities in vaccinations - transportation difficulties, scheduling conflicts, skewed demographics of those in early eligibility categories and the location of clinics - when they were opening about 275 sites. Yet, they said, it was Stanford's clinic that has been a leading driver in immunizing Black Philadelphians.
Penn Medicine collaborated with Mercy Catholic Medical Center and Black pastors and successfully hosted a limited number of clinics focused on the city's Black residents.
"What often happens is we get close to the finish line, and we kind of stop," said Georges C. Benjamin, executive director of the American Public Health Association. "The queues for getting vaccinated diminish, so they stop having some of the evening hours. They stop having weekend hours. Those are the services that get pulled back first."
In any public health program, the early adopters are always easier to reach than the dawdlers, he said, adding that now is the time to double down on efforts to reach the most vulnerable.
"The group we're trying to vaccinate now is much tougher to get to even when they're interested in getting vaccinated," he said.
Telling her patients to talk to their primary-care physician about being vaccinated can pose a barrier to access because many don't have a doctor they see regularly. That means people don't have access to one of the most trusted sources of information about how the vaccine was created and approved so quickly, or its safety and potential side effects. And that creates a barrier to knowledge about appointments and shot providers.
Researchers have found that people living in mostly Black neighborhoods in Philadelphia were 28 times more likely to lack local access to a primary-care physician than people in overwhelmingly non-Black neighborhoods.
Philadelphia is home to five medical schools and more than a dozen acute-care hospitals. It also has been identified by researchers as one of the nation's most racially segregated - and poorest - cities, with much of the Black community living in West and North Philadelphia. Segregation concentrates poverty into communities with an overwhelming number of people who work jobs that don't allow for social distancing, only to return to neighborhoods that are dense, crowded and deprived of resources.
A study published in Health Affairs in 2016 showed disparities in access to primary-care physicians in Philadelphia. Looking at the number of primary-care physicians within a five-minute car ride, it found the rate varied from one physician for every 105 residents in a census tract to one doctor for every 10,321 residents. The average across all census tracts in the city was one physician for every 1,073 people.
A third of the census tracts with populations more than 80 percent Black had the lowest supply of providers.
From the earliest days of the pandemic, the divide in access to services was evident, with coronavirus testing serving as prologue for the experience with vaccination.
"You can have health insurance and not have access. Knowing that is how and why we were started," Stanford said. "People were calling, saying, 'Hey, Ala, I think I have COVID, but I can't get a test anywhere.'"
People were being turned away. Some because symptoms didn't meet early testing guidelines. Others because they took the bus to drive-up testing sites meant for people in private cars. There were those who struggled to get telehealth appointments, limiting chances of acquiring the doctor's referral required by some testing providers.
"The health-care system has been largely untrustworthy to African Americans," Stanford said. "Which is different than saying African Americans don't trust the health-care system."
A study published recently in the Annals of Internal Medicine by researchers at Drexel University's Dornsife School of Public Health found lower testing levels in areas of Philadelphia, Chicago and New York with higher rates of poverty and residents of color. But when testing did happen, positivity rates were higher than elsewhere in the cities.
Analyzing local health department data on the number of tests, confirmed cases and deaths by Zip codes, the researchers found those Zip codes with the highest testing rates but lowest positivity rates were in the neighborhoods with the greatest concentration of White residents.
The inverse was true in predominantly Black or Latino areas. Those Zip codes now overlap with under-vaccinated areas in Philadelphia and many other cities, said the study's lead author, social epidemiologist Usama Bilal.
"We are finding exactly the same pattern," he said.
Darryl R. Brown, a health policy expert at Drexel and editorial peer reviewer for the Journal of Racial and Ethnic Health Disparities, said he has looked at reports involving Chicago and racial disparity in testing.
"One vignette talked about how this particular person went to their physician, who didn't believe their symptoms and said they weren't eligible for coronavirus testing. It leaves a nasty taste in the mouth," said Brown, who was not involved in Bilal's study. "My point is that if you've got all of this in the testing piece, you're not going to have an easy rollout of the actual vaccine."
Often, when it comes to the disproportionate uptake in coronavirus vaccinations, the conversation focuses solely on hesitancy.
"And I always cringe on the inside," said Reetika Kumar, vice president of clinical services with Independence Blue Cross, a health insurer serving the Philadelphia region that has partnered with the city and local organizations to increase vaccination access in communities of color.
Polls show hesitancy can be overcome by tapping into the communities where people live, drawing on information, outreach and vaccine administrators from those communities.
"We've moved the needle a lot on that," Kumar said. "A lot of the challenges that we have with vaccination rates have nothing to do with people of color not wanting to get vaccinated."
Hesitancy often is the consequence of broken trust, the legacy of centuries of mistreatment at the hands of the medical establishment and by public policies.
Take the pandemic. After a year spent fighting to get testing in Black neighborhoods being ravaged by the virus, along come vaccines that people are urged to take.
"Because it happened so quickly, I was kind of like, 'Whoa, whoa, whoa,'" Nwakanma said during an interview. "Once I came to my own conclusion about why this vaccine is important and why I trust it, I felt a certain responsibility as a Black physician, as a Black person, to kind of spread that knowledge."
Public health officials and hospital leaders said they expected the initial phases of the vaccine effort would skew toward White people because of the demographics of those first groups - hospital workers and nursing home residents. But they figured the numbers would right themselves as subsequent phases came online. Officials purposefully included in the next priority group people with medical conditions, essential workers who couldn't do their jobs from home and congregate-living settings where Black people are overrepresented.
They figured wrong.
"It's like with anything else. People who have means and resources, who in Philadelphia tend to be more White, are the ones who are able to game the system better," said James Garrow, spokesman for the Philadelphia Department of Public Health. "So even as we tried to set up these systems to facilitate getting access to underserved populations ... they didn't have all of the safeguards that they probably needed."
The city's vaccination plan had three goals, Garrow said: Get vaccines out fast, do so in a way that minimizes death, "and then to get it out in an equitable fashion."
Garrow said the preference has been to establish vaccination clinics in the community to eliminate huge sites with long lines and wait times that forced people to miss precious hours of work.
In December, the city partnered with Rite Aid, which officials said has numerous locations in Black neighborhoods.
"What we found is that even though they were placed in these communities, the sign-up was still solely online and that ended up being a barrier," Garrow said. "People could sit there on the computer for five or six hours and hit refresh until something came through."
The city adopted a policy restricting registration to Philadelphia residents, figuring that chances of an appointment going to a person of color increased if appointments were limited to residents, given the city's demographics. But, Garrow said, Rite Aide's system didn't restrict registration to residents.
"The slots ended up filling up very much with White folks," he said.
Jim Peters, Rite Aid's chief operating officer, said in a statement that issues with vaccine equity stem from a complex combination of factors, including "dueling and at times inconsistent guidelines" that were exacerbated by structural inequities. No one tactic or organization will resolve the issue, he said.
"We have seen steady and significant improvement as eligibility restrictions in our online scheduler have been lifted, and as we partnered with trusted community organizations," the statement read. "We ... recognize that in such an unprecedented rollout there will always be opportunities for providers to improve, and Rite Aid is no exception."
The city's own online registration system also proved to be a barrier to access, as the link to schedule appointments could be forwarded to friends and family, which is exactly what internet-savvy people did.
"You ended up with everybody from a very White family out in the far northeast coming down to North Philadelphia to get vaccinated and leaving out everybody in that neighborhood who may have received the invitation but was stuck at work all day and couldn't sign up," Garrow said.
Other providers noticed the effect the digital divide was having on the composition of their vaccination efforts.
Stanford said she shut down her group's online registration when she began to see the numbers shift.
"We were in the 'hood, in the cut. Once people started figuring out we had vaccines, you would see Teslas and Mercedes, so we stopped doing electronic," she said. "We're not giving access to people who already have access."
Patrick Brennan, chief medical officer of the University of Pennsylvania Health System, said he "didn't appreciate the level of mistrust" felt by patients of color until the events of the past 15 months forced him and much of the nation to reckon with the entrenched racial inequality in housing, nutrition, education, health care, policing, immigration and employment.
Corporate America, including elite research institutions, held urgent conversations and workshops on the racial divide, and the Centers for Disease Control and Prevention declared racism a serious threat to public health, as did more than 200 local and state agencies. Brennan began thinking back on encounters he had as a practicing infectious-diseases doctor treating patients with tuberculosis.
To Brennan - a White male physician - showing up late to an appointment reflected his terrible time management. To patients of color, it was another example of disrespect and substandard care at the hands of the medical system.
"I can remember seeing an Indian woman. The first time, I was 15 or 20 minutes late, which was my norm. And the second time I saw her, again, I was 15 to 20 minutes late," he said. "She just dressed me down."
She told him he was racist, an accusation that made him angry in the moment. But he said hindsight has allowed him to better appreciate what she was feeling and why.
"I just didn't perceive what people were perceiving," he said.
The momentum of the past year and systemwide discussions about equity issues inspired Brennan and a colleague to reach out to a hospital trustee who is also the pastor of a prominent Black church in Philadelphia. They wanted to know if he and other pastors were interested in collaborating on community vaccination events.
The result: Penn Medicine inoculated some 4,000 residents, most of whom were Black, on seven Saturdays at various locations in the community from February through May at a cost of about $140,000 total.
People involved quickly discovered that the technology normally used in health-care systems to reach people, things like Web portals and emails, didn't work very well.
"We had to use low-tech to no-tech methods," said Kathleen Lee, director of clinical implementation in the Penn Medicine Center for Health Care Innovation and an assistant professor of emergency medicine. "We were calling people on the phone. We were using text messages."
The success with the four community clinics bred confidence, and when the city health department solicited proposals for organizations to immunize people in underserved communities, Penn Medicine applied and was awarded a $1.1 million contract.
Penn had planned to continue the weekend clinics for another six months, expanding from 1,000 doses to 2,500 a weekend, when interest "just dropped off a cliff rather suddenly," Brennan said, standing in the high school auditorium where its last mass immunization event was held. About 400 people showed up, so the hospital pressed pause, canceling the future clinics and retooling efforts, opening five smaller vaccination sites "in pockets of need" since early June.
As Elijah Cantey, a 58-year-old school custodian, sat in the observation area after receiving his second dose, a volunteer asked how he was doing, then told him that Penn Medicine was holding weekday, walk-in vaccination clinics at two of its medical facilities from 8:30 a.m. to 4 p.m.
"I think y'all sent me an email," he said, assuring her he would direct people to the weekday clinic. "COVID is a killer. I just had a friend who died."