When a Texas County Tried to Ensure Racial Equity in COVID-19 Vaccinations, It Didn’t Go as Planned

It takes about eight minutes to try and save a life.

Or at least that’s how long it takes a volunteer with a tablet, standing in the parking lot at the T.R. Hoover Community Development center in South Dallas on a bitterly cold February morning. During the pandemic, the small nonprofit situated in the neighborhood that developers in the 1920s dubbed “the Ideal community” has taken on an ever evolving list of roles. It’s a job-search center. It’s a drive-through food pantry. And, of late, T.R. Hoover is an in-person coronavirus vaccine registration site aimed at helping Ideal’s mainly Black residents, and anyone else who finds their way here, do what for several weeks the county’s online-only registration system has failed to do: put them in line for a shot in the arm.

In January, as first national and then local news began describing the impending arrival of coronavirus vaccines, people visiting T.R Hoover’s drive-through food pantry started asking questions. Most were directed at executive director Sherri Mixon, who was born and raised in Ideal. It’s where she is, without question, a voice of authority, regarded as a repository of important knowledge, drive and information. What did she know about the shots? What did she think of the shots? How could they get a vaccine? Then, when could they get a vaccine, and how in the world could they get on the list for a shot?

Read more: We May Never Eliminate COVID-19. But We Can Learn to Live With It

On this Tuesday morning, Mixon stands wrapped in a plaid shawl and knit cap watching volunteers help those arriving for the food distribution. Her brother hoists orange net bags filled with potatoes, onions, grapefruit, tuna and other canned goods, as women equipped with iPads tell visitors they can help them register for vaccine appointments. Right here. Right now.

Around 11 a.m., a Black man in a pink surgical mask and forest green pickup truck rolls up and asks for help with registration. He’s 68 and has a “touch of high blood pressure but thank God, so far, no sugar [diabetes],” he tells a volunteer. She enters his name, address and health information that indicates he’s at high risk of contracting and dying of the coronavirus. She wears a blue mask beneath a face shield and, to make it easier to fill in the online form, one glove. It’s 29°F outside. The whole thing takes 7 min. 51 sec.

“Everybody should be doing something to help amend some of the gaps,” says Mixon.

In Dallas County, and almost every other part of the nation, those gaps emerged in a vaccine rollout that aggravated rather than addressed inequities that have made the pandemic so much deadlier for some populations. In February, as Centers for Disease Control and Prevention data showed that Black, Latino and Native Americans were at least twice as likely as white people to die of COVID-19, it was white Americans who secured most vaccine doses. In the 23 states that try to track the race or ethnicity of those vaccinated, most reported white people were getting vaccinated at disproportionately high rates, according to a February analysis by the Kaiser Family Foundation.

Dallas County, which includes the city by the same name and other municipalities, is a case in point. Non-Hispanic white residents make up 28% of the population but were nearly 63% of those registered to receive vaccinations as of Jan. 24, about three weeks after online-only registration had opened to people ages 65 and up.

But when local elected officials tried to correct the situation—by prioritizing people in neighborhoods like Ideal, where the need was greatest—the state beat back their efforts, and Dallas County returned to age-based vaccine targeting. That delivered another advantage to white Americans, who tend to live longest. So what might have been a case study in addressing structural inequality instead demonstrated why many Black Americans mistrust the medical system.

“Sometimes it’s in the mistakes that we learn,” says Janice Bowie, a behavioral scientist and professor at the Johns Hopkins Center for Health Disparities Solutions. “And unfortunately, in this case, some of these mistakes, you know, have cost people their lives.”

The Scars of Inequity

Like Ideal, much of South Dallas was deemed a Black residential zone in the early 20th century by law, custom and preference of both powerful and ordinary white people in Dallas. In Ideal, and in neighborhoods around the country where mostly Black and more recently Latino families live, scars and new wounds of inequity are obvious.

Even Mixon, who has been running the T.R. Hoover Community Development Corp. for more than 20 years, is sometimes taken aback by how easy it is to spot the differences between North and South Dallas, whose unofficial dividing line is Interstate 30. Before the pandemic, Mixon took some students attending an after-school program at T.R. Hoover on a field trip that required a drive through North Dallas. Several kids wanted to know where the power lines were. Mixon was surprised they had noticed.

In Ideal and much of South Dallas, power and other utility lines are largely aboveground, suspended along and across streets on giant poles. In much of North Dallas, they are buried, the more expensive but wind- and ice-storm-proof option that often comes with installation of high-speed Internet lines. In South Dallas, where not even Dallas-based AT&T offers high-speed Internet in some sections, rival Spectrum’s service is so spotty that on some of Ideal’s streets, people on one side can get online while people whose front doors are about 40 ft. away cannot.

That’s the kind of thing that made Mixon realize the county’s registration system was driving a new form of disparity. “I was issuing groceries out here,” Mixon says. “I would have different ones come up and say, ‘Ms. Mixon, I need to get registered for the shot,’ ‘I don’t know how to maneuver through the computer,’ or more or less have Internet. I understood all of that. I just went in here to the center and grabbed me a laptop.”

It was late January, and Almeree Jones, 78, was in bed, resting her eyes. If she had been sleeping, she would have earned it.

Jones retired from the Dallas Morning News plant in the late 1990s and a second time from working as a Dallas school cafeteria worker in 2015. She rises early to drive two young granddaughters she’s raising to school when classes are in person. Then Jones, who walks with a limp, cleans up the whirlwind of hair bows and breakfast plates left behind in the four-bedroom house she’s been renting to own for almost 15 years in Ideal.

Since her husband of 48 years died in 2016, Jones has held together her family of five adult children and 28 grandchildren and great-grandchildren. And with a family that size, there’s almost always something to do, someone to help. A ride here. A few words of support. For five family members, a bed in Jones’ home.

Read more: As Schools Close, the Digital Divide is Leaving Some Students Behind

But this was a rare morning that delivered a chance to stay in bed. Then, Jones heard someone at the door, unusual in the pandemic. It was Terry Taylor, a neighbor and friend so solid that she helped Jones bathe after her stroke and brain surgery. Taylor had news. An organization around the corner, T.R. Hoover, was helping people register for the coronavirus vaccine, right now, in its parking lot.

“So I got up … and put my clothes on and drove up to the center, and I had one of the ladies help me do it,” Jones says. She got her first shot on Feb. 4 and scheduled her second.

“It’s so many people of color who don’t know how to register, where to go register,” says Jones, who knows she’s in a better position than many in South Dallas. “And, when you look at the vaccine sites on TV … you see more Caucasian people than you do Black people and Hispanic people because, I don’t know if they got a chance to register first or what.”

The Vulnerability Index

To understand how distant from vaccine equity things are here, it is important to grasp a term that comes up in Dallas a lot: the COVID-19 Vulnerability Index, which was created by the Dallas-based Parkland Center for Clinical Innovation (PCCI). The nonprofit health care analytics company provides data to improve care and reduce health disparities. Its CEO, Steve Miff, says that unless data is applied in a way that drives equity, “It’s just cool math.”

The vulnerability index predicts the risk of COVID-19 infection and death, based on one’s home address. It calculates the proximity and volume of COVID-19 cases in the area, the average number of people sharing homes or living in high-density settings, the share of residents who must depend on public transportation and several other factors, including the area’s rate of chronic disease, number of senior citizens, access to food and opportunities for social distancing. Most people in South Dallas zip codes hit hard by COVID-19 will rank high on the vulnerability index. Most in North Dallas will not. The index was supposed to help ensure equity in vaccine appointments.

Read more: How the U.S. Vaccine Rollout Looks Right Now

So when mass vaccinations began Jan. 11 at Dallas County’s vaccination center, a 227-acre site in South Dallas called Fair Park that in normal times is home to the State Fair of Texas, the Cotton Bowl and several museums, it was clear something was amiss. One person watching things that day was John Wiley Price, the only Black member of the Dallas County Commissioners Court and a Democrat who represents most of South Dallas. Like a lot of counties that are home to major American cities, including Los Angeles and Philadelphia, people of color comprise a majority here. The population is about 41% Latino, 24% Black, nearly 7% Asian and about 1% Native American. That made what Price saw confounding.

“I said to myself, Where did all these white people come from?!” Price says. Almost all in line and on golf carts ferrying people with mobility challenges from the parking areas appeared to be white.

Dallas County judge Clay Jenkins, a white Democrat, noticed it too. He was there trying to ensure that things went smoothly, trying to spot problems.

Jenkins was so perplexed that he assigned a staff member to find out how so many white people—the least likely demographic to die of COVID-19—got vaccines that first day. By close of business, Jenkins’ staff had figured it out.

A white Dallas city council member in an affluent North Dallas district had shared, in a digital newsletter, a link sent by the county to someone registered to get a vaccine. The link served as confirmation of the registration and provided next steps for making an appointment. Two more council people representing similar districts also shared the link. Then, someone posted a link on Nextdoor.com. Soon, thousands of people had used shared links to make appointments, whether they were eligible or not.

Read more: We Asked 30,000 Black Americans What They Need to Survive. Here’s What They Said

Local officials intended to limit the first appointments to those 75 and older, but Jenkins and Price saw that many people at Fair Park were far younger, and most were white.

Jenkins approached some and asked where they worked, thinking they might be first responders willing to stay a few hours and help manage the crowd. “Some looked at me with blank stares,” he says. “Some told me that they were FBI agents but forgot to bring their badges.” When Jenkins asked which ZIP codes they lived in, “They were the most affluent ZIP codes in Dallas, where our police officers generally don’t live.”

Attempting a Major Correction

Three of the five members of the county’s commissioners court insisted on a major correction at their next meeting on Jan. 19. Price and county commissioner J.J. Koch, who is white and the only Republican commissioner, crafted a plan to ensure “the vaccine can reach the most vulnerable populations.”

In short, it said that of those eligible for the vaccine, people living in 11 ZIP codes deemed the county’s most medically vulnerable would get top priority. A 65-year-old with health issues in one of these ZIP codes, for example, might be vaccinated before a 75-year-old from a low-risk neighborhood. Eight of the zip codes were in South Dallas; two were in North Dallas, and one straddled I-30, covering parts of North and South Dallas.

Opponents warned that the situation was fluid; some ZIP codes might see spikes in cases, but their residents could be shut out of appointments. Jenkins, cognizant of his North Dallas constituents, was one of them. “What that means is that North Dallas won’t be getting any vaccines to any appreciable degree for many months,” he said at the meeting, questioning the legality of the move. “You are about to do something that you are really going to regret.”

“Well, I will be the judge of that,” Koch replied.

Read more: The U.S. Fumbled its Early Vaccine Rollout. Will the Biden Administration Put America on Track?

The plan was approved 3-1, with one abstention. Jenkins advised the Republican-led state’s department of health, which sets rules for vaccine hubs, of the plan; one day later, the state told Dallas County that its vaccine doses would be cut and its status as a vaccine hub revoked if the measure went forward. Even as they urged “equitable” distribution of doses, state officials said the hardest-hit areas could not be prioritized above others. Later that day, the county rescinded the plan.

When the Biden Administration took office, it shifted away from the Trump Administration’s vague assurances that after medical workers and people in long-term-care facilities had been vaccinated, other Americans soon would be able walk in and request a jab at their neighborhood pharmacy or health care provider. Instead, Biden wanted mass-vaccination hubs controlled by states, counties and cities, and equity would be a priority. He named Marcella Nunez-Smith, a public-health researcher, dean and associate professor at Yale University, chair of a White House task force to focus on health disparities. But in Dallas County, people responsible for mass vaccinations were scrambling, and it quickly became obvious, Koch says, that the “standard of success is getting shots in arms.”

Shots in arms keep the vaccine supply coming, Koch says. Vaccination disparities do not shut it off.

And disparities were virtually guaranteed, not just because of things like Internet access. The system was tilted in favor of wealthier white people by prioritizing the 75-and-older crowd initially for vaccines. That eliminated many in South Dallas, where living to 75 is relatively rare. In the 75215 zip code, where Ideal is located, life expectancy sits at an area low of 67.6 years. Of the 11 targeted ZIP codes, three have average life expectancies below 75; none reaches the county average of 78.3 years. An analysis produced by PCCI found that in the weeks when vaccine registrations were limited to those 75 and older, 71% of the people registered in that age range were white. About 8% were Black and 11% were Latino.

Moving in a New Direction, Slowly

By the time I visited Mixon at T.R. Hoover, the county and city had acknowledged that the registration system had given North Dallas a huge advantage and that things had to change. Officials added more in-person sign-up locations. They announced plans for a door-to-door registration drive and for a call center so more people could register by phone. The share of Black people signed up to get the vaccine rose by a sliver from almost 11% on Jan. 24 to almost 12% by Feb. 7. During that period, Latino registration increased from 19.5% of the total to just over 20%. And the proportion of white registrants shrunk from about 63% to about 54%. The numbers don’t put registrations close to a mirror of the population or those at greatest risk, but they are moving in that direction, slowly. Black and Latino Americans continue to express greater amounts of hesitancy around the vaccine, and the rollout has offered them little reassurance.

Dallas, a county that tried to address vaccine equity overtly, is a place that people are watching. PCCI’s COVID vulnerability index and the clinical implications for it will be published in April in the New England Journal of Medicine’s Catalyst in Innovations in Care Delivery, focused on health care delivery. And the federal government has stepped in with a plan to offer the type of targeting local officials tried, prioritizing people in 17 hard-hit ZIP codes.

“This pandemic has been a transformative moment for us,” says Bowie, the Johns Hopkins behavioral scientist. “And it’s what we will do with it, as we move forward and move through, this is really going to tell a lot about who we are as a country.”

As the cold air forces an indoor retreat, Mixon and I sit down, masked and separated by several feet, in T.R. Hoover’s computer lab. Theodore Roosevelt Hoover, Mixon’s great-grandfather and the center’s namesake, brought the family to Ideal in the early 20th century. He and his seven brothers left their mark on the landscape by building houses. Mixon tries to build better, and now longer, lives in what some locals still call “the Ideal.”

Down the hall, staff and volunteers are discussing plans to create a database drawn from voter-precinct lists and from names of people who have had contact with T.R. Hoover. Volunteers will call everyone listed to see if they need help registering for a vaccine.

Mixon pokes her head into the meeting and then tells me the group has voted to buy two pay-as-you-go phones to put the registration effort into action.

But she looks a little forlorn. After a moment, she explains that two weeks ago, her neighborhood fishmonger lost his father to COVID-19. She’s just heard the virus has killed her fishman, too.

—With reporting by Julia Zorthian