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UNIONTOWN, Alabama — Eight weeks had passed since the first vaccine doses arrived in Alabama, and now the shots were finally coming to Uniontown. Workers were setting up chairs in the cinder block community center. The mayor was on the way. A caravan of doctors and nurses and supplies was speeding down Highway 5 past fields of cows and rusting gas stations, and when it pulled into the parking lot just past 8 a.m., the line was waiting, a continuation of the waiting that had been life for the past year.
“Connell!” yelled a volunteer, handing out registration forms. “Bennett! Watson!”
“Here I am!” said an elderly woman bumping her walker across the gravel.
“I’m right here!” said a man raising a hand holding a worn Social Security card.
Across the country, the vaccination campaign against the novel coronavirus was picking up speed. The Biden administration was on the verge of securing 100 million more doses, and a few states were even starting to offer shots to the general population. But on a Thursday morning in March, Alabama lagged with one of the worst vaccination rates in the country, as well as one of the worst racial disparities nationally among those receiving the shots, and now a group of community clinics called Cahaba Medical Care was trying to turn those numbers around.
“Good morning!” said John Waits, the doctor in charge of Cahaba, going inside to see the setup for today: five folding tables for registration, six folding tables for giving shots, 12 laptops for entering vaccination data, one spotty WiFi connection, and, inching forward, a line with some of the hardest-to-reach, most health-care-deprived people in the country — the ones who would have to be reached if the pandemic was to be ended. It was a growing line with dozens of people, including the first complicated case of the morning, a 78-year-old man with no appointment.
“Okay, do you have a cellphone?” Waits asked the man, who shook his head no.
“Do you want to write down your Social Security number?” Waits asked, and the man put one hand in his jeans pocket and gave his insurance card with the other.
“All right, we’re good,” Waits said, recognizing the hesitancies of a person who could not read or write. “We’re going to take care of you, okay? It’s going to be good.”
* * *
How Cahaba was tasked with vaccinating the most vulnerable populations in Alabama is one more story of how fumbling and ad hoc the first months of the vaccination campaign has been across the country. In Alabama, it began with the decision by the state health department, weakened by years of budget cuts, to outsource most of the responsibility to community health organizations with experience serving the neediest areas. That was the idea.
The reality was that while Cahaba’s leaders expected that the state would send them vaccines at some point for their own patients, the first clue that they were expected to conduct vaccinations on a massive scale came on Jan. 6, when a box of 1,800 doses arrived at one of their clinics, the word “vaccine” stamped on the side.
It was not exactly a thrilling moment. The box came with no advance notice, no directions for where the doses were supposed to be distributed, no extra funding to help cover costs, no extra anything and at the exact point when Cahaba’s 450 employees were nearing exhaustion after a year of managing coronavirus testing while keeping eight clinics open.
In an ideal world, Waits said, the National Guard would have been doing vaccine drills for weeks in advance and been mobilized to football fields across the state. Instead, a nurse was calling him on the phone saying, “It’s here.”
“So, game on,” he recalled thinking.
Two months later, the situation had not become any less chaotic, because the state could rarely say when the vaccine would arrive, in what quantity, or which of Cahaba’s eight clinics would receive it. It just showed up. One box at this clinic, one box mistakenly delivered to a UPS store, another batch delivered to a clinic without the super-cold freezer necessary for storage, setting off a scramble to transfer the box to one that did, and on it went. Planning more than three or four days in advance, Waits said, was impossible.
Meanwhile, the waiting list for the vaccine was growing by the minute — more than 10,000 names so far, desperate calls every day, a giant SOS rising from small, dying towns that dotted a rural swath of the state as well as the most forsaken neighborhoods in Birmingham, places that were mostly poor, mostly Black and had long suffered the privations of the U.S. health-care system.
“It’s a ridiculous amount of choice in our hands,” said Waits, explaining that the decision about where to go next to administer shots was in a certain sense easy. The need was everywhere, he said, including in Uniontown, population roughly 2,200, where no vaccine was to be found until Cahaba showed up with 400 doses.
“Sarah Hollis!” called the volunteer as the line advanced across the parking lot, up a concrete ramp, and at last over the threshold of the double metal doors.
“Hello, sir, how are you?” a nurse said to a man who worked at the local landfill.
“I’ve been calling and calling,” he said, wiping his forehead.
“Which arm?” she said to the next person, a man with two prosthetic legs.
“Well, any one you want to choose,” the man said.
“Any allergic reaction?” she said to a man who had reluctantly taken time off from his construction job when he heard the shots were coming.
“Yes, penicillin,” he answered, pulling down a shoulder of his sweatshirt.
“Okay, you’re going to be fine,” the nurse said, detecting some nervousness as she swabbed his arm. “Now I want you to relax. Think about something good. Going to the watering hole and getting you” — she gave him the shot — “a fish.”
By noon, 200 people had been vaccinated. Most were older, and, like the people Cahaba had been vaccinating elsewhere, almost all were Black. By 3 p.m., shots had been administered to nearly 400 people, nearly all of them locals because of a deliberate effort by volunteers to exclude out-of-town vaccine usurpers. They had put up fliers at the Chevron gas station. Fliers at Dorothy’s Kountry Kitchen. An announcement at Mt. Olive Missionary Baptist Church. They made calls to neighbors that included hundreds made by the three retired women who were now sitting outside on folding chairs, talking about what was blooming early this year.
Emefa Butler, a local activist who had personally recorded a phone call that went out to people in town — “It had to be my voice,” she said. “I said my name twice.” — checked off the names on her clipboard until all the names were checked. Seven hours after the line had started forming, it was gone. She went inside to see how many shots were left.
“We need two more,” said the nurse, and as they began packing up, Butler rolled up her sleeve, and afterward, called a truck driver she knew.
“Where are you?” she said. “They have one left — hurry.”
* * *
The next day, the location was Bessemer, a former steel town just south of Birmingham, where the only mass vaccination event so far had been one that Cahaba had held a few weeks before, and it had ended badly.
Despite a careful effort to schedule 750 appointments a few days in advance, the event had somehow been posted on Facebook as first come, first served, and hundreds of people had to be turned away, including a man who became so angry that a nurse called the police.
Now the sun was rising on the second try, and by 8 a.m., people were already lining up, a column stretching from the glass doors of an empty school, down the sidewalk and out into the parking lot.
People watched the tables go in. They watched the boxes of syringes go in. They tracked the nurse wheeling in a gray cooler containing 500 doses of the vaccine. As 9 a.m. approached, they leaned toward the doors as if willing themselves inside, and when a nurse began handing out registration forms, a mild panic broke out.
“Do we need that?” a woman called to the nurse.
“Over here!” a man shouted, raising his hand.
“Hey, hey, let me get one!” another man shouted, and soon the doors opened.
“Thank you, Lord,” said a cafeteria manager named Natherene Thomas as she went inside, and behind her the line kept growing with people who had appointments later but were arriving two and three hours early expecting the worst.
One woman brought her passport just in case. Another brought her medication list. James Cochran, a retired steelworker, had a scrap of paper in his pocket where his daughter had written down his email address in case that might be required. He’d tried getting the vaccine in a few places in Birmingham, but as he put it, “Everybody turned me down.”
“It’d be just my luck that I get in there and they say, ‘Oh, we can’t take you,’” he was saying when another nurse came outside.
“Do you have an appointment?” she asked a woman near the front.
“Do you have an appointment sir?” she asked the next person.
“Are they taking walk-ins?” asked a woman with a cane.
“Yes, they have a few slots,” the nurse said.
“Thank you, Jesus,” she said, and soon they were all heading for the registration tables, and then the shot tables, and then the purple bleachers where the newly vaccinated sat in the quiet for their 15 minutes of observation, reading a book, or exercising an arm, or staring out across the empty basketball court toward windows framing the new green of budding trees.
“Which arm did you get?” said a man sitting in the second row.
“Left,” said the man next to him.
“I’ve had a lot of anxiety,” said a woman a few seats away.
They waited under a school clock stuck on 2:02, and soon they got up and walked outside, past a line that was continuing to grow as word spread that the shots were here.
A friend had called a friend who called Yavonda Wilkerson, who called six people she knew before saying to herself, “Well, I better go.”
A woman called her neighbor who kept not answering, and so she walked over and found Gray Leslie outside cutting his grass and told him, “Go now.”
“My niece called,” said the man behind him, James Dawson, 72, who had been laying concrete only a half-hour before now, and as they waited, they talked about how they’d been trying for months to find shots.
They had registered with the county, but no one called them back. They had registered with the University of Alabama at Birmingham but heard nothing. They had called Hinkle Pharmacy down the street: Didn’t have it. Walmarts around the city: no appointments, and as time went on, they began wondering if they were examples of what some people were saying was a racial bias in how the vaccine was being distributed. At this point in March, roughly 15 percent of the people getting vaccines were Black, according to state data; Black people were 27 percent of Alabama’s population.
“I’d just about given up,” Leslie said.
“I tried everything,” said Dawson, who was wearing two of the white cloth masks his niece had given him for Christmas, which he washed each week with Lysol because he was terrified of getting covid-19.
Now a nurse came outside, and as Dawson leaned to get a clearer view of what was happening up at the front, the words “appointment” and “Monday” floated back down the line.
“But we’re almost there,” a man next to Dawson said.
“What’d she say?” said the woman next to him as the nurse began working her way down the line with the news.
“We’re out of vaccine for today,” she said as she walked by Leslie.
“I’m sorry, but you can sign up for Monday,” she said as she walked by Dawson.
The nurse, Ashley Middlebrooks, one of three senior nurses in charge of tracking the vaccine, was the one who wheeled the gray cooler from site to site and drew up shots with the precision required to get extra doses out of the vials, a meticulousness that had enabled Cahaba to give 70 extra shots on this day. She was usually the last one left at these events, and that was true now as the last people in line left with their disappointments.
She put her laptop in a black suitcase and was heading for the door, dragging the suitcase with one hand and carrying the gray cooler in the other when a woman rushed inside.
“I want to get my mom in, she’s 3-16-37,” she said, offering her mother’s birth date.
Middlebrooks stopped, opened the black suitcase, took out her laptop.
“Alright, I’m going to schedule you for 1:30 Monday,” she said.
She put the laptop back in the suitcase and was struggling to push the doors open with her back when she saw a man pulling up.
“Oh my goodness,” she said to herself.
“I want to get signed up for the vaccine?” he said.
“Okay,” said Middlebrooks, going back inside the school, opening the suitcase again, pulling out her laptop again, and when she was done, she pushed the door open again, and was hoisting the cooler and the suitcase into her trunk when another car came rushing up.
“Are y’all finished?” said a woman through the window. “Can’t I make an appointment?”
Middlebrooks took a breath.
“Okay, give me a second,” she said, pulling out her laptop again.
* * *
Later that night, she was giving her children dinner when she and some of Cahaba’s other staff members received a text message.
“Hey all, so sorry for the nighttime text,” wrote Lacy Smith, a doctor who co-founded Cahaba. “Each of you should have received an email from HRSA… I need each of you to log in and place an order for your location tonight. Orders have to be in before 10:59…. Sorry for the night task. I wish HRSA had given us more time….”
HRSA is the federal Health Resources and Services Administration. The orders were for a federal allotment of vaccines. Like the white box that had landed on Cahaba’s doorstep Jan. 6, the email had come with little warning, and 10:59 was in three hours.
And with that, another last-minute scramble was underway. More texts began flying. Middlebrooks excused herself from the dinner table. Another nurse left her son’s T-ball practice. Another driving home turned around and went back to the clinic, and somehow, by 10:59, Cahaba had submitted orders for another 6,810 doses of vaccine for the waiting people of Alabama.
Three days later, when those vaccine doses arrived, the medical staff gathered around a conference table to talk about what to do with them.
“Do we have any update on the new hires?” Smith began, referring to the temporary workers they were hiring to staff the new mass vaccination events they were planning, even as she and Waits were not sure how they would be able to cover costs that kept mounting.
Cahaba is a nonprofit health provider, and making the budget work in the best of times is a challenge Waits likened to a “Kafkaesque” nightmare that he and Smith chose to view as an elaborate game they were determined to win. The vaccinations were making it harder.
The $16 per shot administrative fee they could bill insurance companies or the federal government, for instance, came to $9,600 for a 600-shot event. That amount would cover the roughly $6,000 labor costs but not the additional labor costs for all the extra hours required for entering shot data, registering people who didn’t own computers and the last-minute scrambles that extended into the night. It would not cover the revenue clinics lost when they could not function fully because of diverted staff, not to mention all the miscellaneous costs — the $7,000 ultracold freezer, the WiFi hotspots, the dry ice gloves, the tents, the heaters, the gas, the fine-gauge needles, the Band-Aids, and now the 30 temporary workers needed to keep pace with the increasing number of vaccination events being planned as more vaccine doses arrived.
On it went, including the incalculable mental health costs. Nearly every staff member had broken down crying in recent weeks. Some had quit. One nurse had asked to use a pseudonym after a man threatened her for turning people away. They pressed on.
“What about laptops for the new hires?” said Waits, who had decided at the beginning of his medical career to turn down medical mission work in Indonesia to stay in Alabama.
“I think Brenda ordered them,” said Smith, who was raising five young children and had taken what she called a “blood oath” with Waits never to turn away anyone seeking health care. “So, for next week, we have second-dose events Monday, Wednesday, and Thursday, but we have nothing for Tuesday and Friday, so I’m thinking one rural, one urban. Ideas?”
“I think Bethel would be a great addition — they’ve been requesting vaccine in their area,” said JohnQueta Bailey, the outreach coordinator for Birmingham, referring to a large, historic church in a predominantly Black part of the city.
“Okay, and I’m thinking Linden for rural,” said Smith, referring to a small town that had been begging for vaccine for weeks.
“Another question: I’ve been getting a lot of requests from churches,” said Bailey. “How are we going to fill requests from places where we’ve already been once?”
For a moment, Smith and Waits were quiet.
“Take their request and just give them some expectation that we’re trying to work our way through,” Smith said.
* * *
They could have gone anywhere next but decided to return to the rural, red-dirt band of the state where the civil rights movement was born and the need was greatest.
A small team loaded up an RV with supplies and headed out along the two-lane roads into a region where there had been infestations of hookworm in recent years, a condition more common in developing nations. They drove past one dying town after another, a landscape of shuttered hospitals, few doctors, boarded-up grocery stores, rotting churches, patched-up houses, and dire rates of diabetes, stroke, cancer, maternal death, and lately, covid-19, and finally, they pulled into the town of Marion, where there had been an outbreak of tuberculosis a few years back.
Not one vaccination event had come to Marion until Cahaba’s nurses began setting up a tent and a few folding tables in a vacant lot across from a Dollar General. It was a last-minute event, 300 shots, and the nurses were trusting that word would spread.
It did. Shortly after 9 a.m., Richard Hopkins, 74, rattled up in his dented 1994 Oldsmobile, its fenders sprayed with red dirt, one headlight missing, a cane in the back seat.
“Somebody called me on the phone,” he said to the nurse who came to his window.
“Which arm do you want today, sir?” the nurse said.
“Left,” Hopkins said.
As the nurse swabbed his arm, he began explaining how he’d been trying to find the shot for months. Selma, the nearest town of any size, had run out of doses. Birmingham was too far, and he did not have a smartphone or Internet connection to secure an online appointment, anyway.
“Seems like they looked over me some kind of way,” he said as the shot went in the arm of a man who had been in Selma for the famous civil rights marches of 1965, and then moved to New York City, and then returned home, where he did not want to die of covid-19.
“All right,” the nurse said. “If you will, put on your flashers so we’ll know you’re in your 15 minutes.”
Hopkins tried to turn on the flashers, but they were broken, so he passed his 15 minutes waiting with one headlight beaming in the bright morning as more people came.
“Y’all are giving the vaccine?” said a white-haired woman walking over to the tables.
“You can come right over here and we’ll get you,” a nurse said.
“You can get yours today, baby,” a woman named Rosie Bridges, 69, was saying into her phone after she got her shot. She sat in her truck and called anyone she could think of.
“All you do is walk up here,” she said to a neighbor.
“Across from the Dollar General,” she said to a church member.
Two men drove over from the packaging plant when they heard. Hopkins returned with his two disabled neighbors. Prother Cole, 74, walked over to see what was happening after returning a faucet to the hardware store next door, and to his astonishment, he was soon sitting in a chair and hearing the words he’d been hoping to hear for months.
“Which arm?” said the nurse.
“Well, either one of ’em,” Cole said.
Photo editing by Bronwen Latimer. Design by Tara McCarty. Copy editing by Gilbert Dunkley.