MEMPHIS, Tenn. — Last Friday afternoon’s email had good news: The state of Tennessee confirmed it would send the Shelby County Health Department an allotment of the vaccine each week in January. Eligible residents, including a range of health care workers and people 75 and older, could schedule an appointment online starting immediately, the SCHD said.

But those who needed to register by phone would have to wait two and a half days, until Monday morning, to call a designated number.

Three hours after the SCHD’s email was sent to media and community partners, residents had already snapped up more than 40% of the 10,800 appointments available, according to a review of the online registration site by MLK50: Justice Through Journalism and ProPublica. By 1 p.m. Saturday, fewer than 70 appointments remained. And late Saturday afternoon, the SCHD sent another email: There were no appointments left.

SCHD Director Dr. Alisa Haushalter said the department was surprised by how quickly appointments were claimed, but health equity experts say the SCHD should have anticipated the response. She said the department was planning changes to the system going forward.

SCHD’s decision to give early access to internet users — and its failure to set aside any appointments for callers — raises issues of equity and access, those experts said. By creating a two-tiered system, the SCHD risks disadvantaging Black residents, who research shows are less likely to have broadband access and who have been disproportionately affected by the virus; it also would impact access by the elderly, who are less likely than other Americans to use the internet at all.

As glitchy vaccine rollouts occur across the country, issues of who gets access matter a lot. Last weekend’s flubbed effort in Shelby County provides a look at what can go wrong when an overtaxed public health department, hamstrung by the state’s last-minute announcements about vaccine availability, is caught without an outreach strategy that centers on the most vulnerable residents.

“Anybody who has done anything in disparities in Memphis knows that computer access is a major issue,” said Carla Baker, a longtime nurse and chief operating officer for Common Table Health Alliance, a nonprofit health care collaborative serving Memphis and the region. “If you had 200 appointments, you should have set 50 aside for phone calls.”

In Shelby County, where the population is 54% Black, internet use and computer access vary broadly by ZIP code. Shelby County’s poorest ZIP code, 38126 in South Memphis, has a poverty rate over 65%, and 96% of residents are Black. Just over 70% of residents there have no internet access, according to census data.

Among the ZIP codes where the COVID-19 case rate per 100,000 residents is the highest, internet access varies wildly, with between 6% and 36% of households having no internet access, according to census data. Yet the SCHD’s communication strategy has been primarily digital, such as emails, press releases and social media posts.

In an interview Tuesday, Haushalter said that because the state didn’t notify her agency until Friday that additional doses were on their way, the department didn’t have time to develop a grassroots communication strategy that would have, for example, partnered with radio stations with a high share of Black listeners in order to reach people without internet access.

That explanation didn’t fly with Dr. Gary Puckrein, president and CEO of the National Minority Quality Forum, a nonprofit research and education organization focused on eliminating health disparities.

“Clearly there was time not only to notify people, but to construct a well-thought-out plan,” he said.

Haushalter noted that while some other communities only have online sign-up available, Shelby County has a phone line too. The existence of a phone line proved irrelevant, however, as all appointments had been claimed online by the time the registration phone line opened.

“That’s not how the game is supposed to be played,” Puckrein said. These kind of missteps can erode the public’s trust — particularly the trust of Black residents who have good reason to be leery of medical institutions and public health campaigns given the country’s racist medical past, including the Tuskegee syphilis study. Surveys show that Black people are more hesitant to get the vaccine than white and Latino people.

As it happens, there were some who were able to make appointments by phone Saturday by calling other SCHD phone numbers and reaching employees working on the weekend. Those workers made online appointments for callers, although Haushalter said she didn’t know how many appointments were made this way.

Issues with distribution and access aren’t unique to Shelby County. After Tennessee’s Hamilton County officials turned away waiting seniors in a long car line, officials realized they had more doses than expected, causing them to scramble to find people before the vaccine expired. In Daytona Beach, Florida, some seniors waited in line overnight to get a vaccine. In New York City, one online vaccination sign-up asked users to complete as many as 51 questions or fields and upload an insurance card, according to the city’s comptroller.

Changes Underway

As of Friday, COVID-19 has claimed just over 1,100 lives in Shelby County, according to the SCHD. Black residents are slightly overrepresented in the share of COVID-19 deaths, according to the most recent SCHD data, comprising about 58%, though they make up 54% of the county’s population. People 75 and older make up the largest share of deaths in Shelby County.

In a press conference Thursday, Haushalter said it’s too soon to determine whether there’s a racial disparity in vaccinations because the pool of people is still limited mostly to health care workers and first responders, groups for which the county doesn’t have racial data.

The state’s vaccination plan does acknowledge that “equity remains a crosscutting consideration” in vaccine distribution, and it notes that some “higher risk” counties, including Shelby, are “disadvantaged and slower to recover from adversity.” Some states’ vaccinations plans, such as North Carolina’s, include specific outreach strategies to the Black community. Tennessee’s plan does not include the words “Black” or “African American.”

But while the state doles out doses to counties and dictates the priority groups and the order in which those groups are eligible for vaccination, it doesn’t implement the rollout on the ground. It is the SCHD that decides the location of the vaccination sites and how it spreads the word. And while the state’s plan is publicly available, the county’s vaccination plan is not online, a SCHD spokesperson confirmed.

The SCHD is reviewing what worked well and how it can improve, Haushalter said, and changes are on the way as the incoming Biden administration has committed to releasing almost all available doses immediately.

The phone line and online registration system will open simultaneously, she said, and they’re developing a preregistration system. Contingent on a predictable supply and more staffing, the SCHD plans to add vaccination sites this month. And at some point, the department may have walk-up vaccination sites, no appointment required.

According to the Centers for Disease Control and Prevention, Tennessee has administered about 40% of its vaccine supply. Based on the 55% of people who indicated their race, less than 4% of the vaccine supply has gone to Black Tennesseans, although Black residents make up about 17% of the state’s population. The incomplete data makes it difficult to determine if distribution has been equitable.

State Health Department data shows that as of Monday, Shelby County had given at least one dose to just under 2% of the population, the second-lowest percentage among Tennessee counties.

The impact of unequal access is evident in Shelby County in other ways too. Regional One Health, a large Memphis-area health care system, emailed hospital volunteers — including the wife of the hospital’s CEO — inviting them to be vaccinated to avoid wasting doses.

At a county-run vaccination site in late December, which was only vaccinating health care workers and first responders at the time, elderly people — who said they were told they could get vaccinated — waited in line for hours only to be told they were ineligible, although some got the vaccine anyway.

A SCHD spokesperson acknowledged that county staffers “did vaccinate some people out of phase who were in line at the vaccination site,” but shifted responsibility to residents.

“We ask that people honor the priorities also detailed in the state plan. We ask the public to help us achieve our goal of protecting the most vulnerable persons first by waiting their turn.”

But the problem of people accessing vaccines too soon matters less than those who access them too late — or not at all. And experts such as Bhaskar Chakravorti, dean of global business at The Fletcher School at Tufts University, worry that’s what will happen without a clear communication plan that addresses the county’s digital divide.

“Unfortunately, all of this is highly dependent on the creativity and commitment of local officials,” said Chakravorti, who is also the chair of Digital Planet, a research initiative that explores emerging technology and its impact on the world.

Dr. Bon Ku, a Philadelphia ER doctor and director of the Health Design Lab, which promotes inclusive design in health care, suggested that ensuring equitable access to the vaccine requires efforts that rival Georgia organizers’ get-out-the-vote campaign. Door knocking, flyering, mailers, an onslaught of text messages and even robocalls should be deployed — and public health officials could borrow from census takers’ tactics too, health equity advocates said.

It will be important, Ku said, for health departments to build deep relationships with groups that already have the trust of vulnerable communities.

Asked if the SCHD was partnering with Meals on Wheels, whose volunteers have regular contact with elderly residents, Haushalter said the department hadn’t, but that it was a “great idea.”

“If you have suggestions or others have suggestions on how to more effectively get the message out, particularly when things are changing so quickly, we are always open to that.”