As of Monday, Jan. 11, D.C. residents over 65 are now eligible to reserve a COVID-19 vaccine appointment anywhere in the city. D.C.’s health department aimed to make the process as convenient as possible, setting up sites for vaccinations in every quadrant so seniors wouldn’t have to travel too far from home. But with just 6,700 appointments initially released, spots filled up within hours and some traveled across the District to get vaccinated.

“It’s kind of like a lottery,” says 67-year-old Robin Shuster, who tried and failed to reserve an appointment. The thinking among many seniors anxious for a vaccine was to check every vaccination site to raise the odds that they’d secure an appointment. 

The frustrations bled into a conference call Wednesday afternoon, on which D.C. councilmembers clashed with DC Health Director Dr. LaQuandra Nesbitt over who should get priority for vaccinations. Ward 5 Councilmember Kenyan McDuffie demanded that Black residents, who have been infected with and died from complications related to COVID-19 at a higher rate than other racial and ethnic groups, be prioritized. 

“If you cannot legally prioritize based on race, can you prioritize based on geography to ensure people who need this the most are the people who are going to get it?” McDuffie asked.

That policy, Nesbitt said, is impractical.

“It is not a policy we can have to suggest to someone who is demanding the vaccine that ‘you cannot go into another neighborhood and access it when it is available,’” Nesbitt said.

Black residents make up about almost 75 percent of COVID-related deaths in D.C. Hispanic/Latinx people account for the next highest death rate at 13 percent, according to D.C. government data. Geographically, residents of Wards 4, 5, 7, and 8 have the highest rates of positive tests.

McDuffie said several constituents contacted his office after trying to sign up for an appointment online and over the phone with no success. He also shared an anecdote from a constituent who described a scene at Model Cities Senior Wellness Center, a Ward 5 vaccination site, where they were the only visibly Black person in line. The constituent told McDuffie that others in line said they lived in Ward 3, and the only appointments they could find were at the site in Wards 5 and 8.

“Please explain to me why you are permitting this to happen,” McDuffie told Nesbitt. “I’ve had 140 people die in Ward 5. Ward 3 has had 42 people die,” he shouted. “140 to 42.”

For Nesbitt, the answer was obvious. DC Health set up vaccination sites that can process more people on a daily basis in Wards 5, 7, and 8, where high populations of Black residents live. By that logic, it makes sense that Ward 3 residents are getting vaccinated in Ward 5. She also noted that people of color are generally more hesitant to accept vaccines, according to her department’s own survey data, and she can’t force people to get vaccinated.

Earlier in the call, Nesbitt scoffed at a question from At-Large Councilmember Elissa Silverman, who suggested DOH consider that some low income residents—namely, Black residents—might not have access to computers to book an appointment. Silverman, like McDuffie, wanted to know if any thought had been given to reserving vaccine doses for people in neighborhoods hit hardest by COVID-19.

“I do not practically understand that question,” Nesbitt said. “I simply can’t comprehend it.” 

Using her own 70-something-year-old parents as an example, Nesbitt dismissed the idea that older Black seniors are unable to book appointments through the website like their White counterparts. DC Health also set up a call center for those who don’t have internet access, Nesbitt said.

“I think we’re probably being a little bit pejorative with some of these assumptions that are being made,” Nesbitt said. “I also want people to remember that the sites were selected to create access.”

McDuffie and Nesbitt agreed to talk in more depth about whether it’s possible to prioritize vaccine doses by zip code or ward. In a follow-up interview, McDuffie says the two talked, but did not reach a final solution. Nesbitt promised to follow up with him today, McDuffie says.

“Dr. Nesbitt raised a good point about demand, and I understand that,” McDuffie says. “But we also want to vaccinate people who are hardest hit.” He says he’s not considering any legislation to that effect.

At a press conference in the morning of Jan. 13, Nesbitt said vaccine data based on race will be available soon, so the public will have a better understanding of who is getting vaccinated. Public health experts have advocated for prioritizing communities who’ve borne the brunt of the coronavirus pandemic. The question remains how to do it. Both the National Academies of Sciences, Engineering and Medicine and the World Health Organization came out against using a colorblind approach when distributing the COVID-19 vaccine. It is a delicate balance of promoting equity and avoiding waste. Experts do not always agree on how best to do this.    

“This is a super complicated issue,” says Dr. Rupali Limaye, an expert in vaccine behavior and decision-making at Johns Hopkins University’s Bloomberg School of Public Health. “It’s also putting more burden on already overstretched poor public health departments. They already have no money and no people and then the pandemic hits. It exacerbates this whole issue of pandemic preparedness.”  

Limaye does not think vaccine prioritization should be based on zip code.

“It’s better to prioritize based on what puts you at most risk for severe COVID. That is how prioritization should happen,” Limaye says. “My caveat would be then that the outreach needs to be appropriate by zip code, that’s the important thing here.”

She says outreach could also help to address vaccine hesitancy, which surveying suggests is higher among communities of color, particularly Black people due to a history of mistreatment in medical research.  

Georges Benjamin, the executive director of American Public Health Association who previously served as the secretary of health in Maryland and acting commissioner for public health in the District, also supports DC Health’s vaccine distribution strategy. He cautions against creating a priority group within the senior population based on zip code or reserving vaccines given that distribution is already a logistical nightmare.        

“I appreciate the advocacy for their constituents and one should respect that,” Benjamin says. “But I think the more complicated you make it, the more difficult it is to vaccinate.” 

“I’m not sure the members of the Council appreciate how complicated it is. You’ve got a vaccine that requires ultracold storage, the Pfizer version, and just the logistics of defrosting and filling the syringes and lining people up,” he continues. “If we spend our time worrying about whether somebody came from this ward or that ward … There’s only so much time in the day and there’s only so many brain cells you can bring into this process quite frankly. Let’s focus on getting the shots in the arm.” 

Benjamin believes the current priority scheme—based on age, then occupation and health status—ultimately gets the District to a place where communities disproportionately impacted by COVID-19 get vaccinated. People of color are also more likely to hold essential jobs and have chronic medical conditions that would put them ahead in the line for vaccinations.   

The District is mostly following the latest CDC Advisory Committee on Immunization Practices recommendations. Nesbitt says DC Health deviated and opened up appointments to residents 65 and over as opposed to 75 because local morbidity and mortality statistics, particularly as it relates to the disease burden among certain racial groups, suggested they do so.   

Accounting for residency could complicate the District’s current approach to distribute doses. DC Health has a no wastage policy, advising providers to give a shot to anyone willing and able should they run up against a vial’s expiration date. Residents also do not need to show a D.C.-issued driver’s license or identification card to get vaccinated. This policy accounts for residents, namely the undocumented, who do not have this form of ID.

“There is a strong ethical case for prioritizing the least well-off racial minorities for access to COVID vaccines,” Lawrence Gostin, a professor of global health law at Georgetown University, writes via email. 

Unlike Limaye and Benjamin, Gostin says using zip codes for setting priorities is legally and ethically smart, given that public health experts know vulnerability to disease is closely linked to where one lives. He has written about this issue for the Journal of the American Medical Association. He adds that, “The Supreme Court would likely strike down any explicit racial preference. DC therefore needs to develop criteria that are not explicitly based on race but still capture the poorest, most disadvantaged residents. It can do that by using the geographical area or zip code. It could also factor in socioeconomic status.”

DC Health is accounting for race in its vaccine distribution. Nesbitt says DC Health’s strategy includes direct outreach from United Medical Center in majority-Black Ward 8 and community health centers to people deemed most at risk. Providers like United Medical Center are inviting their senior population of the last two years to get vaccinated through them. The department is also leaning on “social influencers,” and has produced videos of Black leaders such as At-Large Councilmember Anita Bonds, former first lady of D.C. Cora Masters Barry, and former Attorney General Eric Holder getting the shot.  

“In one sense, that’s a good thing,” said Mayor Muriel Bowser about all available vaccine appointments being booked on the first day. “But it also demonstrates the scarcity of the vaccine.”

Supply shouldn’t be as big an issue for much longer says Dr. Jeffrey Levi, a professor of health policy and management at the Milken Institute School of Public Health at The George Washington University. This week, the Trump administration says it will release more doses by no longer holding back vaccines reserved for second shots, an idea first proposed by the Biden administration. D.C. has nearly 85,000 residents over 65, but only received 8,300 doses this week from the federal government to begin vaccinating its seniors.

“All of the issues they raise are plausible,” Levi says of the Council’s concerns. “We don’t know whether this is just a reflection of the fact that so few vaccines were available. And I am willing to bet everyone is complaining to their council member that they didn’t get access.” 

Levi says these issues will become incredibly important once volume of the vaccine increases. He is a Ward 2 resident who successfully booked a vaccine appointment at a Ward 8 site. When asked to describe how he felt about his situation given the Council’s criticisms of people like him, Levi says he has “mixed feelings.”  

“Because of the tremendous need that is in that Ward,” he explains. “But this is what happens when we’re rationing care. I also know that more supply is coming and it will be possible to remedy the situation.”