As D.C. Health leader departs, vaccine equity again comes into focus

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Standing in front of a crowd last month along the District’s 14th Street corridor, outgoing D.C. Health director LaQuandra Nesbitt warned of an emerging viral outbreak facing the city and detailed her department’s strategy to get residents vaccinated.

It was a familiar scene with new circumstances.

Nesbitt became an unexpected face of D.C. city government more than two years ago as the coronavirus pandemic brought public health decisions under daily scrutiny, and she often bore the brunt of criticism from residents and D.C. Council members who disagreed with her rationale.

Now, as the District evolves into a hot spot for monkeypox, it will have to tackle this latest public health crisis without Nesbitt, who stepped down last month, ending her nearly eight-year run at the helm.

As Mayor Muriel E. Bowser (D) begins her search for a new director, advocates for the gay and bisexual men in the city — who bear the highest risk for monkeypox — say the department’s next leader should build on the public health strategy Nesbitt’s team established for coronavirus that has generally been effective: partnering with community organizations to reach residents who may distrust city government or lack access to resources.

And while they’ve noticed a smoother rollout overall with the monkeypox vaccine, compared with the coronavirus vaccine, they felt that some savvy residents eligible for the inoculation had an easier time accessing shots when they first became available, reigniting conversations about health equity.

“I feel very remorseful for the many people who used Nesbitt as a punching bag for the mistakes D.C. had [during the pandemic]; she did the best she could do and was not the only decision-maker,” said longtime education advocate Mysiki Valentine, who is Black and gay. “I hope the next director will have experience in [our underserved neighborhoods]; the city needs to take a grass-roots approach to change outcomes for Black and Brown communities.”

An equitable approach

Nesbitt, 44, got into science at the urging of her mother, a blue-collar worker who was convinced that careers in STEM had the strongest future. After dabbling in engineering and biochemistry, Nesbitt leaned into family medicine, earning her medical degree from Wayne State University and master’s of public health from Harvard — even when she encountered barriers. As a 5-foot-9 Black woman — taller in the heels she prefers — Nesbitt occasionally dealt with inappropriate comments from her medical school colleagues.

“It got to the point where people who trained me would tell me I was intimidating — what do you want me to do with that?” she recalled in an interview, describing a microaggression frequently aimed toward Black women in professional settings. “I would just seek training and opportunity from people who weren’t bothered by that.”

As she trained for her degrees, Nesbitt realized that specializing in family medicine meant she could help a wide array of patients: treating a 6-month-old in one moment before evaluating a 70-year-old with chronic health conditions the next. Her desire to create a broad impact through her work ultimately drew her to policy and city government: She joined D.C. Health as a senior deputy policy director in 2008, and went on to lead the Louisville Metro Department of Public Health and Wellness in 2011. Bowser, upon being first elected as D.C.’s mayor, brought Nesbitt back to lead the health department in 2015.

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Nesbitt’s tenure coincided with significant reductions in infant mortality as well as in new HIV cases in the city, although progress there slowed during the pandemic, and Black and Latino residents still account for a disproportionate share of cases. Nesbitt in 2015 also established the department’s Office of Health Equity, tasked with dismantling barriers to health care and access, particularly in communities east of the Anacostia River.

But at no point was her role as visible as it was during the height of the pandemic, when she appeared almost daily next to Bowser, updating residents about changing trends and policies, notably when credible information about the deadly virus was scarce and public anxiety was at its highest.

In a statement, D.C. Council member Vincent C. Gray (D-Ward 7), whose committee oversees the health department, thanked Nesbitt for “leading the District through the toughest time of the covid pandemic when there was not much information being shared from the Trump administration.”

“It was a scramble just to get supplies, implement vaccination policies and establish testing centers across the District amidst mass chaos,” Gray added. “I respect the difficult decisions she had to make to slow down the spread of covid-19.”

As Nesbitt’s profile grew during the pandemic, however, so did public critique — often in the form of questions from reporters and council members about her department’s recommendations to impose or relax mandates and restrictions, and how much coronavirus data the city disclosed to the public.

At times, those conversations grew contentious: In May, when several members of the council approached her with questions about a lapse in city data reported to the Centers for Disease Control and Prevention, Nesbitt in a letter accused the lawmakers of “undercutting trust in DC Health and public health.”

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Nesbit recalled a “harsh, accusatory” discussion with the council in January 2021 about the department’s process for equitably distributing coronavirus vaccine appointments, when doses first became available to the city’s seniors. At that time, seniors from the most affluent wards were making up a disproportionate share of limited vaccine appointments, even trekking across the District to clinics the city had opened in lower-income neighborhoods, where outcomes from the virus were more severe.

Some council members, lamenting the unequal toll of the virus across the District, called on D.C. Health to reserve vaccine appointments for people who lived in specific, hard-hit neighborhoods instead of on a first-come, first-served basis. Nesbitt initially responded that it was pejorative to suggest that Black residents were less capable of successfully making an appointment, but the department eventually changed the registration process, allowing only residents of certain Zip codes to sign up for vaccines on select days. Outcomes improved.

“We learned that people with resources and means would drive into communities of color that they had never gone to before to get vaccines — you saw people go from Ward 3 to Ward 8 — and the public viewed that as if the health department did not have an equitable strategy, that was inaccurate,” Nesbitt said at the news conference about monkeypox last month. “But we applied that as a lesson learned. Now, scheduling is done for people of color and not just simply the location.”

Appointments gone in minutes

D.C. Health has already made several adjustments to how it disseminates monkeypox vaccine doses, which are in short supply since they first became available in June. Last week, the department shifted to a single-dose strategy to immunize a greater number of residents. Advocates have generally applauded that move, as well as the department’s overall messaging about monkeypox, which includes a focus on educating high-risk groups.

But, just as with the coronavirus, they noticed that more privileged residents seemed to have an early advantage in obtaining the shots.

In late June and early July, before it established a preregistration system for the vaccine, D.C. Health primarily advertised its limited number of monkeypox vaccine appointments through social media, causing a rush that sometimes led to their being snatched up within minutes.

“I had White, gay friends tell me they had multiple devices open in front of them, and they were able to refresh them all at the same time to get their appointments,” said Matthew Rose, a Black, gay activist in the District. “You’re doing this against a whole backdrop of covid and saying we’re going to focus on health equity. Yet those early days for monkeypox did not look equitable.”

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The health department is prioritizing racial and ethnic minorities through its preregistration system, Nesbitt said; the city has sought to administer 35 percent of its vaccine doses to Black, African American and Latino men who also meet the other eligibility criteria.

“We want to make sure we’re not in a position in D.C. or nationally where vaccine doses are disproportionately going to affluent communities or are only accessed by gay, White males in monogamous relationships who are not demonstrating other risk factors,” Nesbitt added.

Thus far, results have been mixed: Although Black residents made up about one-fourth of the city’s monkeypox cases, they received about 14 percent of the vaccine doses that had been administered toward the end of July, Nesbitt said. In mid-July, the health department reported that White D.C. residents made up 76 percent of monkeypox vaccinations and 65 percent of cases.

Just as the city relied on churches, community organizations and other credible messengers to cut through misinformation about the coronavirus vaccine and to lower barriers to access that disproportionately hurt Black residents, Nesbitt is hoping groups that serve the Black LGBTQ-plus community can help close some of the gaps with monkeypox as vaccine appointments become more readily available, and to help minimize stigma related to the virus.

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“There are likely Black queer men who won’t get the vaccine because people are not supposed to know they are queer. That’s why it’s even more critical that we eliminate the stigma around monkeypox and bring vaccine doses to the community,” Valentine said. “People need to feel safe getting these vaccine doses; D.C. needs to depend more on those community organizations.”

A spirit of collaboration

After Nesbitt announced her resignation last month, Bowser vowed to launch a nationwide search for D.C. Health’s new director. In the interim, she selected Sharon Lewis, formerly a senior deputy director at the department, to take over.

To properly address disparities in health outcomes that have long persisted in the District, and to lighten challenges in future public health emergencies, advocates say the department’s next leader should have experience working in the city’s underserved neighborhoods — an important factor in earning the trust of people who have frequently felt left out of public health conversations altogether.

“Nesbitt did a lot of amazing stuff for the city, but there’s still equity gaps between different races,” Rose said. The next director, he added, “must do the hard work of talking to people who are most impacted and figure out what they need.”

Marc Morial, president and chief executive of the National Urban League, a civil rights and urban advocacy organization, said that during the pandemic, many city and health department leaders saw the benefits of tapping into organizations that already had inroads with vulnerable community members — increasing access to services while helping wary residents buy into messaging around health care.

Ideally, D.C. Health’s next director “wouldn’t require a tremendous amount of on-the-job training,” Morial said, and would have familiarity with the city, particularly in areas where health outcomes are the poorest.

“Obviously, they’ve got to go to Dr. Nesbitt and say, ‘Hey, I’m starting out, tell me what I need to know. Any mistakes you made? Anything you wish you had done differently?’ ” he added. “You need community-based organizations, faith-based organizations working with, talking to and providing access to people. Government can’t do it alone, hospitals can’t do it alone, you need infrastructure that people trust.”

As she departs from D.C. Health, Nesbitt is left with a similar assessment.

“My hope is that as the agency moves forward, we’ll see greater collaboration on these health issues that are so critically important for the city to solve, in our partnerships and across government,” she said. “When we have that spirit of collegiality and are leading with the people in mind, first, we can get things done.”

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