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AMA Chief Experience Officer Todd Unger speaks with Steven Stack, MD, MBA, an emergency physician and Kentucky’s public health commissioner, on the role state public health departments play in the reopening of communities during the COVID-19 pandemic. Learn more at the AMA COVID-19 resource center.
- Steven J. Stack, MD, MBA, emergency physician, commissioner, Department for Public Health, Commonwealth of Kentucky
Unger: Hello, this is the American Medical Association's COVID-19 update. Today we're discussing reopening from a state health department perspective. I'm joined today by Dr. Steven Stack, an emergency physician and Kentucky's public health commissioner and an AMA president from 2015 to 2016 in Lexington, Kentucky. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Stack, what role are state public health departments playing in reopening decisions? And is this something that should be left only to the states or should there be national, city and county input as well?
Dr. Stack: Right, Todd, thank you. Thank you for the chance to be here. All three levels of government have a role to play. The local government is closer to their communities, know better their businesses and their unique sensitivities to their population. The state level of government plays an integrating role, pooling resources across regions, ensuring that we distribute capacity and assets across our portfolio of counties. And then the federal level plays an enormous role, giving high powered scientific advice in the form of the CDC. But also in a disaster this big they're the only layer of government who can expand resources financially and also help to improve the supply lines, which have been a real problem. So all three levels have a big role to play.
Unger: Well, given that the states are playing such a large role in the reopening efforts, what factors are you looking at when making important decisions for Kentucky? And do you feel like that you've got buy-in from other state leaders?
Dr. Stack: I definitely have buy-in from other leaders. I'm very grateful to work for a governor who has really responded well to high quality input from his advisors and who's not hesitated to take the difficult but big decisions that had to be made early to have the greatest impact. As far as things we consider, we look at capacity, do we have testing capacity? Do we have PPE supplies that we need? Do we have hospital capacity? We also look at the case rate. So the number of new positives and the percent of positives as a total of the number of people tested. We've looked at a number of those different data to help guide our decision making. It certainly has felt like being in the fog of war though. There's been a lot of uncertainty in the pace and the magnitude have been really challenging.
Unger: Yes, I recall our earliest conversation, which was about three months ago, where you were officially warning people to take this more seriously. Do you feel like people listened?
Dr. Stack: I do. We described our initiatives here as healthy at home, initially, which where people were really having social distancing at a very intense level. As we've now lightened the restrictions, it's healthy at work, where we're trying to adjust people to a new normal. And I do think we've called ourselves Team Kentucky here. And I do think Team Kentucky's come together. It's become more difficult though. And I think that everyone faces that across the country. There's message fatigue. People want to get back with their lives. There's obviously incredible economic consequences. So I think this disaster continues to be a difficult one to navigate for new reasons each week.
Unger: And so you officially took over as Kentucky's public health commissioner on February 10th, during what is arguably the most challenging time in our country in quite a long time. What have been the biggest challenges in getting the state's message out on best practices to Kentucky's physicians?
Dr. Stack: Well again, we've done a really good job here, I think. The governor had the vision to set up a regular cadence of communication. So we've had press conferences initially seven days a week from 5:00 PM to 6:00 PM every day. He had a consistent structure, people could come to be comfortable with the messaging and know what to expect. And we've had an enormous viewership for that. I get thank you notes on a regular basis for the steady, consistent communication. It has been difficult though, because not everyone watches all of those channels, even though we augment that with social media and other vehicles. And as I mentioned earlier, there is message fatigue. People are tired, and they want to move on with their lives. And that it continues to be a challenge as we try to get people to respond to and follow our guidance and not become complacent and falsely assume that this disease has somehow gone away.
Unger: In fact, Kentucky like some states has been one of the hotspots for recent racial tensions, large crowds getting together. How have recent events impacted your reopening efforts in public health?
Dr. Stack: Well, I can't comment on this without first acknowledging that the disparities we face and the inequities in society are serious and longstanding tragedies in our country. We have to address those. We owe an obligation to all Americans to address those so that all of us have equal opportunity and we live in an equitable society. And that certainly is a core part of the mission of public health. I really do worry about mass gatherings of any sort. I particularly worry, these mass gatherings bring together Black Americans in large gatherings where people are vocalizing themselves loudly and in an extended period of time. Those are exactly the things that are at risk of spreading this epidemic. And as we know, unfortunately the disparities that we see have African Americans getting hit particularly hard by this. In our state, African Americans are 8% of the state population, but 17% of the fatalities. And so I worry a great deal for society at large, but also specifically that population, that this could take a toll, which would be even more tragic.
Unger: And I know you had a goal when you started, explicitly, to help make resources and care more accessible. The pandemic's obviously exacerbated underlying problems. What efforts do you have underway or will in the near future to make care more accessible across your state?
Dr. Stack: Well again, I feel very fortunate to be in the state that I am. Our governor has committed to maintaining Medicaid expansion and we are going to pursue that going forward. We are going to work to build back better, not just build back where we started from, but to emerge from this better. So I do hope we will find ways to ensure that every Kentuckian has access to health care coverage that will work to make health care more accessible so that we actually have access to cure, not just coverage. And that at the same time we find ways to use tools like telemedicine in a much more robust way than we did before we entered this crisis. And so I hope we will learn and also use the opportunity to improve our delivery of health care to everybody so everyone has the chance to lead a healthier, happier life.
Unger: You're an emergency physician. And I know your wife is a physician as well. What are you hearing from physicians as their main concerns, both clinical and operational issues as they begin to reopen their practices?
Dr. Stack: Well, there's a real irony here that the physicians really took it on the chin in a way. So we've had physicians whose practices have been, are probably brought to the brink of collapse economically, they had to lay off their staff. We have emergency physicians who have seen pay cuts and hour cuts because there wasn't volume in the ER to support them. This is a bitter irony, because never before have they been in the face of more danger uniformly to have economic difficulty at the same time. But that's not unlike the rest of society. I think the uncertainty is very, very worrisome.
The lack of getting PPE where it needs to be has been an enormous and a really sad failing, unfortunately. In a nation like we have with so many resources that we haven't been able to get that fixed faster is a real catastrophe and unfortunate. So I do think though that I'm inspired by what physicians and nurses and other health care providers have done. They really have risen to the challenge and uniformly they've given us reason to celebrate how much they care about their patients and helping them to stay safe during this difficult time.
Unger: Now, we know that the pandemic is not over and that we may face a resurgence in coming months. What tools, resources were you missing first time around, and what can we do better to prepare for the future?
Dr. Stack: Well, the obvious things we've all heard about, we didn't have access to testing, and we also didn't have access to PPE to keep people safe. We also didn't have plans in place, or if we had plans, they weren't ready to really be implemented for how we could surge capacity if we needed to, how we could change the way we practice medicine. One of the things I think we learned in New York and other parts of the world was you have to be able to rapidly convert regular medical spaces to critical care type spaces and have people, clinicians who don't typically do those types of services, expand their capacity to do those sorts of services. So I think if we experience a resurgence, which is a risk, that we are better prepared now, because we've ramped up testing substantially. The PPE supply lines are improving. And I think now those plans we had on the shelf had been dusted off, brought up to speed, and we are now more prepared to be able to surge capacity should we need to.
Unger: You mentioned supply lines being a problem. I am continuing to hear of issues around PPE. Is there anything that you're doing to help alleviate that situation?
Dr. Stack: Well, each state has struggled with this. But in Kentucky, the bourbon and alcohol industry came together, and they diverted their alcohol to make hand sanitizers, so that was fantastic. I think we found you can do an amazing amount of things with 3D printers. We have an abundance now of face shield masks, those sorts of things we were able to come up with. Our correction institute has, so the prisons, have made face mask, cloth face masks, and they actually got high quality medical grade material and have started making medical gowns for us. So isolation gowns, which are fantastic. The difficult thing though has been those N95 respirators that requires a technology and materials you just cannot easily replicate. And so that's been a challenge and then surgical gowns have still been a difficulty that we're now beginning to get some of those.
Unger: Well, Dr. Stack, a lot has changed since I talked to you several months ago on the very first episode of the COVID-19 update. So thank you for being back here today and for all you've done for the people of Kentucky. That's it for today's COVID-19 update. We'll be back tomorrow with another segment.
For updated resources on COVID-19 go to ama-assn.org/COVID-19. Thanks for joining us and take care.