Not even a year into her post as director of the Allegheny County Health department, Dr. Karen Hacker has faced her share of public health problems: startling obesity rates, an outbreak of lethal fentanyl-laced heroin and public outrage over the environmental effects of industry. Hired after County Executive Rich Fitzgerald ousted the 20-year health department veteran Bruce Dixon, Hacker has been charged with addressing everything from smoking to community violence. The former Harvard Medical School/public health professor – and executive director at the Cambridge-based Institute for Community Health – sat down with City Paper to talk about some of these issues and new directions for the health department.
You've worked in the public health world in a number of cities – what made you seek out a job in a place where fried pierogies and French-fry laden salads are the main food groups?
I'll be honest I just threw my resume in – I didn't think anything was going to happen. My experience has been many of these positions turn out to be political appointments and they're not really looking for other people. What Allegheny County offered was this really interesting scenario where you've got a county health department that is both the county and the city, so you don't have a competition ... you have a very progressive executive and now a progressive mayor. So, from a political scenario, there's interest in moving this forward. And there's still work to be done. The thing about Massachusetts is it's hard to move the needle from 97 to 98. It's a lot easier to move it from 40 to 50.
When you took this office, which was last September, you talked about changing the direction of the health department. Over the past 10 months, how you think the health department's direction has shifted?
The first thing is we've added deputies – so we've actually added some infrastructure. I spent the first six months basically just talking to as many people as I could ... a lot of people who are involved in sustainability efforts – which isn't always thought of as a public health – environment, trails and bikes and fitness folks. The way that the organization was managed before was a very flat organization and I get the impression that the director pretty much made most of the decisions. I get the impression that what I'm doing here is new to people.
There are a huge number of issues a health department could tackle –everything from community violence to smoking cessation. Some are regulatory, some are programmatic. How do you decide where to start?
The first thing I did was start looking at the data to get a familiarity with what is going on the community. Very quickly I started talking about obesity and physical activity, health disparities and the environmental issues. My first hire was the environmental health deputy, and I hope that sent a message to the environmental community that I'm serious about this area, because it's not an area in which I had a lot of experience. The thing about public health is you do your best to try to see into the future, but there are always going to be things that crop up. So when we have a number of heroin deaths, we have to jump in and deal with that. When we have a housing environment that [is] unhealthy, we [have] to deal with that.
What was the data telling you?
Clearly – like you said with the French fries and the salad laughs – there are lots of organizations that are trying to address obesity and physical activity, but the numbers have not gone down for children and adults. But I think that there's a new kind of feeling going on certainly in the Pittsburgh area, if not in the rest of the county, that's really pushing this agenda.
I think with the air issues – this is an issue that's longstanding in this community – there is a very active environmental group focused on everything from coke plants to diesel fuel to fracking ... they're not going to tolerate complacency in this area. And the good news is all the data suggests we're doing better than we've ever done. The bad news is they're still problems. I live in a community where some mornings when I walk out the door it smells like coal.
You said one of the things that attracted you here is this is a relatively well-resourced health department and a community where public health is taken really seriously.
When I mentioned resources I was really talking about the foundation community, which is extremely rare. I will not tell you the health department is extremely well-resourced; it's not. But I do think it's fascinating to see how important public health is to Allegheny County. I've spent more time talking to the press – it's hard for me to believe sometimes that they're really that interested in this.
We're kind of a pure health department: we have a big environmental department, we have housing, we have water, we have plumbing. When you've got all of that under one roof, you think about how those things fit together. And I think that makes it much more clear what a health department does ... I think a lot of people just have no idea what you do in public health. And I think that's tough for resources because when a city's deciding ‘where are we going to put our money?' – ‘we'll just cut the health department; we don't know what they do anyway.'
You mentioned the environment as one of your pillars ... I'm interested in your perspective on the risks of fracking.
The data that I have and the research that we've looked at – the benefit likely outweighs the risk at this point in time. There are risks: They mostly have to do with what happens at the surface and there are differences between dry and wet gas. The wet gas seems to be more problematic in terms of the exposure to benzene and other chemicals like that which are the ones that are particularly related to cancer risk. But in general, and this is where it gets challenging, natural gas is helping to clean up our air. As many of these energy plants switch to natural gas, particularly in places we can't control like Ohio, our air is getting better.
And by ‘benefit' you mean purely the public health benefit?
There's the public health benefit of natural gas ... But I think here there is certainly financial benefit, absolutely. Right now, the health costs of fracking – it's very amorphous.
How do you address concerns form some who might worry that because the county executive in this case has a drilling friendly position that people might not think the health department is an independent voice on fracking?
We do have a board, and the board is appointed by the county exec. So, ultimately, we work together. But if I believed there was a really severe risk, I would say that. I've gone to many of the public forums on this. There's a lot of storytelling, a lot of hearsay. One thing we're doing at the airport is we're monitoring. We're doing the before monitoring and we'll do the after monitoring. We'll be able to say what's actually happening. And unfortunately, given the longevity of fracking, it's really quite surprising there isn't better data out there.
Why do you think that is?
I mean, I know that people complain that it's very challenging with many of the companies that they don't actually let you know what's in their fracking mixtures – so some people talk about proprietary information. The fact is solar and wind isn't up to the point where it's going to make us all very happy with all of our contraptions, so I think there's going to have to be combinations. The hard part about natural gas is it's still based on carbon and it doesn't move us one step closer from our dependency on that.
One other air-quality issue is the Shenango coke plant. I'm interested in your take on whether it's moved into compliance with the consent agreement?
Unfortunately, coal is a dirty business, and as long as we have coal plants or coke plants, this is not a one-shot deal. So you can see this pattern: You go in, you do the consent order, things get better and then they kind of slip. And then you do another one and then they kind of slip and I think that's very frustrating for the community – particularly the advocacy community.
In order to keep the slippage from happening, do you imagine inspecting more regularly?
There are already people who are out there basically every single day doing the inspections ... so they literally stand on top of the batteries and they look at the color of the smoke. They've had very few problems since the consent order, but if you start to see more of those happen, you have to start getting back into legal action.
So is there a different strategy to keep compliance up between consent agreements?
You know, I don't know. I don't know. Obviously – the business people – it's their responsibility to do this.
The hope is the company itself will take the consent agreement more seriously?
Well, that's what they have to do. If they don't comply with the consent agreement, there's additional legal action that can be taken.
And is the difference in the past they haven't pursued that legal action?
I can't speak as much to the past in terms of that. I think there have been other fines levied against them. Some people will say they just consider this the cost of doing business. We use what we have available to us, and I think the advocacy community uses what's available to them so they can get public outrage and they can mount pressure.
But you're not sure if you'll be more aggressive than the health department has been in the past?
Well I think we're being pretty aggressive right now, so I think we're going to do our best to stay on top of it.
I want to switch gears a bit. How's the Affordable Care Act affecting the health department's relationship with hospitals or communities?
We have a scenario in Pennsylvania right now that makes it a little tough because we don't have an expansion of Medicaid. So we continue to have a fairly large group of people that are uninsured. That said, the other thing that the ACA had in it was that they expected hospitals to do needs assessments every three years for their non-profit status. And that, I think, is one of the things that is starting to make hospitals and public health departments start to talk to each other in a different way.
The other piece that is really shifting is this whole construct of population health. It's ‘epidemiology comes to the delivery system.' Because basically what it says is you've got this group of people and now you're responsible for looking at them as a group of people ... doctors don't look at people that way, they look at it as the individual sitting in their office. They don't think about ‘all my diabetics' or ‘all my people with hypertension.' And I think if we're going to control healthcare costs, that this is actually quite a radical change for the healthcare delivery system. So I think it for the first time brings a light into this whole concept of population health which is basically what we've been doing in public health forever. And so now there's a lot going on talking about health and overall policies and making healthy choices the default choice. A lot of that falls into our purview as a health department.
What are the health disparities in the county that are of most concern to you?
The two that have just jumped out – you don't need to be brilliant – are race and geography. Almost every single negative consequence that we have right now -- by and large -- blacks are more at risk than whites. But the other thing is we have a lot of disparities in our geography. We have communities that look dramatically different from other communities.
Are those communities drawn on racial – or socioeconomic – lines?
Probably more socioeconomic. You can almost look at a strip that runs down the Mon Valley and if you look at those communities ... they're really blighted and they didn't get the education, the hospital drivers that the city itself got. And you go out there and they're isolated and their air is not so great and they're property value is really low. And when you look at who's in those communities they have probably the highest proportion of minorities, but I would tell you that the non-minorities in those communities aren't doing so well either.
The restaurant grading system is on the table again.
Hopefully the horse is out of the barn. We've been doing everything we need to plan for it and we've been very methodical in our approach. I would find it very surprising if things shifted at this point.
Is there evidence that restaurant grading systems have positive public health effects?
The particular evidence they've seen in New York is less about do they see less infectious diseases, for example, and more about the fact that over time there are more and more "A's." I don't know that there's evidence right now that there's fewer outbreaks. I do think the restaurant industry is correct is that you go and do an inspection once a year, so you don't know what's happening every single day, but I think there's an inherent incentive in there that I'm hoping will make a difference.
Your predecessor [the late- Dr. Bruce Dixon in a 2009 Pittsburgh Post-Gazette profile said he didn't eat fruits or vegetables because "cows eat vegetables. I eat the cow." What's your stance on vegetables?
[Laughs} That's an interesting comment. I love ‘em!