By Melissa Patrick
Kentucky Health News
Kentucky’s recently installed health commissioner is a 30-year-old doctor, two years short of being a surgeon, a goal he still plans to achieve. But right now he’s in charge of public health in a state with huge health issues, and local health departments with big financial issues.
Dr. Jeffrey Howard is still learning. He will graduate from Harvard University’s master’s of public health program in May and has enrolled in a master’s of business administration program that he plugs away at on Saturday mornings.
He started working at the Kentucky Department of Public Health in July 2017 when then-Commissioner Hiram C. Polk asked him to come on as a senior adviser. Howard said he got to know Polk when he was a surgical resident at the University of Louisville, particularly after he was named the 2014 Hiram C. Polk Jr. Student of the Year. He became acting commissioner in November 2017 after Polk resigned, and was appointed commissioner in July.
Howard said in an interview that one of the reasons he’s uniquely qualified for the job is that he’s at the beginning of his career, not the end, and is “young, bright and innovative.”
Kentucky River District Health Department Director Scott Lockard, who has worked in public health for 28 years, praised Howard at a session on health at the Shaping Our Appalachian Region Summit, where Howard spoke.
“We can see that he is sincere. He has a passion for what he is doing,” Lockard said. “To me, his willingness to look internally at processes and say, ‘We can do better,’ is a breath of fresh air.”
Howard added that he’s also experienced the issues around substance abuse “from the inside out,” having lived with an addicted mother and stepfather until he was 14, and because he was “born, bred and raised” in Eastern Kentucky and understands the culture that prevails in rural areas and often leads to poor health outcomes.
Howard told the story of how his grandmother, a “brittle diabetic” with bilateral amputations, kidney failure resulting in dialysis, and early-onset Alzheimer’s disease, didn’t know much about her disease and like many Eastern Kentucky folks, “you don’t talk about your illness.” She died at 55.
“I understand probably better than most people why rural Kentuckians make the decisions they do,” he said. “We have a culture in Kentucky, and especially rural Kentucky, on how we handle our own personal health that leads to poor outcomes. I do it all the time.”
Fran Feltner, director of the University of Kentucky’s Center for Excellence in Rural Health, said she was energized by Howard’s heart.
“I think that somebody from our region that understands our Appalachian culture will do such a great job at the state to represent us, as well as the rest of the state,” Feltner said. “And I’m honored that he is truly from his heart working on the issues that we have in rural Kentucky. I think he’s going to make a big difference and I’m ready to join him and work really hard to make that difference.”
Howard added that even though his grandmother died when he was 15, she had a “profound impact” on him because when they were alone she would tell him he was going to be a doctor, which he said made no sense since his father had dropped out of high school in ninth grade, his mother and step-father were addicted, and no one in his family had ever gone to college.
“That impact gave me the public-health bug that I didn’t know I had until two or three years ago,” he said.
Local needs and solutions
Howard said he is driven by his desire to improve health outcomes in Kentucky, which leads the nation in cancer and deaths from it; heart disease; adult asthma and chronic obstructive pulmonary disease; obesity, and diabetes.
He is also working to improve the relationship between the state and local health departments and has created an advisory committee led by local health department directors that meets weekly to talk about the issues facing the departments.
“My firm belief is that the issues of health and health outcomes in Kentucky exist locally and the solutions are local,” Howard said. “I’ve tried to bring an air of transparency as far as how public health is run from the state to locals so that they know and understand what we’re dealing with here and how our funding streams are driven and how that we can better support them.”
Howard said he is also working to make sure that “small wins” in public health are celebrated, by emphasizing them at state and local meetings, and to uplift all health department employees at both levels by sending personal notes that recognize both celebrations and concerns.
“I realized early on that our local health departments felt at arm’s length, and I didn’t want that,” he said. “So one of my goals was to bring those relationships closer together.”
Lockard, who sits on the advisory council said, “I feel more a part of the Department of Public Health right now, the statewide department. I feel like there is a more sincere effort being generated right now to be a sincere partner with the local health departments, to really be concerned about what is needed at the local level and how do we work together to make that happen.”
Lockard, who has worked with six health commissioners in his 28 years said of Howard: “I’ve seen many different commissioners, many different styles, all of them had their strengths, all of them had their opportunities for growth, and I’m just very excited to be working with this commissioner. I think he’s the right man in the right place at the right time and I just hope he stays a while with us.”
Pension crisis and local health departments
Howard said the strength of the state health department is its people, who work with a commitment to their jobs that was “through the roof.” He said its weaknesses and threats include lack of money, especially for employee pensions.
This year, the legislature froze for one year the pension contributions of health departments and 11 of the state’s 14 community mental health centers, which were facing increases in pensions of 49.5 to 83.4 percent, averaging 69 percent.
Lockard said, “July 1 of 2019 is the cliff that we’re all afraid of falling off, so we’re doing things differently now. We’re trying to look, we’re trying to plan. Of course, we’re going to try to advocate to see if we can postpone this,” as the legislature let County Employees Retirement System do, phasing in changes over 10 years. “What can we do? How can we change our mode of operation?”
Lockard said his Kentucky River health department, which serves Lee, Wolfe, Owsley, Leslie, Perry, Knott and Letcher counties, “is in the most challenging financial shape of any health department in the Commonwealth.”
Howard said he was working with his advisory committee and the Kentucky Health Departments Association on a plan for what to do if the health departments get no further relief from their pensions.
Howard said making health departments fund pensions at 49 percent of payroll “isn’t sustainable for any business model,” and as many as nine departments would have to close in 14 months if that was the case. He said the “prudent thing to do” is to start sharing resources across jurisdictions, and that must be driven by local health directors.
“I don’t want health departments to close, because I know how important those local health departments are,” he said. “But we’ve got to get to the point where we’re sharing services, we have to do that.” Without sharing, “We are really going to have to look at” redrawing the boundaries of district health departments, “and I know a lot of locals don’t want that,” he said.
Kentucky’s health issues
Opioids: Howard called substance abuse “by far the number one health issue in Kentucky,” noting that almost four Kentuckians die a day from it. He said his agency’s main role is to gather and analyze data, but “I think you’re going to see more education programs, more awareness programs. You’re certainly going to see funding for treatment to a degree that you’ve never seen before.”
Adverse childhood experiences: “It’s one of those issues that is incorporated into every discussion involved in some manner.”
Hepatitis A: In the same month Howard became acting health commissioner, the health department declared an outbreak of hepatitis A in Kentucky. Since August 25, it has reported 1,562 cases, 881 hospitalizations and 12 deaths. Howard said the epidemic will likely last another eight to 12 months in the state. The primary risk factors remain illicit drug use and homelessness; so far, no cases have been linked to a contaminated food source.
Asked what message he wanted to convey about hepatitis A, he said, “I would really like to emphasize that you are OK to go out to eat in your local restaurants. The risk of getting Hepatitis A from an infected food worker as long as they are adhering to normal precautions is very minimal.”
Statewide smoking ban: Howard’s position is the same as that of Gov. Matt Bevin: “Localities should decide what is right for them, and so I will never go out and say we need a statewide smoking ban. What I will say is smoking is bad and I think you ought to have that conversation locally. If you want me to be a part of that conversation and come into your locality and say smoking is bad, then I’ll do that because that’s what I believe, but I won’t tell you from a state level that this is what I demand you do, and I think that’s fairly consistent with our governor’s position.”
Innovation and partnerships
Howard has several initiatives in motion that involve partnerships with other organizations.
One partnership is with UK and the Foundation for a Healthy Kentucky on how health departments do their community health assessments so they ultimately allow local agendas to drive the state assessment. UK will produce an academic publication of this first-of-its-kind process, and the foundation will spread the word about how important community assessments are.
Community health assessments are a systematic examination of the key problems and assets in a community, which are then used to develop strategies to address community needs. Howard said he considers them to be the “cornerstone to driving public-health outcomes in Kentucky.”
Howard has also commissioned research by UK’s College of Business and Economics to show how investments in health affect the economy. He expects it to be ready in the spring of 2019.
“One of the things that I want to emphasize is that health and the economy are linked. We talk about it a lot, but I want to be able to give you some numbers,” he said. This will help “me to emphasize the role of public health” and to “talk to our citizens and our legislators in really tangible terms.”
Howard is also working on an initiative to align the efforts of the department with health-care providers, and with UK to study how state health departments work with medical societies on public-health issues.