ASTHO Q&A: David Lakey
David L. Lakey, MD, Commissioner of the Texas Department of State Health Services, ends his term as president of the Association of State and Territorial Health Officers, (ASTHO)at the group’s annual meeting in Austin this week. NewPublicHealth spoke with Dr. Lakey about his tenure and about his Presidential Challenge to reduce the number of preterm births.
NewPublicHealth: Did anything surprise you during your tenure as ASTHO president?
Dr. Lakey: I don’t think there was a specific surprise. It’s been a very busy year. Perhaps the one surprise might be that four years ago ASTHO started the Presidential Challenge under Judy Monroe, MD (then state health commissioner of Indiana, and now the head of the Office for State, Tribal, Local and Territorial Support at the Centers for Disease Control and Prevention) started this thing called the Presidential Challenge. Dr. Monroe started it as a charge to the state health officers to kind of walk the talk related to physical activity. And now, four years later, the Presidential Challenge really had its own legs and with a lot of support. This year’s challenge—reducing preterm births–became a pretty big initiative. We now have 49 states that have signed on to that initiative.
NPH: What specific actions do you think have helped the decline of preterm births?
Dr. Lakey: I think we’ve gotten better at talking about this issue, making the case of not only the human argument, but the economic argument of why this is a priority coupled with an evidence-based plan of other specific things you can do. And then, we’ve been very fortunate that we’ve had a very strong partnership with a variety of entities at the federal level, with a lot of federal colleagues, and with the March of Dimes and other private sector entities to be able to really move this forward. A lot of people were working on this before. I think we were able to give it a little bit more of a push.
In January, we held a summit with leaders from states throughout the southern part of the United States to put together specific actionable plans and had at the table folks that could actually make things happen in their state. I think we’re moving forward and getting better data out so we can measure our success, but I also think there have been some specific policies that have been put in place through ASTHO but also through states and through other partners. I think an example of that would be identifying non-medically indicated inductions and C-sections that are occurring before 39 weeks and putting in hard-stop policies in hospitals so that doesn’t occur. In the state of Texas, we put forward a policy that our Medicaid program will no longer reimburse physicians for non-medically indicated inductions and C-sections before 39 weeks. And I think identifying the need to provide 17-hydroxyprogesterone to women that have had a preterm baby in the past to decrease the chances of a second preterm baby, and looking at all the barriers that, as a system, can get in the way of identifying that woman so she can get the medicine she needs. And I think there’s been a lot of work to try to improve the health of women so that they are healthier when they do get pregnant– addressing obesity, addressing tobacco use, getting women into prenatal care earlier. It has been a focus for many states to make sure that they bring these women into care.
NPH: How will the initiative keep up its momentum after your tenure as ASTHO president ends?
Dr. Lakey: We put a stake in the ground and we now have 49 states that have committed themselves to reduce prematurity by 8% by 2014. In order to accomplish that, it has to live on beyond this year, beyond next week, and so we now have the commitment of states that they’ve made this a priority and the elected leadership of a lot of states has said this is a priority. But this is also an issue that a variety of partners are going to continue to work on We’ve been working very closely with the March of Dimes. They’ve actually developed a couple of awards for states related to their ability to meet the set goals.
And so, we have that momentum with March of Dimes. Last month, I was in a meeting in Washington with the American College of Obstetricians and Gynecologists. They are looking at the statistics that we use to measure birth outcomes. And the Health Resource Services Administration sponsored our event in January. They’re looking at sponsoring more summits, and moving that into a quality improvement collaborative for the southern part of the United States, and then expand those other parts of the country so that we can steal those great ideas from other states and make things move forward. HRSA is looking at how we continue to sustain this work, working with ASTHO. The CDC has provided some funds to ASTHO to continue the work. I think there will be some additional funding through other federal agencies to ASTHO to continue to pull the states together, and so I think those different elements together create the sustainability plan for this initiative. Health and Human Services Secretary Sebelius is putting together a strategic plan to reduce infant mortality and prematurity, and that pushes this issue to a different level that will keep things moving forward on this issue.
NPH: From your vantage point at the helm of ASTHO, what immediate and long-term changes do you think are needed to the public health infrastructure to both maintain and continue to grow a strong public health workforce and keep the nation healthy?
Dr. Lakey: What we have to do in public health is get better at telling our story. I think we have to not only talk about the health issues, but be able to pull together a very good economic argument for the things that we do, and with implementable plans. A key need is making the economic argument. We also have to get better at how we use technology to do our jobs, including health IT and meaningful use. and we secure that data that we’re entrusted with and we’re going to have an increasing role to play in driving healthcare quality.
The tools of epidemiology I think are very important for us to utilize in trying to improve the quality of healthcare in the United States, we want to get our hands around the cost of healthcare, we have to continue to address healthcare quality, and we also have to get better at disaster response. And the workforce in other state health agencies is changing, and so moving towards that knowledge worker, the technology-savvy worker that knows how to get data, use data, communicate data in a way that can drive improvements in health is very important. I think public health as a whole will be changing in order to meet the new needs.
NPH: What public health innovations is Texas taking the lead on?
Dr. Lakey: I think Texas is leading the nation in several different ways. I think disaster response is one of them. We’ve had more presidentially declared disasters than any other state, and therefore, we have to be very good at responding to disasters. That includes the way that we command, our state medical operating center. It includes the assets that we’ve put together to be able to move them wherever we need to in the state of Texas. The technology of the system includes armbands so that when we evacuate someone we can track them from embarkation to a bus to the shelter to the hospital and back so we don’t lose individuals.
In Austin, where the ASTHO annual meeting is being held, there’s been a lot of work related to chronic disease prevention. We don’t have a state law in Texas related to being smoke-free, but we’re now at about 60% of communities that have gone smoke free, city by city, and Austin is one of those.
We’re in the midst of the West Nile outbreak. The capacity in our laboratory to test, the epidemiology that’s taken place, the GIS mapping that’s taking place so you can identify where there are cases, and where should spraying take place, that kind of overall data analysis I think is very important.
But, there are some things that are occurring in Texas that you’ll never see—such as improving how we get contracts out from our agency. We map the whole contracting process out. We identified over 200 steps. We put together a plan that would reduce that to about 50. It’s going to decrease the time from nine months to about half that, for the time that it takes to put together a contract, get it out, and start paying folks to do that work. We have 7,900 contracts that come through our agency; that is a significant quality improvement initiative that will allow local health departments to do their work.
And finally, another initiative is related to healthy babies. We’re working to improve breast-feeding in the state of Texas with a program called Every Ounce Counts. It’s a multi-pronged approach to improve breast-feeding rates in our state.
NPH: What’s the greatest value to you of spending a couple of days with your fellow state health officers?
Dr. Lakey: I think it’s important because there are few folks that are wrestling with the same type of problems that you do as a state health officer, that are under the same type of scrutiny, and so that collegial environment is critical. But, I think also probably and maybe more important is the ability to go and gather good ideas from other states, and so as I tell folks, I go and I share freely and I steal ideas freely. So if there’s a great idea of how do we address some public health issue that’s been proven in another state, my goal at these meetings is to find those out and bring them back to my state.