Voices of the Virus

The ‘South’s First Office of Health Equity’

What it’s like to direct a poor Southern state through the eye of the COVID-19 storm, according to the groundbreaking former secretary of the Louisiana Department of Health.

By Rebekah Gee

Tagged COVID-19drug pricingInequalityMedicaidPublic HealthRacismsexism

The Louisiana Department of Health has undertaken innovations in recent years that are proving vital today as it copes with a spike in cases currently taking place throughout the South. Much of these were initiated under the leadership of then Secretary of the Department Dr. Rebekah Gee, who held the position from 2016 until just recently. These included the opening of the South’s first Office of Health Equity in 2019, the adoption of a new subscription model to combat our crisis in drug pricing, and the expansion of Medicaid. Associate Editor Sophia Crabbe-Field spoke with Dr. Gee, who is also a practicing gynecologist, as well as the current CEO of LSU Health New Orleans’ Health Care Services Division, on September 2 about these and many other issues facing our country as it fights the ongoing pandemic.

Sophia Crabbe-Field: I know that up until just recently you were secretary of the Louisiana Department of Health. So I just wanted to start by asking you: Why did Louisiana have so many deaths during the first peak compared to other Southern states and what has it done differently now that has made the second peak lower? So, in other words, what did the state get right and what did it get wrong in its response to COVID?

Rebekah GeeI think the first peak was because the virus was widely circulating during Mardi Gras and before we knew that the silent killer was among us. We celebrated in very large mass gatherings—1.4 million visitors and lots of close contact. And so the spread that you saw and the death that you saw early on were result of that fact. It was two weeks post-Mardi Gras that we started seeing the first spikes in cases and then deaths, as you know, are delayed from that point. We have a good governor and good leadership. We have bolstered our public health infrastructure, both post-Katrina, and then during my time as secretary we focused on public health. And we have a public health unit in each county or parish and great expertise.

So I think that that paid off, as well as a governor and a mayor of New Orleans who have both been very strong and more proactive than other Southern leaders on masking. We have seen the governor, about three and a half weeks ago, shut down the bars and require masks. And we’ve seen a really big improvement from those rates, where positivity rates in New Orleans have been below 5 percent. So we are doing better than other Southern states because of proactive leadership. We also have tremendous public health testing infrastructure. We focused a lot on our public health lab and our early efforts to test paid off. We were, at one point, and we may still be, number one per capita in tests in the nation. Certainly, we have a lot of poverty, a lot of health challenges, and continued health disparities that complicate efforts to mitigate the impacts of COVID and some of that you see in our statistics.

SC-FWhy would you say that deaths in general, and cases of COVID, have been going up in the South recently compared to other regions?

RGI think because people haven’t been taking it seriously, that the virus has been politicized. People in Florida and Texas, in particular, are just flouting mask rules, not believing it. You know the President hasn’t modeled good behaviors with masking. And I think the far right has a narrative, including by the President who tweeted that COVID isn’t real, COVID isn’t a problem, people don’t die of COVID. These types of narratives are not helpful. And the South, being so red, I think it has obfuscated efforts because of the poor leadership by the President and others to help the public adopt these practices. I’m just looking at our rates: We’re not in the clear. By parish, we still have a lot of cases, obviously.

SC-FAs a public health official, how do you combat this anti-mask rhetoric coming from the Administration?

RGModel good behaviour, show people that masks work. We have very clear data because the governor  started the mask requirement and then weeks later you’re seeing hospitalizations plummet. So there’s a clear connection between mask wearing and decreased cases and deaths. So I think it’s just showing people that it’s real, demonstrating good behavior, focusing on taking care of your neighbour, and positive messaging, consistent messaging, not changing your message constantly is very important. I think the governor has been spot on in terms of his leadership.

SC-FGoing back to what you were saying about your public health infrastructure in Louisiana, how did it compare in terms of what was in place in other states? Also, has it adapted over the course of the pandemic?

RGI think it’s a lot better than other states. We continue to have a footprint in every region of the state, not only physicians, but also nurses, social workers, staff. Part of that is a residue of the need to have these folks in the event of a hurricane. And part of it is just a belief that I had, and other leaders have had, that we must support this infrastructure, whether it’s for a hurricane or for hepatitis C. And so I think it’s much better. It’s not optimal. It’s not where it needs to be, but it has not been decimated and some other states have none of this infrastructure. 

I also think it’s very important that our state health department is organized centrally. And so Medicaid and public health are together under the same umbrella. And I think that’s very important because, at least when I led the department, we made decisions together and the year of 2019 was the year of public health. Public health drove our decisions, even for Medicaid or behavioral health. This framework of population health underlies the decisions, as well as health equity. I started the South’s first Office of Health Equity in 2019. I think that the infrastructure is robust and the culture is optimal to promote public health, at least in the department.

SC-FHow much worse do you think the outbreak would’ve been in the state if you hadn’t expanded Medicaid in 2016?

RGWell you would have had a quarter of the adults with no health-care coverage. Coverage means everything to people who are sick. With COVID, Medicaid expansion has helped pay for our testing, it’s helped provide health-care coverage, it’s helped ensure that no rural hospitals have closed, it’s helped avoid rural hospitals and other hospitals avoid cuts to critical services because it’s brought billions of dollars of new federal investments to our state. So I think it’s made a critical difference and you see Texas and Florida, just notably, nearby states that don’t have it, they are not fairing nearly well as we are. So I think that the Medicaid expansion has played a critical role.

SC-FI know that you guys already had in place, as well, a state-led test and track plan, including contact tracers. What effect do you think this had and how important is contact tracing?

RGWe have great leadership on contact tracing and we hired to scale contact tracers and deployed them state-wide. I think the public’s trust and buy-in for contract tracing is low. And so I think that the efforts have only been moderately successful. So the state is looking at things like the Google Apple app that uses Bluetooth technology, but when we’re calling people our head of public health tells us that 70 percent or more tell us that they don’t have contacts that qualify, which simply can’t be possible. So people just aren’t participating. I think this speaks to a historical lack of trust in our health-care system and people’s concern about privacy. So I think somewhere the state is going, which I support, is hopefully toward a combination of technology solutions along with bread and butter contact tracing.

SC-FWhat do you think of the Biden campaign’s plan for a new public health corps? Right to Health Action believes that these should also be permanent and unionized jobs. How important do you think that is?

RGI think it’s important that we have a public health corps that is apolitical and is not dependent on the whims of policymakers that year. I think that our public health infrastructure needs to be robust and supported across the continuum and that’s whether it’s through unions or other mechanisms. I think it’s important that these folks are protected, that they can make decisions and act without concern of retribution. If they find issues, whether it’s a water system or an issue with testing, people need to be able to be scientific and professional. And so I do think it’s important that it be a professional corps. We certainly know that creating an anaemic public health system in this country and being skimpy on what we do has not paid off.

And, in fact, we’re paying trillions of dollars to address it now. And so hopefully we will learn from this. I really like the Biden idea for a corps. I think it’s important to just not to think of these people as disaster staff. I think we need to think carefully about what they do when there’s not a disaster, whether that’s having community health workers, which Biden’s also supported. I think that a public health corps could be a part of home visiting for women and babies and working on the nonmedical determinants of health. I think that there’s great promise in the idea and I think it should be further explored.

SC-FCould tell me a bit more as well about the subscription model that you adopted in the state in 2019, I think it was mostly meant to address access to hep C treatment. And I think yours was also the first state in the U.S. to adopt it. Do you think that this is a model that can also be of importance during a pandemic?

RGThere are other subscription type models, like the Vaccines for Children Program, that have been very important in ensuring that our children have access to vaccine regardless of their family’s ability to pay. It’s being envisioned actually, if you look at something like project Warp Speed, it’s kind of like a subscription pre-purchasing doses of something. It’s not exactly what we did. The subscription model that we used, you did not advance pay for the drugs. You agreed to a certain price up to a cap and then after that cap they’re free. But whether you do it as an advanced payment or up to a cap, I think it’s very promising.

I believe that every American life is important, even a life that, unfortunately, is incarcerated. And that was also a really important part of our journey, to ensure that everyone, both who were people who were incarcerated and those new on Medicaid, can have this life saving treatment. And I’ve actually been surprised that other states haven’t followed our lead because we’ve had really life-changing outcomes. We’ve had, just in the first year, 10 times the number of people treated as were treated in my first year as secretary, individuals in prison being treated, and at no additional cost to the state. And if you think about the long-term implications of hep C, it was, previous to COVID, the leading infectious disease killer in the United States. And it causes severe morbidity or mortality: liver disease, liver transplants, liver cirrhosis, people are very sick and it’s completely curable now. And so it’s unacceptable than in the wealthiest nation on earth we would deny people this life-saving coverage.

So I thought what we did was an incredible innovation. It’s impacted many thousands of lives and it should be replicated. And, particularly, it should be something that’s replicated in every department of corrections throughout the nation. We could solve many, many problems in correctional systems with these models. But also I think it’s, in some ways, an exception that proves the rule. I worked on this for three full years. I had the greatest minds in health policy in the nation helping me; I called them the “health-care Avengers.” It was Jon Gruber, who helped design Obamacare, we had Rena Conti, the nation’s leading expert in 340B, Josh Sharfstein, who leads the Bloomberg Health Initiative, Peter Bach, from Sloan Kettering who leads many drug pricing efforts. It was not easy at all. And we were told “no” many times, and it was only after the split—there was a competitive market for these drugs, with three different companies providing them—that we were able to get leverage. And we also brought in, through the help of John Arnold, the National Governors Association. And I also had the support of the governor who was not afraid of the pharmaceutical industry, which is very rare. It was kind of a magical and unlikely confluence of events. It worked for us. I think it can work for other states, but I think it’s certainly an argument for much broader reform in terms of drug pricing.

SC-FI know you’re now working for the LSU system. So I wanted to ask you: How do students safely go back to university or go back to school? Is it possible to do that, at this moment, and under what conditions?

RGOptimally, we would have very robust testing programs in place. Optimal would be nearly daily testing for students, being able to social distance, being able to trace contacts, but it is, particularly in the absence of good federal leadership, it’s every school for themselves and there’s a wide variety of plans. And the ability to carry those out really depends on resources and there are major health equity issues. You have HBCUs and other institutions that are not as well resourced as, say, a Harvard. The differences are glaring. I think it’s important that we learn from what’s happening. I do also think it’s important that people go back to school. I’m a mother of five children, and they’re all in school. I support that. I think it’s very important for young families to have childcare and it’s very important to have socialization for these children to learn. So I think we need to try, but we need to learn as we try and be very reflective and, as we learn, we need to course correct on how to do it.

I am very concerned about residential campuses, particularly those in urban areas. We had Tulane, I think it has 150 kids, just in the first couple of weeks, that are in quarantine. For a health sciences center, I think we’ve got it pretty well organized where you’ve got your distance learning when you can, which is in the first and the second year. And then for third and fourth year, students are in clinical rotations. They have to see patients. You don’t want to unleash doctors on the world who have never seen a patient, or nurses or a PA. So that they have to do clinic, but they have protection. And so far it’s going very well for us. But shame on us if we don’t learn and evaluate the different reopening strategies and by the spring really have a good handle on what works best. And also hopefully we’ll have a vaccine by the spring.

SC-FWhat do you make of the CDC seeming to go back and forth on testing of asymptomatic patients and what should we do when the CDC is showing that kind of lack of leadership?

RGI think that’s outrageous, Sophia. I think the CDC is, we call it “crawfishing” in Louisiana, when you just backpedal. And I think it undermines public trust and it undermines science and clearly asymptomatic people should be tested. Here in New Orleans, we know data from Ochsner shows us that 70 percent of people are asymptomatic at some point when they are infectious. So clearly you should be testing asymptomatic people. My husband tested positive for COVID and we tested all of the household because that’s important, because we know that many youth in particular do not have symptoms. And so what the CDC would then suggest is that we then unleash infectious children, potentially, into the community, potentially infecting then dozens of others. So it’s unacceptable, it’s unfortunate, and it’s sad. It’s a great institution and, and I hope that we can rebuild it. It’s a shame that there are policymakers who would be not brave enough to speak out against these types of political interventions in science.

SC-FLooking forward, are there ways for us to more generally improve testing?

RGYeah. I’m really excited about the saliva test and the antigen testing. I think Michael Mina has a lot of interesting ideas around antigen tests. I think we need to get away, somewhat, from these high sensitivity, very labor intensive PCR methods that are individual based and toward population testing. At LSU, we’re using antibody tests as an entree, which actually seems to be, in a community like New Orleans, a really good way of doing the testing. We’re finding that we’re able to catch a lot of folks who have COVID with antibodies. I think we’re learning a lot. This is certainly a renaissance in science. This is a great time to be in an academic medical center and be a part of solving these problems in a way that actually will save lives. I think we’re learning as we go, but I think the more we can get away from the painful swabs that go way up your nose, the quicker we’re going to have broad scale adoption of testing.

SC-FYou also work, from what I know, as a practicing physician as well. So how has what you’ve seen on the ground affected your perspective as a public health official?

RGI just see a lot of stress. This is a stress test, similar to pregnancy. I always talk about pregnancy as a stress test for health. COVID is a stress test on the problems of society. And what I’m reminded of, I’m a women’s health physician and gynecologist, is that women bear the brunt whether it’s of caregiving or schooling of children, and women are disproportionately impacted by COVID. They’re caring for parents, they’re caring for children, they’re trying to be teachers and professionals. And then, as a society, we have not invested in women. We have not invested in appropriate family leave policies, appropriate childcare policies, appropriate family supports, and women are paying the price for this. And I see it in the stress that they have when they come to see me and their mental health challenges that women are having, particularly young mothers.

SC-FI guess my last question to you is: Have you also seen the racial disparities affiliated with COVID playing out on the ground?

RGI led the governor’s task force on health disparities for his  COVID Health Equity Task Force. As I mentioned, I established an Office of Health Equity, the first in the South in a health department. Certainly our data show that disparities are persistent. The deaths are not as disparate as initially were reported. However, the deaths are still disproportionate and we’ve treated our essential workers as disposable workers. And we certainly saw people pay the price for that early on, where individuals who had to go to work, who are disproportionately people of color, did not have masks, did not have protection, did not have workplace safety, in the setting of a failed, in my view, leadership of OSHA and NIOSH, institutions that should be promoting workplace safety.

There hasn’t been a lot for people to grasp onto in terms of being able to have a legal framework for workplace protection, and particularly black women in New Orleans, they’re caring for parents, they’re caring for children, many single-parent homes. And this is the perfect storm environment for spread between you and elders and we do see the majority of our deaths are people who are older. So, again, I think also our stress test has shown us that the inequities in our society that African Americans disproportionately bear are leading to death. And we knew that before. We knew that with heart disease, we knew that with cancer, we’ve seen it with mental health issues and other challenges. And we’ve also long known about the role of implicit bias and racism in access to care and decision-making about patients and crisis standards of care, but COVID has reminded us.

And I think if there is a silver lining of COVID, I think those who didn’t understand that these things existed prior to COVID, now I think acknowledge this. I think we’re also in the midst of one of the greatest social movements in our country’s history and thinking about social justice and racial equity as a critical component of what needs to be learned from COVID, that we need to build systems back better, as a Vice President Biden would say. And that this is our chance to do it because a lot of things have gotten very broken. So as we build them back, we need to build them back on a chassis of racial equity, to think about the impact of family leave, and in addition things like fair and equal pay, sick leave. All of those things have impacts on health and the ability to obtain optimum health.

And if people are not interested in social justice and they don’t care about racial equity, those who just selfishly care about their own health ought to care about it, because we now know that the health of one person in a community impacts or could impact the health of the entire community. So I do think there’s been an opening, that people’s minds have been opened about racial equity in light of COVID. So my hope is that the groundswell and the support that has developed for COVID—including the governor’s, which was the first ever having a task force on equity in the South, the governor insisted that we have that and there was very broad support for it—will continue and that we shouldn’t forget that this is just the beginning.

Read more about COVID-19drug pricingInequalityMedicaidPublic HealthRacismsexism

Rebekah Gee is a physician and public health expert who served as the secretary of the Louisiana Department of Health from 2016 to 2020. She is currently the CEO of LSU Health New Orleans' Health Care Services Division.

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