How Karen Hacker worked to resuscitate the Allegheny County Health Department

As her tenure comes to an end, a review of the director's efforts to address air quality, opioids and lead while facing political pressure, legal limits and organizational dysfunction.

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Allegheny County Health Department Director Karen Hacker (Photo by Nick Childers/PublicSource)

When an electrical fire broke out on June 17 at the Clairton Coke Works, damaging the plant’s pollution control equipment, it was a defining moment for Allegheny County Health Department Director Karen Hacker.

She had just announced that she was leaving at the end of July to become director of the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention [CDC], almost exactly six years after she was hired.

And so her response to this second fire at the plant in six months would likely be the exclamation point to the changes she’d brought to the health department during her tenure — or highlight how much more was yet to be done. The health department had received some of the most significant backlash of her tenure after a similar fire at the plant on Dec. 24 because it didn’t notify the public for 16 days that the plant’s increased pollution could harm vulnerable members of the community.

When Hacker first took the job, she said she was advised that she needed to figure out what she was legally allowed to do. This meant that many times when she wanted to address a public health issue, her staff told her no. She couldn’t pass a sugar tax to address obesity. The political will wasn’t there. She couldn’t pass a more complete ban on smoking because the law was under the state’s jurisdiction.

And when she asked her staff, “Can I close down U.S. Steel?”, the county’s largest source of pollution, she was told that would not be within her legal purview to consider. Instead, she built a legal department that could ratchet up the pressure on U.S. Steel. She issued a new civil penalty policy, increasing the severity of fines the company faced. And a couple of months after the first fire at the plant, her department threatened to shut down the plant’s coke ovens if it didn’t get its pollution under control.

On June 17, after the most recent fire, it took hours rather than months like it did after the December fire: Her legal department ordered U.S. Steel to fix its pollution problem in 20 days or shut down. A few hours later, the company had fixed its pollution control equipment and a legal showdown was averted. U.S. Steel did not respond to a request for comment.

The moment exemplified what Hacker and her champions in the county’s health community say defined her tenure: A doctor who used data to drive her decisions. A pragmatist who tried to get results even after the initial strategies proved untenable. A reformer who modernized the department so it was capable of taking on the area’s biggest polluters. And an ethically centered activist who would champion public health even if it meant taking an unpopular stance or confronting the powerful.

"She has been much more proactive on enforcement of air quality, including some of the biggest industries in the region,” said County Executive Rich Fitzgerald. "That is something that didn’t always happen in the past."

County Executive Rich Fitzgerald speaks to the media after Pittsburgh did not receive the Amazon bid. (Photo by Kat Procyk/PublicSource)

County Executive Rich Fitzgerald speaks to the media. (Photo by Kat Procyk/PublicSource)

But for Hacker’s critics, the June showdown was an atypical response that was a long time coming. They saw a leader who only in the last year or two had taken significant strides to address air pollution after public pressure had ramped up. To them, she moved too slowly and only after the political winds had changed. She had taken on the region’s cultural and economic behemoth — "the steelers" — but only after the other industries, such as tech and medicine, had diminished the company’s importance. And they’re not convinced that her gradual approach will lead to better health for residents.

"She wants an A for effort,” said Mark Dixon, an air quality activist in Pittsburgh. “And I want to give her an A for accomplishment. But she doesn’t get an A for accomplishment because health metrics haven’t changed that much. "

U.S. Steel's Clairton Coke Works plan in Clairton, Pa. The facility was the site of fires on Dec. 24 and June 17. (Photo by Varshini Chellapilla/PublicSource)

Hacker, the county’s highest paid employee with a salary of more than $220,000, said she thinks she should be judged on the progress she’s helped to usher in, including reduced lead poisoning in children, fewer opioid overdose deaths and a steady decline in air pollution that is on the verge of coming into compliance with the law.

A number of constraints made the work difficult.

The department she’d inherited was organizationally dysfunctional, county officials said. It wasn’t in a position to even apply for many big grants. Several key policies she wanted to champion were not under her legal authority, and she didn’t feel like she had the political or popular support to push them through.

She had to resist pressure from supporters of industry to focus on the health outcomes. And she had to withstand the continual criticism of activists who said she wasn’t doing enough and, she thought, didn’t understand the constraints she faced.

It was difficult to explain all of this complexity to the public.

“If it's this complicated for me and I'm health department director with a whole group of lawyers advising me, how do we then communicate this effectively to the public?” she said. “...And then the people think, ‘Well, you're obfuscating or you're making excuses or you're making things up.’ And sometimes it's like, ‘Well, maybe you should do my job for a little while. Then you'd understand it.’”

Inheriting a mess

The health department that Hacker walked into in 2013 was a mess, according to local health advocates, university professors and public officials.

The previous director, Bruce Dixon, who served for 20 years, said on the radio that the health department would never ban smoking in bars because of how it would hurt local businesses. That typified the previous director’s attitude that the county tried to change by hiring Hacker, Fitzgerald said.

Dr. Steven Albert, the chair of Behavioral and Community Health Sciences at the University of Pittsburgh, said he called up the health department under Dixon’s reign to ask about its data collection: it was primitive.

"I remember someone telling me, ‘We can tell you about the number of cases of tuberculosis but we can’t tell you anything about the major chronic diseases for the county,'” Albert said.

Hacker inherited decades of ineffective air quality enforcement, according to local air quality advocates. The health department would sign consent agreements with U.S. Steel but they would be routinely violated without real consequences.

Clean air seemed “totally unattainable" under the old health department, according to Ashleigh Deemer, the Western Pennsylvania director for PennEnvironment.

“The department seemed totally disorganized,” she said. "More than that, I think [Dixon] was under pressure to lay off of U.S. Steel in particular.”

And Hacker was walking into one of the biggest public health crises since the AIDS epidemic: a rapid rise in deaths from opioid overdoses.

“One of the challenges in public health is that you set your agenda... and then something happens external that you're totally not prepared for...” Hacker said. "And as a result, we really don't have a choice. We have to put our resources there.”

Organizational change

The health department’s dysfunction permeated the organization, Hacker said. Hiring took six months, and there were few applicants. The department employed one IT contractor for 400 employees, and the legal team didn’t have the skills or capacity to enforce the county’s health laws. She hired deputies with leadership authority to carry out the department’s work.

There had never been a community health survey, so the extent and location of the county’s biggest health problems weren’t clear and national health organizations wouldn’t give grants to fix problems that weren’t properly defined.

That meant that as the number of overdose deaths continued to grow each year of her tenure, there wasn’t good basic health data available about the county, let alone good data about the emerging threats of fentanyl. She helped facilitate the first behavioral risk assessments and community health surveys.

Her department created maps of health indicators across the county, which showed a disproportionate amount of the health problems were focused in high poverty, black neighborhoods and, increasingly, in the small municipalities in the Mon Valley.

Hacker said she thinks she should be judged on the progress she’s helped to usher in, including reduced lead poisoning in children, fewer opioid overdose deaths and a steady decline in air pollution that is on the verge of coming into compliance with the law. (Photo by Nick Childers/PublicSource)

This emphasis on data allowed her to get out in front of the public to tell the story of the opioid crisis better, said Rosa Davis, the chief executive officer of POWER, a residential treatment facility for women. Davis would see Hacker speak at more than a dozen opioid events, trying to hit on the humanity at the center of the opioid crisis.

“When you start reporting 400 overdose deaths, 600 overdose deaths, 900 overdose deaths, it can be easy to forget that those are real people,” Davis said. “And she didn’t do that.”

Hacker also used her medical authority to argue for controversial but evidence-based approaches for treating addiction with medications, Davis said, as well as pushing for the availability of Narcan (an overdose antidote) to save lives. These are relatively widespread beliefs now, Davis said, but at the time Hacker had to fight against the perception that Narcan would make drug users take more risks.

"People were saying three times and that’s it, as if someone who was having a heart attack for being on a bad diet would only get three attempts at being revived,” Davis said. "I think by being in the forefront and talking about it constantly wherever she could, I think it helped educate the community."

In 2015, Hacker issued a standing order that anyone could purchase Narcan at a pharmacy without a prescription, five months before Gov. Tom Wolf issued a similar order for the state.

The county also contracted with Allegheny Health Network in 2015 to take over medical care at the Allegheny County Jail. Hacker wrote a letter to the warden supporting the network’s efforts to add addiction treatment services to the prison, said William Johnjulio, the chair of the network’s Primary Care Institute.

The previous healthcare contractor would treat the symptoms of withdrawal but it didn’t help patients resist addiction once they left prison, Johnjulio said. Hacker provided medical authority and political cover for the doctors to push the prison to offer medications to help them deal with their addiction like methadone, Johnjulio said.

"Karen helped validate that this is the right thing,” he said.

Hacker was out in front talking about opioids and coordinating with other agencies, said Marc Cherna, the director of the Allegheny County Department of Human Services, whose department handles the county’s drug treatment contracts.

By mid-2017, the number of fatal overdoses in the county started to drop precipitously. By the end of 2018, the number had fallen by more than 40 percent.

But Hacker wished there had been more funding available a few years ago when the department was desperate for extra money to address the crisis. When she inherited the department, she said, there was little attempt to get grant money. Now, the department routinely receives millions of dollars every year through national grants. And the department will learn in August if it will receive a $5 million per year grant from the CDC to help deal with the opioid crisis.

“It's a little bit late but obviously we will use it to the best of our advantage,” she said.

Like a lead balloon

As Hacker worked to get a handle on the opioid crisis, another health issue emerged: In 2016, Pittsburgh’s drinking water had too much lead in it.

The water crisis in Flint, Michigan, made this a volatile issue. The Pittsburgh Water and Sewer Authority [PWSA] had to start replacing lead water lines until the problem was under control.

The Pittsburgh Water and Sewer Authority's water treatment plant in Lincoln–Lemington–Belmar. (Photo by Ryan Loew/PublicSource)

The Pittsburgh Water and Sewer Authority's water treatment plant in Lincoln–Lemington–Belmar. (Photo by Ryan Loew/PublicSource)

During this time, Hacker said the best available evidence showed that, even with elevated lead levels in the water, the biggest threat to children was the paint in children’s homes. This was controversial.

“What frustrates me is when facts don't seem to matter,” Hacker said. "I went out and said that, ‘Hey, we have a problem with water but the fact is that our bigger problem is with paint.’ It was not met with a, ‘We agree with the doctor.’ It was met with, ‘No she doesn't know what she's talking about.' And that's frustrating."

The director of the PWSA, Bob Weimar, said he believes that Hacker's balance showed leadership. "She wasn’t taking political heat for us but was trying to put the problems in perspective so people could appreciate that...the panic that people were feeling was not appropriate.”

Robert Weimar, the executive director of the Pittsburgh Water and Sewer Authority. (Photo by Ryan Loew/PublicSource)

Hacker helped speed up the inspection process so PWSA could replace lead lines more quickly, Weimar said. The department helped PWSA identify which children on which streets most urgently needed lead line replacements, so the agency could help the most vulnerable children first, Weimar said.

In 2018, the county instituted a universal lead testing policy for infants and preschool children. The department lowered the threshold that triggered a home inspection, so that more children with elevated lead in their blood would receive help.

Hacker added two additional inspectors to take on the additional work and began testing for lead in the water. These tests confirmed that lead in the water wasn’t the main source for childhood lead contamination, Weimar said.

Nobody taught Hacker about lead in the water when she was being trained, she said. And now she receives requests from directors across the country asking how she was able to achieve so much progress. Although lead wasn’t in the county’s initial health plan, because children’s lead levels had already fallen so much, she realized there was an opportunity to make further progress.

"I always say to people, when those windows open you better jump through because you don't know when they're going to close again,” she said.

“This is the nature of public health, which is that it's public. ...You do have to attend to people's concerns. And there is no question in my mind that people [have] anxiety about having water, which they consider to be a right and which comes into their home every day, [that] is tainted, and that is scary."

Air inequality

When Hacker was hired, she admitted that her knowledge of environmental health issues was limited.

And she was walking into one of the most challenging situations in the country, she said. “We're downwind from Ohio. We have a valley. We have the worst possible conditions for air quality that you can imagine,” she said. “And we have all this industry.”

She recognized that industry was a big source of pollution. But the department might jeopardize its ability to function by moving too quickly, she said.

"Are we going to end up in court for the next 20 years because what we did was totally out of our jurisdiction?” she said. "How does that then serve the population of Allegheny County?"

Her new legal team allowed her to eventually increase the size of penalties for pollution violators, instituting the first $1 million fine in the department’s history against U.S. Steel.

And while Hacker hears the calls to close down the Clairton Coke Works, she said, she doesn’t think it’s her authority. The company’s pollution record is getting better, she said.

"If they're showing improvement, it's pretty hard to say you're not going to work effectively with them and you're not going to permit them,” she said.

US Steel’s Clairton Coke Works (Photo by Ryan Loew/PublicSource)

US Steel’s Clairton Coke Works. (Photo by Ryan Loew/PublicSource)

The most persistently dirty air monitor in the Mon Valley came into compliance for the first time in 2018. And in two more years, if the trend continues, the county will no longer be out of compliance with the U.S. Environmental Protection Agency, she said.

"In the past maybe the health department was being more of an apologist for polluting industry,” said Rachel Filippini, the executive director of the Group Against Smog and Pollution. “And now they’re coming out with a harsher tone that they aren’t going to accept the pollution as readily.”

But Filippini said, "Proof is in the long run because talk is cheap.”

Some activists are concerned that emissions from the new Shell ethane cracker plant in Beaver County could deteriorate local air quality and undo any progress. But Hacker said her department modeled how much of the projected emissions would reach Allegheny County and the results were “negligible.”

Mark Dixon, the clean air activist, said he thinks the reason the department has become more aggressive on air quality issues lately is that the political winds have shifted. Lawmakers like Rep. Summer Lee (D-Swissvale) have displaced incumbents who were not as aggressive on air quality. And, he said, U.S. Steel has lost political clout as the region has diversified its economy.

Deemer, of PennEnvironment, said the Breathe Collaborative, an association of air quality organizations, made a deliberate effort to call out the health department’s lax enforcement six months before the department started ramping up its fines.

But air quality isn’t even the most important factor impacting the respiratory health of residents, Hacker said. The biggest killers in the county, she said, are diabetes, obesity and cardiovascular disease, all of which are negatively impacted by smoking, a problem that other cities have more effectively addressed.

“We have a tremendous interest in air quality,” Hacker said. "And, I'll tell you, very little interest it feels like in cigarettes. And yet we still have a very high smoking rate.

"I'm not suggesting that air quality doesn't have a role to play in lung cancer but if you look at the leading causes of lung cancer, the top nine of them are going to be cigarettes and probably 10 is going to be radon, which nobody else is talking about either,” she said. "And then air quality.”

As a health director, this has meant she has had to direct attention and resources to air quality, because it’s a bigger priority for the public, even though she would've liked to spend more energy on passing a tax on cigarettes and eliminating the exceptions that still allow smoking at many businesses in the county.

"I can go out there and talk about it but if the public interest is moving in one direction it's really tough to get people to refocus on something else,” she said.

The next director

The next director will have additional problems to address: The health department is creating a climate action plan, which will identify health risks as the temperature rises and the weather and ecology of the region change, Hacker said.

The higher temperatures could lead to worse air quality, additional allergens, more mold and increases in diseases like West Nile Virus. Hacker even wonders if it may explain the increasing detection of rabies in local raccoons.

“We may not be able to change the climate but we better be prepared for what the implications are,” Hacker said.

Over the course of her tenure, Hacker said she sometimes had to take calls from people who wanted to pressure her. And though she always pushed ahead, she said, she often had to find alternative tactics to achieve the same ends.

"I think there are always going to be people out there who think that they can yank a political chain to get what they want,” she said. "I am a very ethical person...I think it's really up to the individual in this position to hold their ground and do the right thing. But I also think it's up to this individual to figure out how to get it done. And sometimes that means a little bit more roundabout and not necessarily direct. I mean I've certainly known plenty of health department directors who have gotten axed.”

Hacker’s boss, Fitzgerald, said he never pressured her to change her approach. “I basically told [her] my request for her and the board is enforce the laws that are there and I think they’ve done a pretty good job of doing that," he said.

Filippini said she thinks steps should be taken to insulate Hacker’s successor from political pressure.

“Going way back, for decades, there has been political influence that has often left the health department weak and ineffective when it came to enforcing the law,” she said. “So, going forward, I certainly hope the new director and the board can be better insulated from politics and pressure that has pushed them to go easier on polluters.”

She said she doesn’t think county council members, who work part-time, have the bandwidth to provide the required oversight over the department’s air quality regulations.

But the amount of interest in air quality issues has surged in recent years, which has forced the health department to act. “There is a lot more air quality information out there, more people are talking about it,” she said. “More people are getting engaged in this issue than I’ve ever seen before, at city and county council meetings, writing letters to the editors.”

Mark Dixon, an environmentalist and filmmaker working on a documentary about Pittsburgh's air quality, takes photos at a climate change event at the Jewish Community Center of Greater Pittsburgh on Nov. 20, 2017. (Photo by John Hamilton/PublicSource)

The county cannot improve the health outcomes through regulation alone, Hacker admitted. “The political environment helps to create opportunities,” she said. "So there are things that we could get done that we couldn't have gotten done when I first started. ...There has to be leadership that puts pressure on the industry.”

For some activists, this cautious approach of waiting for the right political moment doesn’t sit well.

“We hire them to do this work — not to ask citizens to get more involved to get the pressure they need to make the change, but to clean the air,” Mark Dixon said.

For some, the full measure of Hacker’s legacy will depend on what happens next.

"If we get a new director that picks up on the positive progress we’ve seen and continues to improve on that and it results in cleaner air and better health outcomes, then we can credit Dr. Hacker for getting that started and really spearheading this cultural and operational shift," Deemer said. "On the other hand, if the next director does not continue this important work or backslides or doesn’t make air quality a priority, it will be a little blip on the radar screen."

Oliver Morrison is PublicSource’s environment and health reporter. He can be reached at oliver@publicsource.org or on Twitter @ORMorrison.

J. Dale Shoemaker contributed reporting to this story.

This story was fact-checked by Varshini Chellapilla.

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