Shane Hatchett
Principal and Founding Member, Advent Solutions
Former Deputy Health Commissioner Chief of Staff, Department of Health State of Indiana
COVID Time
A Day to Remember
When Indiana’s stay at home order went into effect, Department of Health Chief of Staff Shane Hatchett was caught off guard. Nonetheless, under the leadership of Dr. Kristina Box, the state’s public health agency sprang into action, often navigating public health guidance and socio-economic concerns.
“On March 23, 2020, when our stay-at-home order took effect, I recall very vividly that even that Friday beforehand I had gone out that evening with friends. Then we came to work Monday to see things had taken a whole different direction. It felt like that was a sentinel event when folks really stopped, looked around, and took a mental picture of like, ‘okay, this was the day things changed.”
“I’m not saying it was the wrong thing to do, or that I disagreed with it at all. I just didn’t see that in the tea leaves, and so it really changed overnight for me and for many of those at the Department of Health.”
“Then it was like, “What’s next? Where do we go from here?” Because the closest that I think any of us at the Department of Health had to touch upon was the 2009 swine flu epidemic. Then we were suddenly talking about something much greater than that. And we thought, ‘Oh, gosh! This has just boiled over the pot, and the stove is now catching fire. What do we do?”
COVID Time
I call it ‘COVID time.’ It feels like an accordion where things were simultaneously compressed, but so drawn out in memory. Nothing felt so intense and potentially hopeless as those initial 3 months or so.
“I think even the governor’s office – and to some extent some of us – had really hoped that once we got to May or summertime, the virus would burn out, and we would get back to normal by the end of the year. Obviously, we know now that that was never going to be the case. I think some of the wiser folks who looked back at the timeline of the 1918 pandemic realized it would probably be a two-to-three-year event for the response to seasonalize and no longer be as virulent and resource intensive.”
Like most states, Indiana had to develop a battle rhythm for their COVID-19 response. There were rocky moments, and part of Hatchett’s job was to keep cohesion amid disagreements.
“Very early on, (the response) was not a smoothly running machine. I think we did as best we could to try and keep that internal to the extent that we wanted to present externally a unified front. I think that’s very critical in a situation like this. Folks would set aside their disagreements in order to really show we’re in lock step.”
We had meetings and briefings, we dialed in on many of the national phone calls, and the State emergency operations center had been activated at a lower level. We had initiated an epidemiologist-led call line that suddenly grew into a full-blow call center to provide COVID information and authorize people to get tested. In the beginning, we were so limited in terms of the assays and the reagents, it was like having a golden ticket to get a COVID test if you had the right symptoms according to the CDC criteria. So much of this was constantly changing and evolving as we learned more. Once this reached a critical volume in terms of press coverage and infection rates, the whole scope of the response had to shift. It wasn’t about scaling up, it was about charting new paths altogether. We spent a lot of time cloistered in rooms trying to discern the goals and objectives so we could map our strategies to them. Looking back, it felt like a perpetual state of flux.
“There were (also) times when we had a fully baked plan, and, based on information or guidance that we received where something changed throughout the day, we had to scrap the plan and start over. Or we misunderstood and still had to scrap and start over. So, there were misfires and false steps. But ultimately it came down to us knowing the right checkpoints for the person who was responsible.”
Making it Happen
Hatchett observed a shift in mindset from the health agency serving as an information provider and a conduit for resources to a role where they were providing direct services.
“In Indiana, the state health department, for the better part of 30 years, had gone from being a direct provider to trying to have the local (health departments) take on that role. When we started talking about COVID testing and the ability to do more tests, there was a real question, ‘okay, we have folks who are concerned about getting sick from people who have died and how best to maintain the bodies because of the poor information around the disease and symptoms. So how do you educate folks? How can we get people tested and not expose the people who are swabbing, do it safely, and start to destigmatize this a bit?”
In April 2020, we built a testing plan and piloted it at a high school parking lot in Northwest Indiana. We were outside with clipboards, paper, and pens, taking information to collect demographics and symptoms because we had to start somewhere and low-tech was the quickest, easiest way at that point. But that spoke to the necessity and the ingenuity. Sometimes the most basic ways of doing things are the quickest ways to get them done right – not over-engineering something right out of the gate.
“On that first day we probably saw about a hundred people, and we were there for about 10 hours. That felt like success in the moment – that was a hundred people who had not been tested before, and we were giving them some sense of assurance. But we also had to ask, ‘is this the right number? How do we measure success here? What are we really looking to do? And how do we make this better?”
At that point, our governor and the state health commissioner were holding daily press briefings. We would watch those with great anticipation at the Department of Health, because we realized early on that’s where we sometimes got our assignments. After the first three days of that testing clinic, suddenly we found out we were spinning up four more the next week, and you learned to be really agile and say, “Okay, yes, ma’am, we’ll do it.” At the same time, it kind of speaks to how quickly things are decided on the fly without necessarily thinking through the logistics – maybe a lesson learned there to make sure the right folks are included along the way.
“In less than 2 weeks of us starting (the testing clinics), we digitized the intake process so that it was much faster. We had fewer samples rejected for poor quality, and it felt like we were making progress.”
Neighbors Protecting Neighbors
Communities came together to protect one another.
“A lot of what you might read about polio vaccination efforts in the 1950s includes people viewing the vaccination effort as a community service and doing something for your neighbor. To be witness to that and to have helped out in some small way was really impactful for them.”
In April of 2021, we held a vaccine clinic in Northwest Indiana. I was at Lake Ridge High School, which is a part of unincorporated Gary, Indiana and is a very impoverished area with low socioeconomic status and high unemployment. This community had so little, but they were adamant that they were going to get their community mobilized, and they were going to get them vaccinated. They asked if we could come up specifically with the Johnson and Johnson vaccine, so that they would be one shot and done, and they would make sure that people showed up.
“At that clinic, we vaccinated something like 2,300 people over 2 days, and it was amazing to see a community partner pull out all the stops. I mean, they literally rolled out the red carpet – because that was their school color – they were so hospitable, they were so thankful. They made it as easy as possible, from the superintendent of the district down to the school staff who are there over the weekend to help out. It really felt like a community event. “
During the vaccination effort in Northwest Gary, we had a waiting area in the gymnasium for the 15-minute clearing period for folks to make sure there were no adverse reactions. There was a woman who was a little outside of that, she was in kind of a back hallway. As I did a big loop around just checking on things, I asked if she was okay. And she said yes, she was just a little startled. I asked if she was feeling nauseated or anything, was it an adverse reaction to the vaccine. Then she said, No, honestly, she just wanted a hug. And I thought: here we’ve been at this grind for well over a year at this point, and this person had such a craving for human contact that, I can’t even explain it.
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I think that the politics and the vitriol that surround the pandemic and the vaccines and all that overshadows too many good things, where we just forget the basic principles of society and caring for one another.
Relying on the National Guard
As it did in many places, the National Guard stepped in with an adaptable workforce.
“A lot of our success I attribute to the leadership we had at the time, in particular the National Guard in Indiana who really mobilized without question and were wherever we needed them to be. They didn’t necessarily always have the clinical background that we needed, so we had to think through the training pieces, but in terms of having people power, they were there. When we had them as liaisons to nursing homes to try and help out with some of the challenges there, folks did that without question. They were at all of our testing sites and vaccination clinics, helping provide support. In fact, they were actually vaccinators. I just don’t think we would have been able to be as successful as we were without that ability to kind of tap into a transforming, dynamic workforce.”
They’re kind of like clay, and we turned them into what we needed to within reason. A lot of that goes straight up to our National Guard’s Adjutant General, who from the very beginning told Dr. Box and others, ‘I’m here to stand in the gap for you. Tell me what you need.’ But, he was also that voice of reason and calm at times to say, ‘We’re going to plan this out, I hear you, you want to go save the world. We’ll do that, but we’ve got to have logistics to do it.’ They were a reassuring presence to say, ‘we’ll get there, but let’s do it the right way.’
Victims of Silent Success
The governor designated the Department of Health to take on the lead operational role for responding to COVID-19. That didn’t mean they made all the decisions, but they were responsible for vetting and implementing them.
“You need to have a leader who isn’t going to be black and white on something as complex and nuanced as this. I think Governor Holcomb is happy to live in the gray and find that medium place, and Dr. Box was a little more black and white but was comfortable taking the cues from him and moving forward. It’s got to be some type of dynamic like that.”
“I can’t help but think there is a real power to having the right people in the right places and that relationship of trust and understanding. At the end of the day, Dr. Box was a good soldier. She would present a good argument and fight as long as she could, but once the Governor and his team said this was the plan, she did that. That’s what ultimately led to the trust and for them to say to her, “you’ve got this, go run with it.” Whereas folks in other states or jurisdictions might have looked to make a name for themselves, or to be so rigid as to think of it only through a scientific theoretical mindset. Dr. Box understood that there were still capital and lowercase P ‘politics’ at play, and to whom she reported, and found the right balance for that. I think Indiana really ended up in a remarkable place because of it.”
Even as health agencies designed flexible approaches for communities across the country to implement masking, testing, and vaccinations, public health leaders struggled to gain trust and deliver guidance in ways that took local autonomy and execution into account.
Public health professionals – and now I’m generalizing and almost even stereotyping, but I’ll stand by it – view the job as delivering the intervention and not necessarily stakeholder engagement and communicating that message. I’m not saying that every public health professional has to be out there with talking points, but the mindset of how and what we communicate will ultimately dictate our success.
“To the extent that we engage people and offer them autonomy, we can respect their dignity to make decisions, even if they’re not the decisions we would choose for ourselves. That’s how we’re going to get through this, and that respect and trust come through consistent presence, not just when bad things happen.”
Pragmatically, I think what would have been really helpful is if, particularly in Indiana, we had a consistent presence in messaging at the state and local levels. What we’ve been talking about a lot in Indiana, especially after the Governor’s Public Health Commission, is being victims of silent success.
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The reality is that, in many cases, we’ve been there the whole time. We just weren’t shouting it from the rooftops, or we were cloistered in our annexes in the bottom of the courthouse in the basement. It’s really important for us to think through as a public health profession how we can make sure that we are seen and trusted, and through that presence become thought of as a pillar of the community or a regular touchstone.
Public health leaders struggled with payment, reimbursement, and confusing payment schemes. In Indiana, they provided services first and asked questions later.
Public health and the Holcomb Administration, particularly with this pandemic, did the right thing by just saying “we don’t care what the cost is or how it gets paid for. We’re just going to go out and do the right thing.” So we went out and we were testing people without collecting insurance information. Then, we were out vaccinating people, but by that point we had realized, there might be an ability to at least charge for the administration fee. So, we tried to collect that for those who weren’t sure, and I think there’s a lack of clarity around the right approach; I don’t know that I ever saw CMS come out with clear guidance on some of this.
“To be clear, it is not a publicly funded health insurance issue, it’s system wide. Some insurers would have been governed by a state department of insurance but were not really paying the same amount of claims but reaping all sorts of benefits from that, while the State and the Federal Government were absorbing these costs. So it seems to me that there was a real shifting of demand there – it’ll be fascinating to see the retrospective on some of that.”
Because we had such a good relationship with our Medicaid agency, we could work with the Department of Insurance and with Medicaid programs to overcome roadblocks with insurers. In any case, we did not let the administrative barriers stop us from delivering critical services to communities across the state. It is the only time I’ve ever seen contracts and purchase orders move so quickly – which highlights the value of emergency conditions provisions to bypass onerous requirements in moments of true need.
Command and Control
There wasn’t a tried and true organizational blueprint for organizing a statewide response to a pandemic emergency.
“Candidly, there was a question, ‘okay, is it the State Emergency Operations Center or is it the Department of Health Operation Center for Emergency Preparedness that is leading this? Which is the tail, which is the dog, and who’s wagging whom?’ It really did take us a while to get into a good stride there. So I think that’s an opportunity for continued discussion and improvement.”
“There were so many growing pains at the beginning. Maybe that’s true in all cases when you’re dealing with such a novel challenge, but I think that for public health, in general, we will continue to struggle in terms of what a Department of Homeland Security, or a “general disaster response” structure looks like versus a structure for a public health emergency. Every State’s going to respond differently based on the political exigencies and dynamics of the day. But I think the federal government, especially through things like funding, will naturally drive that market.”
Perhaps it will always be a challenge based on personalities…but it did seem that, as we were looking back through FEMA and HHS/ASPR materials, there really was no good, true public health framework that matched what we were looking for. So maybe that needs to be built out.
Flashpoints
Like many health professionals, Hatchett struggled with some decisions he had to implement. In many cases, like with the mask mandate, he could see challenges when “guidance” became “requirements.” In others, like with Indiana’s COVID prevalence study, he could see knock-on effects that could have created community backlash and bioethical challenges. He and his team stayed in the fight to shape the outcome.
I think Indiana experienced the “customary flash points” of closing things down, the masking mandate, and I was the one who actually signed all of the public health orders related to closures. It did feel like there was a change in the whole tone and tenor around the pandemic once masking became a requirement, or even recommended. In Indiana, the Governor linked it to the Emergency Management and Disaster law. There was an enforcement provision that said that if you violate the law or a declaration under it, it would be a class B misdemeanor, which comes with a $1,000 fine. Because of that, people suddenly felt like some sort of authoritarian leader had taken over and that we were ruling by fiat. Nothing felt the same after that, in terms of how we suddenly had to think about communicating through things, and I think even how receptive people were to public health messaging.
“It just felt like that was a real turning point, that it finally turned the tide emotionally in terms of the public’s ability to endure something like this over a long period of time. But that’s certainly my opinion on how it was in Indiana.”
Where I live in Indianapolis, Marion County’s local health board issued its own mask mandate. But the Governor’s statewide mask mandate became very politicized. Whenever we were traveling outside of Marion County, you could tell what the volume of compliance was like and that would give you an idea of how to approach your messaging and conversations.