The country is shut down, the city and county are shut down. This unyielding novel coronavirus is driving every public and private narrative from Presidential press briefings that sometimes raise as many questions as they answer, to chats with friends and neighbors at least 6 feet apart.

Ever-mysterious, COVID-19 traffics in the unknowns. In misunderstandings and misdirection.

Vanderbilt COVID-19 model predicts best scenario of mid-May statewide peak, encouraging Shelby numbers

Health Department: COVID-19 surge expected in late May or early June

If the phrase “there is no playbook for this” has become worn, it is because in just a few words it captures the challenge in strategy and tactics.

Rule 1 of a pandemic: When fighting an “invisible enemy” you can’t know what you don’t know until, through trial and error, you discover what you didn’t know.

“It’s just part of the deal,” said Shelby County Health Department Director Alisa Haushalter. “In the moment, you have to make a decision.

“To not make a decision is its own decision. We’ve done what we could at each stage based on the data we had.”

Post 9/11

Here’s a truth that probably hasn’t even crossed your mind: The current crisis, which requires Haushalter to be part of daily media briefings and front-and-center as one of the most recognizable faces and voices among local leaders, is the antithesis of how public health department people usually operate. 

Haushalter has worked in public health almost 40 years. Normally, she and her staff go about their business, say trying to lower Memphis’s high rates of hypertension and diabetes (especially among African Americans), and obesity among us all, behind the scenes.

“If public health does its job well,” she told The Daily Memphian in an exclusive interview, “you generally don’t know we exist.” 

Now, though, we need to hear from them. Haushalter has fought public health crises before, disasters of varying and sometimes acute scale, but not this exactly.

Ever since 9/11, public health departments have been more aggressive in preparing for worst-case scenarios. Terrorism, tornadoes, hurricanes, floods and earthquakes. Outbreaks of measles or tuberculosis. And later, the rising tide of the opioid epidemic.

Eventual trouble is a given. And infectious disease trouble was, in a manner of speaking, bound to be in the air sometime.

“We always knew a pandemic would be coming,” said Stephanie Bailey, who formerly led Nashville/Davidson County’s health department and, a few years ago, was Haushalter’s supervisor there.

Until recently, Bailey was strictly serving in her capacity as a senior associate dean at Meharry Medical College in Nashville. For the foreseeable future, she is back at the metro health department because there is a need.

Not to imply that the pandemic or those fighting it are on a sinking ship, but all-hands-on-deck is a working philosophy.

In Memphis, in Nashville, in New York, everywhere.

The process

If you’ve seen one of Haushalter’s press briefings, then in some ways you have seen them all: With her hair pulled back in a bun, large glasses framing her face, she is serious, stoic.

She stands at a lectern and provides updates and takes questions. And everything she says, or doesn’t say, is influenced by public health protocols. Everything is girded with beliefs she might not always articulate to the public, such as:

“You can’t make decisions yesterday based on what (data) you have today. You make decisions on what you have at that time”

And …

“You can’t do contact investigations until the first case.”

Some see her steadfast persona as a strength.

Others have wondered if it is more a symptom of a leader who is hesitant and, in another phrase of our times, “behind the curve.”

For some questions, she gives precise answers and numbers.

For others, she has given explanations that haven’t always satisfied those asking the questions.

Some people see that as her doing her job, expertly walking the tightrope between public health policy and politics/optics.

“Unflappable,” said Shelby County Mayor Lee Harris.

Critics, especially some in the media, believe the health department either has intentionally withheld pertinent information or at least not been capable enough at collecting, aggregating and disseminating it.

The COVID-19 pandemic, then, was made for playing Monday morning quarterback – and every other day, too.

Haushalter gets it – at some level – and says when any pandemic is over, there is a thorough “hot wash” when everything is up for inspection to provide a better, informed response in the future.

Until then, it’s a micro-approach that in real time might be absent some data that years down the line no doubt will be considered crucial.

“Every day there’s a need for self-reflection,” she said. “What did we do well? What could we do differently?”

The path here

Every era has its public health mountains to climb.

“My grandmother was a psychiatric nurse, worked with a lot of Vietnam veterans and substance abuse disorder,” said Haushalter, who grew up in Pittsburgh. “This was the '60s – LSD and other things. She enjoyed doing that (work), and the patients she served.”

Those patients, Haushalter remembers, would later thank her grandmother for her role in – no exaggeration – saving their lives. It was proof that her impact as a psychiatric nurse wasn’t trapped in a moment, a month, or even a year.

Haushalter considered medical school before setting off for nursing school. She earned her undergraduate degree in nursing in 1983 from Belmont. By 1997, she was completing her master’s at Vanderbilt, and in 2007 she received her doctor of nursing from the University of Tennessee Health Science Center (UTHSC) College of Nursing.

She moved up the public health ranks in the Nashville/Davidson County department under Bailey, worked in a leadership role for the private Nemours Pediatric Health System in Delaware, and then in 2016 joined UTHSC as an associate professor of advanced practice and doctoral studies.

That same year, then-Shelby County Mayor Mark Luttrell appointed her director of the Health Department. Bailey says she was “proud” when Haushalter received the appointment, adding, “I always say there’s a bell curve of people (in any organization). On the right side, are the people that get it and are self-directed, strategic. That’s where she falls.”

Erin Carroll, community resources coordinator at Nemours, reported to Haushalter for about three years. She says Alisa the person, and Haushalter the leader, are one and the same: “honest, kind, humorous and humble.”

Which is not to be confused with being a pushover.

Carroll says when confronted with a problem, Haushalter doesn’t just go along with the popular “agree to disagree” refrain.

Rather, it’s “Let’s see how we can be productive out of this disagreement,” Carroll said. “She would say, 'We need to pierce the edge.’ And what she meant was, we need to push the limits in a mindful and responsible manner.”

Haushalter credits Bailey for showing her how to engage in open dialogue and be receptive to change, or as Haushalter said, “How to have difficult conversations and stay present with someone.”

The person who knows her best, husband David Mills, also is UTHSC’s director of government relations. Beneath every one of her conversations, decisions and actions, he says, is a foundation built on rock.

“She’ll never compromise on principles,” he said, “but she will compromise on practices or program.

“Once you compromise your principles, they’ll take you out. Even at the highest levels. Bill Clinton, Richard Nixon, whatever it is.

“Once you’ve crossed that line, you can’t get it back.”

Big data, huge challenges

The numbers are staggering.

As of Friday, April 10, data from The New York Times showed more than 1.6 million COVID-19 cases globally and more than 100,000 deaths.

In the U.S., there were almost 18,000 deaths; only Italy has reported more.

During Friday’s city/county briefing here, the Health Department reported 1,049 confirmed cases in Shelby, and Haushalter said there were 26 fatalities.

Further, out of 11,495 tests given, the 1,049 positive results equated to 8.8%; more than 10,000 tests, or 91%, have been negative.

With COVID-19 tests out, number of cases uncertain

But just as the numbers spin daily, so do the opinions about what could have and should have been done and when; what could be and should be done now and going forward; and how effectively everything is communicated to the public.

When the first confirmed case was reported here, on March 8, Haushalter said there was “no community transmission.”

In her mind, the statement reflected that the first person diagnosed traveled to New Orleans for Mardi Gras. And New Orleans already was on the national public health radar as a place where there were COVID-19 cases.

“The context is based on information at the time,” Haushalter said. “They always evolve. At the time, we knew the first case absolutely was related to travel. We also knew the second case was absolutely connected to the first case.

“The information should allow people to make choices, be actionable. There wasn’t a risk of communication if they went out in public. It was a risk if they traveled.”

Hear the echo? Her decision on what to say March 8 was based on the limited data they had at that time. The first case had just been discovered, and so the first contact investigation had not begun.

But as the pandemic’s storyline unwound, many public health officials across the country, including Haushalter here, found themselves increasingly changing their stances.

First, testing was reserved for those who clearly had what Haushalter subsequently called “loud” symptoms, such as a fever and a dry cough.

Later, there was a move to ramp up testing. Although even then the tests did not seem as readily available to poorer members of the community. In many cases, those people are without health insurance, reliable transportation, and continue to be put at risk working low-wage “essential” jobs.

Testing sites have greatly expanded in Shelby County, but she says the CDC does not recommend random mass testing: “You don’t go to a provider’s office to get tested for flu unless there are signs and symptoms or you’ve been around somebody that has the flu.

“It’s not that you need to test more people,” she said. “It’s that you need to make testing available to more people.

“It’s an access issue.”

Differing views

A student of history – especially where it intersects with public health – Haushalter once visited the village of Eyam, site of the first case of the plague in England.

When she moved to Memphis, she wanted to learn all she could about the city’s Yellow Fever epidemic, which peaked in 1878 and killed thousands. 

140 years after yellow fever, surprisingly little has changed

“People with more resources and people who don’t have resources have different outcomes,” she said. “With Yellow Fever, people who could afford to move, moved. During the current pandemic, people with more resources are more likely to get tested.”

This is why she counts among the “small wins, people who can’t afford testing and our staff going out of the way to make sure they get tested; and watching our staff step up and exhibit leadership skills, or people having to transition from working in health promotion to infectious diseases.”

Critics, however, say data has been lacking or was slow to be made available – be it the number of people tested, the locations of those who tested positive, or the person’s race. The Health Department released a map showing confirmed cases by ZIP codes, but partial race data wasn’t made available until last week.

First local COVID numbers on race confirm disparity in virus spread

“Unfortunately, much of our race data has been missing for a variety of reasons,” Haushalter said at one of the media briefings. “That’s one of the pieces of data that’s not necessarily on the report.”

Specifically, she said race is not on the lab report. The Health Department’s contact investigators are trying to bridge the gap and determine race. Once partial race data was made available, it showed a disproportionate number of African American testing positive here (68% as of last Friday) and dying from COVID-19 (71% of deaths, as of Friday).

Multiple media reports, however, either stated or inferred that race and other data was held back by the Health Department.

“I’m fairly transparent,” Haushalter told The Daily Memphian. “I don’t have any reason not to be transparent. To say I refused to release data is inaccurate. That’s absolutely not correct.”

During Friday’s briefing, she released data on gender (53% of confirmed cases were females), on age (70% were people ages 21 to 60), and said currently 500 people are under quarantine following contact investigations into almost 2,000 cases.

Haushalter did not release through the Health Department numbers on people hospitalized and the number of those requiring ICU beds and/or ventilators. She reiterated to The Daily Memphian that those numbers come from a state tracking web site intended for planning purposes and that the county is not permitted to release the numbers.

Metro hospitals release ICU, ventilator counts; Health Department refuses

But Baptist, Methodist, Regional One and St. Francis hospitals did release to The Daily Memphian the counts of those hospitalized, in ICU, and on ventilators.

Haushalter said that the reports alleging information was held back from the public were “demoralizing” to her staff.

“For me, personally, as a leader,” she said, “I recognize reporters are going to have the narrative they have.

“Like anything in life, there are multiple perspectives.”

A little personal

Disapproval has not been limited to the what, when, where and how of making data available.

“I’ve gotten feedback that sometimes I haven’t worded something in the best way,” she said. “Or that I’m too calm in the way I speak.

“If I view myself as a public servant-leader, then it’s critical I’m open to feedback. I’m here to serve.”

She even has questions she asks herself: “Am I role-modeling for team members? Am I showing up early and staying late? Am I being sensitive to the emotional toll this is taking on them, knowing they all have families?”

Her defenders are staunch. Yet there is a degree of understanding about the near-impossible task she has.

“I don’t know of anybody in this situation that can get 100% support on everything they do and everything they say,” said Carroll, her colleague at Nemours in Delaware.

“There’s a lot of pressure to be perfect in the moment,” said Harris, the county mayor. “She doesn’t break a sweat.”

Harris adds that balancing policy and politics is also an impossibility.

“They’re in direct conflict,” he said. “The public wants officials to defeat this invisible and infectious and deadly virus. And policy suggests you can’t do that. You have to do containment and contact tracing – that’s the detective work; if you do that well, you slow the spread. And it’s hard, methodical work, inch by inch.

Mining the mundane: How local investigators track COVID around Shelby County

“You’ve got to have thick skin,” Harris continued, “because people expect you to defeat the virus yesterday.”

If that’s beyond nonsensical given what we know, then the idea that Haushalter is “too calm” is perhaps more puzzling – at least to those who know her well.

Her step-daughter, Ann-Kathryne Mills, is attending New York University, pursuing a master’s of fine arts in acting. Thus, she understands something about stage presence and audience response.

“I can imagine it’s disconcerting to see someone so calm,” she said, “but you’re also trying to combat panic, which can lead to worse outcomes.”

Bailey, Haushalter’s old boss in Nashville, is more direct: “Everybody wants somebody frantic in leadership? Yeah, I’d push back on that.”

Harris was especially upset with what he deemed harsh pieces in The Daily Memphian and The Commercial Appeal about withholding data after the release of what racial data they had to that point.

“It definitely ticks me off,” he said specifically of criticism aimed at Haushalter. “I believe it to be unfair. We cannot be in better hands than we are with Alisa Haushalter. Does everybody make a mistake here and there or have a different opinion? Sure.”

He added that upon assuming his elected position, area hospital leaders, including one high-profile local physician, were “effusive” about the job Haushalter was doing.

“Some of these people are prickly,” Harris said, “and they basically said, 'Yeah, I don’t like a lot of people, but you gotta keep Haushalter.’”

Putting her life on pause

Every one of us is giving up huge parts of our lives, things we love to do.

Between them, Alisa Haushalter and David Mills have five children and 10 grandchildren. They like to travel, take their Irish Doodle Aiofe for long walks (Aiofe means “Warrior Princess” in Irish legend), and in normal times they would be doing all this and more with nary a care.

“Laughter, tears, little scrapes, riding bikes, eating ice cream ... simple pleasures,” Mills said of their time with the grandchildren.

All that must wait now.

For Alisa Haushalter, director of the County Health Department, the day starts at around 3 a.m., has her out the door of their Bartlett home by 5, and then it’s go, go, go ...

Mills tries not to nag her, but he knows she often won’t take time to eat. Maybe she’ll allow herself a moment to sit outside, soak up a little sun and enjoy nature.

She’ll return home after a day that stretched 15 hours, or sometimes 18 hours. His job, he says, is to make sure she walks into a clean place and with dinner ready. She might just want a salad or, as happened the other night, he might have been poised to prepare an elaborate meal only to hear her say, “I just want a juicy hamburger.”

So, back to the store he went for ground beef. Whatever it takes to provide a little comfort.

They’ll eat, adjourn to what they call the “hangout room,” and maybe they’ll flip on one of those forensics investigation shows – she can appreciate that at some depth – but more likely, she’ll settle into her chair, put her feet up …

“And she’ll be gone,” he said. “Her head will tilt to the side, she won’t last five minutes.”

Too soon, though, the pings will begin. Text messages and emails from just about anyone you can imagine: Harris, one of the suburban mayors, the director of the Tennessee Health Department, a Shelby County commissioner …

She’ll jerk awake, respond where she needs, then drift away again. Finally, she will head to bed and, if she’s lucky, get five or six hours of sleep.

Then it starts all over again.

Common sense would suggest that it could leave her own health at risk.

“She needs to put her oxygen on first,” Bailey said. “You can tell her that for me.”

In it for the long haul

COVID-19 is vicious, an adversary that remains as it ever was: insidious, highly infectious, heartless and, so far, unyielding.

Still trafficking in misunderstanding, misdirection and unknowns.

“It causes a lot of fear and anxiety,” Haushalter said of the effect on the people she serves, but sometimes in quiet moments, it must be no less true for her.

On Friday, she reaffirmed the imperative that is social distancing as the public health community and each individual citizen partner to try and wrestle this beast to the ground.

“Professionally and personally, she’s a caregiver,” said her step-daughter.

But Haushalter, like any public health leader, is dependent on the resolve of the people to faithfully stay this mind-numbing course.

Meanwhile, more criticism is bound to come. It goes with the territory.

But she will accept the feedback, even when it is sharp.

“It doesn’t mean,” she said, “the feedback isn’t sometimes painful.”

It is not, however, what makes for fitful sleep.

Because she chose this. Having left the public sector for the private sector, she came back to it when she moved to Memphis.

“I’m much more mission-driven, care about outcomes for people,” she said. “Does it mean I’m perfect? By no means. Does it mean I don’t make mistakes? By no means.”

Said Carroll, her colleague in Delaware: “She’s very passionate about this and it’s very heavy on her heart and mind. I don’t think (second-guessing) is what bothers her.

“What bothers her is people are sick and dying and she wants to be part of the solution.”

The way, two generations ago, her grandmother, Katherine Haushalter, was when working as a psychiatric nurse treating Vietnam veterans and people with substance abuse disorders.

Different time, different mission, same resolve.

“Alisa is fiercely committed to her calling,” said her husband, David Mills. “That’s what this is, a calling.

“And it’s not her first rodeo. She was made for this time.”