Dr. Karen Shelton tours the Feed More food bank warehouse in Richmond. Shelton, a native of Bristol, was named the state's health commissioner this spring. Photo courtesy of Virginia Department of Health.

For 19 years, Dr. Karen Shelton was an OB-GYN in Bristol. She delivered babies for many of those years before her career took an unexpected turn toward public health.

Dr. Karen Shelton. Photo courtesy of Virginia Department of Health.

During the height of the pandemic, and while the substance abuse crisis raged, she headed up one health district and was acting director of two others in Southwest Virginia.

The Bristol native then served for about a year and a half as vice president and chief medical officer at Bristol Regional Medical Center before she was plucked in April by Gov. Glenn Youngkin to serve as the state’s new health commissioner, heading up the Virginia Department of Health.

She has been on the job since May 1. She moved to Richmond but returns frequently to Bristol, where she still has family.

Recently, she talked to Cardinal News about what she has learned in her first months on the job and what are the state’s most pressing health needs. This interview has been lightly edited.

What are you learning are the state’s biggest health challenges?

The biggest health challenge is a lot of what we dealt with when I was health commissioner in the Southwest. The substance use crisis is also a statewide crisis and even a national crisis. As we look at substance use disorder, as we look at the opioid crisis, the overdose crisis, the fentanyl crisis, there’s so many aspects to this we see happening at the state level, so Southwest is not alone and unique in that.

It looks a little different in different areas of the state, but for the main part, it is still at work across the state, and so many of the things that we’ve already championed in the Southwest are great things that are now going on in the state as well, and the state has promoted them all along. Having naloxone available in communities, making sure that that our local communities are educated about substance use. So many people feel they’re alone or their family is alone as they go through addiction or have a family member who struggles with addiction or crisis. As we educate people and talk about it, it really helps people to open up and seek help and learn what they can do to promote health, even within their communities.

Another thing that we’ve talked about, and it’s related to substance use, is our mental health crisis. We have so many people who struggle with mental health, and much of that also contributes to substance use as well. So we’re very thrilled about the governor’s initiative. Since he’s come in, he’s been working very hard on the Right Help, Right Now initiative, which makes sure you have someone to talk to when you need to, someone who could help you respond and someone who helps you go where you need to go to seek mental health. We’re very thrilled about the initiatives. In some places in the state, they’re further along than others. … I think a big push is the 988 hotline for mental health crisis and suicide crisis. I really feel that people’s awareness of mental health issues has been a huge part of this campaign. It’s kind of like substance use: A lot of people struggle with mental health, but no one talks about it. …

There’s a lot of other great initiatives that are going on that the Health Department is working on. Some came through the governor’s initiative, Executive Order 26 [designed to strengthen Virginia’s interdiction and enforcement response to the fentanyl crisis], working on the naloxone distribution plan for the state; looking at expansion of comprehensive harm reduction; looking at media campaigns, again for awareness; looking at wastewater surveillance, how can we tell communities where there might be an increased use of substances and where we can go in and provide more prevention, education and naloxone; looking at fatality review, people who have passed away from an overdose crisis, how do we intervene earlier and make a difference and save those lives? … 

And then there’s the data-sharing agreement between multiple agencies, whereby we can learn from each other about where people are having more issues with crisis and to help. It’s called the Framework for Addiction Analysis and Community Transformation, FAACT.

Dr. Karen Shelton met with students and faculty of Radford University’s public health programs during the Virginia Public Health Association annual conference in September. Photo courtesy of Virginia Department of Health.

Has there been any improvement in the substance abuse crisis, particularly in Southwest Virginia?

One thing we always look to is how many overdose deaths have there been. And unfortunately, we’ve been going up every year. When the crisis was first declared in 2016, we had a lot of initiatives at the end of 2016 and into 2017, and I think it was by 2018 and 2019, we were seeing a little downturn in the total number of overdose deaths. However, those numbers picked back up again and so, unfortunately, we’ve not seen them go back down.

I think a bigger problem that we’re having now is the influx of fentanyl. We had some of that back in 2016-17, but a lot of what we experienced early on, especially in Southwest, was prescription pill use. There was education for health care providers and there was looking at the establishments that weren’t providing appropriate services and getting rid of those as we turned toward that.

Then what we know is that sometimes there is a turn to other substances. So, we look at the heavy market now on fentanyl. When you got a prescription pill, you knew exactly how much you were getting. When you buy a pill off the street, you don’t really know what’s in it. And so now they’re being mixed, not only in pill forms, but also in things like methamphetamine and cocaine. Over 70% of [overdose] deaths last year in Virginia were associated with fentanyl.

I think that’s what is really taking the crisis further, especially the death part. So, we’re still working on it. … Naloxone is a wonderful tool to have people aware and ready to give if they see someone in overdose crisis to prevent that death. As we look at other numbers, how are we making a difference? We would want to look at things like treatment centers now. That doesn’t mean there’s less people in addiction, but how are people in addiction able to find help? We have more medically assisted treatment centers, and there are also some non-medication-based treatment modalities available as well for those who choose that. We have more drug courts across Virginia to help triage people into appropriate care. … We have a lot more services to help people in addiction, and I think we have a lot more paths and referrals that we can give.

What was it like to be director of the Mount Rogers Health District and acting director of two other health districts for seven months during the COVID-19 pandemic?

I guess you would call it the pinnacle of public health. It’s a pandemic. It was interesting because you could see it coming, COVID, when it first started to ramp up worldwide, and so you could watch it coming and then begin being prepared for what was coming your way. It was frightening, really. But it was a moment to really step up and say, “This is what we are here for. We are here to protect the health of our community.”

We stood up as a leadership team and we looked to our state for guidance, and as a local leadership team we prepared to lead the communities through the pandemic. When it started, I don’t think anyone knew how long it would last. I mean, the projections that we had at the time was it’ll come, and it’ll be a month and it’ll be over. But after the month came and went, things were just beginning.

We were going to be in this for the long haul, and it was very difficult because there was so much fear in the community. We were trying to educate people and there was a lot of the unknown. I think the greatest fear was the fear of the unknown — what was this new novel coronavirus? How were we going to combat it? How are we going to keep people safe? How are we going to get through the stages of it?

This is public health. You have a disease, you do surveillance, you need to test for it. You need to make sure that people are in isolation if they’re sick. Because we were still learning about how the disease would spread.

Then we were working so closely with our communities, our local governments, our schools, our businesses about what do you do when you have a case and how do you prevent the spread of the cases and how do you clean to make sure that you’re doing all these things. There was so much community education at that time. And then we were able to pivot when the vaccines became available, and the real hope of being able to give the vaccine when it first came out for this disease and to give that in our communities to those who needed it.

We looked at outbreaks going on in nursing homes and how devastating that was. So we began to roll out vaccinations throughout the state. Being able to provide the vaccines was a wonderful experience. There were so many questions about the vaccines, and we had to really work with people as far as their fears and concerns and educate them about the vaccines. Was it right for them? …

It was a very challenging time to be in public health, but also a very rewarding time because we did what we could to help protect the community.

Dr. Karen Shelton gets a flu shot at an event last week. Photo courtesy of Virginia Department of Health.

Recently, there’s been an increase in COVID-19 cases due to another new variant. How big of a challenge is it going to be going forward?

COVID has now become what we would consider endemic. It’s in our community now. It’s in our population, just like flu, just like colds, just like other diseases. COVID has now just become part of life, unfortunately, but even though we have experienced an increase, and it has been about 20% statewide, this is not nearly on the scale of what we’ve experienced over the last three years. Even this uptick is nowhere near where we’ve been before. So this will probably be more about how it settles out; some of the predictions going forward are that it will come and go.

It seems to like to go up right around this time. In the last few years we’ve had that little increase around in the August and September time frame. The kids have gone back to school, people are going back indoors. We have holidays coming, we have families gathering. But at this point, people need to live their lives. They need to gather with their families, they need to be in school, they need to do all the things we did before. …

I think it’s just something we have to learn to live with. Our messaging is if you’re sick, you should stay home. We should do that with any illness that we have, specifically if you’re running a fever. You should stay home. Nobody wants your cold or your flu or your COVID. … If you’re out and about, make sure you cover your cough or sneeze with your hand or your elbow. Make sure that you use hand sanitizer and wash your hands frequently. The good thing is that hand sanitizer is effective for COVID. And we recommend cleaning of surfaces and that sort of thing. But it’s just really that people need to take care of themselves. Unfortunately, COVID is just part of our community now and we need to live our lives and go on.

How does a doctor go from delivering babies in a private practice to being the state’s top health official? Did you foresee your career shifting to public health?

No, I didn’t. It’s been a journey, I have to say. I call it my journey of life. I practiced for 19 years as an OB-GYN in Bristol; actually the last few years of my practice, I did GYN only. As I was in my career, I decided it was time to do something different. I had become involved in my local hospital, Bristol Regional, in an administration-type duty that was department of surgery chair. I enjoyed working kind of outside my clinic, and looking at other aspects of health care really opened my eyes.

I mean, as a doctor, in practice, I was really focused on that one-on-one patient relationship, which is a great foundation in health care. And I really enjoyed my practice there. But as I began to look around and see health care in general, I realized there were a lot of other things in health care and who was advocating for the greater health care picture. My eyes really got opened … and as I looked at other opportunities, I really kind of found public health. As I looked into that further, specifically there at Mount Rogers, we did a lot of women’s health services in that area. And I thought, “I’m an advocate for women’s health services. I can do that.” As I looked at some of the other services they provide, it was very interesting to me.

When I took the job, when I was selected for the Mount Rogers health director, I fell in love with public health and my time there. I always said I wish I’d done it sooner in my career, but I really enjoyed my time in public health there, and it was so eye-opening to think that you can go from helping patients one-on-one and then you look at a whole community and say, “What can I do to make a positive difference for the health of my community, the community I lived in, the community I served in?” Working on that regional level with the eight localities of Mount Rogers and then the 16 on into the pandemic with LENOWISCO and Cumberland [health districts], being able to see how can I advocate for the health of my whole community, what do I need to do for that and building those partnerships …

One of my epitome moments in public health was realizing, I think, previous commissioner Dr. [Marissa] Levine said that health care is necessary, but not sufficient, for the well-being of a community, and I really took that to heart. That spoke to me. We need health care. We have to have access to health care. We have to have health care providers because that’s the crux of it. But when 80% of your health comes from your community and not just the health care you receive, it really opens your eyes.

The potential of, how can you make a positive difference in the community around you? Getting to know leadership in the community, our local government, our schools, our community services, DSS [department of social services]. What about our community-based organizations? What about our colleges and how they educate people and our future workforce and all those aspects of public health? How do you bring people together to look at the greater good, really, of health?

And so, those lessons learned, I’m just now beginning the networking phase at the state level. But as I look at that, like I said, it’s an interesting journey. I did practice for Mount Rogers for five years and then I did go and work at the local hospital as chief medical executive officer for a year and a half. But that was also an interesting part of the health care journey, to really look at health care from that acute-care perspective. … In the acute-care setting, how does the hospital function within the community? Ballad Health has really taken a strong stance with its population health and working in the community as well. And as a health director, I appreciated that, and as the chief medical officer, I did as well. So, when this opportunity opened up in public health, again I was very excited to step into that role.

Susan Cameron is a reporter for Cardinal News. She has been a newspaper journalist in Southwest Virginia...