Dr. Nate Smith on why Arkansas isn’t sheltering in place

In light of the startling estimate of 200,000 COVID-19 deaths across the U.S. from the White House, should Arkansas consider a shelter-in-place mandate as has been done in 37 states? Eight other states have issued city or county mandates to folks to stay at home. Arkansas is one of only five without any sort of stay at home order. Instead, the state has closed businesses where people congregate (bars, restaurants, hair and nail salons, tattoo parlors), prohibited gatherings of more than 10 people, placed strict rules on entrance to nursing homes and, as of April 1, closed state parks to overnight camping.

Arkansas Secretary of Health Nate Smith defended Arkansas's approach.

"Shelter-in-place, or lockdown, or whatever you want to call it, sounds really good in theory," he said. "And in theory, if everyone stayed at home and didn’t go out, the virus wouldn’t spread. In practice, though, it’s a different thing."

Smith said there are problems with lockdowns:

"First of all, getting people to do it. You can say it, you can tick it off your policy list, on the map you’re one of those states that’s done everything. Then you go out and you see just as many people out and about as you do in a state like Arkansas where we’ve taken different approaches.

"We have not even gone to shelter-in-place or closing down nonessential businesses, and I’ve already got a flood of letters from various trade groups saying they should be considered an essential service," Smith said. "And then it comes down to who’s got the most political leverage, the best lobbyists, et cetera. The bread bakers ... they’re all essential in a sense, but then you get so many exceptions. People who don’t get exempted are the most vulnerable in the first place, and it ends up having a disproportionate impact on people suffering economically to begin with."

Then there is the problem of getting people to keep staying in. "Whatever you do, you’ve got to sustain it: I say at least at least eight weeks, but it could be longer than that. So if you start something you can’t sustain, then two or three weeks in people [start] getting stir crazy and coming out right at the time you have accelerated transmission.

"So our approach has been to take a careful, measured approach. You notice that we have, over the last three weeks, increased restrictions gradually and really tried to enforce the restrictions that are there. We’ll keep doing that."

Smith said Arkansas's limited approach "matches our particular epidemiology." It's not New York's. It's not even Louisiana's, which has seen an explosion of cases since its March 23 "stay at home" mandate. (Definitions of shelter in place and stay at home are overlapping; stricter shelter-in-place orders may even prohibit trips to the grocery store.)

Smith noted that even the state's limited restrictions "won't be sustainable if we keep going forever. Large sections of our economy will die off." The state has to do what it thinks works to slow the spread of infection without creating a sense of unfairness and unwillingness to work together, he said.

"So my take home message is if we all work together and do the things we know to do, we’re going to get through this OK," he said.

Smith acknowledged the fine line he and Governor Hutchinson and others leading the pandemic response must walk: to be informative but not panic people about what is down the road.

"I try to be as transparent as possible," Smith said. He has increased the kinds of information given out at daily COVID-19 briefings with the governor, going beyond numbers to describe underlying diseases that patients have, noting the number of health care workers who are infected (a statistic he promises to break down into specialties), how the nursing home population is being affected. He does not provide names, though that information can be gotten from coroner's offices.

But if he withholds information — such as what modeling tells him about the potential number of deaths Arkansas might see — it is because, he said, information given out of context can be misunderstood. What a model might predict for the U.S. as a whole does not take into account variability by place.

As an example, he noted how once foster children's HIV status became known years ago, the community wanted to keep the children out of school. "They had knowledge [that the children had HIV] but they didn't understand the children were not at risk of transmitting" the disease. "It's better not to know the children's HIV status unless you know what that means."

If terrible things come to pass, and people believe they didn't get the warning they need? "Honestly, I'm not concerned about what people are going to say about me," Smith said. He believes he's providing the information people need to know "to help themselves and the people they love. Knowledge is power, but, again, it's the context."

Smith, whose work begins even before he arrives at the health department every day at 6 a.m. and doesn't end until dark, brought to Arkansas a broad background in the treatment of HIV, in hospitals in Houston and Kenya. When he began seeing HIV patients, during an explosion of the virus in Houston in 1997, there was nothing that could be done for them. He saw them shunted aside. He continued working with HIV patients in Kenya and back in Houston with his wife, an ob/gyn. But Smith, who is also Rev. Dr. Nate Smith and a leader in St. Andrew's Anglican Church in Little Rock, was drawn to the patients that others shunned. His belief in God is an "integral part of who I am or who I am aspiring to be."

Smith, 55, became state epidemiologist at the Department of Health in 2009. He was appointed by Gov. Mike Beebe to lead the department in 2013. He's the longest tenured member of Governor Hutchinson's cabinet and the only carryover from the previous administration. Despite his background in trying to help patients suffering from the dread HIV and his current job steeped in handling the state's response to a new virus as mysterious and frightening as HIV was in its day, Smith is quiet, calm and unruffled.

"He's not one to jump out in front of the cameras and ask for a lot of attention," Dr. Greg Bledsoe, the state surgeon general who has worked with Smith for several years, said. "He is really an exceptional asset for the state, an unsung hero in my opinion." Bledsoe believes Arkansas has benefited from his "proactive" leadership during the pandemic. "He's getting the job done without any fanfare." He praised Smith for what he believes is his candor and that, while he controls information to the public about the coronavirus, he projects the "gravity" of the situation.

Dr. Gary Wheeler, senior medical advisor at the department of health, called Smith "a rare individual who has what seems to be really contradictory qualities. He's humble but confident, strong-willed but open to other ideas, intuitive but logical." Wheeler said he is a "master at handling dense information," and called him "the ultimate technocrat with a heart ... He is the kind of person you want steering the ship at this moment."

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