A veteran doctor shares 4 lessons to strengthen US public health
As Baltimore health commissioner, Leana Wen helped tackle measles, rat infestations, and a disparity of resources across communities. Her new book tells how.
Excerpted from LIFELINES: A Doctor’s Journey in the Fight for Public Health by Leana Wen. Published by Metropolitan Books, an imprint from Henry Holt and Company. Copyright © 2021 by Leana Wen. All rights reserved.
It’s been said that public health succeeds when it’s invisible, since we are in the business of preventing bad things from happening. By definition, then, there is no face of public health. There is the face of the person who suffered food poisoning, but we don’t see the faces of the millions of people who benefit from food safety through the work of health inspectors. There is the face of the person who overdosed, who was shot, who had a heart attack, but we don’t see the faces of all those who avoided these dire outcomes because of public health efforts.
But if public health is invisible, nobody will make the case for our work. When it comes time to decide the budget, it will be the first item on the chopping block.
This was my constant struggle in Baltimore, and the struggle of my colleagues around the country. One of the most frustrating parts of our jobs was having to continuously make the case for programs that had already proven to be effective. In Baltimore, foundations and philanthropists often stepped up when government funding was limited, but private sources cannot make up for the government’s responsibility. The private sector can help, but it can’t fill all the holes left by the public sector.
Take the Zika epidemic. In late 2015, a mosquito-borne virus became linked to severe birth defects for women infected during pregnancy. Babies were being born with microcephaly, an abnormally small head, and associated brain damage such that they may never walk or talk. The virus began spreading throughout South and Central America. At its peak, it was estimated that 1.5 million people were infected with Zika in Brazil, with over 3,500 cases of infant microcephaly in less than a year.
The Aedes mosquito that carries Zika is found in the continental United States as well, including Maryland and as far north as Massachusetts. Public health experts sounded the alarm that we needed to begin Zika prevention efforts to mitigate the harmful effects. We needed to do surveillance of mosquitoes to check for Zika, spray for them and eliminate their breeding locations, and educate health professionals and patients about travel warnings and other precautions. If we didn’t, the health effects would be dire, as would be the economic consequences: according to the CDC, the cost of caring for and educating one child born with severe defects from Zika would be as high as $10 million over their lifetime.
Even though the CDC and the World Health Organization declared Zika a global public health emergency, it took ten months for Congress to approve President Obama’s $1.9 billion allocation to fight the epidemic. I joined other local and state health officials to speak to members of Congress about the urgent need for action. We pointed out that the delay made no sense. If thirty-five hundred babies with severe defects were born in the United States, that would cost our country $35 billion. Not to mention the cruelty of knowing that a lifetime of suffering could have been prevented, if only we’d acted sooner.
Practically, the lack of prompt action forced the CDC to shift funding from other aspects of local public health to cover the cost of Zika preparedness. In Baltimore, had we not secured additional resources, funding work for Zika would have cut our emergency response staff by a third. These were the same staff who prepared the city for hurricanes and bioterrorism, who were on the front lines to respond to civil unrest. What sense would it have made to cut their numbers, to reduce the staff working on some emergencies in order to respond to another? This extended beyond health and economic issues—it was also one of public safety and national security.
Public health fails if people don’t see its value. We learned this at great cost, only a few years after the fight over Zika funding and action. With the arrival of COVID-19, the struggle played out on a far morecatastrophic scale. It’s up to those in public health to make its case. We have to make the invisible visible.
At the end of my first year as health commissioner, the team came together to look at our progress and our goals. We reaffirmed our commitment to the three major areas from my initial listening tour: addiction and mental health, youth health and wellness, and care for the most vulnerable. We also took on the overriding mission that would help us achieve our goals: making public health visible.
Over the next few years, we used five strategies to deliver on the promise to improve health and reduce disparities while putting the face on public health every step of the way. First, we made use of every crisis as an opportunity to amplify and solve an existing public health challenge. When we received reports of suspected cases of measles in Baltimore, we held mass immunization drives and educated residents about vaccines, emphasizing their safety and effectiveness. The vaccination rate among Baltimore’s public school students soon became among the highest in the country, at over 99 percent. When there were deaths reported from synthetic marijuana, we launched a public health education campaign and got the city council to pass legislation banning the sale of these drugs from corner stores. When animal control officers rescued dozens of emaciated puppies bred for dogfighting, we used the public outrage to drive awareness of animal abuse and enact a city law outlawing dogfighting paraphernalia.
All of these issues were important to public health, but each by itself was insufficient to draw wide interest. Every year, there were calls for immunization. Our website stressed the importance of immunizations and the dangers of synthetic drugs; plenty of articles described the link between animal cruelty and violence against humans. Still, it took inciting events to capture media attention—and thereby public attention. We took advantage of the moment and made something tangible come of the crisis through the three-pronged approach of service delivery, public education, and policy change.
Second, we set long-term goals while demonstrating short-term successes. The trajectory of public health is long. Typical metrics of health outcomes are life expectancy and rates of diseases that will take years to manifest and measure. As scientists, we need to use these metrics, but we also have to come up with more immediate measures of success that will give confidence to the community and shore up support for our efforts. Our Healthy Baltimore 2020 goals set these long-term metrics (and accompanying measures of disparities); we also laid out short-term actions to show that we were making good progress toward our desired outcome.
While we aimed to reduce cardiovascular disease, we also strove toward a goal that was more quickly attainable to increase the healthy food options available to Baltimore’s most vulnerable residents. We worked with corner stores to help them provide healthy options and expanded our partnership with a chain, ShopRite, to deliver groceries directly. We then held community celebrations and invited local media every time a new corner store signed on or a new senior center or library became a food delivery site.
These “Baltimarket” programs were very popular. Addressing food deserts was something the city’s residents had requested, and it meant a lot to them that we listened and delivered on our promises. Our food access programs drew international attention, with health officials from the World Bank and delegations from as far afield as Saudi Arabia coming to learn how to duplicate them in their locales.
Third, we spoke about our work in a way that was grounded in databut highlighted by stories. As Senator Mikulski said, “Data validate, they don’t motivate.” Data provide context and credibility, but it’s stories that compel action. Every time we talked about a program, we shared a story and attached a face to it of someone who was a participant.
One of our programs was designed to prevent falls among the elderly. One in four people over age sixty-five will fall every year, resulting in nearly three million fall-related injuries seen in ERs across the country, including eight hundred thousand hospitalizations and more than twenty-seven thousand deaths. I’ve treated seniors who’ve broken their hips, cracked ribs, and suffered brain hemorrhages from falls. I’ve seen how someone working and caring for their grandchildren could lose mobility and independence after one slip and fall. Among the elderly, falls are also a major cause of social isolation, depression, and cognitive decline.
The program started by analyzing hospital data to map out where older adults were falling. When we found clusters, we started looking for commonalities. In one housing complex, a hallway lightbulb had gone dark directly over a shaggy rug. Multiple people were tripping and suffering injuries in the same hallway. In other cases, we found problems in the home, like out-of-reach light switches or overwhelming clutter. We also identified medication interactions that led to frequent falls. The statistics alone helped funders understand the health and economic impact of our work. The stories and the faces of the individuals drew human interest. When a local TV station featured an exercise class for seniors, many people called us, wanting to improve their agility and take part in Tai Chi and dance aerobics. When two seniors gave testimonials about how home renovations reduced their risk of falls, dozens of others requested services in their homes, too. Data grounded the work; stories are what brought it to life.
Fourth, since people don’t often think of public health, it’s our job to connect the work of public health to whatever they prioritize. There is one degree of separation between our work and everyone else’s, but we have to be the ones to proactively make the case. If the conversation is around education, we need to show how medical conditions like asthma correlate with chronic absenteeism and poor academic performance. A program to treat asthma in schools will thus prevent the child from missing school to go to the doctor—and the parent or caregiver from missing work. An investment in school health therefore is also an investment in education.
The same argument can be made about public safety, employment, housing, climate, and infrastructure needs. Everything is influenced by public health, and the public’s health is influenced in turn by everything else. There is no such thing as a non-health sector. Those of us working in public health need to reach out, constantly, to those who don’t yet know the impact of our work and demonstrate how we bring them value. We will encounter skepticism, criticism, and downright hostility along the way, but we cannot be afraid of venturing outside our comfort zone. If all we do is talk to people who think like us, we will never make progress or advance our priorities. In much the same way, we need to be at the table for strategic conversations about the future of our communities. If other officials neglect to invite us, then we must set our own table and bring everyone else along.
No one told me or my staff that the health department needed to convene the fentanyl task force. In other jurisdictions, law enforcement was the convening entity. We could have waited for someone else to invite us, but that would have taken time and cost lives (and if we’d waited, we might never have been invited). Furthermore, having law enforcement as the convener would have undercut my aim of having addiction be understood primarily as a health concern and not as a criminal justice matter.
No one told me or my staff that the health department needed to bring together tech and engineering companies. We saw an opening and started TECHealth. Not only did we gain invaluable technical expertise, we also engaged local start-ups that became even more invested in the city. No one had expected the health department to convene businesses around health priorities, but when I did, with Don Fry’s help, all the major businesses stepped up. In time, they would become key contributors to our Healthy Baltimore 2020 goals, including spearheading initiatives on a citywide workplace wellness designation and leading a “Billion Steps” exercise challenge.
Partnerships can also engage stakeholders who may not agree on every issue. At the same time that I, on behalf of the health department and the city, was the named defendant in a lawsuit brought by the Catholic Church over a reproductive rights issue, I also worked with Catholic Charities and representatives of the Catholic Church on projects we all cared deeply about. Together we successfully advocated for the passage of state legislation on paid family leave. Together we championed increased funding for children’s health and violence prevention and collaborated on delivering mental health and trauma care services. We transcended ideological differences in some areas to further the greater common good.
By developing and cultivating these partnerships, the health department was able to innovate, lead, and prove that public health should be at the table—and often at the head of the table.
There is one drawback when an agency chooses to place itself at the forefront of key issues. As our work became more prominent, people began to ask us to be responsible for things far afield from our work. I received letters from residents who argued that potholes were a public health issue. Not a day went by when we didn’t get constituent calls asking what we were going to do about rat infestations. These were the responsibility of other agencies—the transportation department filled potholes, and the public works department ran the program for rat eradication. We politely declined and referred the responsibility to our partners.
Then there were other issues that didn’t neatly fall to any particular agency, that the health department could have addressed but for which we simply didn’t have the bandwidth. Another commissioner might have chosen to focus their work on environmental policy, homelessness, and chronic disease prevention. But as Mayor Stephanie Rawlings-Blake frequently reminded us, if everything is a priority, nothing is a priority. And so we chose to focus on the most pressing needs of the community, on where we could make the biggest impact, and on what would make the invisible visible. We knew that what may have seemed like incremental progress made a tangible and lasting difference to the people we served. Our focus was on the big picture, but we could not get there unless we started with what could be done now. And we never forgot that what mattered was not what we were fighting about but whom we were fighting for.