Baltimore’s recent violence a ‘call to action’ to address health disparities

Since January, Dr. Leana Wen has served as Baltimore’s health commissioner, heading an agency with a $130 million budget and 1,000 employees.

Wen took over a few months before the city erupted into protests and violence following the death of Freddie Gray, a young black man who died in the back of a police van. She worked to make sure hospitals and their staffs were protected during the street violence. Wen argued that drug abuse, poverty, mental illness and high incarceration rates for blacks were the background for the protests, and that better programs for drug-addicted and mentally ill people would help. Wen previously served as director of patient-centered care at George Washington University’s emergency medicine department and as a GWU professor of emergency medicine. She was founding director of “Who’s My Doctor,” a campaign calling for radical transparency in medicine, and wrote the book When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests. Modern Healthcare reporter Andis Robeznieks recently spoke with Wen about the role of health disparities in the recent violence, her advocacy for wider access to the opioid overdose treatment drug naloxone, and the state’s unique system of global healthcare budgeting. This is an edited transcript.

Modern Healthcare: In a JAMA editorial you co-wrote this year, you encouraged public health officials to embrace finding solutions to the nation’s health disparities. How do you think those inequities led to the unrest and violence in Baltimore? Dr. Leana Wen: These inequities and disparities are in every U.S. city. Here in Baltimore, there are neighborhoods just blocks apart where the life expectancy differs by 20 years. These disparities tie into every single part of the work we do. They don’t only affect health, they also affect employment, education and opportunity. What happened in April is a reflection of decades of problems of poverty, racial inequality and structural racism. But it also offers a call to action for us to start addressing these deeprooted health disparities. We have renewed our emphasis on priorities that we established when I came into this office in January, focusing on youth health and wellness, substance abuse, mental health and care for the most vulnerable.

MH: How has childhood exposure to lead contributed to some of these problems? Wen: Lead poisoning is a symptom and an effect of other deep-rooted disparities. The effects go beyond health. An individual who is leadpoisoned as a child has a higher chance of lack of cognitive function and lack of educational outcomes later on.

Similarly, individuals who are lead-poisoned or lead-exposed also tend to come from areas of decreased economic opportunity.

One of the great successes we’ve had in Baltimore is on lead. In the last 12 years, we have reduced the percentage of children in our city who are lead-poisoned by 86%.

MH: Why do you advocate wider access to the drug naloxone, which is used to treat opioid overdose cases? Wen: Heroin and opioid abuse is a huge problem. Even though we know we need other treatments including psychosocial support and long-term medications, we have to get naloxone into the hands of everyone who needs it, including individuals who use substances themselves, their friends and family members, paramedics and police officers. We are expanding our efforts to reach every one of our 620,000 residents to teach them how to use this lifesaving medication.

We have launched a citywide Overdose Prevention and Response Plan, where we have taught this year over 5,000 people how to use naloxone. We have trained our police officers, and already in the last month our officers have saved two lives. We advocated for legislative change so that as of October 2015, I can give a standing order to every city resident, which means that people don’t have to go to their physician to get a prescription for this medication as long as they go through brief training.

MH: You previously served as president of the American Medical Student Association. What is the importance of

“We have renewed our emphasis on youth health and wellness, substance abuse, mental health and care for the most vulnerable.”

young doctors and medical students taking activist roles in public health and healthcare reform? Wen: We all enter medicine for the right reasons, but for a number of other reasons we end up losing sight of why we came into medicine. Medical students and future public health leaders have a critical role to play in keeping that humanism alive. A lot of the work we did within AMSA was to advocate for healthcare access at a time when we did not have Obamacare yet. We saw 50 million people without access to health insurance. That is not equitable. We also saw disparities everywhere, and we advocated for programs on the local level that worked to reduce disparities. I would say to young physicians and other health professionals: Don’t wait until you have the perfect position or title. You may never get there. If your goal is to work on HIV in South Africa, don’t wait until you can buy a ticket to South Africa. Work on HIV in your communities here and now.

MH: How has your experience as an emergency physician helped you in your new job? Wen: This is not a career change at all for me. This is my dream job, focusing on public health and service delivery not only for the individual, but also for the community.

I entered emergency medicine because I wanted to treat everyone in their time of need. I didn’t want to ever turn away a patient because of inability to pay, skin color, homelessness, mental illness or age. But in the ED, I also saw how much we cannot do, how we end up treating bullet wounds but actually what needs to be done is providing somebody with safe housing and understanding why that person was the perpetrator or victim of crime. Also in the ED, I saw patients coming in over and over again from overdose or intoxication, but we were unable to get them the longterm help they needed. This is a dream job because now I can implement everything that I’ve researched and taught and been an advocate on, and we can implement this in a city that really needs our assistance and that has so much heart and hope.

MH: How has your job been affected by the state’s system of global healthcare budgets for hospitals and health systems? Wen: Global budgeting is an experiment that was started by the CMS with Maryland about a year and a half ago. This means that instead of hospitals being paid fee-for-service, now they are going to be paid one lump sum at the beginning of the year and are incentivized to keep their populations healthy. So there is an incredible opportunity in Maryland to work together. We are aiming toward a few key population health goals. On Sept. 30, the health department brought together healthcare leaders for our first-ever summit on population health. Instead of every hospital developing its own casemanagement program for high-utilizing patients, we asked how can we instead work together to have a citywide care-management plan? Because the high utilizers for Mercy Hospital are probably going to have some overlap with Johns Hopkins, University of Maryland and Bon Secours. We’re working closely with our hospitals and other partners to come up with a strategy on population health goals.