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

Modern Healthcare - - Q&A -

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.

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