Leana Wen: Managing the Health of a City Amid the Freddie Gray Riots

Editor's Note: In part 1 of this two-part One-on-One interview, Medscape Editor-in-Chief Eric J. Topol, MD, talks with Leana Wen, MD, MSc, city health commissioner of Baltimore, Maryland, about her experiences in crises management—from treating victims of the Boston Marathon bombings to managing the healthcare of Baltimore's citizens during the Freddie Gray riots.

Dr Wen further discusses her public health response in the months following the riots, as well as her "boots on the ground" approach to treating Baltimore's most vulnerable residents.

From Boston to Baltimore

Eric J. Topol, MD: This is Eric Topol, editor-in-chief of Medscape. I have a terrific guest with me today, Dr Leana Wen from Baltimore, Maryland. Welcome to Medscape.

Leana Wen, MD, MSc: Thank you. I'm a big fan of your work and am delighted to be able to speak with you and your readers and viewers.

Dr Topol: You are quite a fascinating person. We met at the Aspen Ideas Festival and now we are finally getting a chance to talk about your background, as well as what is going on in Baltimore.

Dr Topol: You were in Boston. You were at Brigham and Women's, on the faculty at Harvard. You were an emergency medicine doctor who attended the victims of the Boston Marathon bombing. That must have been a horrific experience.

Dr Wen: It's one of those things that you can never prepare for. Like in other fields, we go through all kinds of disaster drills. In emergency medicine, we are trained to think of the worst-case scenario. If I were in this kind of situation, what would it be like? But what I could not have prepared for was how personal it was, because it happened in my city two blocks away from where I lived. I was terrified because my husband had texted me just before that to say that he was about to go watch the marathon at the finish line. Many patients were coming with really horrific injuries. I knew what to do, but I kept wondering—and I know that my colleagues felt the same way because we all had loved ones or people we knew who were somehow involved in the marathon, including our colleagues who were working the marathon—what if the next patient we see has ash and blood all over him or her, and what if we don't even recognize a husband, a co-resident, an attending, or a nurse? That was one of those experiences that I will never forget, and it emphasizes the importance of preparation, something that we saw in Baltimore as well with the recent unrest.

Managing the Health of a City

Dr Topol: You seem to have a knack for being at the right place at the wrong time. You took the job as the commissioner of health in Baltimore in January. Then in April the Freddie Gray riots began, and that obviously was something that you could never prepare for. You are responsible for the health of the city at a time when there are fires and riots and people dying. What was that like?

Dr Wen: In medicine, we say that this is a black cloud. I always felt like I was a black cloud in the ER, and now this. I was so excited to take on this job. I am still incredibly grateful to have this opportunity because it is a dream job that I have always wanted. I have the intimacy, the chance for a boots-on-the-ground experience, because that is what I love. That's what I love about emergency medicine. I get to incorporate my clinical training, together with public health inclination, and work on policy and education. This is everything that I have ever wanted to do and I was very excited to start in January. I had started a listening tour in the city and met with our various community groups, faith leaders, nonprofits, hospitals, and insurance companies, and made a list of three issues that we wanted to focus on: youth; health and wellness; and substance abuse, mental health, and care for the most vulnerable citizens, all to be integrated with population health. We were getting ready and finally said, "Okay. We have done our 100-day listening tour. Now it's time to get started—not just listening but asking."

A Tragic Death Turns to Rioting

Dr Wen: Then Freddie Gray passed away. His funeral was on April 27 and that's when everything changed for us in the city. We knew that there would be protests. We didn't know that there would be riots. I remember that bad afternoon we heard that there could be rioting around one of the two clinics we run in the city. The clinic is on North Avenue, near where the CVS burned down and where a lot of the activities ended up happening. We were concerned about the safety of the employees who worked at the clinic and our patients at the clinic. But more than that, we were also concerned about the safety of our 1000 employees who mainly work out in the field. We have employees who do home visiting for pregnant moms, who visit seniors, who transport patients for chemotherapy and dialysis and other life-saving functions, and they are in the field. So I thought that our immediate response was going to be limited to making sure that those employees were safe and that we were coordinating with our local agencies, fire department, and police department to help them remain safe.

Then I realized that our responsibilities went way beyond that. We also had to help our hospitals get their employees to work on time. We had to make sure that the hospitals had their safety plans up and running. Because of all the information that was going around, people were hearing 20 different things at any given time, and it was hard to separate fact from fiction.

We ended up convening hospitals on hourly conference calls to update them about what we knew and to help make sure that their concerns were being addressed as well. That was the immediate response. The day after, we began hearing about people who could not get access to their medications because the pharmacies were closed all over town. We had a woman call who was on insulin for diabetes who said that she just stopped eating because she thought that that was the best way for her to deal with this issue. By the time she called us, she was so groggy that we ended up having to rescue her because she was in a diabetic coma. We had another person who called us, short of breath, saying that she was out of her medication. I was thinking that she needed an inhaler. But she was out of Coumadin® and Lovenox®—she was being treated for a pulmonary embolism. This was a life-threatening issue for people.

I think we sometimes forget about that. We see the pictures of burning cars and real buildings. People forget that there are many people who may not be involved in whatever movement is going on, or they are at home, and we can't just tell them, "Well, go an extra three blocks to get your medications." If somebody is oxygen-dependent on a walker, if they are extremely vulnerable and are watching the TV, they don't even know whether it's safe to set foot outside their building. So we set up a 24/7 prescription delivery line where we literally delivered medications to people in need. People were calling us for trauma and mental health concerns as well. Many people already had significant mental health concerns that were exacerbated by the unrest. We also set up a 24/7 mental health crisis line, and we did group counseling and healing circles for free in various places around the city, including in schools. All of the issues that we identified prior to the unrest from the listening tour—the youth wellness, the substance abuse, mental health, the care of the most vulnerable—were still our key priorities, but the unrest really gave additional urgency and impetus to the work that we had in front of us.

Baltimore: After the Riots

Dr Topol: You had a trial by fire. You were thrown into the deep end of the pool to figure out how to deal with a challenging scene. Things, I take it, have calmed down and you are now trying to execute what you originally had planned. How are things in Baltimore these days?

Dr Wen: There is an energy to Baltimore that I have always loved, and it's the reason that I am here. I love how passionate people are, how many things are happening, how innovative we can be. We are the oldest health department in the country and we also have a long history of doing things far before anybody else. We have had needle exchange for dozens of years. We don't argue about whether this is good policy; we know it is, based on the fact that we have saved tens of thousands of lives. There is still that energy in the city, but I would say that there is even more than before, because public health has been in the news in a way that I haven't seen since Hurricane Katrina—on the front page of the New York Times and on CNN. We have been talking about how Freddie Gray was lead-poisoned, how there are differences between neighborhoods where people have 20-year differences in life expectancy, how 1 in 12 white people live in food deserts, but—even worse—1 in 3 African Americans live in food deserts.

All of these statistics are finally out there and we are talking about them. We know that we can do something about them. That is the extra energy that we have now and it adds more urgency to our work. We have developed proposals together with our state and federal partners, with local foundations at work, hoping that this is our chance to talk about the underlying issues, that we don't just see violence and rioters and say, "Well, that's the problem." No, that's not the problem. The violence and rioting happen because of years of racism and mass incarceration and us not seeing the links between trauma, poverty, and violence. And it's also years of us criminalizing mental illness and addiction rather than seeing these as chronic medical illnesses. We finally have the tools and the political energy. Now we are looking for the funding and the will of the city, to make sure that we are convening around the same goals and that we are addressing these core social determinants and reasons for why our city, and other cities around the country, are unhealthy. I am an optimist, but I really do believe that we can take this opportunity to make Baltimore a model of what urban public health—and, in fact, what urban cities—can be.

Advice to Young People

Dr Topol: If ever a person could turn a crisis into an opportunity, it would be you. Every listener will see the passion that you exude for the people, not just in Baltimore, but regarding improving the health of many urban cities that are confronting similar issues.

Do you have any words for the young doctors out there? You are still very young. You are a big inspiration. Your mother had a big effect on you, but what about your effect on others? What can you impart to them about trying to follow in your footsteps?

Dr Wen: I have three pieces of advice. These are things that I learned from my mentors over time. I had tremendous mentors like Dr Fitzhugh Mullan, and Dr Anthony So, and many others who have been instrumental in guiding my career and helping me to see that it is possible to do what I love doing even if I can't put a name to it. My first piece of advice is: Don't do what other people think you should be doing. A lot of people throughout my career said, "You should pick one thing and stick with it."

Maybe that's easy if you know that you want to be an interventional cardiologist in private practice. That's great if you know that, and it is the one thing that you can aim for. But if you want to do medicine and public health and policy, it's much more nebulous, and a lot of people have told me over the course of my career, "No, that's not quite right. Pick something, stick with it, and do that." I say that you will find a way to do what you love to do, so don't lose that passion. Don't lose the humanism or the reason you got into medicine in the first place.

My second piece of advice is: Don't look for the title; look for what it is that you can do. Many people, especially those of us who look at a lot of CVs, know that there are a lot of people who submit beautiful CVs. They are secretary of this club and president of that club. But when you look at what they did, there isn't much substance there, versus someone who doesn't have a title but who volunteered at their local nonprofit, with their church group or other organization, and actually did a lot. That action speaks much louder and will be obvious to everyone else. Look to see what it is that you can do and don't ask for a title.

The third and most critical piece of advice is: Don't wait. So many medical students and public health students say, "My passion is to work on HIV in Sierra Leone" or "I am going to work on nutrition in Malawi." I'm not discounting the importance of these issues. But you can't be so specific early on, because if you are you will never get started. It's like if a very sick patient comes in who is unresponsive and has a strange-looking EKG, and you see a long medical record—you can feel overwhelmed. But you can't start from nowhere and just say, "Well, this patient is too sick and complicated. I'm not going to do anything." Figure out what it is that you can do now. Look at what you can do in your own community. Look at what groups exist on your campus. I was very lucky when I got involved early on in my medical training with the American Medical Student Association.

Dr Topol: Which, by the way, you were the president of.

Dr Wen: But it was a great experience and I got to do things immediately, and I think that's really important. Don't wait until you can take that trip to wherever and work there; make a difference in your community starting now. That passion is so important.

Dr Topol: It has been great to have a chance to visit with you and for a lot of the Medscape community—physicians and health professionals—to get to know you. We are going to be watching your career. You have many more decades ahead and you have already had an extraordinary impact at a very young age. Baltimore used to be my home city back when I trained at Johns Hopkins. They are very lucky to have you. Thanks so much for joining us on Medscape. You qualify unquestionably as one of the most interesting people in medicine.

Dr Wen: That's extremely kind of you, Dr Topol. I have the best job in the world.