Leana Wen's Fight Is Our Fight

Yes, we are our brother's keeper.

The new book by Dr Leana Wen, Lifelines: A Doctor's Journey in the Fight for Public Health, describes the blend of individual caring, community activism, and intelligent government necessary to protect the health of the public. The author is a public health leader who recognized, chronicled, and acted out what public health must consist of, even before COVID proved it for the world.

In this book, Wen briefly but colorfully recounts her own journey from an impoverished childhood of disability in China to becoming a brilliant, early-teenaged Los Angeles college student; to Rhodes Scholar; to advanced degrees and education from Washington University, Oxford, and Harvard; to a professorial position (George Washington University), a high-level public health position (Baltimore Commissioner of Health), and now a highly visible thought leader (CNN, The Washington Post) while also becoming a new mother.

In the process of the step-by-step, year-by-year, barrier-by-barrier, position-by-position reporting of her still young, extraordinary life, the book chronicles this remarkable emergency physician's irresistible lifelong effort to maneuver her way from her disadvantaged childhood in China to a pinnacle of world influence.

As she describes her journey, she is remarkably candid about facilitators and their opposite, but always gracious toward those who stood in the way or had differing agendas, most particularly some of the leaders at Planned Parenthood, where she was briefly president and CEO. That highly visible coming together and falling apart is described as a confusion between the search committee's understanding of the position and that of some of the other leaders.

When you have your health, you have just about everything. After genes, which are currently immutable, Dr Wen points out that clinical medicine contributes 10% of health while social determinants such as housing, education, income, and access to healthy foods and clean water and air, etc. — public health writ large — contribute 90%.

He who has the gold makes the rules. This modern Golden Rule is nowhere more evident than in American healthcare.

Clinical medicine at its best consists of one intelligent, involved patient and one educated, ethical physician, sharing decisions informed by best evidence and considering costs. I am a great fan of well-done clinical medicine, but that modest 10% contribution to a positive outcome comes at a huge cost and leaves little money to fund the other 90%. Who among us could lead a fight for a more effective and equitable distribution of that multitrillion-dollar pie to improve overall outcomes?

American physicians deserve to be paid for their work. That work has historically been piecework, fee-for-service when patients present with illnesses they can't fix — in other words, clinical medicine, patient by patient, and even procedure by procedure.

Physician actions are linked to patients' (or more likely, third parties') payments at whatever price the market will bear. But prior to the internet, and still in emergency situations, the physician-patient power relationship unfairly tilts toward the physician. Plus, restrictive licensing laws, health insurance schemes, and physician group lobbying have resulted in annual incomes of American physicians that far exceed those in most other developed countries.

By contrast, public health professionals are traditionally salaried government employees with workforce categories, numbers, and salary scales set by politicians and bureaucrats. No contest for recruiting.

Public Health or the Health of the Public?

While I was JAMA's editor-in-chief, I sat in the boardroom at the American Medical Association listening to such a discussion being led by C. John Tupper, MD, the incoming president. Tup (whom I knew well since he was the dean of medicine at UC Davis and had recruited me some years earlier to become the professor and chair of pathology) was arguing that the concept was important and he wanted his presidential year to focus on it, but that mainstream physicians just did not get this "public health" thing. They were into clinical medicine. This was at a time when "population health" was hardly on the radar. So, he said to call it "the health of the public" because maybe that would resonate better.

At this point in 2021 (nowhere near over), large countries that have been most successful at dealing with the COVID pandemic (China, Australia, New Zealand, Taiwan, Singapore, Korea, Vietnam) were steeped in applying public health methodology. The worst COVID disaster countries (United States, Brazil, Russia, India, United Kingdom, Spain, Argentina, Indonesia) are bulwarks of clinical medicine.

When there is no individual curative patient treatment for COVID-19 but there are clear-cut successful public health preventive interventions, the best approach would seem to be a no-brainer: Use public health methodology.

My own view of public health is much like Wen's: expansive and all-encompassing, but perhaps regrettably unrealistic and unpopular — maybe even unachievable. However, in the age of COVID, proper funding of broad-based public health is at least thinkable and could even be popular, if explained repeatedly and persuasively.

Public health is disease prevention in individuals who comprise a group. Individual clinical medicine that produces positive health results that will affect others promotes (or retards) the health of the public. It all depends on human behavior. How to change human behavior in this era when the need for uniform vaccination against SARS-CoV-2 is ridiculously obvious and yet strenuously refused by tens of millions of Americans?

When Roger Egeberg was dean at the USC School of Medicine, he taught me that one can use sugar or a club — variations on a continuum theme — to induce a desired behavior. Others prefer the carrots or sticks metaphor. Sugar or carrot approaches include education, sweet talk, persuasion, lotteries, bribes, and rewards. Club or stick approaches would include laws, mandates, regulations, penalties, fines, and loss of jobs. On the continuum in between, leading, blaming, shaming, shunning, rewards (entry to desired places or events with a COVID "green card"), or penalties (denial of entry to bars, restaurants, etc.).

Revisit the US public health movement to not drink and drive, to wear seat belts, to drive cars with airbags, to wear motorcycle and bicycle helmets, and to not smoke on airplanes or in restaurants. Our society went through some big, whole pushback with all of these necessary public health measures until they became part of "normal" life. So will vaccinations for COVID-19, but only after tens (hundreds?) of thousands of additional American deaths.

Pretty much everyone I know wishes to be held in esteem by people whose opinions they respect. That is called peer pressure, at any age. Move a group in the healthy direction; peer pressure powerfully follows. It's the same for an unhealthy direction.

In the real world, the health of the public depends on the ultimate informed cooperation of that very public.

I believe that those of us who have benefited from higher education, especially in the health field, bear a moral responsibility to help those who are less fortunate, whether or not they desire the help. Author Leana Wen is one spectacular human being (Disclosure: We are friends and colleagues, and she has served as the Lundberg Institute Lecturer), a one-of-a-kind. In this startlingly frank and well-written new book, Leana has performed yet another great service on behalf of the health of the public. Thank you, Dr Wen.

That's my opinion. I'm Dr George Lundberg, at large for Medscape.

George Lundberg, MD, is contributing editor at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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