Baltimore's health commissioner is revamping the way we think about drug addiction—and so much more

It is a cold, wet, dreary Saturday morning on the first day of October. It's the kind of morning most people would rather spend stretched out in bed, or maybe sipping a cup of coffee and daydreaming about nothing much in particular. But at 9 a.m., inside the Baltimore War Memorial, Baltimore City Health Commissioner Leana Wen is addressing a crowd of about 50 people at something called "Solutions Summit: Behavioral Health Forum." Organized by the nonprofit Open Society Institute, the event is a way for citizens to come together and work toward solutions to the city's lingering structural problems.

This morning, she's talking about addiction deaths, and how they have increased in part due to fentanyl, an opioid that can be added to any number of drugs. According to the Drug Enforcement Administration, fentanyl is up to 100 times more powerful than morphine and 30 to 50 times more powerful than heroin.

Wen speaks with passion and authority, and the room is silent as she makes her case about the urgency of this situation.

"The number of people dying…has increased by tenfold—not 10 percent—10 times in the last two years because this medication fentanyl has gotten mixed with heroin, with cocaine, and people don't know that it's there," Wen says. "There is so much work ahead of us but now we have to focus on saving lives."

She tells the crowd that the way we speak about addiction can have a huge impact on whether lives can be changed.

"When you say there's an addict, there's a drug user, there's a junkie, when you use those words…people are much less sympathetic than if you say an individual with a substance abuse disorder, or a patient with addiction," she says. "For so long, we have had this total misconception that somehow addiction is a choice, that somehow, addiction is a moral failing, and that's why if we then have this individual who ends up in jail or ends up dead, that's their choice. This is how our conversation has evolved."

"And yet we know that that is not true. I mean, I'm a scientist, and a doctor, so I have to go to science and our science is unequivocal." She repeats herself for emphasis: "Our science is unequivocal that addiction is a chronic brain disease. The science is unequivocal that opioids are some of the most addictive substances that are out there."

Wen's more compassionate approach to drug treatment is on-trend with a more recent nationwide movement, but it also coincides with the work Baltimore City has been doing for years. In 1994, former Health Commissioner Dr. Peter Beilenson began a drug needle replacement program in Baltimore. He did so in the face of opponents who argued that giving drug dependent people access to needles was only encouraging the problem. In July of 2015, a special Heroin Prevention and Treatment Task Force assembled by the mayor called for improvements to the city's drug treatment system, including access to around-the-clock treatment. Wen has established a website, dontdie.org, where anyone can not only learn about Naloxone (also called Narcan), a medication that can stop overdoses, but learn how to administer it, too. Once someone watches a short video on the website and takes a quiz, they receive a printable certificate that they can use to get Naloxone from a pharmacy. The certificate is valid for two years.

At the conference, Wen continues: "We would never, by the way, say this about any other disease. We would never say to someone I'm sorry that you're dying of a heart attack, but if you're not dead in three weeks maybe I can find you treatment then. We would never find that to be acceptable. And we never say to someone how come you're still on insulin after a year? Shouldn't you be sober from insulin by now? Can't you just manage your diabetes by going to a program and after 30 days you're done? We should be using the same language to reflect substance abuse disorders, to reflect mental health, as we do for all physical ailments, because that is what the science shows us."

"We know that we must invest in treatment. We know what works, actually," she says. "This is the crazy thing, right? We know what treatment works, we have thousands of people across the country who are living in long term recovery, who are living testament to the fact that treatment works, that recovery is possible and now we must fund that treatment in the same way that we fund all other types of treatment."

The audience applauds. Nationwide, she tells them, only 11 percent of people suffering from addiction are able to get treatment. "What other disease would that be accepted?" she demands.

Wen concludes, identifying the crux of her job: the fight to connect people who are suffering with the resources that they desperately need.

After her speech, Wen, accompanied by a staffer, heads for the door—but not before stopping politely to chat with a few people who ask for more information—then, almost without pause, she is on to the next thing.

 

Appointed by Mayor Stephanie Rawlings-Blake in January 2015, Baltimore's health commissioner is everywhere all at once, it seems. On the radio telling listeners how to avoid the Zika virus, at a press conference announcing some new health initiative, visiting a classroom to talk about the city's most pressing health issues, addressing a TED Talks audience about doctors or the Chinese economy, or live tweeting and streaming an educational discussion. Always polished, always relatable, always urging this city toward health, she chides, cajoles, and counsels residents and city officials—just the way a doctor might at a check up.

Since arriving in the city, Wen has not only built the aforementioned comprehensive opioid overdose prevention program, but through a recently-awarded $500,000 grant, Wen will soon broaden the reach of the Safe Streets program into local hospitals. Safe Streets uses people in high risk communities to help mediate conflicts and prevent violent retaliation. Then there is her ambitious Healthy Baltimore 2020 program, aimed at making a serious dent in lingering health disparities in the city by the year 2020.

Heading up a department with a $130 million budget and 1,000 employees, Wen hurdles through her day tasked by the city with overseeing things like maternal and child health, youth wellness, emergency preparedness, prevention and treatment of sexually transmitted infections, disease outbreaks, chronic illnesses and prevention, vaccines, and even restaurant inspections and animal control.

But everything she has done prior to this has prepared her for the wide-ranging job—and she has always moved through the world at full tilt.

She came to the United States from China with her family when she was eight years old, seeking political asylum. A prodigy, she never attended high school because she gained entrance to California State University, Los Angeles, when she was 13. She graduated summa cum laude at the age of 18 with a bachelor's degree in biochemistry.

She studied medicine at Washington University School of Medicine and was a clinical fellow at Harvard Medical School. She went on, as a Rhodes Scholar, to study at Oxford, where she got two Masters degrees in public health and health policy. She has also worked as a consultant with the World Health Organization and the Brookings Institution. Before she came to Baltimore to replace Dr. Oxiris Barbot, who left to head up New York City's health department, she was a professor of emergency medicine at George Washington University.

In 2012, she wrote a book, "When Doctors Don't Listen," which describes a model for an ethical, caring doctor-patient relationship that is founded on transparency. She elaborates on her website, writing: "I say to my patients, 'I'm Leana Wen, I'm your doctor. I belong to an initiative called Who's My Doctor, that aims for transparency in medicine. I accept no money from drug companies or device companies. I do not make any more from ordering more tests or procedures on you, and I also don't make more for ordering less. I'm telling you this so that you can be sure that everything I do for you is in your best interest.' In other words, this is me. Now tell me about you. This is the beginning of our partnership. We're in this together. I'll be vulnerable with you."

She explains that her thinking about the medical profession evolved when her mother developed breast cancer, writing, "My mother's illness coincided entirely with my medical training, and her experiences—including multiple misdiagnoses and medical mistakes—shaped my life mission: to be the best doctor possible for my patients and to redesign our healthcare system to provide safe, effective, and humane care."

Serving as the health commissioner gives her a platform for making some of those systemic changes. As she points out, her job isn't just making sure that we know about the Zika virus or that the homeless know where to go for relief when the weather gets too hot or too cold, she must also act as the face of the department. That means always staying relevant and always making sure that there is money for much needed resources.

"The health department is 80 percent grant funded out of a $130 million budget," Wen tells me. (Approximately $25 million of that budget comes from city coffers while the rest is raised by applying for government and private grants.) We are riding in a car driven by one of her staffers, just four days after the Open Society Institute event. We are on the way to Johns Hopkins University, where she'll talk about her job with students in a class taught by former Baltimore City Health Commissioner Dr. Peter Beilenson.

It's around 1 p.m., but Wen has been up since seven this morning. In that time, she has already worked on remarks she will give to a group of lawmakers in Annapolis the next day, and met with both her immediate staff and a larger group of staffers. She's also already held a press conference with the mayor, announcing the latest success of the health department's B'More for Healthy Babies campaign. The goal of the program was to reduce infant mortality rates in the city, and it has. At the conference, Mayor Stephanie Rawlings-Blake tells the small gathering of local media that since the program began in 2009, infant deaths have dropped 39 percent—lowering the rate from 128 in 2009 to 72 last year.

"To work with Dr. Wen," adds Rebecca Dineen, the city's Assistant Commissioner for Maternal and Child Health, "is just like working with a lightning bolt."

Wen manages by fitting things into her schedule like pieces of a Tetris game. Our time together begins, somewhat abruptly, following the press conference, on the walk back to the Health Department's offices on E. Fayette Street from City Hall. It saves time, she tells me. That's also when she decides the best place for us to conduct the rest of the interview is in the car, en route to Hopkins.

"No other city or state agency is like this," Wen continues. "Our structure allows us a degree of flexibility but also is a level of pressure that we have to sustain our funding constantly. Fundraising, writing grants, is constantly on my mind, on the minds of all of my senior team, it's a big part of our goal."

Wen understands the cash-strapped city has a myriad of public health issues it is struggling to address, but she won't accept that the obstacles are insurmountable.

"We say, what is the need of the city based on data, based on what our community has expressed and then we look so see what sources of funding can we find."

The problem of relying so heavily on grant money, she tells me, is that it's easy to keep chasing things that could work, and ignoring those that do.

"There are programs that you know are successful that are not funded but yet they save the city and state and federal government millions or tens of millions of dollars, and that's the frustration that we'll always have in public health."

"This is the daily grind of our work," she says. "To make the case every single day that public health saves lives, that it saves money, and frankly it's the ethical thing to do, it's the humane thing to do."

"There are core services that we do in the health department that people don't think about until things go wrong. We do animal control, we do all the restaurant inspections in the city, every disease outbreak," she says. "If there were issues with disease outbreaks, we're in charge of providing antibiotics and prevention for the entire city…All of these things are what we think about every single day in public health."

"This is what's keeping everyone healthy, they just may not know it," she adds.

 

Wen has a lot on her plate. "I came from the ER, I think I'm pretty good at time management—just being very, very efficient with time, because ultimately there is so much to be done."

She gives a lot of credit to her team, which is comprised of a mix of seasoned health professionals and bright-eyed, young go-getters. On the day that I'm with her, two of her staffers, connected with the health department through the Baltimore Corps fellowship program, buzz around her like bees, driving her to the Hopkins engagement, taking over her cell phone so that the over 7,000 people following the Baltimore City Health Department on Twitter can stay updated on various events of the day, and sitting in on strategic planning meetings.

"It's hard to be burned out in a job I think where you're doing what you love to do with people who are the best people in the world."

One of those people is Gabe Auteri, who now serves as the Health Department's Deputy Chief of Staff. He started with the department as Wen's Special Assistant in April of 2015.

Auteri, like the Assistant Commissioner at the B'More for Healthy Babies press conference, uses natural phenomenon to describe how a Wen-run health department works.

"It's like being in a controlled and productive hurricane," he says. "In a life saving hurricane. We're driven by the idea that we are only limited by the number of hours that we can stay working. The situation that we're in is we can make a big difference in Baltimore."

He saw up close how intense the job was, and how passionate Wen was when, after the chaos and looting that came with the Uprising, some of the city's health needs were thrown into chaos, too.

"How do we make sure that hospitals are functioning? How do we make sure that the life sustaining operations that we perform every day, like taking people to their dialysis appointments, how do we make sure those things are happening?"

He says that he and other health department officials also realized that many residents didn't have a way to get their medications—because of the CVS that had been burned and other pharmacies that temporarily shut down as well.

Led by Wen, he says, the department set up a subscription access line. Residents could call a number and give their information, and the department would arrange to have the needed prescription transferred to another pharmacy and even dropped off at their door, if necessary.

Auteri and Wen went door-to-door at some of the city's senior facilities, to let residents know about the program.

"It was an incredible experience," he says.

"People answered their doors and they almost always had one of two responses—what candidate are you here for; or is this another survey, which is really telling. In such a state of crisis, that our community members still see government as being there for us and not for them. I think that has really underscored the work that we do."

Back at Hopkins, Wen is preparing to addresses about 100 students in Beilenson's Public Policy and Politics class.

The room is stuffy and warm, and it's the mid-afternoon, but Wen seems eager to engage with the students. As a bit of trivia, Beilenson asks the young people to name two things that he and Wen have in common. One student raises her hand. "You're both 33?"

"I wasn't this bald when I was 33," Beilenson deadpans.

"You guys both grew up in California?" More specific, Beilenson urges. "L.A.," she responds.

Another volunteers that they were both the youngest to hold the title of Health Commissioner in Baltimore City. Bingo (Beilenson was 32 when he first took the job).

Wen tells the class how lucky they are to have Beilenson as a teacher. She points out that Maryland just began a statewide needle exchange program on Oct. 1, but that Beilenson championed Baltimore's needle exchange program over 20 years earlier.

"All of you have this incredible professor for your class. Peter is a god in the public health world," she tells the students.

She reminds the class that Beilenson had to absorb a lot of the brunt of negative public ideas about people who use drugs, but was able to make real change anyway.

"I can only imagine the types of things that were said, the really stigma-laden comments that Peter must have heard. But Peter, I think, never forgot that public health should not take a backseat because if public health takes a backseat, then everybody else is going to suffer."

She fields questions from the class about how she got her start and what kind of jobs fall under the umbrella of the health department. Then she guides them through training so that they, too, can administer Naloxone if they are around when someone overdoses. She also tells a story that many of the young students in the room, many women of color, can probably identify with.

"I was at an event where I was being introduced to about 30, 40 people. It was a private event and there were individuals in the city who were leaders, who were heads of different groups and businesses and foundations, and I wasn't there to speak—I was there as a guest but I was still being introduced in my official capacity. The person introducing me said, 'This is Dr. Leana Wen, the health commissioner of Baltimore City.' So far, so good," Wen pauses for dramatic effect. "'And isn't she just a cute little thing?'" The class groans and one person boos.

"The subconscious bias is something that we must be aware of even if so many of the battles have been fought by those ahead of us. I think, even as our presidential politics will tell us, these things still happen."

A few weeks later, over the phone, Beilenson tells me that this was the second time that Wen has spoken to one of his classes, and each time she gets a good reception.

"Both times they were very taken with her. She's actually not much older than they are, so they could relate to her," he says.

"She started meeting with me before she started the job, to get advice and to talk about issues," Beilenson says. "So we kind of became friends."

Beilenson says that Wen's go, go, go approach to public health is not how he ran the health department.

"Not at all. She's more like Josh [Sharfstein] who was in between the two of us. Works all the time. I had a much different schedule. I think I probably delegated more—also I have five kids. If anything I would talk to her about, and I do talk to her about still, is to try and balance her life a little better, she can't go on that way."

I ask whether youth—his own when he started at the health department, or Wen's now—is a blessing or a curse when it comes to this job.

'I think it's both. It would be helpful to have more experience managing people—I know she worked in the ER…for a while, mostly she was a resident. For me it was my first real job. At that age you probably don't have the management skills and wisdom. On the positive side, you tend to be more innovative, wanting to make a difference."

Walking back to the car after the Johns Hopkins class, I ask Wen how someone with such a high-profile job can still be so open, so unguarded. She says that she decided to take that approach because she stuttered severely as a child.

"And I did not acknowledge it or get therapy for it until I was in medical school. So for as long as I can remember I just didn't really have friends, didn't have close friends, because I didn't want to acknowledge this most basic part of myself. If that's my greatest shame and secret and I was hiding it all that time, I just couldn't come to terms with it and never let anybody get close to me. It wasn't until I was in my mid-20s that I thought, I can't live my life like this. I can't be someone who can't get close to people, who can't be open with my patients, I just didn't want this to be my identity or my life anymore."

She said she decided to seek help through speech therapy, and part of the advice she got through that was that she has to make an effort to be more transparent.

"It's somewhat intentional on my part, too, to say I can't do this job if I'm not true to who I am. And who I am now is very different from who I was even 15 years ago. I need to be open, I need to have this level of transparency or else I can't be functional."

There are many leaders in this city who conduct their business by talking at their constituents, rather than listening to them. Wen doesn't do that. Her background—learning how to adapt and thrive in a foreign country, hiding and then addressing a potentially embarrassing problem like a speech impediment, or fighting to be seen as a competent professional and not "a cute little thing"—may be why.

Earlier in the day, as we'd bustled our way across traffic to her office, I asked Wen about some comments she made at that Saturday morning conference. Wen had discussed how the attention being given to heroin addiction has grown as the problem began to increasingly affect white people. When poor black people had the problem, she said, no one seemed to care. Addressing racial disparities can be a controversial subject, and it's easy to just skip over them in the interest of not inviting any unwanted attention.

Wen said that talking openly about race has been a process for her, but it's just another part of doing her job to meet the needs of this mostly black city.

"When I first started here, I didn't talk about race nearly to the extent that I am now. I mean I talked about disparities and quoted statistics, but I certainly did not specifically call out race and racism as a public health issue the way that I am now," she said.

"The reason I'm doing that now is, this is what I'm hearing from our community. When I go to community events to speak with our neighborhood leaders and community members and students, it feels like it's the elephant in the room that people don't want to mention. And I think that…we in the health department, we have the statistics to show for it, we also have the will of our community to address it. If we don't call them out, then who is going to?"

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