Before she was old enough to understand the US public health system, Leana Wen witnessed it fail. Growing up in the ’90s in Los Angeles after her family immigrated from China, many members of her community didn’t have the money or insurance to access health resources, and they ultimately succumbed to preventable diseases.
Could their lives have been saved by a system that valued every life equally?
As Wen details in her new book “Lifelines: A Doctor’s Journey in the Fight for Public Health,” it was this lingering question that inspired her career as both an emergency room physician with the power to treat patients regardless of their identity or ability to pay, and as a public health official with the power to reform policies that she had seen fail so many people.
Her passion led her to medical school at Washington University when she was just 18 before going on to study health policy at the University of Oxford as a Rhodes Scholar. Now, at 38, she has already amassed the titles of physician, medical analyst for CNN, contributing columnist for the Washington Post, professor of public health at the George Washington University, fellow at the Brookings Institution and former health commissioner of Baltimore. And from these experiences, she knows first-hand that creating and maintaining a robust public health infrastructure is no simple task, in large part due to a fatal flaw of any strong public health system: it is inherently invisible.
We don’t see the faces of the kids who never got lead poisoning because of remediations to their homes; the lives that were spared because of community crime prevention programs; the children who go to bed full each night because of the food assistance they received. So, how do we fight for public support or funding for a system, the successes of which are so hidden?
Compounding the issue, the Covid-19 pandemic has all but made public health synonymous with disease control in the public consciousness. But in times of crisis, as in times of normalcy, it is so much more than that. It’s the air we breathe, the food we eat, the housing that shelters us and the education we have access to. As Wen defines it, public health is the ultimate example of “all boats rise” – the idea that improving the health of a community benefits all.
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The key to achieving a strong and functioning system, Wen says, is to reimagine public health as having two components. The first is made up of public health agencies, which need to be vocal about the aspects of their programs that are successful. The second is comprised of all the people who are served by the system. They need to see themselves as being on the front lines of the public health battle and support the efforts that keep the community safe and healthy.
When viewed this way, public health isn’t just about the application of science and medicine, but rather an ongoing effort to win the hearts and minds of a community. And that starts with reminding the public, as Wen puts it, that “public health saved your life today – you just don’t know it.”
This interview has been edited for length and clarity.
CNN: You witnessed in the ’90s that not every life is valued the same, and that includes in our public health system. Do you still see that inequity in our public health system today?
Wen: Absolutely, and tragically. I write in “Lifelines” about a child that I saw die in front of me from an asthma attack. His grandmother didn’t seek medical help because she was afraid of the immigration officials and of her family being deported. That just should not happen in a just America. There are also people who do not receive preventive health or primary care services because they can’t afford health insurance. This is why public health is so important – it is about providing core safety net services to the most vulnerable.
CNN: What do you see as the fundamental roadblocks that are currently inhibiting access to health care and public health for those people?
Wen: It’s the policies we have in place. For example, I treated patients before and after the Affordable Care Act was implemented. The ACA definitely made a difference in many people’s lives by promoting the correct health care incentives – like free preventive care. It’s not perfect and there’s still a long way to go, but it encourages people not to wait until they’re really ill to seek out care. Before the ACA, I had treated a patient whose kidneys were failing. She was glad when her kidney failure was bad enough that she had to be put on dialysis because it meant that she finally qualified for Medicaid. I mean, for somebody to be glad to be tethered to a machine three times a week and unable to work or care for her grandchildren because it means that she finally can afford her health insurance – that’s so tragic.
CNN: Doctors constantly challenge their own understanding of human health. But what really struck me when reading about your career journey is that you’ve done something rather unique: you’ve challenged the role of doctors and the system that you work within. Can you talk a little bit about how you view a doctor’s role as one that not only provides treatment for patients but also advocates for them on health care and public health matters?
Wen: My view on this has evolved over time. When I first entered medicine, I saw my role as treating the medical ailments of the patient in front of me. I was drawn to the ER because I never wanted to turn people away due to their inability to pay or their immigration status. But in the ER, I also saw how a patient’s health can be directly impacted by policies – and so it was my job to not only treat my patients’ medical conditions but to advocate for policies that would help them, too. I also saw how often the patient’s biggest problems were things that I could not address in the hospital. So, advocacy took the form of helping to connect patients to housing, food access, and other social services they needed in order to achieve better health.
CNN: In your book, you candidly detail how your mother was misdiagnosed with depression when in fact she had breast cancer, and your regret at not speaking up when you accompanied her to an early doctor appointment. What advice do you have for patients or their loved ones who don’t have a medical degree or don’t know what questions to ask but want some agency over their health care? In other words, assuming someone does have access to health care, how can they be sure they are getting thorough, quality care – and what should they do if they feel they are not?
Wen: I always think back to the moment when we could have gotten to her diagnosis sooner, but I just didn’t speak up because my mother asked me not to. She was afraid of being “fired” by her doctor and somehow getting worse medical care if she spoke up. I think about this moment all the time and what could have happened if I did help advocate for her – but I also realize from going through my own medical training that when misdiagnoses happen, it’s not for lack of caring on the part of the doctors or nurses. It’s that there are systemic issues that are creating this disconnect between what patients need and what the health care system is providing. Coming at this from a position of empathy for both sides is really important. But while we work for systemic change, there are things that patients should do. I give the example in “Lifelines,” that doctors often interrupt patients within seconds after they start speaking about what’s going on with their health. This is not the way medical care should be, and we need to reform the system. But being a patient advocate means navigating with the system we have, while working towards long-term change. If you need medical care right now, you need to be able to figure out a way to tell the story of your health. That includes writing down the components of your history that are the most important, making sure that you come with a list of questions and, if you can, bring someone with you who can advocate for you.
CNN: You write about being stretched so thin as a physician that you often didn’t have time to prioritize your own wellbeing, let alone to stop and reflect on how to reform the public health system around you. Given the realities of the patient care demands that are placed on doctors, do they reasonably have the bandwidth to take on issues of systemic health policy reform? And, if not, how do we ensure that health care and public health work in tandem to keep society healthy?
Wen: The reality is that many health care providers are burnt out, but it’s not just due to their long hours. The burnout also comes from knowing that what our patients need isn’t what we’re able to provide for them. People deal with burnout in different ways. For some people, it helps to spend more time with their family and be attentive to their own mental health. For others, being involved and actively engaged in solving these systemic issues is a way to counter burnout. Policymakers and people working in all sectors should be engaged in reforming policy, but I also think that health professionals on the front lines of these issues need to be really involved as well in sharing their stories, making their voices heard, and explaining what they’re seeing on the front lines and why these policy changes can have such a huge impact on our patients’ lives.
CNN: We can’t talk about health care and public health in this current moment without talking about the pandemic. Do you think Covid-19 has revealed any particular strengths and weaknesses of these systems?
Wen: Yes. The pandemic laid bare the problems that arise when public health is undervalued, underfunded and forgotten. Prior to the pandemic, people working in public health were already wearing multiple hats. They were already stretched to the brink so that if any new issue came up, they had to drop whatever they were doing to deal with it. So when the pandemic hit, that’s what many did – they dropped whatever else they were working on. Now, overdoses are through the roof. We had a record 93,000 overdose deaths last year, in part, because many people who were working on the opioid epidemic were pulled off to work on Covid. We’re robbing Peter to pay Paul; we’re taking people away from one element of public health to work on another. And we’re seeing, as a result, problems such as soaring overdose rates and a drop-off of other childhood immunizations. Another element that Covid-19 has exposed is our deep inequities. We’re seeing African Americans, Latino Americans, and Native Americans being disproportionately affected by Covid because of existing health disparities and the social determinants of health. And we’ve also seen during Covid that unless there is intentional focus on ameliorating the disparities, they only get worse.
CNN: What about any strengths that were revealed?
Wen: The pandemic revealed that our health care system is very strong. As a country, we have one of the best systems in the world when it comes to treating someone who is acutely ill. And we have seen this play out during Covid; while encountering this novel virus, clinicians were innovating at the bedside. One of our strengths is improving treatment and coming up with new ways of providing clinical care, not to mention the collaboration among scientists that led to the development of vaccines in record time. The resilience, courage and scientific prowess of our medical and scientific institutions really shined and, certainly, many lives were saved because of that. In addition, people saw the incredible life-saving work being done by local and state health departments, and community-based organizations working alongside them. All these people who work in public health – they are our heroes.
CNN: You write in your book about your time as Baltimore’s health commissioner – both in terms of the problems the city faced, like addiction and infant mortality rates, and how policies were implemented to address these issues. Can you talk about the lessons you learned from that experience?
Wen: One lesson I learned is that when everything’s a priority, nothing’s a priority. Because public health is so broad, it was important for us to focus on key issues. I chose to focus on the opioid epidemic, maternal and child health, and improving care for the most vulnerable. The second lesson is that we cannot just admire a problem – we need to define the interventions that will address it and take action. An example of that was the opioid epidemic. I chose to start addressing the issue by providing widespread access to the opioid antidote, naloxone. I issued a blanket prescription for naloxone to all residents in our city and our team conducted trainings on how to use it. Within three years, everyday people saved over 3,000 lives. The third thing I learned is that we need to focus on equity. In addition to setting health goals, we also set equity metrics. On the issue of infant mortality, for instance, over seven years, we reduced the rate by 38%, and that was a big accomplishment overall. But just as importantly, we cut the disparity between Black and White infant mortality by over 50%. Disparities are not a zero-sum game – we don’t take years of life from one group to add to another. Rather, by improving outcomes for the most vulnerable, we help improve outcomes for all.
CNN: Our public health system is not immune to political influences, and where there is political will to pass public health measures there will almost always be efforts to oppose those measures. So, in a system of such opposition, how do you make real progress happen?
Wen: It’s really hard. And I think that Covid in some ways has made it harder. Before the pandemic, public health agencies resided in the sleepy backwaters of government for the most part, which meant that its budget was always imperiled but it also meant that public health issues weren’t usually in the crosshairs or viewed as ideological culture wars. But in recent months, we’ve seen some state legislatures try to curtail public health emergency powers that could impact how their communities respond to other infectious diseases moving forward. I’m really worried about the future of public health, but I think that we can counter this in different ways. Public health must navigate politics but not be engaged in partisan politics. The goal of our leaders should be to find common ground and, as my mentor the late Congressman Elijah Cummings used to say, to aim for higher ground. Also, public health needs to be constantly visible because public health hinges on public trust. We need to deliver key services to people to consistently earn that trust. Public health is not just about the professionals assigned to do the work. It’s about the role that everyone has to play in improving the health of our communities.
