Interview by Ian Goldstein, Web and New Media Specialist, NACCHO
On April 12, Freddie Gray, Jr., was arrested by the Baltimore City Police Department. He died on April 19, due to spinal cord injuries. In the aftermath of this death, citizens held a variety of demonstrations; while most were peaceful, the city saw several days of violence and unrest. NACCHO interviewed Baltimore City Health Department Commissioner Leana S. Wen, MD, MSc, FAAEM, about her department’s response to the unrest and about the ways local health departments (LHDs) can address the root causes of health inequity and structural racism. This interview was originally conducted as part of NACCHO’s podcast series. See the notes after the interview for two additional opportunities for engaging in this important conversation.
- NACCHO: As someone who is charged with ensuring the health and safety of the community in Baltimore, could you share with us your perspective on the civil unrest and the role of the city health department during that time?
Dr. Wen: I have to say that in the beginning, I didn’t even know that there was a role for the health department in civil unrest. If you look at our emergency plan for civil unrest, the lead agencies are fire and police–IT even, because they do the 3-1-1 and 9-1-1 call systems. When I was initially asked to go to our emergency operations center as one of the lead agencies, I was surprised because I didn’t know what the role of the health department would be. This was on Monday, right after things began happening. The reason that we got involved in the first place was because one of our health clinics is right across from the CVS that burned down. It’s at North and Penn, right where the “purge” was supposed to happen. We heard about the purge happening and that it was a credible threat. We had to make a decision about whether to close the health center, which actually is a difficult decision because we want to make sure that we serve our community. We have to serve our patients who are most in need but we also have to keep our staff and our patients safe. We were activated immediately to go the emergency operations center (EOC). I was asked to be one of the lead agencies and then things began unfolding.
- NACCHO: Who was in the emergency command center with you?
Dr. Wen: Our mayor, Stephanie Rawlings-Blake, was very clear that every lead agency needs to be present at the EOC at all times—24/7—during emergencies. We’ve been tested on this before in different weather emergencies and even H1N1, so we knew what needed to be done. We had a very clear structure in place. The people in our EOC, especially that first day, were all the lead agency heads. We had fire, police, housing, human services, and many of our other key city agencies present so we could make decisions together. We also had our state partners there as well so we could better coordinate communications and plans. From our standpoint, one of the first things that we had to do was to make sure that our hospitals were safe. If our patients don’t have a way to go to our hospitals, if ambulances don’t feel safe bringing patients to hospitals, if patients are discharged safely, then we weren’t doing our jobs. A lot of it was about communication, setting expectations, and making sure that we loop back and always keep the hospital leaders as up to date as we could.
- NACCHO: How close was the EOC to North and Penn where most of the disturbance was?
Dr. Wen: One of the things that’s most unsettling about the unrest is that we didn’t know when things were happening at all. This was different from a weather emergency, in which case there is some predictability. Safety is the main issue and it ended up that most of the disturbance that day happened at North and Penn. Our operations center was downtown and so a bit separate from it, but Baltimore isn’t that big.
- NACCHO: Did it matter that the EOC wasn’t in the center of the unrest?
Dr. Wen: I’m an emergency room (ER) doctor and every one of my analogies comes from the ER. Let me explain it as running a code. Say you have a patient who is dying. They are wheeled by the paramedics, their heart isn’t beating, maybe they are not breathing. So the person running the code needs to have a whole view of the situation. Everybody else—the ones who are doing CPR, the ones doing a chest read, the ones doing vital signs—they have to be in the midst of it to know what’s going on with that patient. But the person running the code needs to step back and be removed enough—because if they’re in the midst of it, they can’t actually be in control of the situation. So if we had been right in the middle of the action, where we were so concerned about our own safety, we wouldn’t be able to direct the operations of the center. Where we were was actually the perfect location because things were happening everywhere in the city, not just at Penn and North. We had potential shootings on the East Side. We had fires throughout the city. Over 150 cars and many other buildings got burned; 370 businesses were destroyed. No matter where we were, we were in the midst of it. But you should never be in the situation where running the center you fear for your own life because then you’re probably not doing a very good job of directing everything else in the city.
- NACCHO: That’s a great analogy. Can you describe the relationship between the Baltimore City Health Department and the Baltimore City Police Department? Have you discussed ways you could jointly build trust in the community?
Dr. Wen: That’s a great question because we know that violence is not just a criminal justice or police issue. We in public health feel very strongly that violence is a public health issue and it’s something like measles or the flu that spreads from person to person. As a result, it is something that can be prevented and protected against and treated. At the same time, many of these problems that we’re dealing with—deeply rooted disparities and inequalities—have their roots in people feeling like they aren’t respected, feeling like they are not heard, feeling like the people at the leadership level—whether it’s the police or the health department—don’t care about them.
Prior to the unrest, the police commissioner and I had been meeting to talk about community policing practices. Part of what we had been working on was naloxone training—for police to be carrying naloxone so they could also save the lives of individuals who are dying of a heroin or opioid overdose. That training had already been started prior to all of the unrest happening. That was important to us because we believe that the police are saving lives and that the police need to be showing the community that it’s not about arresting people with heroin on them—it’s about saving their lives and preventing them from dying.
In the same way, we’ve been speaking to the police department about better ways to partner around mental health. Arresting someone who is suffering from an acute mental health tragedy? That’s not going to work; that’s not a good way to help with their ongoing mental health crises. So we’re trying to figure out how the police can be involved; maybe it’s having plain-clothes officers partnering with a mental health professional. These are all things that were already in the works and that we continue to be committed to. But I think that the unrest has given us more impetus than ever to focus on partnerships between city agencies so that we can tackle the structural problems in our community and society surrounding racism and inequality.
- NACCHO: To the other health department staff hearing your story, what would you recommend that they do now to prepare for similar events of civil unrest and related emergencies?
Dr. Wen: We in public health know that we have to proactive and not reactive. Preparedness is one of our key functions so we have to make sure we have protocols in place and that we have a deep bench. We didn’t know, for example, how many people would get activated in the health department. I started this job just four months ago and many of our staff are also knew and came in with me so we didn’t have a very deep bench. Now we do because we were able to train many people and activate them. But having those processes in place is really important.
Even more important than being prepared is being nimble and creative and giving people the flexibility to lead. We saw during the civil unrest that nobody knows what to do in terms of the public health response. It’s not something that we’ve dealt with a lot in this country. There isn’t a manual that would have explained how we could have prepared. When I was practicing in the ER, I was one of the physicians who took care of the victims in the Boston Marathon bombings. Nowhere in my training did I learn what to do for a scenario like the Boston Marathon bombings—those aren’t things that you ever learn in advance. But you know that you have the core preparation, the core skills, and the right people there. The only thing left is to make sure people can be creative and nimble and respond to the challenges that they are presented with. We did have a lot things that our staff dealt with absolutely phenomenally.
Things came up all the time that we would have never envisioned. For example, our health department is also in charge of animal control. Part of our function is to protect the zoo and the aquarim; during the unrest, there were threats against the zoo. I never thought about how we could protect the Maryland Zoo but it was one of our core functions. Our staff are creative and nimble and flexible and were given the latitude to adapt the situation and to respond to the best of their abilities.
- NACCHO: Switching gears a bit, how can local health departments begin to confront the root causes of health inequity, structural racism, class oppression, and gender inequity?
Dr. Wen: It is a big question but this is the time for us to do it. I have not seen public health in the news as much as I have in the last several weeks. Maybe after Hurricane Katrina we saw public health in the news. But now we’re talking about issues like lead paint, substance abuse, and life expectancies that vary by zip code. These are things that we as public health leaders talk about every day.
It’s an interesting time because this is our chance, our opportunity to say “Let’s talk about the underlying issues.” In Baltimore, just like everywhere else in the country, we cannot be talking about better jobs for people without also addressing homelessness, food deserts, the heroin epidemic. We can’t talk about violence just as violence without also addressing mental health. Right here in Baltimore, four out of 10 people who are in jail have diagnosed mental health disorders. What are we doing to provide them with mental health treatment options instead of incarcerating them? This is our time to address these core public health issues and to link them to the problems that we’re seeing. So not just talking about mental health and substance abuse and youth wellness separately but to say actually these led us to where we are now. This led to the discontent in our communities. And the discontent is also fueled by structural racism, by discriminatory housing policies, by lack of educational opportunities. This is our opportunity to address all of these issues together as we think about the recovery process moving forward.
- NACCHO: What issues do you feel need to be addressed from a public health perspective to engage with the Baltimore community, especially the youth?
Dr. Wen: The hashtag that was used on social media after the social unrest here in Baltimore and also in New York and in Ferguson, MO, #blacklivesmatter, resonates so strongly because it’s a statement for all of us in medicine and public health. We know that all lives matter but when people are systematically oppressed, when they are not given opportunities to do the right thing, when they are told that their voices don’t matter and cannot be heard, they don’t feel like their lives actually matter. It’s our chance now to say to our youth, “We want to engage you in a conversation about what to do. Your voice does matter. In fact, we want to hear from you about what we need to do.”
Before the unrest, I met with a group of about 50 local youth ages eight and 16 and I asked them, “Of all the things that we’re doing in health, what is the one thing you think we should be doing more of?” These are eight-year-olds, ten-year-olds, twelve-year-olds; I thought they were going to say cigarette smoking or sexually transmitted diseases—things I thought they might want to hear about. They said something that I could have never predicted: mental health. They articulated the trauma that they are seeing every day in their communities. They understand it and they see it. They have classmates and friends who don’t have a home to go to at night. They see their friends—or even themselves—go in and out of foster families. They are in and out of 12 different schools. This eight-year-old told me “Look, I don’t see why I need to go to school every day because my caregivers—my aunt, my grandma—they don’t get up to go to work every day.” They see severe mental health and substance abuse issues that are untreated. To connect with our youth, we have to address the problems that are important to them by bringing it back to hearing the needs of our youth as they articulate them.
- NACCHO: What can other cities learn from Baltimore about health inequities and how to address them?
Dr. Wen: I want to tie it back to the civil unrest because I believe this experience has taught me so much about what we need to do in Baltimore in situations like this but that I also hope are going be to useful lessons for other cities. So there are three things: The first is that there is a role for health in everything. We know this as public health professionals. We know that health is so closely tied to housing and employment and so many things. But even as we saw in the public health response, we were involved in everything—at the very beginning in safety but also later on with other needs that our community identified as well, which leads me to number two: Ask the community about what it is that they need. What is it that our community needs from us at that moment?
I would have thought that the main issue was safety; that’s what were so focused on: getting people safely in and out of hospitals and dialysis and chemotherapy appointments, which are some of our core local health department functions. But then we heard that 13 pharmacies were closed or burned or looted as a result of the unrest. The majority have now reopened but at the time we didn’t know how many pharmacies were closed. People didn’t know how to get their medications transferred. Imagine you normally go to CVS; you don’t know how to get your prescriptions transferred to RiteAid. We were even hearing from people that the closest open pharmacy was five extra blocks away, which may not sound like much to you and to me, but if you’re in a wheelchair or depend on a walker or are on oxygen, five blocks can mean the difference between life and death.
Within 24 hours, we set up a 24/7 hotline for people to call. We said to people that we understood getting prescriptions transferred or delivered is difficult and that we would figure it out for you—no matter what your insurance is, no matter what pharmacy you go to, we’d figure it out. We saw many cases of people who ran out of insulin, who were literally dying; somebody who was out of their Coumadin and was short of breath because her pulmonary embolism had come back. We saw so many of these cases where it was literally a matter of life and death and for us. It was about providing those services in the short term but also connecting them to information and ongoing services, too.
- NACCHO: It’s amazing that you had the resources for that.
Dr. Wen: We didn’t. We had no extra resources to do this. Our staff was working 24/7. We mobilized about 100 volunteers in our community, most of whom are graduate students in public health, to assist us with these operations. We didn’t have any new resources that we devoted to this at all. This is also part of my third lesson: Be nimble, be flexible, make the best use of the resources that you have, and don’t forget that there’s a longer term that we have to prepare for as well. The immediate crisis might be over for us here in Baltimore, but the longer-term recovery is what we must focus on. We hope that other cities across the nation will also follow our example and really push these issues of disparities and inequalities to the forefront, as they should be.
Interested in continuing the conversation? View a live webcast on the NACCHO Annual 2015 session “Police & Community Relations: How Local Public Health Can Help Bridge the Gap” on Thursday, July 9, 9:45–11:15 AM EDT. Dr. Wen will join health commissioners from New York City and Cincinnati to discuss why police violence is a public health issue and how public health practitioners can address the root causes of inequity. Bookmark the webcast link: http://bit.ly/1SQPfdT.
At 11:30 AM EDT, immediately following the webcast, NACCHO will host a Twitter chat with Executive Director LaMar Hasbrouck, MD, MPH, to explore why unjustified police violence is a public health concern and how LHD leaders can help bridge relations between law enforcement and the community. To participate, follow @NACCHOalerts and @drlamarmd; join the conversation by using the hashtag #NACCHOchats.