Leana Wen, health commissioner of Baltimore. (Photo: Tracey Brown)

This Immigrant Doctor Is Reimagining Health in the American City

Leana Wen wants to remove barriers to well-being in areas held back by poverty.

Dec 15, 2016· 15 MIN READ

Julie Scharper is a freelance writer living in Baltimore. Her work focuses on medicine, the social sciences, and public policy. She is a former longtime reporter for The Baltimore Sun.

BALTIMORE—“See, son, since the day you was born, you was judged.” Tyesha Harrell read from a notebook to several dozen people crowded into a purple-painted back room of the Safe Kids Zone in West Baltimore. Her voice cracked with emotion. “But Mommy got you. Mommy got you. And I will try my best to teach you how to be a man. I will not always hold your hand, but I promise you will be a man.”

The poem’s subject, one-year-old Tymond, wiggled away from his aunt, pushing his way through a sea of knees. He toddled past students from a troubled high school and their mentors, health officials, community activists, a member of Congress, and Baltimore Health Commissioner Leana Wen, whose department had organized the gathering.

As his big brown eyes peered around the room, Tymond was the very embodiment of pure potential. But as his mother knows all too well, the odds are stacked against him. He is an African American boy growing up in Sandtown-Wincester, the impoverished neighborhood where Freddie Gray lived until his fatal 2015 encounter with police. The average life span here is 70, about the same as in North Korea, while residents of wealthier neighborhoods nearby can expect another two decades of life. People here suffer more; they are more likely than residents of wealthier neighborhoods to be born prematurely, develop lead poisoning or asthma, have a baby as a teen, struggle with addiction, or become a victim of violence.

Harrell, an organizer with an advocacy group for public housing residents, and the others had gathered in the Safe Kids Zone, an after-school drop-in center about two blocks from the epicenter of the unrest that arose after Gray’s death. They had come to celebrate a grant that they hoped would lift some of the barriers that hold back children here. Wen had secured $5 million in federal funds to help three West Baltimore communities recover from trauma. Unlike most grants, a board of community members would decide how to spend the money.

As Harrell brushed away tears, Wen smiled encouragingly. She projects the mix of briskness and polished empathy you might expect from an emergency room physician, which is what she was until she became the city’s top doctor two years ago. It was a surprising move. She doesn’t have a public health degree. She had no experience working in government. And she was just 31.

But Wen has never turned away from a challenge. When she was eight, she moved with her family from China to the U.S. Though she arrived without knowing any English, five years later she was enrolled in college. When her mother was diagnosed with breast cancer, Wen cared for her while slogging through medical school and serving as president of the American Medical Student Association. After her mother’s death, Wen channeled her grief into a book aimed at helping patients and doctors communicate more effectively.

Wen arrived excited by the job’s possibilities—here was a way to make sweeping and lasting improvements to the health of hundreds of thousands. But Wen wanted to go beyond the usual purview of city health departments such as restaurant inspections and vaccination campaigns; she wished instead to address the causes of poor health outcomes in Baltimore. Yet the challenge has proved to be more immense than she could have imagined. Months after Wen started as chief of the Baltimore City Health Department, the city exploded in violence over the death of Gray. The unrest laid bare the poverty and despair that framed Gray’s life and the lives of so many others. Since then, Wen has found herself caring for a most complex and deeply troubled patient: the city of Baltimore.

“These issues that we’re seeing in our city did not happen overnight. Unless we are honest about diagnosing the problem, we can’t treat it,” Wen told the group that evening. “We’re specifically calling out violence and trauma as health issues. We’re specifically calling out racism as a health issue. We’re saying that we need these problems to be aired in order for us to accept the responsibility of solving them.”

Baltimore is a city of stark disparities, one where the wealthiest and poorest residents lead widely divergent lives and rarely interact. In the battered neighborhood around the Pimlico racetrack, home of the Preakness Stakes, 23 out of every 1,000 babies died before their first birthday in 2014. Just north of the track, in the upper middle class Mount Washington neighborhood, the infant mortality rate is zero. In Roland Park, an area of quirky mansions where Anne Tyler sets many novels, the teen pregnancy rate was zero in 2014. In gritty Greenmount East, nearly 10 percent of teenage girls were pregnant.

These disparities are no accident. Throughout most of the 20th century, Baltimore’s civic leaders, bankers, and real estate agents aggressively enforced racial and socioeconomic segregation. In 1910, after a black Yale law school graduate dared to purchased a home in a white neighborhood, the city passed a law barring black people from living in white neighborhoods—the first law of its kind in the United States, according to historian Antero Pietila, whose book Not in My Neighborhood: How Bigotry Shaped a Great American City, details the city’s racist housing practices.

Despite the passage of the Civil Rights Act in 1964, redlining and blockbusting persisted in keeping African American families confined to poorer neighborhoods and trapped amid the social ills that pervade them. Today, many predominantly black neighborhoods bear the scars of decades of disinvestment. Schools lack air conditioning and computer labs. Grocery stores are a long bus ride away, and most people get food from greasy carryouts or corner liquor stores.

Generations are ensnared in cycles of trauma and the drug trade. The city’s murder rate soared in the 1970s and early ’90s, dipped in the early 2010s, and leaped back up after Gray’s death. Last year, 344 people were killed in Baltimore, and more than 900 were shot. And all too often, the people charged with controlling the trauma on Baltimore’s streets add to it.

In August, the Department of Justice issued a searing report on the city’s police department, documenting a pattern of racially biased stops and searches and excessive force. Police stopped black people three times more often than they did whites and routinely ignored allegations of sexual assault, according to the report. The city and the Justice Department have been locked in negotiations over a consent decree to address these issues.

Meanwhile, the city’s population—and its tax base—has dropped by about a third since its peak in 1970. As an independent municipality, Baltimore reaps few monetary benefits from the wealthy county that surrounds it. The exodus has left some 17,000 vacant buildings, which attract vermin and create hazards. In March, an elderly man was killed when an abandoned house collapsed, crushing him as he sat in his car outside. On some streets, the only trees are those growing on vacant lots.

Wen understands what it’s like to grow up in uncertain conditions. She was born in Shanghai, the daughter of dissidents who sought political asylum in the United States after the Tiananmen Square massacre.

They arrived in Logan, Utah, in 1991 with their life savings—less than $100. Wen’s mother, a university professor in China, and her father, an engineer, were forced to take whatever jobs they could find—cleaning hotel rooms, delivering newspapers, washing dishes.

“My parents were working menial jobs where there was no job security, and we worried every month that we would be able to make the rent,” Wen recalled. “We were very frugal. Even now, I have trouble accepting birthday gifts because as a child we didn’t receive birthday gifts.”

No longer bound by China’s one-child policy, Wen’s parents had a second child, Angela, when Wen was 11. Unable to afford childcare, they were forced to send her to China at only three weeks old to be raised by grandparents, Wen said. The family would not see her again for three and a half years.

The family moved to Southern California in search of better employment opportunities, and Wen switched schools frequently as they moved from one troubled neighborhood to another. She says she was an unremarkable student, but in eighth grade she learned about a work-study program at California State University, Los Angeles, where she could learn laboratory techniques and get paid for going to school. “We really needed money for our family. My parents were working. I thought, ‘Why not contribute my share?’ ” she said.

She applied for the program, took a placement test, and was accepted, starting college without having attended high school.

“I look back now, and I’m astounded by the number of things that had to go the right way” when she was growing up, Wen said. We spoke in her window-lined office in the brick building in East Baltimore that houses the city health department. “There were so many times that I could have gone down the wrong ramp. We struggled with food insecurity, not knowing about jobs. I had all these dreams, but I had no idea how to achieve them. I didn’t know anyone who was a doctor.” In the impoverished neighborhoods where her family lived, she never had the opportunity to meet anyone who had attended college. She graduated from Cal State L.A. summa cum laude at 18.

Wen had her pick of full scholarships to medical and doctoral programs and chose the medical school of Washington University in St. Louis. Meanwhile, her mother was beginning to notice strange symptoms. Her primary care doctor dismissed her complaints for a year; by the time she was diagnosed, cancer had spread to her lungs, bones, and brain.

Wen took a year off from med school to care for her mother, and even after she returned, she frequently traveled to California to advocate for her. “My mother would not have wanted [her illness] to affect my education. She had guilt on her end, and I had guilt on my end,” Wen said.

Wen became involved in the American Medical Student Association and took another year off from school to serve as its president. Running an organization that represents 65,000 medical students gave Wen leadership experience she would tap as health commissioner. It also gave her a platform.

Wen led a push to encourage doctors to end the practice of receiving lavish gifts from pharmaceutical companies. When Hurricane Katrina devastated New Orleans, she organized hundreds of medical students to help survivors.

“She always had a strong sense of social mission,” said Dr. Fitzhugh Mullan, a longtime mentor. “She knew she wanted to do something to use medicine as a fulcrum for change.”

Wen also turned her interests internationally as a fellow with the U.S. Department of Defense. In 2007, she studied the aftermath of the Rwandan genocide. She also joined New York Times columnist Nicholas Kristof on a reporting trip to Rwanda, the Democratic Republic of Congo, and Burundi, where they interviewed and cared for victims of horrific conflicts. In one Congolese village, she encountered a woman covered in bedsores who weighed no more than 50 pounds because of severe malnutrition. Wen arranged for her to be cared for in a hospital and visited her again before returning home to be sure she was recovering.

Soon after the trip, Wen attended Oxford University as a Rhodes scholar. She studied modern Chinese history and economic and social history, receiving two master's degrees. In England she met the man who would become her husband, Sebastian Walker, a native of South Africa.

Wen was a resident in emergency medicine at Brigham and Women’s Hospital and Massachusetts General in 2013 when there was an announcement that a bomb had gone off at the Boston Marathon. Patients began pouring in: a woman who had lost her foot, a man whose legs were nearly blown off.

“It’s what we train for; it’s what we prepare for. But nothing can really prepare [one] for what we saw,” she said.

The Boston years were a hectic time for Wen and imbued with sorrow. After suffering from cancer for eight years, her mother entered the late stages of the disease. Wen flew out to California to find doctors poised to put her mother on a ventilator, despite her expressed wish to die without such intervention. Wen’s father and her sister, a college freshman, “were paralyzed by the thought of letting her go,” she wrote in a blog post. Wen instructed the doctors to follow her mother’s wishes and let her die. It was the hardest thing she had ever done, she wrote.

While caring for her mother, Wen saw the medical system from the other side. Doctors were abrupt, rude, perfunctory. One yelled at her mother, prompting her to cry. Wen wove these experiences into a book, When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests, to help patients navigate the often confusing, frustrating, and impersonal medical system.

In 2014, Wen heard that Baltimore was seeking a new health commissioner. Dr. Joshua Sharfstein, a former city health commissioner who had also served as Maryland’s secretary of health and human services, encouraged her to apply. The idea of tackling Baltimore’s problems appealed to Wen, said Sharfstein, a member of the search committee and now associate dean at the Johns Hopkins Bloomberg School of Public Health.

“The more she got into it, the more she caught fire,” he said. “She said, ‘This is what I have been preparing to do.’ ”

Wen understood that the job would pose a monumental challenge, Sharfstein said. “I think she realized that this was a choice with some risk for her. It wasn’t a natural progression from an academic career, and she was going to be entering into a very difficult and political environment,” he said. “The experience could be great, but it could also be really dispiriting.”

Even before Wen took over as health commissioner, she declared war on the city’s inequalities. “My passion is to tackle unjust health disparities,” she wrote in an op-ed in The Baltimore Sun published the day before she began. “My goal is to change the unfortunate reality that geography is often destiny.”

An emerging body of scientific evidence is showing that adverse childhood experiences such as high levels of stress, exposure to violence (whether as witness or as victim), a lack of nurturing relationships, poor maternal diet, and environmental toxins such as pollution can have damaging consequences for an individual’s long-term health and cognitive development. Such conditions are concentrated in low-income areas; Wen hoped her department could have a greater effect on health in Baltimore by addressing these root causes.

Wen kicked off her new role with a 100-day listening tour, much as a doctor begins an exam by asking patients how they feel. Just as the tour was wrapping up, police arrested 25-year-old Freddie Gray near his home in West Baltimore on a sunny April morning. As a neighbor filmed the arrest, officers shackled Gray and loaded him into the back of a van. Despite multiple investigations and trials, it’s still unclear how Gray was injured. About 45 minutes after Gray was arrested, he was found unconscious in the back of the van. He was taken to the Shock Trauma Center at the University of Maryland Medical Center, where he underwent two operations but never woke up.

For days, Baltimoreans peacefully protested Gray’s death. On the night of Gray’s funeral, tensions simmered over. People torched buildings, smashed windows, looted pharmacies and shops.

As the city began cleaning up the next day, Wen and her staff worked to ensure people could get medical care and pick up prescriptions. They mapped out how to get patients to methadone clinics, dialysis, chemotherapy. They made plans to get prescriptions to homebound people whose pharmacies had been looted. Then Wen and other senior staffers knocked on the doors of homes in the hardest hit areas. They went through senior apartment buildings, letting everyone know they could help. The team also set up a permanent 24-7 crisis line, where people with mental health or substance abuse issues can receive referrals to counseling.

In the year and a half since the unrest, Wen has unveiled an array of programs to help residents recover from trauma and remedy social disparities. Unlike most city agencies, the health department derives the vast majority of its budget—80 percent of its $130 million operating costs—from grants. That gives Wen a lot of latitude to set her own agenda. “It gives us a degree of flexibility that no one else has,” she said. “As long as we can fund-raise for it, we can do it.”

That also means that Wen must be, as she says, the “chief marketer of the department,” devoting substantial time to trumpeting Baltimore’s health struggles and successes. NPR’s All Things Considered shadowed her in the spring, and she has made a number of high-profile media appearances. On a recent morning, she contacted staff members about a raft of upcoming interviews, then reminded them she would be available for media bookings on an upcoming trip to San Francisco.

Wen garners a lot of headlines for her fresh and forthright approach to the job. Healthy Baltimore 2020, the five-year plan to address underlying health disparities in the city, which her department released in August, calls out the harm caused by “structural discrimination, racism, poverty, and historical practices of exclusion” and commits to addressing these inequalities while not “shying away from the difficult conversations that may arise.” That commitment came through in finalizing the plan. “We were about to go to print," Wen recalls, "and then I thought, If we don’t call out race, who else is going to? Let’s write this down and codify it,” she said. “If we don’t diagnose the problem, we can’t treat it.”

Wen acknowledges that there’s no easy tonic for centuries of institutional racism. She recently organized a half-day retreat around race equity for senior staffers. She strives to be “intentional” in hiring a racially and socioeconomically diverse staff by, for example, drawing home visitor health workers from among those who formerly benefited from the program.

Then there’s the question of trauma. Baltimore’s African American and poor residents are significantly more likely to have witnessed or experienced traumatic events than white or wealthy residents. One-third of children have a score of at least two on the Adverse Childhood Experiences Study, a tool for measuring early trauma. Many suffer from undiagnosed post-traumatic stress disorder; encounters with police, emergency medical technicians, or strangers on the street throw salt on psychic wounds. Wen started an initiative to teach “frontline city employees”—those who deal with the public—to recognize and mitigate the signs of trauma. More than 1,400 employees have been trained, said Gabe Autieri, Wen’s deputy chief of staff.

Perhaps the most inventive program for addressing trauma is one being planned in the West Baltimore children’s center where Harrell read the poem for her young son. Wen secured $5 million in funding from the federal Substance Abuse and Mental Health Services Administration for the three neighborhoods most affected by the 2015 unrest. After discussions with local leaders, social workers, and public health scholars, Wen decided to have a board of community members determine how to appropriate the funds. The board, which has yet to be selected, will be composed of a mix of residents and those who work and worship in the communities. The board will decide how to spend the grant money to help treat and prevent trauma.

Wen is also a staunch advocate of one of the city’s longest-running—though controversial—programs for stopping violence. Safe Streets trains ex-offenders to de-escalate conflicts. Mediators do not report information to the police, which makes them better confidants but alarms critics. Wen’s support of the program helped convince others that it is effective, said City Councilman Brandon Scott. “She’s starting to push the envelope to get people thinking about violence differently,” he said.

Wen has continued a number of successful initiatives started by her predecessor, Dr. Oxiris Barbot, including the B’more for Healthy Babies campaign, which has led to a dramatic drop in the number of infant deaths. She has come up with concrete plans to fill voids in health care, such as a public-private partnership that will provide free eye exams and glasses to all elementary and middle school students.

Many of Wen’s initiatives have centered on substance abuse, a persistent problem in Baltimore. To cut the number of people dying from overdoses, Wen issued a standing order for naloxone, a prescription medication that can reverse the effects of heroin and other opioids. Since she issued the order in October 2015, some 15,000 people have learned how to use naloxone, saving at least 400 lives, according to Wen.

She’s working to open a stabilization center for people with addiction problems, which could divert drug users from hospitals and jails. Intoxicated people would have access to a bed, showers, medical care, and referrals for treatment. Wen negotiated with the city’s hospitals to gain their support and has been searching for a location for the center.

As commissioner, Wen has taken a “comprehensive and holistic approach” to health, said U.S. Rep. Elijah Cummings, who has worked with her closely to secure federal funds. “She looks at drug addiction not from a criminal standpoint but from a health standpoint. And she comes up with a practical solution,” he said.

Still, some Baltimore leaders would like to see Wen more boldly address the roots of the city’s disparities. Morgan State University public health professor Lawrence Brown has called on Wen to oppose business deals that he and other activists believe exacerbate the city’s extreme divisions, such as tax breaks for wealthy developers. Brown wrote a letter to SAMSHA criticizing the awarding of funds to the city when its police officers, as detailed by the DOJ report, inflict so much trauma. “You can't deal with trauma if the systems that inflict trauma are still there,” he said in an interview. “The only way to truly heal trauma is to get rid of the systems that inflict trauma.”

Yet Wen’s programs have caught the eye of other public health officials, aides said. A representative from the San Francisco Department of Public Health flew out over the summer to document a storytelling program for LGBT African Americans. The Centers for Disease Control and Prevention’s Project PrIDE has also expressed interest. The Detroit Health Department got in touch while making plans to build a school vision program similar to Baltimore’s.

Wen said she’s not looking to move up in government; she doesn’t have her eye on becoming state health secretary or surgeon general. She and her husband, who works for the Legg Mason investment firm, are about to purchase a house in Baltimore. She wants to stay at the health department to see her programs come to fruition and make course corrections as necessary. With Mayor Stephanie Rawlings-Blake’s term recently ending; her successor, former state Sen. Catherine Pugh, intends to keep Wen in her post.

“I already like what Leana Wen is doing,” said Pugh. “She understands the health disparities; she understands the city; she understands drug addiction and the other challenges. What she wants us to do is to help support her as she goes after grants.”

The voices of children playing filtered into the back room of the Safe Kids Zone. Each afternoon, they come here to read and do homework, practice yoga and dance, and eat a free dinner. A poster on the wall read, “I can’t wait to go to college.”

Cumming, who grew up nearby, spoke to the group gathered to map out plans for the grant. “When I walked in here and saw all of those children, it made my heart glad,” he said. “This is a place where they can come and be safe and then have food. A lot of our children don’t even know what normal is.”

He thanked Wen for “not proceeding in the same old, same old way” and instead allowing the community to steer the grant funds. Baltimoreans have had enough of “people coming into our communities and telling us how to handle it.”

Harrell, the mother who read the poem, told a story about a teenage neighbor who had been chatting with her as she hung laundry. She told him to be careful because six people had been killed in recent weeks near the McColluh Homes, the public housing where they lived (and where Freddie Gray once lived). The teenager said, “I already watch my back more than I watch my front.”

“To know that he’s living his life like that, that’s heartbreaking,” said Harrell. “I see other young boys growing up in his footsteps, but now”—through the SAMHSA grant—“I’m able to give them a chance to change it. I know I’m not Wonder Woman, but this makes me feel like Wonder Woman.”