Influence Beyond Authority: Advice from Dr. Leana Wen on Meta-Leadership and Moving the Needle in Public Health
By Simone Wahnschafft
Content Note: This article discusses the opioid crisis and overdose in the U.S. and references addiction and death.
“Getting things done” — the words spilled out with conviction as Dr. Leana Wen delved into her motivations for serving at the frontlines of public health leadership. Driven by her own experiences growing up in a family dependent upon public services, Dr. Wen honed in on her passion for increasing access to care and services for her patients:
“I actually don’t know that I ever thought about my work as leadership…when I look back, and look at the titles I’ve had, or the things that I’ve done in these titles, it’s always because there was something that nobody else was doing. And it was my opportunity to step up and do that. And if it’s anything that’s driven me throughout my life, it’s not the idea of leadership, but rather the idea of access to care.”
Dr. Wen’s passion for healthcare access was integral in her decision to train as an emergency physician, as she never wanted to have to turn any patient away. Her passion for her patients ultimately took her well outside the confines of her clinical practice and into the helm of myriad leadership roles in public health. Most recently, she served as the President and CEO of Planned Parenthood, where she led a national healthcare organization with a presence in all 50 states. Ultimately parting with the organization due to philosophical differences in July 2019, Dr. Wen is currently a Visiting Professor of Health Policy and Management at the George Washington University Milken School of Public Health and Distinguished Fellow at the Fitzhugh Mullan Institute for Health Workforce Equity.
Previously, Dr. Wen served as the Health Commissioner for the City of Baltimore, during which time she led initiatives to combat the growing opioid epidemic, reduce infant mortality, and address gun violence as a contagious disease, among others. Under her leadership, the Baltimore City Health Department was recognized as the Local Health Department of the Year in 2018. As the author of the critically acclaimed book, When Doctors Don’t Listen, and speaker for over six TEDx and TEDMED talks, Dr. Wen has leveraged her voice to become a staunch advocate for patient-centered healthcare reform.
On Tuesday, January 14, 2020, the Voices in Leadership series kicked off a new year by welcoming Dr. Leana Wen to share her lessons on moving the needle in public health. In conversation with Dr. Leonard Marcus, the founding Co-Director of the National Preparedness Leadership Initiative and lecturer on public health practice in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health, Dr. Wen reflected upon her experiences bringing community and political stakeholders to the table to address health disparities.
Meta-Leadership: Meeting People Where They Are
For the past two decades, the United States has been in the throes of the opioid epidemic. This epidemic has not been distributed evenly across the country. Over the past several years, press coverage has focused largely on the impact of the epidemic on white victims in suburban and rural areas where the crisis first began; however, as the epidemic has spread into urban centers with a vengeance, far less attention has been paid to hard-hit, urban, predominantly Black communities and the hindrances they face in accessing preventive services and treatment.
Soon after Dr. Leana Wen was appointed as Baltimore City’s Health Commissioner in December 2014, the city’s opioid overdose rate skyrocketed, from 305 deaths in 2014 to 694 deaths in 2016. The city still has one of the highest rates of drug-overdose related deaths in the country. This trend is largely attributable to the dramatic rise in illegally manufactured fentanyl, a synthetic opioid 80 to 100 times more potent than morphine. Throughout her tenure as the city health commissioner, Dr. Leana Wen spearheaded response efforts to address the epidemic, including issuing a blanket prescription for Naloxone, the opioid overdose reversal medication, to all of Baltimore’s 620,000 residents in 2015, an intervention that has since saved nearly 3,000 lives.
Of course, as Dr. Wen was quick to point out in her discussion of this initiative and other milestones in her career, such change can never stem from only one person or even one organization. Driving change in the face of public health crises requires action across multiple stakeholders, and coordinating such efforts calls for meta-leadership.
Meta-leadership, in short, refers to the leading of leaders. Developed by faculty at the National Preparedness Leadership Institute and the Centers for Disease Control, the meta-leadership framework emerged from analyses of national crises, such as the September 11 attacks and Hurricane Katrina. It is grounded in the premise that effective emergency preparedness and response necessitates a form of leadership outside the scope of conventional understanding. Meta-leadership is grounded in the idea of “influence beyond authority”, preparing leaders to influence a wide range of stakeholders over whom they hold no direct authority in order to initiate system-wide responses.
In discussion with Dr. Marcus, one of the original authors of the meta-leadership framework, Dr. Wen distilled her perspectives in exerting influence beyond authority to drive systemic change. One of the essential lessons that Dr. Wen shared, particularly in the context of addressing the opioid epidemic in Baltimore, is the importance of meeting people where they are. Dr. Wen explained that, had she approached the problem from her ideal perspective of expanding addiction treatment, she would not have been able to corral the necessary stakeholders to begin to address the epidemic. Rather, Dr. Wen and her team recognized that Baltimore had a rich history of spearheading harm reduction programs, as one of the first jurisdictions to begin a syringe exchange program (SEP) in 1995, which prevented thousands of new HIV diagnoses. Consequently, Dr. Wen decided to first approach the epidemic from a harm reduction standpoint, focusing on increasing access to Naloxone in order to build awareness and support around addressing addiction as a public health issue.
Since the implementation of the standing order for Naloxone, the city of Baltimore has seen a shift in attitude around addiction, from that of a personal failing to a preventable disease that necessitates policy and public health action. In 2017, the Maryland General Assembly overwhelmingly passed the Heroin and Opioid Prevention Effort (HOPE) Act, which included provisions for the establishment of behavioral health crisis treatment centers and a statewide 24/7 crisis hotline, amongst several other interventions aimed at holistically addressing the opioid crisis. Dr. Wen made it clear that such subsequent steps were only made possible by the initial approach that prioritized meeting stakeholder values and building influence beyond authority:
“Once we were able to show the success of this program, once we had hundreds, then thousands of people whose lives were saved, whose family members can attest to what it meant for them, then we were able to get the treatment…because of the naloxone work, we were able to get the public to be mobilized, and energized for people to realize this is not someone else’s problem.”
The Guidance of A North Star
VUCA — Volatility, Uncertainty, Complexity and Ambiguity. A framework first introduced in 1987 by the U.S. Army College, and explored in the context of public health leadership in a previous Voices in Leadership discussion with Dr. Jonathan Woodson, this acronym is used to understand the conditions in which leaders must make decisions. Operating in a context characterized by changing conditions, Dr. Wen pointed to the importance of a North Star — a reliable constant to drive forward her vision and action. For Dr. Wen, that North Star has always been her patients. When prompted on the source of her imagination as a public health leader, Dr. Wen pointed without hesitation to the role of her clinical practice:
“We did a lot in Baltimore, when I was the Health Commissioner there, around a number of issues, including the opioid epidemic, maternal and child health, gun violence, all of which we conceptualized as public health issues. And people might look at the programs now, and say, oh that was an innovative, creative solution. But that solution came about because of the patients that I saw.”
By continuing her hands-on practice in clinical medicine throughout her time as the Baltimore City Health Commissioner, Dr. Wen was afforded a first-hand view of the health issues disproportionately impacting her community. She revealed that the initial idea to issue a blanket prescription for Naloxone, which was particularly innovative at the time, emerged from her experience working in the emergency room (ER) as the opioid epidemic began to escalate in Baltimore. As she administered the drug in the ER to increasing numbers of patients, she realized that, if Naloxone were to be made more readily available in the hands of residents, thousands of lives could be saved.
With Politicians, Short-Term, Highly Visible Progress is Key
As many in the public health field can attest, time is a salient challenge in public health. Often, public health interventions are focused on promoting change that will improve health outcomes for hundreds, even thousands of people, as well as save significant sums of money for various stakeholders. However, these changes are generally projected to unfold over the course of several years at minimum. Such a timeline is often in direct contrast to that of the political arena, which tends to operate on election cycles. Dr. Wen spoke to this tension in the context of how public health practitioners should be interacting with political leaders, highlighting the importance of building political support through short-term progress in public health.
As a case study from her own work, Dr. Wen pointed to the example of Vision for Baltimore, a program she led out of the Baltimore City Health Department, which provided free eye exams and glasses to children from kindergarten to 8th grade in all Baltimore City public schools. She spoke of how this program served to bridge local political priorities, namely improving childhood education, with public health in a way that elevated the importance of intervention in the purview of local politicians:
“Probably in every jurisdiction, what people care about will be some combination of crime and public safety, jobs, education, housing. These are kind of bread and butter local issues, and national issues too. If we know that a certain candidate cares about these issues, or let’s say that their one platform is education, then it’s up to us to make the case for why public health is important to education”.
Dr. Wen expressed the harsh reality that public health programs of vital importance, even those with a strong evidence base, are often severely underfunded. She highlighted her experience overseeing B’more for Healthy Babies, a comprehensive initiative to reduce infant mortality in Baltimore. Within the first four years of implementation, infant mortality rates dropped by 28% and the disparity between white and Black infant deaths decreased by 40%. Despite such strong evidence of success in improving infant health, however, the program was consistently under-prioritized in the government budget, and Dr. Wen often had to pull funding from various philanthropies to continue to run the program.
Bringing Public Health to the Public’s Attention
In stark contrast to the political sphere, public health lacks a public face. The successes in public health are grounded in the prevented outbreaks and the incremental progress that does not naturally capture media headlines. Ultimately, it is our responsibility as public health practitioners to make the case for our own work — to capitalize on short-term successes and highlight the risks inherent in the absence of intervention. From her own experiences fighting for the importance of public health, Dr. Wen implored the audience to recognize the following truth:
“If we don’t make the case for public health, nobody else is going to.”
Story written by Simone Wahnschafft, a Master of Public Health candidate in the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health. Born and raised in Boston, Simone received her Bachelor’s degree in Biology and Global Health from Georgetown University. Following graduation, Simone pursued two service terms with AmeriCorps National Civilian Community Corps, serving as both a Corps Member and a Team Leader on myriad community development projects across the Southwest region of the United States. Simone’s academic and professional interests revolve around nutrition, food insecurity, and health equity.
Story edited by Sherine Andreine Powerful, MPH, a second-year Doctor of Public Health student at the Harvard T.H. Chan School of Public Health. A Diasporic Jamaican, she received her Bachelor’s degree in Latin American and International Studies from Yale University and holds a Master of Public Health degree in Population and Family Health, with a concentration in Global Health, from the Columbia University Mailman School of Public Health. Her interests, centered around the English-speaking Caribbean, include feminist global health and development leadership; gender and sexual health, equity, and justice; and pleasure, healing, and liberation.
