Think Big, Move Fast
As Baltimore’s long-tenured health commissioner, Peter Beilenson daily confronts some of the nation’s most entrenched big-city health problems. He does it with political savvy, a flair for statistics, and one foot on the accelerator.
On a Tuesday morning in Baltimore in late June, Peter Beilenson is digging into some numbers. Baltimore has just had a bad weekend, with eight homicides. But none involved juveniles, to the relief of the dozen people assembled with Beilenson around a conference table. According to a bar graph projected on an overhead screen, since the first of the year 10 Baltimore kids have died by homicide. That’s 10 too many, but it’s a 33 percent reduction compared to this point last year, which is the kind of number this group is after.
They meet weekly as part of a city health department data review called KidStat. Beilenson, MPH ’90, is the Baltimore City health commissioner. He’s held the job for the past 11 years, a long tenure for a big-city health commissioner. And the job gets more challenging all the time. Commissioners like Beilenson must deal with all the old problems—restaurant sanitation, vermin control, epidemics of sexually transmitted diseases, drug addiction—and new urban nightmares like bioterrorism, SARS, and “dirty bombs.” For more than a decade, Baltimore’s health problems have been Beilenson’s headache, and he’s responded by thinking big and moving fast.
During Beilenson’s time on the job, Baltimore has not been the healthiest city in which to live. It has had high rates of violent crime, sexually transmitted diseases, and substance abuse, especially heroin. National television viewers of Homicide, The Corner, and The Wire know it mostly as that place where you’re either an overworked cop, a junkie, or a murder victim. Newspaper readers may recall it as the city that a few years ago managed what Beilenson, 43, ruefully calls “the trifecta”: the highest incidence of syphilis, gonorrhea, and Chlamydia among American cities. Baltimore ranks second in per capita violent crime, behind Detroit, with an appalling murder rate of five or six per week.
But to Beilenson, the city is becoming healthier by the day. He has a formidable memory, and he’s practiced at listing for reporters, legislators, and the public one sign of progress after another. Baltimore has had, for three years running, the biggest drop in violent crime of any major U.S. city—a 26 percent reduction since 1999—and the largest two-year drop in drug-related emergency-room visits. In what Beilenson has described as one of the most
important accomplishments of his tenure, the city recently recorded the lowest infant-mortality rate in its history (10.4 deaths per 1,000 births, down from 11.9 deaths in 2001) and, for the first time last year, it saw infant mortality among blacks drop below the national average for blacks. Beilenson has set a goal to eradicate syphilis and tuberculosis in the city by 2008; he claims to be ahead of schedule on both. And in a time of straitened public finances, “we’ve increased drug treatment more per capita than any city in the United States, by far,” he says. “In fiscal ’97, we had 4,000 drug-treatment slots that treated 11,000 individuals that year. This year, we have approximately 9,000 treatment slots treating about 26,000 individuals.”
Beilenson’s admirers are generous with their praise. Stephen Teret, JD, MPH ’79, director of the School’s Center for Law and the Public’s Health, says, “Baltimore couldn’t be luckier than having Peter as its health commissioner. He has a towering intellect, so he’s able to immediately understand the dimensions of a problem and the complexities involved in solving it. Then he has the courage to take action.”
Beilenson has indeed been unafraid to endorse aggressive remedies for Baltimore’s health problems. Teen pregnancy? Provide long-term contraception in school-based clinics. Heroin junkies spreading HIV/AIDS and hepatitis C through dirty needles? Start the biggest city-run needle-exchange program in the country. Syphilis a major problem? Do blood testing in crack houses and bolster staffing at city clinics. Tuberculosis? Aggressively pursue all patient contacts and supervise patients so they achieve 100 percent compliance with medication regimens.
“Unless you’re trying to make a difference,” Beilenson says, “this job doesn’t interest me.”
Beilenson likes to refer to his current position as “the only real job I’ve ever had.” After graduating from Harvard and completing medical school at Emory University in 1987, he served a family-practice internship at the University of Maryland. There, he says, “I realized that almost everybody we were seeing in the emergency room were people coming back over and over again for conditions that were related to behavior: smoking, alcohol or substance abuse, and AIDS. I was very interested in politics and public health policy—my dad was a congressman [in California] for 20 years—and I was looking for a combination of the two.”
He opted for a residency in preventive medicine at the School, earning his MPH and finishing as chief resident in 1992. Teret says, “I remember him as one of the great students. He had more intellectual curiosity, and was willing to think critically and challenge a professor when appropriate. Peter didn’t shy away from controversial issues.”
During his residency, he lost two close elections for the Maryland House of Delegates and the Baltimore City Council. He may have established an undesirable electoral pattern, but he also got to know Kurt Schmoke, then running for reelection as Baltimore’s mayor. “Two months after I completed my residency,” Beilenson says, “Schmoke called me out of the blue and offered me this job.”
At 32, Beilenson was, he believes, the youngest major-city health commissioner in the country, running North America’s oldest health department. He walked right into major controversy. In his first year, the city began dispensing Norplant, an implanted, long-term contraceptive, through some of its school-based health clinics to teenage girls who requested it but could not afford it. Parental consent was not required. Some African-American community leaders denounced the program as racist, charging that it would not have been implemented had the majority of recipients been white. Strident critics even called it genocidal. The city and Beilenson stayed with the program. (Baltimore now offers Depo-Provera injections instead.)
“I would not want an extra day in this job unless I felt like we were really pushing things. We’re quite proactive,” he says, noting, “I think we’re the first place to directly observe therapy for AIDS patients.”
There are other examples: After more than 50 Baltimore city schools failed to comply with his order to shut off lead-tainted drinking fountains, Beilenson fined 15 of them, garnering much publicity and forcing compliance. (He later waived the fines when the schools finally obeyed his orders.) When three people in Baltimore showed symptoms of SARS last April, Beilenson moved swiftly to have them isolated. None had the disease, but he wanted to prevent a Toronto-style outbreak.
After 9/11, the health department created the Office of Terrorism Preparedness and Responseto prepare the city for potential biological, radiological, or chemical attacks. Among other things, the new office has developed large-scale smallpox immunization plans. It also monitors the number of dead animals collected from city streets, emergency room traffic, and over-the-counter drug sales, vigilant for any indication of a bioterrorism incident. In July, the city conducted a large-scale bioterror drill.
But to Beilenson’s eye, by far the biggest public health problem in Baltimore is drugs. “Substance abuse—heroin, cocaine, marijuana, alcohol to some extent—impacts every aspect of life in the city,” he says. “Somewhere between 75 and 90 percent of all felonies and misdemeanors are related to drugs. Health consequences from hypertension to AIDS to a lot of emergency room visits often relate to substance abuse.”
He remembers a 13- or 14-year-old girl he saw as a patient at one of the school-based health centers. “[She’d been] referred by a teacher because she kept falling asleep in class. Turns out, Dad was dead from a drug deal gone bad. Mom? AIDS, out of the house. The girl lives with Grandpa, who is 70-something and has Alzheimer’s, and her 5-year-old brother. Every day, she goes out to get food for the family, makes the little guy’s lunch, tries to keep Grandpa in the house, and still is actually doing decently well in school. But she’s falling asleep all the time because she’s running the household. This is a common example.”
Beilenson, who manages a department of around 1,200 people with a budget of $200 million, admits that he gets bored easily and has trouble sitting still. He likes to get out of his office to deal with a situation firsthand, give a speech, testify before a committee, attend a meeting, or even see patients; once a month, he tries to work a shift as a physician in one of the school-based clinics. Sometimes he just drives around for an afternoon to observe Baltimore’s streets.
On a Thursday morning, Beilenson strolls into the New Life Evangelical Baptist Church for a meeting of the board of trustees of Baltimore Substance Abuse Systems, Inc. Baltimore’s goal is to provide drug treatment on demand within 24 hours for anyone who wants it, and BSAS is the nonprofit corporation established by the city to make that happen. Many members of the board are sharply dressed in dark suits despite the summer heat. Beilenson is more casual and rumpled in khaki chinos and a creased button-down shirt, his sleeves rolled up and his tie loose. He delivers a brief report, then listens as board members discuss issues involving drug treatment in Baltimore.
Afterward, he tours the adjacent, newly opened Turning Point methadone clinic. Beilenson sort of bobs and dances as he walks on the tour, as if dissipating excess energy. At some points during the meeting he seems to nearly vibrate in his chair. He describes himself as antsy, and when he climbs into his white Honda Odyssey and rolls out of the church lot to head for Good Samaritan Hospital, the Beilenson Speed Limit through Baltimore’s streets often tops 45 mph.
At the hospital, he speaks to a lunch gathering of physicians. For an hour he genially discusses SARS and drug treatment and HIV/AIDS and STDs in detail, without once referring to a note. Beilenson claims to have about 150 pages of material in his head, and seems to have effortless recall. He’s wry and articulate, and happy to answer questions afterward before striding across the parking lot for a fast drive back downtown. As he walks he checks his pager and his BlackBerry wireless e-mail receiver. “I couldn’t live without this thing,” he says.
Beilenson’s command of detail has helped him persuade Maryland legislators to keep the money flowing. About 65 percent of the city’s drug treatment funding comes from the state, and the state’s contribution has grown from $22.4 million in fiscal 1999 to $52.2 million in fiscal 2003. When Maryland
Governor Robert Ehrlich recently mandated significant cuts to the state budget, Beilenson was ready with more numbers to argue against the reductions: “The amount saved from the budget will be lost in increased expenses in this very same budget year. For example, the $600,000 cut from drug treatment means at least 500-plus fewer addicts getting treatment this year, resulting in 30,000-plus more days of illegal activity with its concomitant costs in crime, prosecutions, incarcerations, etc. The $552,000 cut from our core public health grant can easily mean the elimination of our maternal and infant nursing program, which is in part responsible for the greatest single achievement in public health in Baltimore in the past few years—the lowest infant mortality rate in the city’s history.”
Beilenson knows politics and knows what legislators want to hear: that the money spent is having the desired effect. So he is always equipped with positive-outcome numbers. His department has adopted the New York City police’s model of data-retrieval and analysis (called ComStat) to effectively deploy resources. DrugStat tracks drug-treatment statistics. LeadStat does the same for the city’s lead-abatement program (which has seen a 61 percent reduction over the last three years in lead-poisoned children, Beilenson says). KidStat meters the city’s Operation Safe Kids program, which identifies juvenile offenders most at risk of becoming a city homicide statistic.
For each of the health department’s major initiatives, Beilenson sets benchmarks, then at the various Stat meetings he and his colleagues track progress toward those goals. Failure to meet expectations can result in a program losing city support; with DrugStat, Beilenson has defunded six programs for nonperformance since the program began. Does this sort of accountability help him persuade state legislators? Says Beilenson, “Abso-positive-lutely.”
He will need a lot of legislators in his corner for his most ambitious initiative—Health Care for All.
“We’re trying to become the first state in the country to have universal health insurance,” Beilenson says. “We’re always fighting in Annapolis and Washington for more funding for specific ailments, when the problem always comes down to no insurance.” He says the state’s total cost for health care, outside of nursing home care, is $20 billion annually. The proposed Health Care for All plan would cost $673 million, Beilenson says, all of it paid for by an increase in the tobacco tax, a 5 percent payroll tax charged to employers who don’t already provide employee insurance, funds reallocated from existing programs for the uninsured, and fair premiums charged to those newly insured who can afford them. The private sector would cover more than 80 percent of Marylanders through employers’ plans and individual access to small-group rates previously available only to small employers. Medicaid and expanded eligibility for the Maryland Children’s Health Program would insure about 16 percent of the population. Only about 4 percent would need to be insured by “MdCare,” a new quasi-public entity created for that purpose. Beilenson is optimistic about the plan’s chances in the next Maryland legislative session.
The plan has infuriated Robert O.C. Worcester, president of Maryland Business for Responsive Government, a political research and advocacy group sponsored by the state’s business interests. He says, “What this plan’s advocates want is overnight imposition of government-run health care. The 5 percent payroll tax would bring about the collapse of private insurance in Maryland. If employers can drop from the 10 or 12 percent of payroll [they now pay for private coverage] to the government-sanctioned 5 percent, why will they continue to pay for health care coverage for employees?”
Beilenson responds,“Government-run health care is defined as government owning all the hospitals and employing all providers. Our plan is virtually the opposite. [It] gives more business to the private insurance industry since all 600,000 who are uninsured currently will be required to be covered, and the vast majority of those will go to the private sector.”
Worcester is not Beilenson’s sole critic. Baltimore City Council president Sheila Dixon says she’s not convinced that the health department’s priorities are what they should be; she’d like HIV/AIDS regarded with the same urgency as drug abuse, for example. Ruth Ann Norton, executive director of the Coalition to End Childhood Lead Poisoning, believes the city could do more to empower community groups like hers to help with problems like lead abatement. Norton says: “I think Peter is good at empowering people. I just think it’s good to have that empowerment reach out to communities.”
Former Baltimore Mayor Schmoke says of Beilenson: “He’s a hard charger, a focused guy, and for some people his personality is an acquired taste. He could walk in a room and without saying a word, some people would be pissed off. They don’t like his casual dress, they think he should look more like a doctor or something, I don’t know. Sometimes people get annoyed by it, until they sit down and listen to him. Then they forget all that stuff.”
His 11 years on the job make Beilenson an uncommonly long-serving health commissioner. Baltimore Mayor Martin O’Malley is running for reelection, and if he wins another term, Beilenson seems sure to retain his health commissioner job—if he wants it. “I go through occasional lull periods,” he says. “But then something happens, like terrorism or SARS. You don’t get bored. This may be the job I’m most suited for in the whole world. I feel very lucky to have it.”