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Dr. Leana Wen - Addressing Mental Health and Health Equity (Mental Health Services Research Conference Day 1 Keynote Address)


Welcome back to the main virtual conference room for the Mental Health Services Research Conference. We're thrilled that you had a great start so far. And now we're gonna start the afternoon session with a great keynote speaker, followed by several symposia, and then we'll be capping it off at the end of the day. It is my distinct honor to introduce to you Dr. Leana Wen, who is our first keynote speaker of this conference. Dr. Wen received her medical degree from the Washington University School of Medicine, and studied Health Policy at the University of Oxford, where she was a Rhodes Scholar. In 2015, she began serving as Baltimore's health commissioner, and her bold leadership in that role made a profound impact on treating and saving the lives of many people with mental illness and addiction. Since then, Dr. Wen has served in several leadership roles. And currently, she's an emergency room physician and public health professor at George Washington University. Dr. Wen is also an invited op-ed columnist for the Washington Post, and as a medical analyst on CNN.

More recently, Dr.. Wen has skillfully communicated a strong research base public health message to help those who are most vulnerable and affected by the COVID pandemic. And on a personal note, I have found her thoughtful account on the importance of addressing mental health stigma in her recent writings to be explicitly inspirational and powerful. Dr. Wen, thank you for joining us.

Thank you so much, Denny. And it's really a delight to be with all of you today at your 25th Mental Health Services Research Conference. And I want to first thank our conference co-chairs, Dr. Denny Pintello and Dr. Jennifer Humensky. Thank you so much for the hard work that you put in to bring us together virtually. And I also wanna thank the director, your director, Dr. Josh Gordon. And all of you at the National Institute of Mental Health. I understand that we have quite a diverse audience here today. And I wanna thank all of you, regardless of your particular role. Whether it's in providing care and treating individuals most vulnerable, or conducting cutting-edge research, or being patient advocates and people with lived experience. I know that all the symposium, all the sessions that you have in bring us together. I think all these diverse points of view will help us with what we really want to address at the end of the day, which is addressing mental health and health equity. And it's that topic that I will be discussing today.

And my talk is divided into two parts. And then I look forward to any questions that you may have. The first part that I wanna discuss is what have we learned over the last two and a half years during the COVID pandemic, especially when it comes to mental health? And then I want to talk about what we can do going forward to advance health equity and address mental health. And so as somebody who thinks in threes, I'm going to be giving three ideas for what we've learned from COVID and then three things about what we can do going forward. And in case you're wondering, I don't have any slides. So this is not a technical malfunction as to why you're not seeing any slides. Alright, so what have we learned from COVID? Three things. The first and I think all three, maybe somewhat common sense, but I think it helps to also to lay them out. And again, look forward to your thoughts about this. But the first is that there are a lot of neglected issues that have long been there for those of us who are in these fields, but now they are bared for everyone to see.

For example, there is a lot of focus now, long overdue focus on health disparities. But health disparities, of course, were not created during COVID or created by a virus, but rather the pandemic has amplified disparities. We've seen, for example, that social distancing is a privilege that not everyone has. That when individuals live in crowded multi-generational housing, they don't have the ability to avoid infecting everyone else. Or when vaccines first came to be available, it was individuals who had access to the vaccines, who could drive 50 miles, or who could get on their phone and find appointments who were able to access those vaccines. Well, we've also seen that disparities don't go away on their own. And actually now with monkeypox, we're seeing so many of the new disparities or of those existing disparities being amplified once again. That once again, it is those with privilege, for example, who are able to access the very limited supply of the vaccines. And so I think the issue of disparities needs to be put up first and foremost as something that, again, COVID did not create, but did unmask for everyone to see.

Another neglected issue is that of social determinants of health. Again, not a new issue to any of us working in mental health, not a new issue to any of us working in public health, because we know that all of these issues are tied closely together. We cannot talk about healthcare without talking about housing, which in itself is a form of health care, or food access, or access to working conditions. I mean, all of these things very much affect the health and well-being that people are able to experience. Again, not a new issue to those of us in public health but bared for everyone else to see. And then I wanna add one more issue here, which is that of public health infrastructure. The Wall Street Journal, this past week had a really sobering article that looked at all the different ways that COVID-19 has impacted health care and health service. Whether it's with mammograms and colonoscopies and other preventive services not being done, or childhood immunizations falling off a cliff, or as all of you know, record numbers of overdoses of individuals reporting in depression and anxiety.

We know that the disruption of our basic social safety net has resulted in many of these other issues that are already not being attended to, really being underserved even more. And introduction that I served as the health commissioner in Baltimore. Well, I know firsthand about how much our public health infrastructure was really in trouble before. We've lost something like 30% of our workforce in public health over the last two decades. And even before COVID, it always felt like with every new emerging crisis, that we were robbing Peter to pay Paul. That the same people who were working on the opioid epidemic when Zika hit, were then pulled off to work on Zika. Then when there was a weather-related emergency, and we had to figure out how to house individuals experiencing homelessness in the winter, or become the summertime when it's very hot outside, those same people are moved to work on that issue. All of these are really important issues. But the problem is, it's the same number of people working on them.

And so we're always in this moment of crisis, where we're leaving one crisis to go to another. I think that most Americans are beginning to see why that's a big problem. And why this is something we in public health talk about a lot that there is no face of public health. That by definition, public health succeeds when we are invisible, right? Because we have prevented something from happening. The problem though, when your work is invisible, is that it becomes the first thing on the chopping block. In prevention, whether it's prevention when it comes to mental health or physical health, or really any issue, prevention is always neglected. And I think it's important for us then as practitioners in the field, as researchers, to stress what we know is true. Which is that, as my former mentor, the late congressman, Elijah Cummings would say, "the cost of doing nothing isn't nothing." The cost of doing nothing isn't nothing because when you're not investing in prevention, when you're not investing in overcoming disparities or addressing social determinants of health or public health infrastructure, then these neglected issues that are already crises will become even worse.

Alright, so that's the first thing I believe that we have learned from COVID. Let me move on to the second, which is that public health depends on public trust. And when public trust is eroded, it's very difficult to get back. You know, Denny mentioned that, I like all of you, have spent the last two and a half years doing both practice, research, as well as communicating on COVID-19. And when I look back, there are a number of things that with the benefit of hindsight, I think we should have done differently. One of those is being even clearer that change is the bedrock of good public health policy. I look now and there are a lot of people who are for whatever reason that we can speculate on later on, but are accusing scientists like Dr. Fauci or Dr. Francis Collins or others or me of flip-flopping. When actually what's happened is that the guidance changes when the science changes. I mean, we all know that instinctively, right? We know that, for example, from clinical medicine, if you have a patient who has cancer and there's a new chemotherapy regimen that comes out, you would expect that the guidance is going to change.

You would expect that the new recommendations would match the recommendations based on emerging science. Then, of course, things also evolve. We have new variants that we couldn't have dreamed about when COVID first came to be. And there are a lot of emerging circumstances and changing circumstances. At the beginning of the pandemic, if you had said that more than a million Americans will be dead, or that we would be two and a half years into this. It still have a high rate of community transmission. I don't know that we would have known that. And so with changing circumstances, with changing science, I think it's important to communicate that change is to be expected. And in fact, that is the bedrock of good public health policy. I also think that we're looking back, I think there could be even more done on transparency. For example, looking back at the very early days of the pandemic, when there were discussions about masks. Initially, we as the public health committee did not recommend masks for everyone, because there were limited masks.

And we wanted those high-quality masks, in particular, to be saved for healthcare workers who had trouble accessing them at the time. Well, unfortunately, that's then led to some mistrust around masks, some people accusing doctors or scientists of not being truthful about masks. And I think that's really unfortunate. And as it applies going forward, we can have a level of transparency around, for example, looking at monkeypox. Right now, we have to ration monkeypox vaccines, because there are not enough vaccines to go around for all those at risk. I think it's really important to come out and say that. It's not that we don't think everybody who wants a vaccine should be able to get a vaccine. But rather, if you only have very limited vaccines, they should go to people who are at the highest risk. And I think that level of transparency is important going forward. Similarly, is the issue of being intellectually honest. I think that there has been a desire by public health communicators to want to be, to have one central message.

And then if there is a deviation of the message, they concerned, because others might accuse them again of flip-flopping. But that's resulted, though, in I think, in a way even more distrust. So let me give you an example of this. I attended a conference recently, an in-person conference where people came up to me afterwards. And three people came up to me afterwards individually to ask a question that they said they didn't want to ask in the group setting. And that question specifically was on natural immunity. They wanted to know, is natural immunity a thing? And I asked them, well, why don't you want to... why didn't you wanna ask this in the group setting? And they said because I don't want to come across as an anti-Vaxxer. And look, I understand exactly where that sentiment is coming from. Because I think that there has been a hesitation to talk about natural immunity, which is immunity after infection. I think we can say both things are true at the same time that, yes, you do get some level of immune protection after getting COVID-19.

That immune protection may not be as long-lasting or as consistent as vaccination. And people who got infected should still also get vaccinated in order to have the best level of immunity possible. Both of those things can be true at once. Natural immunity is a thing. And also, vaccination is highly protective, it should be done too. And I think if we are not intellectually honest with people, then that's going to further breed distrust. One more thing I wanna add here is that I also think it's important to meet people where they are. When we look around the country and we see that most Americans are moving on from the pandemic, I don't think it's helpful to keep on giving the same message as we did back in 2020. Masks and social distancing had their place. But if people are no longer following those recommendations, I think we need to switch to a different tactic because there's no point in mandates or recommendations if people are not following them. And in fact, it may gender for their backlash.

And so I think part of public health is meeting people where they are to see what it is that people are willing to do. So for example, have a treatment plan. Understand that BA.5, our current variant is extremely contagious. Know that if you are up and about and going about daily life, you're probably going to encounter COVID-19 and so have a treatment plan. Do you qualify for Paxlovid? Where can you get treatment? Also, if you're going to expose yourself to additional risk, can you test yourself before getting together with vulnerable individuals to shield them? Also, if you know that certain settings are very high risk, for example, crowded airports, security lines, you know, trains, how about wear a mask during those settings? Even if you're not wearing masks and other settings. Again, I think that meeting people where they are is an important part to engendering trust. Alright, of course, in a discussion about mental health, we need to talk about the importance of mental health too.

And I actually think that this may be a silver lining coming out as a lesson from COVID. So that's my third lesson coming out of COVID, which is that I think there is growing recognition that mental health is just as important as physical health, even if Traditionally, it has not been understood that way. I don't need to tell all of you that there is a huge stigma on mental health in communities around the country. But now there is more attention to this. And I just wanted to share two quick stories with you about how... about two things that over the years have really affected me in my understanding of mental health. One is that I remember, there was a mother who was talking about how she lost her son, and she had lost her son due to opioid overdose. And her son also, her son was young. I think was a college-aged student, also suffered from anxiety and depression, and a number of other. He had also been hospitalized due to psychiatric illness in the past as well. And she had just lost her son and said that she wished that addiction and mental health were seen as casserole diseases.

And I did not understand, I was like what is that casserole? You know in medical school, I did not learn about casserole diseases. I don't understand what is a casserole disease. Hence I said, what do you mean by this? So she said, if her son had died from cancer, or tragically passed away from a heart attack, or some other medical physical ailment, that her neighbors would have brought her casseroles. And she would have been able to talk about her son and all that he went through, and people would have shared in her grief. But she said that people were avoiding her because her son died from something that they maybe didn't understand, or were afraid to discuss, or were stigmatized in some way. And she said that her hope was for addiction, overdose, mental health issues to be seen as casserole diseases. That always stuck with me. My other story is a personal one, which is that after the birth of my first son, who is now almost five. I had postpartum depression, but I didn't know it. Even as somebody who at that time I was the health commissioner of the city, I ran a program, oversaw a program that was on healthy babies and helping moms and postpartum families, including with postpartum depression, I thought that I would understand the signs, but I didn't.

And even worse was when I actually sought help for postpartum depression. I remember going to see a psychiatrist for the first time, and actually being embarrassed that I was there. And having this guilt of, well, if I love my son, if I want to be a mom, how can I possibly have... how can I possibly experience this and even though again, as somebody who understands depression and who previously had talked about postpartum mental health to people. I was still ashamed to tell others and then I felt shame for being ashamed. And so I think that, you know, I share this because I think that the stigma around mental health issues run very deep. And it is a really important thing that now coming out of COVID, or at least the acute phase of COVID, that there is more attention to this, there are certainly more discussions in workplaces around it. But at the same time, there are so many challenges, including the fact that public health infrastructure is being diverted elsewhere. We still don't have nearly enough resources.

Also, mental health is not seen the same way as physical health. There is not insurance parity, for example. They're still in... basically everywhere around the country, there's still a lot of difficulty finding providers, when it comes to mental health. Much less providers were able to take certain types of health insurance. And I think it's my dream. And I would imagine that it is yours as well, that we need to get to the point that we can see mental health, address mental health with the same compassion and the same resources, and the same empathy as we do any physical health ailment as well. Alright, so let me move to the second part of the talk, which is well, what can we do going forward? Now that we understand some of the issues that we've seen, how can we move forward to advance health equity, address mental health? And, you know, the problems that we have are so overwhelming. And sometimes it almost feels like, we don't know where to start. And so I want to go broad and give some ideas, three ideas again, for things that we might be able to do.

I talked about, by the way, some of these ideas in my new book called 'Lifelines'. And I want to draw from some of those lessons today. So again, thinking in terms of the threes or three things. One, start somewhere. Sometimes again, the problems that we see are overwhelming. And when we talk about social determinants where everything is connected to one another, sometimes we end up in this position where we are admiring the problem, but not moving on to the solution. And I would encourage us to not be bound by the perfect as the enemy of the good, that it's important for us to start somewhere. When I first started in Baltimore, we had opioid overdoses that were going through the roof, really driven by fentanyl which is a continuing issue now. At the same time, I also very much understood the nimbyism, Not in My Back Yard, that was present in our city and around the country. When it comes to methadone clinics and treatment centers, and so I knew that if I'd come in as the health commissioner and said, we need more treatment.

Even though that is a true statement, that people would have heard it as we need new methadone clinics, and immediately turned off on this issue. And so we did something else. Instead, we said we realize that what we need ultimately is more treatment. While we work on that, let's help people focus on something that we can do right now. And something that maybe does not have at that time at least did not have the controversy that treatment may have in our community. And what we decided to do was to focus on Naloxone or Narcan access. As you know, Narcan as the opioid antidote. And so we got legislation changed to Maryland so that in June of 2015, I became the single prescriber for Naloxone in our city. Essentially, I issued a blanket prescription for Naloxone so that everyone in our city was able to access it without a prescription. We also did 1000s of trainings across our city. Within three years, we trained 10s of 1000s of people. And everyday residents, by using that Naloxone standing order, saved the lives of more than 3,000 fellow family members and community members in our city.

Recognizing, of course, that that's not the only answer. We also did other things too. We were able to start a stabilization center, for example, which was a pre-hospital diversion from the emergency department for individuals experiencing mental health or addiction crises. We also worked with all of our hospitals, all of our acute care hospitals, 12 acute care hospitals to start what we call levels of care, for hospitals to start addressing... to start treating addiction as well. We had consolidated our phone lines to have a 24/7 crisis line, which I think the new 988 number is fantastic. But we had started that back in 2015. And again, I give all these examples not to say that we were able to solve the problem in Baltimore, but rather to say that when we have very complex issues like addiction, or food access, or mental health that sometimes it helps to start with something. And for us starting with Naloxone was a way to demonstrate to the community that we are doing something, and it helps to get momentum for our other efforts as well.

And so when we apply broadly to the other issues that we're facing, I think there's a lot that can be done depending on where you are, whether you are somebody working on research, or whether you're helping your local community, or whether you're advising legislators. I mean, 988, for example, it's a wonderful step. Well, what more do communities need in order to do crisis response and then get people connected to treatment? How can we leverage the attention now on 988 to get additional funding from state legislatures? Something that all of us can work on in different ways, for example. Also, we know that there's a lot of need for addressing mental health in children. How can we meaningfully improve school-based mental health services? It might there be some innovations that we can do even when it comes to, for example, telemedicine. Overdose, we know we need treatment for individuals facing addiction. We know that we need more help with mental health treatment for these individuals as well.

Ultimately, this needs to be better integrated with primary care. How can that be done? Employers, for example, or people who are working with employers in workplace health. Now that there's attention to mental health, is it covered as part of health insurance plans the same the way that physical health is covered? Is there just as much access? Also, I think there is a need to focus not just on disease and somebody who was diagnosed with a condition, but also on wellness. What can be done to develop resiliency as a tool throughout? So all those, again, are the category of starting somewhere, and not being paralyzed because of the huge numbers of unmet problems and unmet needs that are out there. The second thing that I'll offer in the solutions category is about disparities. That health disparities don't go away on their own. And we have to be really intentional about addressing them. I think it's important for any of us working in this field, who will leave in a tried to achieve health equity that, equity is not a zero-sum game.

That we're not trying to take resources from some group in order to give it to another. I mean, in my city in Baltimore, for example, there's a 20-year gap in life expectancy depending on where you live. But we're not saying that bridging that gap means trying to decrease the life expectancy for some people. We're saying that we want to increase the life expectancy for everyone. And so I think one way of talking about this is having equity metrics, which is something that we started in Baltimore. We have had and stall have a very successful program that's a public-private partnership called B'more for Healthy Babies. And that program brings together over 115 hospitals, community health organizations, religious organizations, insurers, neighborhood organizations, and so forth, for one goal, which is to reduce infant mortality in our city. Well, within a seven-year period, we were able to reduce infant mortality overall in our city by 38%, through a combination of home visitation services, educating on the ABCs of Safe Sleep, outreach, providing housing, and so forth in mental health services.

We were very proud of this 38% reduction citywide in infant mortality. We had also said that another goal is to reduce the disparity between black and white infant mortality as well in that same time period, because we also specifically focused on reducing disparities. We also close that disparities gap between black and white infant mortality by over 50%. And I think that's an example of how you can do both. Reassure people that this is not a zero-sum game, that this is about closing the gap while lifting up everyone. And I think here, it is important to actually do those things. I think sometimes in recent years, I've noticed that there's been a focus on language and saying the right things. Well, I would just challenge us to really focus on doing the things and being practical in approach in our approach to deliver the services that matter to people. Then I'll add one more in the things that we can do before I welcome your questions, which is the... I think we really also have to work on strengthening our public health infrastructure, and our social service safety net.

I really worried that because of COVID, public health is under attack even more than before. More than 25 state legislatures have enacted laws or passed laws in some way restricting Public Health Authority, which is not only an issue for COVID. But what happens, in the case, if we have tuberculosis, any local health authority can no longer impose mask mandates? Or what happens if we have a resurgence of polio, or measles, or something else, and now, there cannot be vaccine mandates, including for school children? So I really worry about the further polarization and politicizing of public health. And in the meantime, we have seen that overdoses are at a record high, alcohol-related deaths are up, gun deaths are up, we have issues. We have things that were going down, going in the right direction like gonorrhea, chlamydia, cancer rates, heart disease rates that are now climbing up again. And I really worry about this. I really worry about what has already happened to rob Peter to pay Paul, and defund public health.

And I think what needs to happen now is we need to work towards a sustainable public health infrastructure. Recently, the Commonwealth Fund had a commission that brought together a bipartisan group of experts to look at what needs to be funded going forward. And I think funding the public health workforce is crucially important. And part of that also is ensuring attention to these neglected issues, that again, those of us here know so well. These neglected issues of social determinants of health disparities, and crucially, incorporating mental health as part of the core strategy to address physical health and public health overall. Now, there is no doubt that the work ahead is very difficult. We have already just gone through this extremely challenging time. And we have new challenges every day. And I want to end with a quote and an appreciation for all those people who work in public health. And this quote is by Dr. Harrison Spencer, who was a public health leader on the local, state, and federal levels.

And Dr. Spencer said that, "public health is filled with heroes, both well-known and unknown. They are visible on the national or international stage or they work quietly in communities with families and individuals. When they do their job, they often become invisible." Well, when the long arc part of history is written, all of you are going to be the heroes, no matter what it is that you are doing, serving on the frontlines, treating patients, conducting research, or helping those around you as advocates and as family members who have lived experience. You are the heroes, and it is an honor to join all of you today. Thank you very much. And I turn it back over to Denny for your questions.

Dr. Wen, that was a fantastic and thoughtful presentation. We really, truly appreciate it. And the wonderful thing is we do have some questions coming in. And let me go ahead and get started on those. We have someone who asked a question. When you first became the Baltimore health commissioner, you had a meeting with some of the city's youth to change how you thought about mental health concerns for them. Do you feel that mental health professionals and those that oversee services and systems need more or different ways to learn of their priorities and impediments encountered by different subgroups in their communities?

Well, that is such a thoughtful question, which I appreciate. And since you mentioned the experience that when I first came the health commissioner, which I talked about in Lifelines. Let me just... I'll briefly tell you about it here. Or tell the audience about it here, which was that when I first started, I embarked on a listing tour. Because I was new to the city, I knew that I did not understand all the complexities of and the issues faced by individuals. And I also did not want to just meet with the leadership, who had their own views and maybe their own agenda. I also wanted to hear directly from the people that we were serving. It's always difficult to get a representative sample. So this is not meant to be, you know, qualitative research, but this was I just wanted to understand where people were coming from, and to meet them where they were. So I went to a lot of community meetings. And one of the meetings that I attended was a meeting of youth in the city. And I came actually expecting them to talk about what the Baltimore City Health Department is known as in what I thought that it was being known for, which is the agency of bugs, drugs, and sex.

So I thought that I would get questions about sex ed, or tobacco prevention, or whatever other issues we're talking to youth about. But what was so striking and actually, so heartbreaking, was that all the kids and they ranged from ages eight to 15. The one issue they all brought up was mental health. They didn't actually necessarily name mental health. But for example, somebody told me about how they are the only person who gets up in the morning to go to school because everybody else in their family is addicted to drugs. So when I talked about Narcan, and I asked, what does it look like? You know, have any of you been around somebody who's overdosing? Basically, everybody raised their hands. And people started telling me about what their folk remedies. You know, how they were taking, you know, milk out the fridge and pouring it on people's faces, not something that I recommend by the way for reviving somebody from an overdose. But, you know, I was hearing about these things that these like nine-year-olds and ten-year-olds were doing, or a number of them talked about trauma too.

The trauma of going to school and not knowing, and being put back further in school, and then be labeled as being disruptive when actually they really wanted to learn. I mean, it was really heartbreaking to hear about all this. Again, not saying that these were mental health diagnoses, per se. But these were children who needed assistance in some way with mental health. And in fact, they were flagging mental health as something that they needed assistance with. And so, to your question about, how can we be more attentive in a sense... And tell me if I'm understanding right, but how can we be attentive to the needs of communities? I think part of it starts with listening intentionally to the people that we want to serve, and not making assumptions. And also being a little bit skeptical of the people who are saying that they are representing members of the community. They might well be representing the needs of that community. They might not be. What I mean is so just having a broad sample, and I think always being attentive to what it is that we're trying to do.

I think a lot of times in research, all of us, I am certain are well-meaning. We want to do the right thing for communities. But can we do this in a way that also takes into account of what would benefit the community the most? Asking that question, you might often get answers that you're surprised by.

Thank you. That was a great response. We have another question about what can mental health services researchers do to be most effective when communicating their research findings to policymakers and other decision-makers in order to have a maximum public health impact?

Really great question. I wish I had the answer here, I'm gonna give you some ideas for what I found to be useful in communicating to legislators. The number one, and number two, number three to number ten. And so here is find out what it is that they care about, and link what you care about to what they care about. As in, if mental health is something that they do not care about, but they're taking a meeting with you, I think they're just gonna tune it out. And the moment you talk about your issues in a way that they don't understand or don't relate to, they might nod their head and think about this as a checkbox. Done. I met with this constituent. Done. You know, maybe somebody helps you facilitate that meeting, I can then tell so and so that I met with this person. I'm done, I can go think about my next meeting. This is not on a bad intention, just that people are really busy. They care about what they care about. And so what I would say is, I'm sure you have your agenda, right? Whether, and your agenda is probably my agenda is to get additional funding for mental health issues, et cetera.

But if that's the case, look to see who it is that you're meeting with. What is their number one priority? If they typically are always talking about homelessness, I'm sure that we can that direct link between how addressing issues in mental health will address homelessness. Or if what they really care about is children's well-being and school and education, we can also talk about how addressing mental health in children will help with their ultimate goal, which is increasing educational outcomes. While most legislators care a lot about public safety, we can definitely draw that through line also between how increasing treatment or treatment and increasing mental health treatment will also assist with crime issues as well. And so I think, you know, it's really incumbent on us to do our research. Before meeting with any legislator, I would recommend just doing a simple Google search. You spend an hour, watch talks that they've given recently, look at how they came across in their campaign and ads in their written materials.

Maybe there's a video of them, I'm a visual person. So I learned through watching things, but you know, maybe they've also written things. But you know, look at their last community meeting, what is it that they're talking about? What did they run on? What are the last piece of legislation that they passed, or that they were really proud of and touting to their community? Link your issue to their issue. And always think about, how can you help them achieve their goal by using the lens of what you know. You are the expert when it comes to your field. And so I'm certain that you will be able to the through line between what you care about and what you need to what is their goal.

Thank you. That's fantastic. We have another question for you, of course. One audience member said that's a great point that if public health works, it prevents something bad from happening. But when you said that, when it works, it's invisible. If it's invisible, it's first on the chopping block. Can you discuss more about how the mental health community can communicate the value of their services, especially preventive care and mental health?

I think it's really challenging. And so again, I don't know that I have a great answer here. But I'm going to try and give some ideas. And I've also, by the way, recognized that what I'm saying is somewhat controversial, and that not everyone wants to follow this. But I think that's I'm here to stimulate conversation. And I am so open to other viewpoints. And I also think that, by the way, this is an ecosystem approach. As in, I may approach things in a certain way, you may approach things in a different way. And it's by us working together, that we're able to elevate our field. I mean, I am not a banging down the doors advocate who's going to have a big rally and get arrested. I mean, that's not my background and what I want to be doing. But if you want to do that, that's another way of addressing the issue and elevating the cause. And I have no judgment for people who are addressing this in different ways. I'm also not predominantly a researcher, but there are incredible people doing really important research as a way to make changes.

So all of these things, I think, make a difference together. So that's my first comment about the ecosystem approach. Is to see where your strengths are, to see how you can elevate this field in talking about prevention. Maybe it is by raising the issue through research, maybe it is through social media. Whatever it is, that's I think knowing where your strengths are is always a good approach. Another thing that I want to offer here is that, it is true that there's no face to public health. But if there's no face to public health, we need to put the face on public health. And I think one way to do that, again, is by looking at what is it that people are thinking about right now? And I am not, you know, I'm not necessarily saying that we "capitalize on crises", but rather recognize them in moments of crisis or when people start paying attention to issues. And so, for example, if I were trying to increase funding for lead poisoning and lead poisoning prevention, it's really difficult to get people to care.

However, if there is a case of a child who tragically was lead poisoned, that is an opportunity to talk about how home lead remediation and regular lead testing is so important to save lives. I think we need to look for those opportunities to share our message, knowing that the ultimate goal is to raise awareness and that legislators and people who are in charge of funding, executives are... they have limited attention spans. And if their attention span right now is on this issue, that's the opportunity to put forward our best argument. And again, have this ecosystem approach. Some people who are doing research on this issue, they have the data to present on this issue, that's great. Others are doing the advocacy. Others are doing the behind-the-scenes work. All of that is really important in achieving our ultimate goal.

Fantastic. We have more questions. And we'd have a limited time. Let me go ahead and try to get a few more in. What approaches strategies and research do we need to do to continue combating the public stigma of mental illnesses and treatments in historically marginalized communities from a public health perspective?

Really important question. And again, I will share some ideas. One is, I do think that storytelling has such an important role to play here. I don't think that we should be distinguishing between, "good stories and bad stories." I actually think that just have all the stories come out because somebody's story is going to... is somebody's going to relate to someone's story. And there are different stories. And with some stories, you might hear and think, that's not quite me. But some other story might really grab you. And so I think the more we can share those stories of individuals experiencing mental health challenges in different ways, whether they're really, you know. And I actually don't think that we should necessarily say, hey, you know, we're only sharing stories that people from privileged backgrounds. Well, you know, guess what? Some people also relate to that kind of background as well. And so I think it's important for us to share throughout and not make a judgement about which stories are "good stories to share, which ones are bad" because people will relate differently here.

I also think that when it comes to communities that are traditionally marginalized as you were saying, recognizing that in these communities, just like others, mental health is really stigmatized. And hearing from the community members themselves about how to address that stigma is going to be important, because the language that we use across communities may be different. And so I think this is another one where not making the assumption is key.

Thank you. That's great. And unfortunately, we have time for one more question. And that one is in the context of constrained resources, what is your approach to de-implementing practices that may be well-liked by practitioners or communities, but are not supported by the evidence?

OK, well, since you asked a tough question, I think I'm gonna give you a controversial answer, which is I'm not sure that they should be de-emphasized. And I think that, OK, so let me back up and say that, of course, I believe in evidence and science. And if there truly is something that is just really bad, for example, rapid detox, that's not accompanied by any kind of mental health support. I mean, that's bad. But it's associated with, as I understand, you all are the experts. But if there's something that's associated, for example, with increased rates of death, that's not good. And we should probably stop those practices. And again, I think that's going to... that will take work. And I think having alternate treatments to get people into not just saying, don't do this, but now you don't have anything, that's not really a good approach. But don't do this, instead, do that. I think, is one way of accomplishing it. I think also if there are practices that don't do very much, but aren't actively causing harm, but if getting people to change their minds on these practices will actually lead to distrust.

I'm not sure that that is something that I would focus on. I am a practical person, a pragmatic person, and I think part of the pragmatism is meeting people where they are. If that's the practice that they have, maybe coming to terms with how you have to live with that while also getting them to do the thing that really works, maybe a better approach.

Great answer. Thank you so much. And unfortunately, we are having to bring this session to an end. I'm so sorry. Oh, it was a great conversation, a great presentation. And I wanna thank you so much for joining us today, Dr. Wen.

Thank you so much.

Thank you. So now we're going to go ahead and invite everyone to transition to the concurrent symposia sessions where you can choose from three different scientific symposia and then we'll go through the rest of the day. Thank you, everybody. Take care.