After years of experience in both primary care and public health, Nicole Lurie, M.D. ’79, is now the highest-ranking federal official in charge of preparing the nation to face such health crises as earthquakes, hurricanes, terrorist attacks, and pandemic influenza.
By Rita M. Rooney and John Shea
She visited Manhattan’s historic Bellevue Hospital, eerily quiet after almost every patient had been evacuated because of the fury of Hurricane Sandy. There, she watched as nurses wrote their notes by flashlight.
She toured the Brooklyn Armory, crowded with beds after it had accepted patients from three nursing homes imperiled during the same emergency.
She took shelter in a Boston neighborhood as police searched relentlessly for the perpetrators of the Boston Marathon bombing.
These intense experiences are all part of the job that Nicole Lurie, M.D. ’79, accepted back in July 2009: Assistant Secretary for Preparedness and Response at the Department of Health and Human Services. So there she was, a witness to the hurricane’s devastation and disruptions as well as to the fear and turmoil in Boston. What stayed with her from those experiences, however, was a sense of how much more devastating both events could have been. Without preparations and practice, said Lurie during a presentation on the Penn Medicine campus in May, “it could have been a lot worse.”
And preparation, as her federal title suggests, is Lurie’s focus. As she herself acknowledges, the job is not one for the faint of heart.
“Beginning with development of a strategy,” she says, “my role can be defined as helping our country to be ready for any kind of adverse public health event, including a response to any challenges the future may bring.”
Lurie’s professional life has been spent dealing with vulnerable populations, an experience that has ideally prepared her for such challenges. That experience includes years in primary care. She joined the University of Minnesota in 1985 and eventually rose to professor of medicine and public health, director of primary care research, and director of the Division of General Internal Medicine. Her service and skill as a practitioner, teacher, and researcher were acknowledged by her peers, and in 1987 she was elected to the Council of the Society of General Internal Medicine. She later became the Society’s president.
As she put it in the Society’s newsletter in 1998 after she was sworn in as Principal Deputy Assistant Secretary for Health in the Department of Health and Human Services, she was eager to fulfill her new federal position in the Clinton administration. But, she added, “saying farewell to my patients has been the hardest part about taking leave from Minnesota.” Noting that she worked in a public hospital, “most of my patients are, or have been, pretty down and out at some point in the time that I have known them.”
In addition, however, Lurie has had a different kind of experience –- confronting issues of public health. While in Minnesota, she served as medical advisor to the commissioner of the state’s Department of Health. During her first appointment at HHS (1998-2001), she worked to advance Healthy People 2010 and the Health Disparities Initiative as well a pandemic influenza plan. In an article in the Reporter, the newsletter of the Association of American Medical Colleges, she cited current research showing, by and large, that the health of Americans was better than it had been ten years earlier. Yet, she wrote, “there are still a number of areas where disparities exist. For example, a black infant has more than twice the chance of dying in its first year of life as its white counterpart.” While conceding that the goal was ambitious, Lurie insisted it was worth pursuing.
The Office of the Assistant Secretary for Preparedness and Response was created in its present form in 2006. It was formed “as a lesson learned after Katrina,” which demonstrated how vitally important preparedness was.
Lurie’s next stop was as senior natural scientist and the Paul O’Neill Alcoa Professor of Health Policy at the Rand Corporation, the nonpartisan think tank based in Arlington, Va. There, she directed its public health and preparedness work as well as its Center for Population Health and Health Disparities. Her work included projects done with the Office of the Assistant Secretary for Public Health Preparedness at HHS, the predecessor of the position she would accept in 2009.
As she explained in testimony before the Senate Subcommittee on Bioterrorism and Public Health Preparedness in March 2005, her work included evaluating public health preparedness in California and Georgia; conducting 32 tabletop exercises on hypothetical crises caused by smallpox, anthrax, botulism, plague, and pandemic influenza; and interviewing officials from 44 communities in 17 states. She reported evidence of progress in preparedness, “although I’ll also be the first to tell you that we have miles to go before we sleep, especially as we face the threat of pandemic influenza.” RAND’s research, she continued, emphasized the need for continuing investment in technologies to promote shared “situational awareness.” The researchers also found widespread confusion about who is supposed to do what in a public health emergency –- and exactly when responsibility shifts from local to state or federal entities.
These remain some of the concerns of the Office of the Assistant Secretary for Preparedness and Response, officially created in its present form in 2006. As Lurie put it during her presentation at Penn in May, the office was “formed as a lesson learned after Katrina,” which demonstrated how vitally important preparedness was. The office was meant to be, she continued, “a single focal point” for all activities related to preparedness and response. And there are many. In her current position, Lurie heads a staff of close to 700 people, including offices responsible for making countermeasures, the Biomedical Advanced Research and Development Authority (BARDA), for emergency management, and for policy development.
When Lurie’s appointment was announced, Jeffrey Levi, Ph.D., executive director of the Trust for America’s Health and professor of health policy at George Washington University’s School of Public Health, issued a statement: “The President could not have selected a more qualified and capable candidate for the job. . . . Dr. Lurie blends strong medical and subject matter expertise with proven, pragmatic managerial skills.”
Colleagues who cite Lurie’s energy and focus on her job say she has the rare ability to cut through complex issues and balance many priorities simultaneously and with apparent ease. One colleague sums it up by explaining that Lurie is the kind of person who genuinely cares about making things better.
In addition to her responsibilities at HHS, Lurie makes time to see patients who are without health insurance at the Bread for the City clinic in Washington, D.C. How does she fit everything in? “It’s all about managing a team,” she says. “I get to work before 7:30 in the morning and work late. I find my work extremely challenging. I work across HHS, other government agencies, and communities throughout the country. Each component has a wholly different perspective on a problem. Each has lessons from which we can learn. The challenge is to synthesize these lessons so that we can continue to improve our preparedness and do the best job possible for the American people.”
When asked what helps her to confront the inevitable hurdles in meeting such a goal, she considers for a few seconds. “The only way I stay grounded is with a fair amount of exercise each day,” she admits. “I run, swim, and do yoga regularly, and place a high priority on family time.”
Lurie’s office in Washington is large enough for efficiency -– and just that. Dominated by the American flag, it is clearly a place where the business of the country takes precedence. Directly above her computer screen, in direct line of sight, however, is a framed picture of the late Samuel P. Martin III, M.D., former executive director of Penn’s Leonard Davis Institute for Health Economics. He was the person Lurie considers her mentor and whom she credits with guiding the educational choices that enabled her to accomplish all she has professionally. In fact, Lurie delivered the first Samuel P. Martin III, M.D., Memorial Lecture and returned to the Penn campus in 2007 to deliver the tenth as well.
On May 19, Lurie delivered the graduation address for the Perelman School of Medicine, and she took a few minutes to tell the new graduates about meeting Martin and the impact he had. When Lurie was an undergraduate at Penn, she did not plan to become a doctor; her goal was to address poverty. As a sophomore, however, she spotted a listing for a course called “Health Care as a Human Right.” But it turned out to be for freshmen only. “Instead, I began working for the professor, a remarkable man named Sam Martin, who became my lifelong mentor. Through him, I came to see medicine as a tool for promoting social justice and reforming the health-care system as a key component of that effort.”
In an interview, Lurie elaborates. “I would say that much of what I have been able to accomplish in life goes back to my roots at Penn.” From the start, she says, she was surrounded by Martin and other people who showed her how to combine a life in medicine with a life in policy. “So many of the issues with which I now deal relate to health economics and the health-care marketplace,” Lurie continues. “How grateful I am for all those courses I took at the Leonard Davis Institute of Health Economics. I was exposed to some of the top economists at Wharton and learned from people like Sam and Bill Kissick.” (William Kissick, M.D., Ph.D., who died this year, wrote Medicine’s Dilemmas: Infinite Needs Versus Finite Resources. He taught at Penn’s School of Medicine and the Wharton School 1969-2001.)
It was because of exposure to Penn faculty that she ultimately applied to and was selected to be a Robert Wood Johnson Clinical Scholar. The Clinical Scholars program comprises academically exceptional physicians who have completed their training and have an interest in public policy, community health, and health-services research. According to Lurie, it was through the Scholars Program that she first met people who were considered giants in their field of medicine, people with whom she continues to confer.
Apparently, the intellectual exchange has worked both ways. Raina Merchant, M.D., assistant professor of emergency medicine at Penn, is a recent Clinical Scholar who received her medical degree from the University of Chicago. She has worked with Lurie on a number of projects, both at HHS and at Penn. “Nicole is the most phenomenal mentor in the world,” says Merchant. “She’s an incredible role model who is a diehard in her dedication to her work and who is determined to see we have the kind of policies that assure people are safe and informed.”
Career is not the only phase of Lurie’s life that has benefited from her years at Penn. As a student, she met her future husband, Jesse L. Goodman, M.D., G.M.E. ’79, M.P.H., now chief scientist at the Food and Drug Administration. “We met in the cafeteria one night when we were both on call,” she says. They have three sons.
“I would say that much of what I have been able to accomplish in life goes back to my roots at Penn,” says Nicole Lurie. From the start, she says, she was surrounded by Samuel Martin and other people who showed her how to combine a life in medicine with a life in policy.
In her graduation address, Lurie explained more fully how she came to view her mission. She had brought a copy of The New York Times to anatomy lab. There, “as I was struggling to remember whether the nerve, artery, or vein was on top and wondering if I would ever make it through what I felt was mindless memorization, I heard a big booming voice above me: ‘Dr. Lurie, please stand up. . . . You will put that newspaper away –- you need to know anatomy and not concern yourself with what’s happening in the world. Doctors need to focus on their patients. I never want to see a newspaper in this class again.’” Humiliated, Lurie put the newspaper away. But for years, she continued, “that voice and the message it conveys has haunted me.”
“Fortunately for me, my first patient encounter let me know that I love patient care and I do so to this day. I was assigned to Mrs. Ross, a wise and deeply philosophical concentration camp survivor who I followed through her two-and-a-half year fight with metastatic breast cancer. . . . And in turn she taught me about the importance of listening and healing, about the human condition and the role of medicine in preventing and alleviating human suffering.” Then, in her third year of medical school, “I did an ambulatory pediatrics rotation in a storefront clinic in a neighborhood in North Philadelphia and watched in amazement as my preceptor wrote prescriptions for cans of the food supplement Ensure” for patients –- “because they needed food just as much as they needed antibiotics.”
“It affirmed for me that health and poverty are inextricably linked, and if health care is a human right, which I believe it is, then part of my responsibility as a physician would be to help address both the dysfunctional health-care system and the inequalities that contribute to making my patients sick.” And for her, that also meant engaging with the larger world -– and reading the newspaper.
“As a young doctor, I experienced this constant conflict -– a conflict between being a clinician and an activist, between being an activist and a scientist, and only now do I realize that a life in medicine not only led me but compelled me to do all of this.”
After several years in practice, she had another patient encounter that strengthened her sense of mission. A patient who had missed several visits to the clinic arrived, with her grandson. Her daughter, explained the woman, “had recently landed in jail,” and the grandson had severe asthma. After providing care, Lurie sat down to write her notes about the visit. But, she says, she could not write. “There was nothing to say. They were sick because their community was sick. . . . I said to myself, my patients can’t get better ’til my community gets better, and I need to learn to be a doctor for my community.”
Lurie noted that “many of my colleagues, my university, didn’t really understand what I was doing or why.” But for her, there was no conflict. Instead, “it was an incredible way to engage with the world around me, which in turn nourished me as a researcher and a clinician and made me better at both.”
Today, as she described it in her Graduation Address, “I have the honor to serve as a doctor for my country.” In the little more than four years that Lurie has headed the preparedness program at HHS, her office has organized health responses to several catastrophic disasters such as the earthquake in Haiti in 2010 and Hurricane Sandy. It has also developed national preparedness measures. These include contributing to a presidential directive focused on strengthening the security and resilience of the country through systematic preparation for a full range of hazards, such as acts of terrorism, cyber attacks, pandemics, and catastrophic natural disasters. The directive has an integrated set of national planning frameworks. Included are plans for interagency cooperation and guidance for state and local governments, to end the confusion that Lurie described to federal legislators in 2005.
As The Washington Post put it in a brief posting about Lurie, “Why She Matters.” The reason, it continued: “Lurie is the person the U.S turns to when it gets seriously ill.”
On March 11, 2010, The New England Journal of Medicine published an article by Merchant, Lurie, and Janet E. Leigh, B.D.S., D.M.D, on the organization of health-care volunteers in the wake of a disaster. On such occasions, as in the Haiti earthquake, they write, many providers looked for effective ways to help, “and many were frustrated by their inability to connect with a system that could immediately take advantage of their sills. Unfortunately, such spontaneous volunteerism can overwhelm a response system and, unless coordinated, can make things worse instead of better.” Based largely on her experience in helping to coordinate response efforts following the Haiti earthquake, the article points to some of the difficulties volunteers encounter and how they often can enhance their efforts by planning before the onset of disaster.
Discussing such tragedies, Lurie points to the differences between the events in Haiti and Japan and asserts that response efforts must take the differences into account. “In each case, the events were met with deployment of physicians and other health-care workers and provision of supplies,” she says. “However, the challenges of infrastructure were more difficult in Haiti, where many government personnel had either been killed or had their lives totally unsettled. We took care of 30,000 people, bringing many of them to this country for medical treatment.”
Another example of preparedness is recent drug development aimed at protecting Americans in the event of attack. Drugs to combat bioterrorism are being developed under a partnership between HHS’s Biomedical Advanced Research and Development Authority (BARDA) and pharmaceutical companies. According to Lurie, public-private partnerships offer a new way to develop a robust pipeline of drugs and vaccines, including novel antibiotics that addresses gaps in the country’s preparedness.
In January, Lurie announced that the Food and Drug Administration had approved a new influenza vaccine manufactured with novel technology, which she called “a landmark in influenza vaccine history.” The drug, Flublok, was developed through a multi-year public-private partnership with her office. It may help meet the increased demand for flu vaccine quickly because, unlike other flu vaccines, it is not based on eggs, and it is an example of the new technologies Lurie’s office is responsible for developing.
Despite her many responsibilities, Lurie continues to show a strong allegiance to the Clinical Scholars program that helped her on her own professional course. Recently, she has provided HHS policy rotations to young physicians in the program who rotate through her office. Raina Merchant, who last year received the Robert Wood Johnson Foundation Young Leader Award, was the second of those who benefited from an internship with Lurie. Today, Merchant’s research at Penn is focused on preventing potentially avoidable deaths from cardiac arrest.
“The whole genesis of my current program came from work I did with Dr. Lurie at HHS,” she says. Originally funded through the Clinical Scholars Program and currently through several NIH grants, the program, MyHeartMap Challenge, seeks to increase as well as identify the number of automated external defibrillators (AEDs) in public places. Despite the number of defibrillators available, few people knew where these life-saving devices were located. The challenge was for contestants to track them down, often via apps on smartphones and other devices used in social media. More than 1,500 AEDs were identified throughout Philadelphia, and the data collected was used to create a searchable, interactive map of AED locations to help bystanders and health professionals access them more quickly. The Challenge is being expanded to other parts of the country, so that 911 operators will be provided with the information to direct callers to the nearest defibrillator station.
In her enthusiasm, Merchant says, “I wanted to take on the entire country from the start. But Nicole convinced me there was a lot to be learned from a pilot project. She was right, of course. We now have a tool kit on how to institute such a program in other areas.”
The challenges of infrastructure were more difficult in the Haiti earthquake of 2010, because many government personnel had either been killed or had their lives totally unsettled. “We took care of 30,000 people, bringing many of them to this country for medical treatment.”
That program became part of the impetus leading to an article in The New England Journal of Medicine, written by Lurie, Merchant, and Stacy Elmer, M.A., called “Integrating Social Media into Emergency-Preparedness Efforts” (July 28, 2012). In the paper, the authors, citing the Haiti earthquake and the Deepwater Horizon oil spill in the Gulf of Mexico in 2010, contend that social media have become an important resource in recovery efforts following a disaster and that devices like smartphones can allow disaster victims to connect more readily with assistance. “In many instances, by sharing images, texting, and tweeting, the public is already becoming part of a large response network, rather than remaining mere bystanders or casualties.” Social media can both “push” information to the public and “pull” information from the bystanders.
As Lurie noted in her presentation at Penn, however, “social media is not a panacea.” Responders have to be able to tell “what’s signal and what’s noise,” and there were, she added, many wrong messages sent during the crisis following the Boston Marathon. In the article, the authors also raise the issue of privacy. More studies are needed to evaluate the use of social media in public health, but there is great promise.
At Penn this spring, Lurie noted some of the damage inflicted by Hurricane Sandy. More than 1,800 federal medical responders were deployed at the request of the affected states, and federal assets had been “pre-positioned.” Eight hospitals were evacuated; 14 needed generators to continue; and even today, Long Beach Medical Center on Long Island has not reopened. What made the difference, Lurie emphasized, was preparedness. In some cases, administrators were thinking “this could never happen to us.” The hospitals that survived did so “only because they practiced.” Those that were dependent on electricity were especially vulnerable. Looking back to Hurricane Katrina, Lurie noted that the hospitals in New Orleans had not prepared adequately and the circuits were quickly overwhelmed. During Sandy, some researchers associated with hospitals who had not shared their research with others were unable to retrieve it and lost everything. In a letter published in Science, Lurie and Kristin L. Rising, M.D., urged greater preparedness. “Individual researchers must take responsibility for developing an emergency plan that protects their research material and date from unanticipated losses. . . . They might also consider collaborative arrangements in which irreplaceable material is routinely stored at a backup facility or another institution” (11 October 2013). Likewise, some hospitals suffered because they did not have electronic medical records. Rising, an attending physician in the emergency department at the Hospital of the University, is another young physician who rotated through Lurie’s office.
In contrast, hospitals that built capabilities for all hazards remained in operation; that may have included having “redundant” methods of communications, in case one or more failed. Some hospitals also made sure to have their patients receive dialysis before Sandy struck. As Lurie observed, these kinds of preparations can work for cities as well. Boston, she said, has an “all-hazards approach,” and the city now holds annual “mass gathering” drills. The relative calm and control after the bombing itself “wasn’t an accident,” said Lurie. “They had a plan for it.” One important lesson the emergency teams had learned: don’t bring every casualty to the closest trauma center.
In this context, Lurie would appreciate that three hospitals in Penn’s Health System recently took part in a tabletop exercise led by the Philadelphia Department of Public Health, called “Pandemicize 2013.” It was designed to test the ability of public health and hospitals in the city to plan for a response to an outbreak of a viral respiratory illness.
“From my vantage point, I see the great looming threats of our time, but also the great looming solutions. . . . I am increasingly heartened by your generation’s drive to make a difference.”
Her years in Washington have not daunted Nicole Lurie’s enthusiasm. She says she’s still excited about getting up every morning and doing what she is doing. Rewards? “They are all around,” she says. In 1998, as part of her parting comments as president of the Society of General Internal Medicine, she wrote about her patients in the public hospital: “Many days I have wondered if what I do –- primary care –- makes any difference at all.” She went on to give brief histories of some of her patients, such as Mario, who had been a homeless schizophrenic, and Louis, a young man with recurrent pancreatitis. “Sometimes the progress is less dramatic than I would have liked, but it’s progress nonetheless,” wrote Lurie. Most of her Minnesota patients “have overcome seemingly incredible odds and had remarkable achievements. They have taught me . . . how to be a doctor, and now have taught me again the true value of primary care, not only for each of them but for populations.”
For most of her career since then, Lurie’s focus has been populations. Still, as she says today: “When you see that you’ve been able to make a difference, that’s the big reward. I continue to believe that public service is a calling. Regardless of what I do in the future, helping to make a difference for people in their communities will remain paramount.”
Her own service has been widely recognized. In addition to being the Graduation Speaker at the Perelman School of Medicine’s graduation ceremony this spring, Lurie received the school’s highest honor for graduates, the Distinguished Graduate Award, in 2009. On the national front, she has received the Young Investigator Award of the Association for Health Services Research; the Nellie Westerman Prize for Research in Ethics, presented by the American Federation for Medical Research; and a Mastership from the American College of Physicians, among other honors. In addition, she is a member of the Institute of Medicine.
In her graduation address, Lurie touched on the challenges facing the new M.D.s. “From my vantage point, I see the great looming threats of our time, but also the great looming solutions. . . . I am increasingly heartened by your generation’s drive to make a difference.” Conceding that the new graduates would “work harder than you’ve ever worked before,” she urged them to be “the next generation of America’s health leaders.” She also urged them to be open to what patients tell them. “Stay connected and engaged with the world around you.” And that, of course, entails reading the newspaper!
Like many members of the Obama administration, Lurie also argued that today, “you are closer to health care as a human right than we have ever been . . . and we’re on the verge of expanding access to care to millions of Americans through the Accountable Care Act.” Health care as a human right – that has a familiar ring.
Does it all in some way come back to Penn? At the end of every day, Lurie says, she looks up at the picture of Sam Martin on her wall. “It reminds me I have a lot to give back.”