Public Health Stories: Will Ross, MD, MPH

The following profile is a portion of a collaboration storytelling effort between the City of St. Louis Department of Health, its Joint Board of Health and Hospitals, and Humans of St. Louis to examine public health in the St. Louis community.

“Public health is the science and art of keeping individuals and communities healthy.”

Dr. Ross: Where do you want me to start? I can go as far back as you want me to go. Do you want me to go back to the point where I got interested in public health?

Humans of St. Louis: That’s a perfect place to start!

Absolutely! When I finished my fellowship in nephrology at Washington University School of Medicine, I took a position at the public hospital, which then was St. Louis Regional Medical Center. I went there to oversee the dialysis unit and do research in transplant markers to look at why African Americans and other groups were less likely to receive an organ transplant, particularly a kidney transplant. I was focusing on the disparities in kidney diseases between Blacks and whites. I knew about public health but wasn’t sure it was what I wanted to do long-term. Then something happened. I was doing research on HLA transplant markers and splits on DR3 versus DR4 — oh, it would bore you to tears! But I thought it was really cool and I was getting some great results. 

Well, I was asked to give a presentation at the Surgeon General’s Workshop on Organ Donation in D.C. I was about 30 years old, relatively young in my career, and that was a big thing. So I gave my talk at this event hosted by the Surgeon General at the time, Antonia Novello, who was the first Latina and Puerto Rican to have that position. It was co-hosted by Dr. Clive Callender, an African American who founded the National Minority Organ Tissue Transplant Education Program. And for some reason, we just all hit it off. 

After my presentation, Toni said, ‘It sounds like you’re interested in researching why African Americans develop high blood pressure and kidney disease. That’s good stuff. You’re well-positioned to do this. But if you really want to do this at a population level, you need to step back a little. Look upstream. Think about public health.’ Dr. Callender said, ‘I wholeheartedly agree.’ That changed everything.

“These are the two people who became my mentors. I have a picture with them in my office from that day. So when I walk through my door, I see it.”

Dr. Will Ross with Surgeon General Antonia Novello and Dr. Clive Callender.

I went back home, met with the dean and the chairman of nephrology, and told them I was going to move into public health. They said, "Will, this could really derail your career." They didn’t make the connection because they thought public health was something people do who weren’t really into academia. Thank goodness I remained true to my aspirations. I started looking at indicators for infant and child mortality. I began working closely with Dr. Corinne Walentik, a neonatologist, and another one of the reasons I went into public health. She told me, "You really need to take a class on this." Well, she wasn’t so nice about it. She was more like, "Will, you don’t know crap about public health. You need to go back to school." So I did.

I left the St. Louis Regional Medical Center in 1996, and it closed a year later. I had been running four community health clinics and, as I walked out of the hospital for the last time, there were some dialysis patients outside waiting for the van to take them home. I saw a couple of my patients including Bea, who had to have been like 78 years old. Bea saw me, grabbed my hand, and said, "Dr. Ross, I know you’re going on to a new place, but please do not forget about us." I said, "Bea, how could I forget about you?" She said, "Do you hear what I’m saying? Do not forget about us." All the patients gathered around me and she wouldn’t let go. 

She said, "You’re not hearing me. Don’t forget about US." And I really got it the third time. It wasn’t about them. It was about what we were doing at that hospital providing culturally appropriate care and showing humility towards individuals who were falling through the cracks. That hospital was a last resort for patients who wouldn’t necessarily be embraced by large academic medical centers and who wouldn’t feel comfortable navigating them because of the cultural disconnect. She said, "You need to remember who we are and not forget that your career sees to it that we are receiving the highest level of care." She gave me the definition of public health. And she never formally knew that definition.

Public health is the science and art of keeping individuals and communities healthy. You’ll find dozens of definitions for public health. But that one resonates with me.

When Dean Bill Peck brought me back to Washington University School of Medicine as the associate dean of diversity, I said, "We need to transform this whole system. We need to start thinking about how we get our medical students to understand care for individuals who are marginalized and economically disenfranchised. How do we get them to understand all the factors that contribute to someone’s poor health that we sometimes blame them for when, in reality, it’s all those upstream social determinants of health?"

I helped create modules, classes, and platforms to teach the students, which is why we started the WUMP Program — Washington University Medical Plunge. We took them around St. Louis to get out in the community and we brought in providers to talk about healthcare, public health, and the science and art of keeping people healthy. It was well-received in 1998, mandatory by 2010, and incorporated into the full curriculum in 2019. Now it’s not just done a week before classes start, but longitudinally throughout the students’ education, which is how public health should be. 

The key was building things. I approached the deans about building a public health enterprise at WashU Med School. That led us to create public health programs and now we have a combined MD/MPH program. I was pushing aggressively to get these established. It wasn’t easy. We didn’t truly respect public health back in those days. But this was important. Remember what Bea told me: "Don’t forget about us." Remember what Antonia Novella told me: If I wanted to make a difference, I had to think broadly.

Along the way, I felt like I had to get a more formal experience in public health. So in my late 40s, I went back to get a Master of Science in Epidemiology from Saint Louis University. It was rigorous and research-based and my area of study was maternal-child health. That gets back to what Dr. Walentik said: "You don’t know a damn thing about public health." And, at that time, I concluded, If I’m interested in keeping communities healthy, and addressing high blood pressure and diabetes in African American and Latinx populations, then I have to ask, What’s causing those things?’ 

I found that women who are micronutrient deprived have changes in their bodies that lead their babies to develop genetic alterations predisposing them to high blood pressure and diabetes as adults. If the mother’s unhealthy, the baby will be unhealthy. And as the baby grows up, they’ll be unhealthy too. It’s called the developmental origins of health and disease. That became my main area of study. I’m still a kidney specialist and I see patients in the ICU and that’s what I love to do. But I found I also had to pour my time and resources into studying maternal-child health. That is intricately linked to my role as a kidney specialist. And that’s why I still focus on maternal and child mortality.

Almost 10 years ago, WashU Med School was asked to work with a medical center in Ethiopia. It was a fledgling medical school and they wanted to expand it. While I was there helping, I talked to them about the work I was doing in maternal and child health. I thought there shouldn’t just be a focus on building a medical school in Ethiopia. They should also bring in the public health aspect too. A couple of years later, I was having dinner with Professor Lora Ionnatti, a colleague from the Brown School, whose work is instrumental in addressing infant nutrition in Haiti. I told her how much I wanted to expand this focus on maternal and child health nutrition and to imagine how much healthier the world would be as a consequence. She said, "Will, we should create a public health program in Haiti." As I respect her immensely, my response was, "Let’s do it." And darned if we didn’t do it. 

We went to Cap Haitien and created a public health program for the school there. This is relevant because, after the earthquake in 2010, the public health infrastructure collapsed in Port-au-Prince and the country was reeling from cholera cases. So if we could help create a program in the north of the country, less affected by the earthquake, Haitians could do their own science and art of public health as opposed to relying on a litany of NGOs who maybe didn’t have accountability or couldn’t sustain projects longitudinally. We created the curriculum, the school opened a couple of years later, and it’s doing phenomenally well. Although with political unrest in both countries, the research was put on hold until we can return again.

When Bea said, "Don’t forget about us," I started thinking of what the outcome would be of the Regional Hospital closing. One, what was going to happen to the patients who were getting care from providers who knew them, who looked like them, who cared for them? What could we do to ensure there would be seamless healthcare delivery for them at BJC and Saint Louis University Hospital? And, two, we were doing great public health at the hospital — we were doing the science and art of keeping people healthy — and I was concerned that with the collapse of the hospital we’d need a much more robust public health infrastructure. I love talking about this because I find it so fascinating. 

I asked myself, "What does public health look like at the St. Louis Department of Health?" And it didn’t look good. I called Mayor Harmon at that time and said, "You don’t know me from Adam. But I think your administration needs to do a review of public health at the health department. Like, what are the issues? What’s being done? How do we make it top tier?" So he appointed me to oversee the job. I went to the health department for a couple of weeks, worked with FOCUS St. Louis, and did a top-down review. It was a devastating report on how poor things were going: lack of oversight, lack of focus on the core functions of public health, too much turnover. It was not well. Public health was getting modest funding and it still does now. Missouri ranks dead last among all 50 states for public health funding. We’re better than we were, but we’re dead last.

I’ve been involved as a board member at the health department since 1997, rotated off, and started seeing the department retrenching in a negative way. Our lead poisoning rates in kids in St. Louis were higher than in Flint, Michigan. We had high rates of sexually transmitted infections. We were in the midst of the crack epidemic. HIV rates were skyrocketing and we were having poor case tracking. Let me give an example of what got me involved in the health department again. There was this guy, Darnell ‘Boss Man’ McGee, who was a gangbanger and contracted HIV. He knowingly transmitted this to a number of women in St. Louis and East St. Louis until someone on the street killed him. Well, we didn’t have the staff to track those women. I knew that was a core public health function and things had to change. 

I reached out to Mayor Slay at the time and told myself I had to make the group a professional academic board, tie us to our core functions, get accredited, get connected to our communities, and identify a public health leader to guide us forward. And since then, we’ve attained full national accreditation. We brought in a top-notch leader as the director. We work closely with other health departments and hospitals. And we did all the things that needed to be done. We have a top-tier public health department in St. Louis City, and the next goal is to merge that with St. Louis County. One of my end goals, but that’s a whole ’nother story.

It’s not just St. Louis. All health departments are underfunded. When I started working with the Department of Health, I was just troubleshooting to get things done. Then, I took on a leadership role as board chair and was able to focus more strategically on a number of issues. First was establishing violence as a public health issue. We couldn’t succeed as a region if we had the threat of gun violence mitigating our ability to excel. As a consequence of declaring that, we could speak to the mayor and Board of Alderman about driving funding to that area. And by making that statement, I tried my best to bring that to their attention. At the same time, we had to get the health department up to the 21st century and we couldn’t do it without getting nationally accredited. I had to create a system to bring in new leadership. That was not easy. I lost a lot of hair doing that. But once we got accredited, the staff were elated because they finally felt respected. It was amazing because you could see it. 

Next, the key was to focus on assessment, policy development, and assuring the public that they are safe. Over the past decade, the public had lost confidence in the City of St. Louis Health Department. And I had to talk to the staff to say, ‘You now have to go out and assure the public that we’re doing the right thing. Make our communication strategy stronger when it comes to health literacy, utilize video and images, and make sure people are connecting with our message.’ We just went all in assuring people we could be trusted and that these were the things we should be focused on.

Mayor Lyda Krewson called saying it was time to get a true health director who is well ensconced in public health principles and practice. She asked, "Will you lead this search?" I said, "I’ve been wanting to do this search for 20-something years. Of course." And we identified the current director, Dr. Fred Echols. He was a former military guy, he worked at the Illinois Department of Public Health and the Saint Louis County Department of Public Health and he knew public health. He was very regimented. He knew what he needed to do. And he has been stellar. We worked with the community to create an organization called Think Health, an amalgamation of the St. Louis Regional Health Commission, hospitals, health departments, and nonprofits to work on prioritizing public health. We’re one region, so we all got in the same room to do one community health assessment instead of being so fragmented. After all, "Aren’t we all talking about the same issues? Maternal-child health, behavioral health, mental health? We all have to agree on the same thing." Dr. Echols was instrumental in getting that started and it’s still going. It’s one of the things I’m most proud of. It’s more than we could have ever imagined.

Humans of St. Louis: What happens if we don’t pay attention to public health and honor it the way that we should?

Let’s talk about COVID. At the inception of the pandemic, it was apparent to me that the science and art of public health had to be there so the whole community would be healthy. In public health, we look at populations. When the pandemic hit, it was obvious through the data that particular populations were going to be hit harder than others. It was imperative that public health gets to work with all these populations, create testing sites, and share information about handwashing and face masking and other protective measures. We had to primarily do this for African American and Latinx populations, who had a disproportionate number of cases and deaths early on. And that’s because the healthcare system had been slow in addressing the root causes, particularly structural racism. So that’s when we had to state that in order to make sure people are healthy, we had to call out the system changes that were needed. We made the bold statement that structural racism is a public health threat. We passed a motion to this effect and called the mayor to state that for the record. 

Whether people are marginalized or part of a dominant culture, not everyone understands how structural racism affects them. We had to start talking about it as part of our wheelhouse. This was painful with a capital ‘P.’ By talking about racism, we were taking what some would see as a political stance. As a consequence, we have aldermen, the state department, and the governor asking, "Why is the health department making a political stance? This could affect our funding." And to a degree, it did — maybe it was one of the reasons COVID vaccines were delivered to rural areas of Missouri more than urban areas. Public health is innately political. If you aren’t going to get political, you aren’t going to have the outcomes you want. So we called it out. We had a lot of discussions at the board level. And we finally, unequivocally passed the proclamation. Now that changed how we were seeing the pandemic.

That led to the creation of Prepare St. Louis in which the health departments got together with the Missouri Foundation for Health, the St. Louis Regional Health Commission, and others to create a nonprofit that provided public health info and prevention and addressed populations at greater risk of contracting and dying from COVID. It’s been a remarkable success.

St. Louis is still number one or two in the country for sexually transmitted infections. We can’t do the same thing over and over again. That’s the definition of insanity. So we had to develop a different response. We brought in academics and clinicians to work on the STI Response Team. Remember ‘Boss Man’ McGee? We weren’t effectively deploying the science of contact tracking back in the ’90s. So we had to do that more effectively in looking at which core groups were contracting STIs. Where is it propagating? How do we track? We started using GIS mapping to effectively track this. We also did this with COVID, using maps created by the Washington University Institute for Informatics to track cases at the neighborhood level to know where to deploy resources. These are tools we now have in our arsenal and now we have the resources to deploy them. Same thing with lead poisoning. We had to track cases and do an aggressive community-based awareness campaign using those same principles we did with COVID and STIs. 

These are things we’re doing to keep people healthy. In public health, we look at the total burden of health in a population and determine if there are certain populations at risk. With COVID, we were losing lives and that’s why we couldn’t worry about how language was going to be perceived. The threat was real and we needed to act more swiftly than we had. Now, if we’re going to call out racism as a public health crisis, then we have to respond to the crises. So how were we going to resolve this as public health officials? You can’t say, "This is a crisis. Too bad." No, this is affecting the health of our community. It warrants action. And that’s what we’re continuing to work on moving forward.

Humans of St. Louis: How do you make people care about public health who don’t think it’s all that important?

It is still difficult. I was one of the founders of the St. Louis Regional Health Commission in 2001. The first thing we did was to work on a conceptual framework to ensure everyone has healthcare access. That meant we needed to look at levels of illiteracy across the system. I became enamored with the concept of health literacy and helped start an organization called Health Literacy Media. I was invited to give a talk at the University of Oxford after putting a paper together — how cool was that?! — and I was as nervous as I’d ever been because those people really had their game on. 

When I started talking about health disparities, the audience looked at me like, "Why are you Americans always looking at one group versus another, comparing and pitting them against one another? Here, we talk about health equity. We don’t talk about depriving one group or another. We talk about bringing everybody up, assuring everybody has the opportunity to reach their full health potential." Now, I had heard that term. But it was much more powerful from them at that time. They were absolutely right. 

Returning home, I wanted to make sure my message was that everybody should be able to reach their full health potential. I didn’t care if they’re in Ironton, Poplar Bluff, Kansas City, or Haiti. I’ve lived in urban and rural communities. So I came back and started saying, "I care about you and I care about your community. This is not a zero-sum game. We can’t play that. We can make everybody healthy. We have the resources to make us all better."

Humans of St. Louis: Instead of thinking that we’re operating at a deficit — no, we are solutions-oriented.

You just nailed that. That is beautiful. I just love that! And that’s how we help make people understand.

Humans of St. Louis: What public health outcomes in St. Louis do you think need to be celebrated more?

Rahm Emanuel said, "You never want a serious crisis to go to waste." Well, we didn’t. And as a consequence of coordinated action with grassroots community engagement, St. Louis City had a lower COVID case rate than St. Louis County. In fact, the City — known for its dysfunction — had a lower case rate than all of Missouri. That was not an accident. And we still don’t talk enough about how well we did. In public health, we don’t like to brag. We just like to get our work done, help communities become healthier, and then disappear. But that’s a story that has to be told. We did extraordinarily well. People still died, but there could have been more. 

To do well, we met people where they were socially, intellectually, and psychologically. We met with community health workers, low-income populations, and people of color and we worked very aggressively. We got testing kits into FQHCs. We created responsive messaging and tools. We wasted no time communicating which groups were more vulnerable. We were on the ground, we believed in ourselves, we watched the outcomes. And at the end of the day, we were shocked that on a per capita basis, our rates were among the lowest in Missouri. And we didn’t tell anybody because we had too much other work to do. Twenty years ago, we may have looked like New York City did at the height of the pandemic when it first came to the U.S. That didn’t happen because we were prepared.

Apart from addressing all the other health indicators, the most important thing is being able to create a structure able to sustain all these efforts. That means having a formal relationship with Washington University and Saint Louis University and a memorandum of understanding outlining how they will provide faculty help, how we will bring their students over as interns, and how we will share databases. We’re also working on having a shared health department. We’d ultimately like to see one health department for the City and County. But for now, we’re working on shared processes. If we’re doing our job well, individuals would recognize they’re healthy. 

If I walk out in the 63115 neighborhood and ask people, "What do you think of your health and the health of this neighborhood?" they would tell me it’s not too good, but it’s getting better. What we want to do is put that racial equity lens on public health and to start talking about everything at the macro level — here’s what’s going on in The Ville, here are the community health workers doing this work, here’s what we’re doing to reduce asthma exacerbations. We may not make a disease go away, but we can assure the community that someone’s watching and looking at indicators to make them healthier. It’s time-trusted and evidence-based. We want to make people healthy.  We tell people what we’re doing to address health disparities. As a consequence, people are going to feel better about themselves, feel better about their communities, and call when something is wrong.

“How do you bring patience and grace to your work with all the difficulties you’ve had to work through?”

“Because I grew up in the ’60s in Memphis, Tennessee during the civil rights movement. I was taught a lesson by some civil rights icons about what needs to happen. As Dr. King was stating ‘I have a dream,’ I was taught that this is aspirational for all Americans — that this aspiration can be achieved across cultural barriers, across economic barriers, and it infers that everyone has the potential to be engaged citizens and do good. We can’t afford to write anybody off. That is what drives me. If I hadn’t grown up in that place, at that time, I wouldn’t have this perspective. I’m not saying it was all good. I grew up in a tough time, dirt poor, in a horrible environment. But, in retrospect, it gave me a long-term perspective on change. Things don’t change in two years or five years or 10 years. I started with the health department in 1997. We didn’t get accredited until 2017. It takes patience, humility, hard work, and a level of strategic thinking to get these things accomplished.”

Interview and photography by Lindy Drew / Humans of St. Louis