A Steady Hand in Rough Seas

Erie County Commissioner of Health Gale Burstein is a calm yet potent force in the battle against opioids

Story by Lynn Freehill-Maye

“In medicine you never feel completely prepared for a new position. You just figure it out.”
Gale Burstein

From her ninth-floor corner office in the Rath Erie County Office Building, Gale Burstein (MD ’90) can see storms move over Buffalo, but it’s a clear summer morning when she walks in to find six people already waiting for her. They all look up, though not too high. Burstein still has the 5-foot-1 frame of a coxswain, the small-bodied navigator of a rowing-crew boat, which she was as a teen. But now her presence is outsized, and she commands the room from the moment she enters.

“My life is changed,” she announces, sounding a bit dazed. She’s describing how her older son, Zachary, graduated high school over the weekend, but she could just as easily be talking about her work. Her nearly 30-year career as a pediatrician and researcher had focused largely on providing smarter medical care for teenagers and reducing rates of HIV, chlamydia and other STDs. Now, at 53, she’s leading Erie County’s Health Department just as a new public health crisis has swept across the country and into Western New York: opioid addiction. Driven by the meteoric rise of prescription opioid and heroin abuse, and compounded by the proliferation of synthetic drugs like fentanyl, drug overdose is now the leading cause of accidental death in the United States, and the leading cause of death overall for those under 50. On average, someone dies in Erie County every day.

It’s a complex issue, yet under Burstein’s leadership, the county is becoming a model of how officials can work collaboratively to respond to the epidemic. She helped form the county’s Opiate Epidemic Task Force and now co-chairs it with Mental Health Commissioner Michael Ranney (MS ’84), working with a range of other agencies. She’s also thinking about how to reduce narcotic-painkiller prescriptions and deaths in some of the ways she did STD rates, through better educating doctors and patients. But the transmissible diseases and environmental exposures of most public health crises are one thing. For a widespread addiction like this one, which too often begins with a prescription and ends with heroin, there’s no response template. “This is completely different,” she says.

Even so, the opioid crisis is just one of the threats Burstein has dealt with over five years leading the county health department’s 400 employees. She oversees everything from restaurant inspections to lead-poisoning response. Today key employees are joining her to meet Linda Pessar, professor emerita at UB’s Jacobs School of Medicine and Biomedical Sciences, Burstein’s alma mater. The team will talk about how to expose more doctors-in-training to real-life patients and the issues they face—refugees, for example, who may have endured unspeakable trauma in their home countries.

In the meeting, each employee takes turns contributing ideas. They are the rowers, the public health area experts who know their populations and outbreaks; their work powers the department’s boat forward. Burstein, meanwhile, gazes at Pessar intently through tortoiseshell glasses, chin in hand, mostly silent. “I’m not a micromanager,” she says. “The people who run their programs know more than I ever will.” To an unknowing observer, her presence might seem unnecessary. But a coxswain is essential to a crew; she coordinates the rowing and controls the boat’s direction. Burstein breaks in every so often to keep the meeting running efficiently.

Near the end, after checking her phone, she breaks news that parts of the Trump administration’s select-country travel ban will be upheld for 120 days. “We may not have refugees to help,” she says. In public health, there always seems to be a new crisis. True to form, Burstein remains calm, but after the meeting she strides purposefully to her computer. Without the experience and steadiness she brings to meetings like this and crises like opioids, Erie County residents would undoubtedly face more health risks, and with far less support.

Taking On the World Early

As soon as she was old enough to know that women could do it, Burstein wanted to become a doctor. Her parents, raising her in the Buffalo suburb of Kenmore, weren’t a bit surprised. Her father, Irwin (DDS ’60), was a periodontist; her mother, Marna (EDM ’78, EDB ’58), a teacher who encouraged science and math. Gale was the assertive eldest of their three daughters. “I was a little feminist,” she says. “I didn’t want to be a nurse—I wanted to be a physician who called the shots.”

At 12, after years of Kadimah School, a Jewish academy providing bilingual education in English and Hebrew, she took charge of her own bat mitzvah. “It was fantastic,” Marna remembers. “She did the whole thing in Hebrew and wrote her own speech.” The women’s liberation movement was in full swing then. Feeling empowered, Burstein began her speech, “As a woman in 1976…” The crowd busted up laughing. The 4-foot-and-change preteen still looked like a child, but she evidently felt ready for the world.

Travel was important to the Bursteins—“I think it’s part of becoming a well-rounded person,” says Marna—and while a student at Nichols School, Gale piled up experiences like other ’70s kids did record albums. Ecuador to master Spanish, Brazil to visit relatives, Israel to explore Jewish faith. She later lived on a kibbutz, catching chickens for slaughter and enduring a staph infection when they scratched her.

In high school, she joined a West Side crew club, where she was naturally coxswain. She carried the sport into her first two years at Union College in Schenectady, N.Y. Crew was partly social for Burstein, who had always run around Buffalo with packs of friends. She was the loud one, so shouting instructions at the rowers was no sweat for her. But the leadership and discipline the sport fostered would serve her well in the notorious slog of medical school, which brought her back to Buffalo to study at UB. Med students sat alphabetically in lab, and the group that called themselves the Killer B’s included a gastroenterologist-to-be named Peter Bloom (MD ’90, BA ’85), a Buffalo native with a taste for adventures like mountain climbing in the Dominican Republic. Burstein and Bloom started dating during their first year. He took Burstein horseback riding once and was deeply concerned when she fell and hit her head, but then astounded to see her back in class the next day. Between graduation and residency, they married.

During their med school and residency years, the young couple took advantage of research and work-service opportunities in rural Cambodia, Zambia and South Africa. Together, they witnessed the traumatic end of the Pol Pot era, the election of Nelson Mandela, the early stages of AIDS. At Shongwe Hospital in South Africa, Burstein was made pediatrics chief. She grimly recalls being told that the country didn’t have HIV, when it clearly did. “I had to tell mothers—through a translator—that their children had this terminal disease, and that they did, too,” she remembers. “It was tough.”

Burstein always had wanted to help vulnerable young patients, especially teens; after her residency training in the United States and work abroad, she pursued an adolescent medicine fellowship at the University of Maryland. There she noticed that whatever teenage girls walked in with, they seemed to walk out with a chlamydia diagnosis. Mentors urged her to study the disease’s reach, an idea that appealed to her. All her experience in different countries had begun to spark a more macro-level interest in how entire health systems worked. Epidemics, she saw, weren’t just a matter of disease and fate; they could spread or be contained based on the responses of officials. Bloom also noticed the growth in his wife’s ambition. “In private practice you’re down in the trenches,” he says. “In public health you can work on the bigger picture. That’s part of what drove her.” Burstein followed her expanding interests to Johns Hopkins University, where she began by taking a few epidemiology classes and wound up earning a master’s in public health.

A seminal career moment arrived at the same time as her son Zachary. The week after he was born, in the summer of 1998, Burstein published a landmark study on reducing chlamydia rates, which ran on the cover of the Journal of the American Medical Association. The work raised her national profile—Burstein did major media interviews from bed as she nursed Zachary—and gave her a taste of how satisfying it could be to make a major impact on a public health crisis.

Facing Down a New Epidemic

Her stock price high, Burstein was snapped up by the Centers for Disease Control (CDC) in Atlanta to help write national guidelines on testing teenagers for sexually transmitted diseases. But by 2005 federal support for sexual health-related work was ebbing, and she and Bloom felt the tug to raise their boys, Zachary and Joshua (born in 2001), back home in Buffalo. She took a job with the Erie County Health Department but quit in frustration in 2008 when the county, after pulling back support for public health initiatives, began closing clinics and eliminating other important health programs.

Burstein arranged to divide her time between Women and Children’s Hospital and working for the CDC from Buffalo. Then, in 2011, Mark Poloncarz (BA ’89) was elected Erie County executive, and Bloom suggested his wife apply to serve as health commissioner. She’d never met Poloncarz, but family members and mutual friends thought he’d value her experience. On the application due date, Burstein hit a three-hour delay on a work flight to Florida. Always loving to connect with new people, she figured since she had the time, she’d apply at least as a networking thing. She drafted a cover letter in the airport.

Poloncarz was indeed impressed with her past work, and Burstein landed the position. She remembers being “very pleasantly surprised” in their initial meeting. “We had a lot of the same aspirations for improving health in Erie County, so I was really excited about the job,” she says. She started in January 2012 and spent her first three years building up departmental morale, learning the political process, finding her public voice. “In medicine you never feel completely prepared for a new position,” she says. “You just figure it out.” Yet she scored early wins like the 2014 opening of the Erie County Health Mall, a public-private collaboration where patients could access UB Dental and other health care providers in one spot on Buffalo’s often-neglected East Side.

Then opioids flared up in Erie County. Overdose deaths doubled from 2014 to 2015. Channeling Mr. Spock from “Star Trek,” whose plastic figure sits among the countless mementoes in her jammed office, Burstein retained her calm—and called upon the work ethic legendary since her med-school days. She hit the pool for 25 laps by 7 a.m., five mornings a week. She grabbed family time in the evenings. She stayed up until 2 a.m. on emails. In between, she began to gather every collaborator she could.

Opioid addiction is biopsychosocial, experts like to say, which is to mean: unusually complex. Doctors overprescribe pain medications. Painkiller addictions turn criminal when users turn to heroin. Addiction treatment options are limited. Burstein took charge last year of helping Erie County form the Opiate Epidemic Task Force to dig into the issue’s multiple aspects. She and Ranney pulled together law enforcement, hospital systems, health insurers, advocacy groups and more to trade ideas and collaborate. “For the first time,” she says, “all the competing hospitals and health plans were able to put down their sabers and address this problem in a collaborative way.”

Burstein pushed naloxone, the overdose-reversal med often called by the brand name Narcan, into the hands of local police officers, firefighters and EMTs. In 2016 Buffalo first responders applied naloxone more than 3,000 times, reflecting an estimated 1,000 deaths prevented. “That’s a pretty nice thing to have on your record, even though the individuals saved will never know how she made that happen,” says Poloncarz.

Not every effort tried has been an unqualified success. The 24/7 Addiction Hotline, for instance, has been criticized for receiving an average of only seven calls per day. Yet without a template, and with the complexities of addiction, part of what officials have to do with opioids is simply test different initiatives and see how they work. Next Burstein is hoping to get more people into medication-assisted treatment, which includes getting more providers certified to prescribe meds like buprenorphine.

That openness to new-and-next ideas has impressed task force members like Emma Fabian (MSW ’14), director of substance user policy at Evergreen Health. “Gale’s the type of person who will send really interesting articles about buprenorphine and what people are doing with it in other parts of the country,” she says. “It’s rare that a health commissioner would take such a hands-on, relationship-fostering approach.”

Burstein also collaborates with doctors and their professional organizations—for example, working with the American Academy of Pediatrics to push SBIRT substance abuse guidelines (Screening, Brief Intervention, and Referral to Treatment) among pediatricians. Says district vice-chair Michael Terranova, a Burstein collaborator on this initiative, “If you ask the right questions, you can detect an abuser before it gets to the stage where kids are dying.”

Burstein isn’t shy about speaking to media, either, knowing that news outlets can reach patients directly. “People need to advocate for themselves,” she says. And she walks the talk. When son Zachary needed a tooth extracted recently, Burstein objected to the doctor’s suggestion of two weeks of pain medications. Teenagers, she knows, are particularly vulnerable to addiction. Ibuprofen treated the inflammation that actually causes pain, she says, and Zachary reported feeling fine.

Largely as a result of Burstein’s collaborative approach, Erie County increasingly is being seen as a leader in opioid response. County offices have been attracting inquiries from Tennessee, Ohio and beyond for help, even as Burstein and Poloncarz, who serves on a national opiate task force, travel around the country presenting about the epidemic. At such times, Burstein draws on the same attributes she did as a teenage coxswain: big voice, huge energy, always looking forward. “She often notes that she doesn’t use the microphone because if she could scream loud enough to get those big rowers to row, she can definitely speak loud enough in a room of 50 people,” Poloncarz says. “She’s not very imposing physically, and people underestimate her. But when she starts passionately arguing on behalf of whatever she’s there for, they realize she’s the real deal.”

UB Applies Its Substantial Resources to the Fight

Recovering from opioid addiction, sufferers say, is like trying to put together a 1,000-piece puzzle. Experts grappling with the opioid epidemic see it the same way. Thus, six UB schools—medicine, public health, pharmacy, dental medicine, nursing and social work—have partnered with the Erie County Department of Health on a comprehensive approach to fighting the epidemic, with the schools of law and management serving as adjunct partners.

Richard Blondell.

Richard Blondell

Among those trying to put the pieces together is Richard Blondell, a professor of family medicine at the Jacobs School of Medicine and Biomedical Sciences and a national leader in educating primary care doctors about addiction. While under his direction, the National Center for Physician Training in Addiction Medicine developed curriculums and guidelines for addiction medicine fellowships that led to the formation of 40 such programs across North America. Blondell and his colleagues are also working locally with Western New York physicians and UB medical students. “We have to start with young doctors who are training now,” he says.

In addition, Blondell is part of an innovative Buffalo City Court initiative. Hailed as the nation’s first opiate intervention court, it allows defendents to be sent immediately to an addiction-treatment program, prior to any adjudication. Blondell supervises the treatment program.

Meanwhile, UB’s Research Institute on Addictions (RIA) is conducting research on what drives people to seek treatment after an overdose-related ER visit. It is also hosting seminars and bringing national speakers to campus to talk about issues like medication-assisted treatment. Says RIA Director Ken Leonard, who chairs the Erie County task force’s Best Practices subcommittee, “I try to bring what I know about the research literature and frame it in a way that is helpful for the practitioners to take into the community.”

Blondell credits the task force with bringing so many people together from different areas of expertise and thrusting opioid addiction to the forefront. But he cautions that the puzzle is far from being solved. “We have just begun to scratch the surface of this epidemic,” he says. “We’re not going to be able to fix this quickly.”

Lynn Freehill-Maye is a freelance writer in Buffalo, N.Y.