Smoke billowed from the tires burning at a junkyard in Northeast Portland’s Cully neighborhood. Plumes expanded west toward downtown as Portland Fire and Rescue called on every available engine to fight the five-alarm blaze.
Nearby schools and public buildings closed that afternoon in March 2018, as officials evacuated homes closest to the fire and ordered other residents to stay indoors. But that wouldn’t be enough for long. The longer smoke remained in an area, the higher the chance it would seep into homes, endangering anyone who stayed inside.
Dr. Paul Lewis, the Tri-County health officer, worried that the evacuation order might have to expand, and soon. He called on regional partners to coordinate a broader health response. Was there any air monitoring data that might support a wider evacuation, he asked. Then he learned the Environmental Protection Agency had brought in air quality monitors to test for particulates.
Normally, formal results can take as long as 24 hours, with the monitors pulling in snapshot after snapshot, every five minutes, to assemble a clear picture. Lewis already knew, after the first snapshots came in, that they didn’t have 24 hours to wait.
That evening, monitors across Cully registered levels of particulate matter anywhere from 36 to 100 times higher than the levels normally considered unhealthy. Lewis gathered with agency officials at Portland Bureau of Emergency Management’s crisis center, seeking guidance on what the numbers meant.
Everyone looked to Lewis to decide whether to call for a broader evacuation.
By 9 p.m., Lewis drove from the command center to Cully, where media had gathered outside a shuttered meat market, amid fire hoses and smoke. Lewis climbed into the back of the EPA’s mobile monitoring van for a look at the latest numbers.
Then he took a deep breath and stepped outside to face the cameras. It was time for more residents to leave their homes.
“The health officer does what doesn’t fit,” Lewis said of his role. “It’s everything and it’s nothing. It’s everything because you’re essentially the one doctor for an entire population, so every problem is your responsibility. And it’s nothing, because it’s hard to individually influence those things.”
Lewis stepped down this week as the region's lead health officer after more than five years. During that time he’s coordinated regional responses to environmental disasters, like the Cully fire, and plans for disease outbreaks, like when Ebola first touched Multnomah County. He launched an annual review of deaths among people without housing and took on the opioid epidemic by helping to dramatically expand access to a drug that can reverse overdoses, leading to sharp declines in overdose deaths.
Dr. Jennifer Vines, a family doctor by training and Multnomah County’s deputy health officer, has been appointed to the role of lead health officer for the county. Vines has worked as a regional health officer in Oregon and Southwest Washington for more than a decade.
“Paul once described leadership positions as giving part of your life to the County. And that’s true. You carry the phone, no matter what,” Vines said. “He’s really given himself to the County, and for his next chapter I hope he gives his life to whatever he wants, whether it's his teenage kids, or being back at the bedside as a pediatrician. He’s gathered up all the things he’s learned, he’s given some to me and he’s taking them into his next phase.”
Disease and Outbreaks
Lewis came to the County in 2008 after working as a pediatrician and an infectious disease specialist, 12 years after moving to Portland and launching Oregon Health and Science University’s pediatric AIDS clinic. For Lewis, who earned a bachelor’s degree from Yale and then a medical degree from Stanford, the job at OHSU was the culmination of a career journey that also took him to California, Utah and Washington.
Dr. Gary Oxman, Tri-County Health Officer at the time, was impressed with Lewis’ passion and knowledge.
“He was the go-to guy in the community for children with HIV, back in the days when there was no treatment,” Oxman said. “He was all about making sure his patient had the right to attend school. Paul was a strong advocate but also was extremely well-versed in the science of how it was spread and what was known at the time.”
Lewis continued to work as a pediatrician and professor of pediatrics at OHSU as he transitioned into public health, first with the Oregon Health Authority and then as Multnomah County’s deputy health officer, working under Oxman.
He focused on prevention, and he welcomed a role that relied on so many other people to succeed.
“Everything the health officer does,” Lewis said, “is a partnership with health department staff, other county folks, other jurisdictions, the private sector, nonprofits.”
Oxman and Lewis worked with a team of public health staff on outbreaks and emergency preparedness plans, including the 2009 threat from the swine flu virus, or H1N1.
“It was very scary,” Oxman said. “It looked like substantial mortality, so we were really concerned we might be off and running on something that looked like one of the great influenza pandemics. There was a lot of pressure. We were working very hard.”
Oxman and Lewis,along with other health partners worked long hours, to build a regional strategy including plans for vaccination, isolation, medication and treatment. Lewis kept going back to the science: What do we know from modeling about how this disease would spread?
“He has a calm demeanor, tends not to stir things up,” Oxman said of Lewis. “He pulls back and says, ‘Where are we now, folks?”
At that time, Lewis and Dr. Vines were working across the river from each other. While Lewis covered Clackamas and Washington Counties with Dr. Oxman, Vines worked under Dr. Alan Melnick covering health officer duties for a four county region in southwest Washington state.
She and Lewis would meet for lunch, calling themselves the Deputy Club. They shared a mutual admiration for Oxman, and in a pinch would ask, “WWGD?” — what would Gary do?
“Gary always taught us, ‘Do your homework, but be humble’,” Lewis said. “‘Know what you know and know what you don’t know.’”
When Oxman retired in 2013, Lewis applied for the job, and Vines, who’d come back to Multnomah County in 2011 to serve as deputy health officer primarily in Washington County, moved into the position of full time deputy health officer covering Multnomah County.
Their first big challenge was the 2014 Ebola outbreak of Ebola virus. Multnomah County’s West African immigrant community estimated they lost more than 50 relatives to the virus. Fear spread that local transmission was just a plane ride away. Lewis convened hospital systems and health departments, and private physicians and community nonprofits, to develop a plan. And when a visitor from the region was quarantined with symptoms of the virus, Lewis brought the family groceries.
Lewis’ work made national news again, one year later, when he made the call late one Friday afternoon, before the evening dinner rush, to close 43 Chipotle restaurants across the region as health officials investigated an E. coli outbreak that sickened more than 50 people, including 13 in Oregon and 27 in Washington.
Over the years Lewis and Vines have juggled their share of ongoing outbreaks and illnesses, from annual influenza outbreaks to measles, mumps and the possibility of hepatitis A.
But the job didn’t end there.
Environmental Threats
In early 2016 local officials learned high levels of cadmium and arsenic had been detected in the air near local glass manufacturers, following a study of cadmium concentrations in moss supported by the U.S. Forest Service. The pollutants were among more than 700 industrial air toxics that went unchecked by state or federal authorities.
Lewis joined a team from Multnomah County for a community open house at Cleveland High School, where more than 750 people turned out to share their fears.
The regulatory loophole led Gov. Kate Brown to launch Cleaner Air Oregon, which directed the Department of Environmental Quality and the Oregon Health Authority to overhaul industrial permitting rules.
Lewis was among those who sat on Cleaner Air Oregon’s rule-making committee. But when the rules appeared to weaken regulations instead of making them stronger, he called on the state to protect children who, he said, “are like hummingbirds, they breathe quickly and, for their size, end up with more pollution in their lungs than adults.”
“I think the Cleaner Air Oregon rules process was very challenging,” he said recently. “They’re not my rules, but I was able to be part of the concept of putting people before profit.”
Matt Hoffman, who worked on air quality issues for the County before moving to the DEQ said Lewis was pragmatic but optimistic.
“He really understood the physiology of pollutants and particulate matter, and how that affects your body and the impact on growing bodies,” Hoffman said. “But he realized how complex of an issue air quality is. It’s not like turning off a faucet.”
‘Father and pediatrician’
Lewis’ colleagues describe him as equal parts serious and passionate, relaxed and calm. He commutes everywhere by bike. And he opens his Sellwood home to a broad array of colleagues and community partners, hosting barbeques to celebrate even the smallest public health wins.
Lewis and Vines have a long shared professional history. When Vines took maternity leave six years ago, she was fraught at the idea of leaving Lewis without an extra deputy, even temporarily.
“In the world of doctors there’s a lot of guilt and obligation,” Vines said. “But Paul stepped in, he put on his father and pediatrician hat.”
“Early infancy is magic. Enjoy it,” he said. And he sent her off. Lewis brings people along through stories and metaphors. And when Vines learned Lewis was stepping down, she jotted down some of her favorites.
“Password hygiene” is the way he recommends keeping one’s digital passwords up-to-date.
“Belts-and-suspenders” is the rule of always having two health officers on call, in case one can’t be reached.
“Barnacles” are tasks that get assigned to a person that they can never shake off. “Ricochet” is the verb used when he bounces between meetings across town. And to "immunize" is to plan ahead for a worst-case scenario to lower the chances that it actually happens.
Domicile Unknown
Lewis worked when the work was needed; and that work was never done. It was air. It was water. It was illness and outbreaks. But some were ills he could not cure. And those weighed heavily.
In 2011, he volunteered to lead a project — called Domicile Unknown — that would, for the first time, identify and acknowledge those community members who died while living on the streets. Before Lewis stepped up, no one made time to tackle such a project. And no one had money to hire someone to do the work.
But Lewis joined then-Commissioner Deborah Kafoury, and Israel Bayer, then-editor of Street Roots.
“I just remember him working after hours to get this report off the ground,” Bayer recalled. “It could have been a two-page report. But to really break down the research, that was him going above and beyond.”
Lewis and Bayer shared the same realistic goal. The annual review of deaths might not lead those numbers to drop. But it could lead to policies and funding to mitigate those deaths — like housing, treatment and an expansion of overdose prevention drugs. And it forces the government — and the community — to hold up a mirror.
“Domicile Unknown is an accountability project for the whole County,” Lewis said. “It’s a difficult, unpleasant task, but I think it’s one that I hope to see continue, because I think it does hold us accountable for our condition.”
“It’s a collective understanding of how brutal the streets are,” Bayer said. “It’s given leverage to local officials and advocates to support housing, new programs, harm-reduction models. It has helped change the way we think.”
Opioids
As Lewis stepped into the role of tri-county health officer, the depths of Oregon’s opioid crisis were just coming into focus. Oregon had logged the highest rate in the nation for illicit prescription drug use when Oxman, Lewis’ predecessor, lobbied the state in 2013 to expand access to a drug called naloxone that could reverse an overdose.
Lewis picked up the cause and kept running. In 2014 he organized the Tri-County Opioid Safety Coalition to track overdose deaths and emergency room visits in real time, while convening providers and health systems around prescription guidelines and education.
In 2015 he championed Senate Bill 839, which became known as the Good Samaritan Law. The bill removed the risk of arrest anyone who called 911 about an opioid overdose and stayed on scene while awaiting first responders. Multnomah County saw fatal overdoses drop 30 percent in the year after the law took effect.
The next year, Lewis testified in support of House Bill 4124, which further expanded access to naloxone by allowing pharmacists to sell the drug without a prescription.
And then, in 2017, Lewis advocated for removing naloxone training requirements to make it easier for people to administer the drug. He also lobbied for House Bill 3440, which made it easier for doctors to get people into treatment quickly while increasing oversight on opioid prescribing.
“I love a lot of things about Paul, but most of all I love his enthusiasm and value system. It’s so important to him to do the right thing,” said Claudia Black, the County’s former legislative director. “Taking him to Salem was gold. He was so trustworthy. His word was his bond."
Lewis would pick up any time Black called. He would drive to Salem anytime she asked. Black relied on his expertise, his passion and his relationships to convince lawmakers to move the needle on opioids.
“He was my champion,” Black said. “He has so much credibility, and people really really liked him. He built relationships wherever he went.”
In 2018, Lewis convened a full-day summit on opioid abuse. Commissioners from Multnomah, Washington and Clackamas Counties joined district attorneys and sheriffs, first responders, and staff from county health and human services divisions, nonprofit treatment providers, regional hospital systems, and health insurers. The participants agreed to continue the work, including medically assisted treatment in jails and expanding programs like Law Enforcement Assisted Diversion.
Last year, as Lewis was winding down his work at lead health officer, his office shepherded through a project to provide people leaving jail with access to naloxone. At the same time, he advocated for a bill that expanded naloxone access in schools and another that requires jails to continue addiction treatment for inmates who were receiving it before their arrest.
Through the years he advocated alongside Haven Wheelock, the syringe exchange coordinator with Outside In.
“Paul is brilliant and kind and mission-driven and gets so excited. It’s contagious,” Wheelock said. “I’m confident without Paul’s leadership things would be so much worse. Paul championed the good Samaritan law. Our access to naloxone, giving naloxone coming out of jail. We know these are life saving interventions. I don’t believe many of those things would have happened without Paul stepping up.”
What’s Next
Lewis is stepping down as tri-county health officer to take a pediatric infectious disease position with Kaiser, allowing him to spend more time with his wife and three teenage kids.
He likened his tenure to running a 400-meter relay and said he’s ready to pass the baton.
“To run one lap at full speed is impossible. But you have to sprint or you’re going to lose,” he told the Board as Commissioners proclaimed Jan. 9 Paul Lewis Day in Multnomah County.
“But since it’s a relay, as you stagger at the end you get to hand your baton to a fresh teammate who is ready to run,” he said, looking at Vines, seated beside him. “I’m tired. I can’t keep up that pace anymore. But there’s good news. You have fresh legs to continue this race.”
Chair Deborah Kafoury, who has worked with Lewis since her election in 2008, said she would remember Lewis as a person of courage, a caring physician and an advocate who could look at a complex issue such as air quality and distill the science into what matters most.
“You said, ‘Children are like hummingbirds, they breathe fast and they breathe a lot and we need to protect the hummingbirds.’” Kafoury said, her voice breaking. “Thank you Paul, for protecting the hummingbirds and, by doing so, protecting all of us.”
