Thursday, May 23, 2013

My Lonely Journey from Almost Obese to Almost Healthy

We Americans are fat.

We were able to hide it for awhile under our loose fitting dresses and Hawaiian shirts, but now it’s staring us in the face.  One-third of American adults are obese, and obesity among children has risen from 5 to 18 percent in the last 30 years.  Almost no one looks good from behind anymore. 

The costs and consequences involved with this new obesity epidemic are much more serious than just those related to the additional fabric needed to cover us.  Type 2 diabetes, which we used to call adult onset diabetes when I was in medical school, is now occurring in childhood.  The estimated medical costs related to obesity-related illnesses were nearly 21% of our annual medical expenditures in 2005.  Many of these costs are covered by Medicaid and Medicare, two important programs that are under attack because of their high price tags.  The U.S. military has a smaller pool of potential recruits because so many in the pool are too large.  Airlines are now charging many of us for two tickets or forcing us to move up to business class if we can’t fit into a seat with the arms down and an extension seat belt.  Hospitals are renting and buying extra-wide wheelchairs and big sturdy beds as well as training attendants on safer ways to move obese patients.

But that’s all part of the “big” picture (sorry!).  Let me get closer to home.

I've known for a long time that I needed to lose weight.  I tried to fool myself into believing that I hid it well, but I've been in the official “overweight” category for most of the last 20 years.  I’d usually slim down some in the summer, when I’d get more exercise outdoors, but it always came back in the winter.

I've also had a persistent sense of guilt, since I've felt I should be a healthy “role model” for my department, and because I was getting closer and closer to falling over the “obese” line on the BMI (body mass index) chart.  Then I was hit with a “perfect fat storm.”

Three events poured the truth onto me.  The first was a conference I attended which was all about how health care workers should model healthy lifestyles.  The second was when I tried to buy some new jeans at an outlet store.  I told my wife I couldn't find any that I liked, and she said, “ You've got to try them in a larger size.”  She was right.

The third event was sitting by a hotel swimming pool.  As I sat sucking in my stomach and comparing myself with the young people who were swimming and tanning, I decided I either had to buy some large gold-chain necklaces and a tiny pair of Speedos® or lose weight.

I decided to lose weight.

No, really.  I meant it this time.

I’d played around with diets and exercise programs before, as most Americans have, but this time I was serious!

Unfortunately, there are thousands of diets, and programs, and surgeries, and medical devices out there that guarantee weight loss results.  It is very confusing even for someone trained in medicine.  And while I’m sure many of these plans meet the needs of certain individuals, I didn't want to spend any of my own money, my insurance wouldn't pay for surgery, and I’m skeptical of most “guaranteed” programs.  So I decided to make up my own weight loss plan.  Here is my five-step-lose-weight-and-get-back-into-shape plan:

            1.  I would set a goal weight;
            2.  I would weigh myself every day;
            3.  I would eat breakfast every morning;
            4.  I would count calories, and;
            5.  I would increase my physical activity.

Setting a Goal Weight

This is one of the things that the U.S. Preventive Services Task Force has found to be included in most effective weight loss programs.

The definitions of “obesity,” “overweight,” and “healthy weight,” are tied to something known as the body mass index, or BMI.  The BMI is an admittedly inappropriate way of gauging an individual’s body fat, and was invented by a European (Adolphe Quetelet) using metric measurements and high-level mathematics like square roots to confuse and bewilder Americans while still being able to prove that we are fat.  As you can see from the table below, a BMI above 30 is considered obese, a BMI between 25 and 29.9 is considered overweight, and a BMI between 19 and 24.9 is considered healthy.  (Evidently in Europe there are some people with BMIs below 19, who are considered underweight, but this condition is so rare in the U.S. (outside of Hollywood and New York) as to be irrelevant.)

My weight loss journey began on the precipice of obesity at 216 pounds (BMI of 29.3).  Not wanting to be too aggressive or presumptuous, I set my goal weight at 185 pounds (BMI of 25.1).  (See arrow in table below.)  It was like taking a leap over the overweight category from the edge of obesity to the doorway of normality.

Weighing Every Morning

This is a point of some controversy in the weight loss community.  Weighing every day has been shown to decrease the amount of weight regained after weight loss, and the U.S Preventive Services Task Force has found that effective weight loss programs often include active self-monitoring, which could include frequent weigh-ins.

Daily weighing also has been shown to have potential negative effects, such as unhealthy eating habits or discouragement leading to abandoning the program.  Daily weight can fluctuate for many reasons that are not related to body fat.  The item most often implicated is water retention, but a scale can’t differentiate between fat, bone, blood, muscle, water in tissue, water in the bladder, or stool moving through the intestines.  Fluctuations of one or two pounds are common, and it is difficult to retain or “burn off” 7000 calories a day, which is what 2 pounds of fat would represent.  Some suggest not weighing at all, and just keeping track of your measurements.  I, however, enjoyed the daily weigh-ins, and found them motivating.

Eating Breakfast

Numerous studies have shown that eating breakfast is important both in losing weight and in keeping it off.  The National Weight Control Registry, made up of individuals who have lost 30 pounds or more and have kept it off for at least a year, shows that most  (78%) of them eat breakfast every day, and almost 90% of them eat breakfast at least five days a week.  It has long been taught that while skipping breakfast may seem like a good way to cut down on calories, breakfast skippers quite often more than make up the difference by nibbling throughout the day or binging at lunch or dinner.    However, two randomized controlled trials that studied this issue showed no difference in weight loss between those who did or did not eat breakfast.  Still, it seemed like a good way to get a good start on the day, so part of my plan was to eat a small, but healthy breakfast every day.

Counting Calories

This is another complicated and controversial issue.  Expert advice ranges from counting everything to counting nothing.  But I figured that I wanted to lose my fat, and if each pound of fat equals 3,500 calories, the simplest way to approach it was to cut 500 calories out of my usual diet every day, or increase my exercise to burn off 500 more calories every day so I would lose one pound every week.  Unfortunately, it isn't quite that simple.  With weight loss we usually lose some fat, some muscle mass, and some water, so as we lose weight we need to adjust our caloric intake to account for all of that to get to our desired weight. 

I found that counting calories also helped keep me from falling into the “that’s a toxic food” trap.  There are many diets these days that focus on only one part of the food we eat, such as carbohydrates or proteins, and treat them almost like poisons.  By counting my calories and reading the labels on foods, I was able to pretty much stay within the nutritional limits that many experts consider healthy.  (This is probably the area of most disagreement.  Many “experts” feel we Americans get way too many carbohydrates and not enough protein.  I tend to agree with the dietary guidelines for Americans recommended jointly by the U.S. Departments of Agriculture and Health and Human Services.)  I found that my weekly intake was almost always in the range of about 60% carbohydrates, 10% proteins and 30% fat, which is within the U. S. Health and Human Services dietary guidelines (See graph below: Carbohydrates 45 – 65% (blue grid lines); Proteins 10 – 35% (yellow grid lines); Fat 20 – 35% (pink grid lines)).  Reading labels also helped me keep track of total fats, saturated fats, cholesterol, fiber and sodium, all of which are important players in a healthy diet. 

Increasing Physical Activity

I don’t mind exercising, but I hate jogging.

I have never reached a “runner’s high.”  Even when training for a marathon.

Some have said that the jogging craze has probably been the worst thing that ever happened to physical fitness for the average American – since so many of us have found jogging to be so miserable that we totally gave up on physical activity of any kind!

But it is true that:  1) you almost never see a fat runner, and 2) it is almost impossible to lose weight without increasing your physical activity.

I knew I would have to increase my physical activity if I was going to be successful in my weight-loss program, and since I didn't want to jog, I didn't want to buy a lot of expensive equipment, swimming is too much hassle for me and it’s hard to find time in the day during the week to ride my bike, I decided to walk. 

I began to walk every night in my 5-year old running shoes and regular clothes.  I began walking a mile, but soon found that I was up to 3 miles, then 4, and eventually 5-6 miles every night.  I learned, however, that I couldn't just saunter around town if I wanted to burn calories.  I had to push myself.  I started out at about 3.5 miles per hour, and gradually worked up to about 4.7 miles per hour, which almost doubled the calories I expended every night!


Amazingly, I began to lose weight!

Disappointingly, no one seemed to notice!

It wasn't until I had lost over 10 pounds that anyone asked me if I was losing weight, and the majority of folks didn't say anything until I had lost about 20 pounds.  By then most of them were saying I was looking better.  I bought that new pair of jeans and began going shirtless whenever I could!

Eventually I lost about 35 pounds and around 5 inches of waist, and have been able to keep my weight between 180 and 185 pounds now for over 9 months.  I've learned, however, that this 5-step plan has to be a lifelong plan.  Whenever I start feeling smug, and start slacking off on any of the steps, my weight starts heading back toward the overweight category.

Conclusions, Tricks and Suggestions

In conclusion, there are three main points I’d like to make:

1) It’s hard work losing weight!

Although I've been rather flippant in an attempt to make this more interesting, there were many times when I wanted that piece of key lime pie or crème brûlée and many nights I really didn't feel like getting out in the stormy weather to walk. It was especially discouraging when I was losing weight and no one seemed to notice! A couple of things that really helped me, and made this more like a game, were some apps for my smart phone that my son showed me. I used the Lose It! app to keep track of my weight and my calorie count every day, as it has a large list of foods, calories and nutritional values both for eating at home and for eating at many popular restaurants. The Map My Ride app uses GPS to track your work out, whether you’re riding a bicycle, walking, running or doing numerous other activities, and estimates your caloric expenditures. Both of these apps are free, and both of them have more deluxe programs that you can purchase if you wish. There are also many other similar apps available that you can experiment with to see which ones work best for you. Using the data from these, I've estimated that about two-thirds to three-fourths of my weight loss was from cutting back on food, and the rest was from the exercise.

2) It’s got to be a lifelong change of lifestyle!

As I mentioned above, you can’t lose weight down to your goal, and then go back to your usual way of living in the past. It has to be a permanent change of lifestyle. There are still times when I want that piece of pie, or I don’t want to go out exercising, and I have to remind myself about my goals and priorities. (This is not to say that I can’t ever have another piece of key lime pie! It just means that if I do have the pie, I can’t have some other food items, or I’m going to have to walk a few extra miles tonight. That’s one of the benefits of tracking calories and exercise with the apps.) I also understand that not everyone has a smart phone or a safe place to walk. While the apps may make it more fun, there are still ways of tracking calories and exercise without them. And if you don’t live in a neighborhood where you feel safe walking at night, you’ll have to creatively find other forms of exercise that you can do during the day. I personally don’t believe you can lose and keep weight off without lifestyle changes that impact both food intake and physical activity.

3) It’s worth it!

Although I've used myself and my journey as an example, it really is not all about me! While I do feel better, and the compliments, and movie offers and autograph requests are flattering, the two things that have made this all worthwhile are the fact that it has inspired other family members and co-workers to begin losing weight and it’s something my son said to me after the recent funeral of one of my classmates who died suddenly of a massive stroke. “Thanks, Dad,” he said, “For losing weight and taking better care of yourself."

Dr. Johnson still walks almost every night and continues to keep track of his calories and his weight. He has been an inspiration for many at JCPH who are taking steps toward a healthier lifestyle.

Thursday, November 29, 2012

Public health – the sewer system of health care!

One of the biggest challenges I’ve faced in my 25 years as a public health official has been finding ways to get people to understand the difference between public health and the traditional health care system. I’ve tried statements like, “Public health is focused on prevention and populations, while health care deals with treatment and individuals.” I’ve explained how public health works to keep people well, while most of the emphasis in traditional health care is on illness. I’ve even used graphics showing the spectrum between premature death and disability and high level wellness, emphasizing how public health “sets the floor for the personal health care system.” But nothing has really worked.
Then one day, as I was replacing the concentric float fill valve on my toilet at home, inspiration struck me like a bolt of lightning, “Public health is the sewer system of the American health care structure!”

A number of my colleagues in public health have been less than enthusiastic about this analogy of mine, but let me give you some of the reasons why I think it’s so brilliant.

First of all, it gets attention and is easily remembered. Sewers, and all of the scatological functions of the human body that require them, fit into one of those categories of discussion that polite, civilized people avoid. They transport obscene matter, about which genteel, well-mannered folk just don’t speak. In actual fact, they are full of s#@% and they stink! But precisely because it seems that no one would ever willingly compare their profession to a sewer, the analogy does seem to grab and hold attention!

The second reason I believe this analogy is so appropriate is because sewers are in large part the foundation of the civilized world, and public health is the foundation upon which the health care system is built. That’s why the Patient Protection and Affordable Care Act (PPACA) has so much to say about revitalizing this country’s public health system, and includes funding to do something about it. It makes no sense to try to improve a health care system by rebuilding it on a crumbling foundation! Unfortunately, some in Congress have not yet accepted this analogy, and continue to try to chip away at the funding that was placed there to protect the foundation.

A third reason that this comparison of public health with a sewer system is so inspired is because no one ever thinks about either public health or their sewer unless something has gone terribly wrong. We take both of these systems for granted until there’s an Ebola virus outbreak or influenza epidemic somewhere or until the sewage starts backing up into our basement or kitchen sink. Then suddenly we wonder why we didn’t invest more time and money in the upkeep and support of the system in question!

Fourthly, sewer lines connect private individuals and industries to public sewer lines and utilities. This public-private partnership is mirrored in public health. Public health provides the interface between governmental health departments at the local, state and federal level and private health care providers and health care systems. This collaboration is what has allowed us to build a strong baseline of health in this country, and facilitates rapid action in the health system when emergency responses are needed.

Finally, modern public health and modern sewer systems were born together in mid-19th century London! They were not born as allies, however. Each was the product of a different theory of disease. Public health grew out of the theory that cholera was a disease that was caused by something like germs being carried in the water system. Sewers, on the other hand, were originally developed on the theory that “bad air” caused disease, and there was a need to move the filth that was being collected in basement cesspools and causing a terrible stench, or “bad air,” out of the city and into the rivers. Eventually, the germ theory was shown to be correct, and public health and public sanitation began to work together to produce the greatest level of health that the world had yet seen. And so I believe it is no insult to my colleagues or to our profession to say we are the sewer system of the health care structure of America. But please be sure to remember while we may be like the system, we are in no way similar to that which is transported in the system!

Wednesday, April 11, 2012

Time and Money Ill-spent on Medical Marijuana

This blog post can also be viewed where it was first published in the Denver Post on April 8, 2012:

I know of no one who is neutral on the issue of medical marijuana. Some claim that it is a myth. They do not believe there is anything medicinal about the use of marijuana, or if there is, it is nothing that can't be replicated by pills or shots, which are much safer and much less damaging to society. 

People may feel better, because they get intoxicated, or "high," but it does nothing positive for their medical conditions. In fact, smoking marijuana causes harm to the lungs and may lead to lung cancer. How can that be medicinal? This is the official position of the U.S. Government. In July, 2011, the U. S. Drug Enforcement Agency denied a petition to reclassify marijuana from a Schedule I controlled substance (like heroin) to a lesser schedule. In their response they stated, "Marijuana has no currently accepted medical use in treatment in the United States."

Others claim marijuana is a magic potion that is being withheld from patients who are in severe pain and distress. Not only does it combat the pain, nausea and vomiting, poor appetite, intraocular pressure, muscle spasms and seizures of those conditions for which it has been "approved" in the Colorado Constitution, it also helps those with asthma, atherosclerosis, bipolar disease, Crohn's disease, diabetes, anxiety, hepatitis, hypertension, opiod dependence, arthritis, depression, Tourette's syndrome and post-traumatic stress disorder.

They believe it is a travesty of justice that an influential but small-minded group of puritanical government officials can keep it from those who are suffering with these debilitating conditions.

I believe that medical marijuana is at best a misalliance, and at worst is an oxymoronic name used in the manipulation of voters by the political, economic and social proponents of the legalization of marijuana. By playing on the humane sympathies of the Colorado electorate for those who are obviously debilitated by their conditions, and by claiming a medical benefit that is questionable at best, the proponents were able to weave together a constitutional amendment that aligns marijuana and medicine in a relationship that is truly a shotgun wedding. 

Nothing about the way marijuana has been studied, produced, distributed or used in any way resembles the normal pathway of an approved medication. Research on the medical benefits of marijuana is scarce, and reported studies usually include questionable methods and small populations; there is no standardization of dosage or regulation of "prescribed" amount; the "medication" is not obtained at a pharmacy with a licensed health care provider's prescription, but is grown at home or "handed out" at a dispensary to those whose names have been registered based on a physician's certification that they have a qualifying debilitating condition; and instead of taking a prescribed dosage at a prescribed periodicity, the users self-medicate to their own level of symptom relief on their own time schedule.

I believe that the time, money, and emotions that have been spent trying to wedge marijuana into a medical model have been ill-spent. There are already FDA-approved medications available that are chemically identical to the active ingredient in marijuana that have gone through the approved medical pathway to legitimacy. For numerous reasons, though, (time to response, level of response, inability to control level of response, etc.) most qualifying "patients" prefer smoking the plant to taking the medication. 

But smoking the plant, even for the relief of symptoms, falls outside of most physicians' acceptable range of appropriate medical modalities. No respectable doctor would encourage patients to start smoking cigarettes, even though there are some scientifically proven benefits, (very few, and not worth the risk), and most doctors in Colorado are reticent to encourage patients to start smoking marijuana. There's something about that "first, do no harm" mantra that seems to get wired into our DNA somewhere in our years of training.

There are clearly some individuals who deserve and get comfort from smoking marijuana. For the most part, they are those who are described in the constitutional amendment we approved in 2000. They are so severely debilitated that they require a caregiver for most of their daily needs, and they have found no relief in the available treatments or prescription medications. Most of them have diagnoses that can be objectively validated. If asked on a ballot to once again approve the use of marijuana for the relief of their symptoms, I would be sorely tempted to vote "yes." 

But the roller coaster ride on which we as a state have been, mostly for the past four years, with zealots on both sides of the issue doing their best to manipulate the legal and medical systems in their favor, and the fact that currently 94 percent of the registered medical marijuana users have been certified with only the diagnosis of "severe pain," the one qualifying condition that cannot be objectively validated, has finally made me nauseated. 

It is time for decisions about the use and legalization of marijuana to once again be made by the whole community, based on the political, economic and societal arguments for and against it, instead of continuing to hide the issue behind the white coats of medicine.

Thursday, August 25, 2011

Swimming Upstream with the Salmon: Analogies of the U.S. Health Care System

“… It’s in the nature of the human being to face challenges. We're required to do these things just as salmon swim upstream.”
Neil Armstrong

Our health care system is a very complex, complicated and expensive structure which nobody really understands. I certainly don’t claim to understand it, even though I have been schooled in it and have lived and worked in various portions of it for the past thirty-five years. But not understanding something and thinking you can’t explain something are two completely different things. I am more than happy to explain the U.S. health care system to you, even without understanding it.

I believe the best way to explain something that is extremely complex, is to make it mind-numbingly simple. This is one of my gifts.

I would like to use three analogies to describe the U.S. health care system: the example of beached whales; the story of starfishes on the beach; and the heroic journey of the salmon swimming upstream to spawn. I believe these analogies describe the three main categories of individuals that we have in our health care system.

Beached Whales

Almost every year we hear a story about a whale, or a group of whales, who have stranded themselves in shallow water and have subsequently been beached, or left up on the sand out of the water. The reasons why they do this are not well-understood, but there is some thinking that it has to do with sick or diseased whales, who are accompanied by other sympathetic whales, particularly in whale species that are very social. Most beached whales die.

The human response to beached whales is very interesting. Almost no expenses are spared in trying to keep these animals alive, when possible, and to rehabilitate them so that they can be set free. One effort earlier this year in the Florida Keys included hundreds of volunteers, including veterinarians, college students, an Olympic swimmer and a movie producer, who donated thousands of hours to help move the whales back into the water or get them to safe places for rehabilitation.

The people in our health care system that remind me of beached whales are those individuals who apparently take little interest in their own or anyone else’s health. They choose to smoke despite health problems or physicians’ recommendations; they are abusive in their use of alcohol and drugs; they ignore all dietary guidelines, hate fruits and vegetables and choose to overeat on a high fat, high cholesterol, high sugar, high salt diet; they refuse to partake in physical activity; they scoff at seat belt usage and won’t wear helmets when motorcycle riding, or bicycling, or skateboarding or hang-gliding; and they ridicule the use of condoms in their sexual escapades.

I personally think these “beached whales” represent less than 10-15% of our population, but they disproportionately raise the cost of the entire health care system. There also may not be any one particular individual who exhibits all of these characteristics in their life, but there are plenty of Americans who “beach” themselves by consistently falling prey to two or three of these unhealthy behaviors despite the availability of resources and tools to help them change. And almost no expenses are spared in trying to “save” these folks.

Stranded Starfish

You may have heard or read the story by Loren Eisley, about the older man walking on the beach and discovering a young boy almost frantically throwing starfish back into the ocean at low tide. When told that he cannot possibly save all of the starfish, the young man picks up another starfish, throws it into the ocean, and replies, “I saved that one!” In the original story, the older man then joins the young man and starts throwing starfish back into the ocean himself.

I think this analogy is a good one for the vast majority of folks in our health care system. Although they are much more passive and less reckless than the beached whales, they too find themselves ill and in need of help to get back to health. One by one, physicians, dentists, nurse practitioners, physician assistants, chiropractors and other health care providers try to help as many of them as they can, but there is no way that they can reach all of them. Still, they do their best as they methodically work their way down the beach one starfish at a time in their heroic attempt to save every starfish.

Swimming Salmon

Salmon have a very active and amazing life cycle. It begins when they are hatched from eggs in stream gravel beds far upstream and inland from the ocean. For some time they grow here, learning to catch food, and avoiding predators. They fiercely guard their territory, and imprint the scent of their home. As they grow, they eventually migrate downstream to estuaries, where they adapt to salt water and develop their characteristic scales and color. When large enough, they migrate to the ocean, where they spend about half of their life, increasing in size and mingling with other salmon. They then begin a long migration back to their place of birth, often overcoming tremendous hazards on route, where the female salmon lays up to 3,000,000 eggs, which the male fertilizes, and then they die.

It is not the “spawn and die” analogy I wish to highlight here, although it may well describe the life cycle of some in the U.S. health care system. Instead, it is the “swimming upstream” analogy that I think fits. “Moving upstream” is a phrase that is often used in the medical community to describe primary prevention, which means getting to the root cause of a problem and preventing it before it occurs. There are a number of stories, or fables, that have been used with this analogy. Here is one of them:

A small fishing village was situated near the mouth of a large river, where it entered the ocean. One day, as the villagers were fishing in the river, they heard the screams of someone coming down the river, pleading for help because they couldn’t swim. The villagers rescued the drowning victim, but soon another person came down the river, once again screaming for help. Before long, the villagers found themselves spending the entire day rescuing drowning people from the river. This gave them little time to fish, but they found that the rewards, or presents, that were given to the village by the drowning victims more than made up for their lost fishing revenue. Most of those who were rescued also stayed in the village for they said it was too dangerous to return home, so the village grew in both wealth and population.

The villagers soon became experts in the art of rescuing drowning people. They eventually broke the job of rescuing down into areas of specialization for which the children of the village could be trained. While it was true that some of the people drowned before they reached the village, and some were swept by the village on the strong currents in the river, for the most part the villagers were able to save the victims. And the village grew very rich.

Then one day, a visitor to the village asked a question that shook the very foundation of the village’s economy. “Why are so many people drowning in the river and from where do they come?” he asked. (He spoke very grammatically correct English!) This deeply disturbed the village elders! No one had ever asked such questions before! This visitor was obviously an intellectual and would cause a great deal of trouble, so they drove him out of the village.

It turned out that he was, indeed, an intellectual, and his curiosity was aroused to such a degree that he hiked up the river to see if he could answer his own questions. What he found was rather startling. He discovered a second village a number of miles up the river that had been severely damaged by a violent earthquake several years previously. The damage had altered the pathway that led into the village so that it now ran along a beautiful, but steep and slippery cliff that overlooked the wild river below. It was here that so many of the second village’s inhabitants were slipping over the cliff into the river, never to be seen again. The second village was a very depressed, and dwindling, place.

“I am a builder of fences,” the visitor told the elders from the second village, “and I believe if we build a fence along the pathway into town, it will keep your people from falling over the cliff and into the river.” The village elders conferred. This visitor was obviously an intellectual who might be able to save the village, so they hired him.

The fence did as he predicted. People soon came from miles around to look over the beautiful (but protected) cliff into the raging river below and to buy souvenirs from the villagers. The visitor was made the chief of the second village, which flourished and became very prosperous.

The river rescuers in the village downstream noticed a precipitous drop both in the number of victims to be rescued and in their income. Eventually they began to get hungry. Before long they all went back to fishing.

Members of this third group in the U.S. health care system are searching for ways to improve their health and to prevent death and disease. They are swimming upstream, like the salmon, and are learning that their dietary habits, and their exercise activities, and their refusal to use tobacco or abuse alcohol lead to positive health consequences downstream. They are flourishing, whether or not they become very prosperous.

There are many problems with the U.S. health care system. But most of us won’t be able to do much to change it. Each of us, however, can choose whether we end up beached like a whale, stranded as a starfish, or swimming upstream with the salmon.

Friday, March 25, 2011

What do I do for a living? I fight Poop!

I have felt Clark Kent’s pain.
When my children were young, they and their playmates would often ask me what I did at work all day. Each time I answered, I would feel a twinge of guilt and pain as I hid my true identity from them. “I go to meetings,” I would say. Better for them to think I was a mild-mannered, somewhat cowardly bureaucrat than for them to know the terrible truth.

I fight poop.

As hard as it may be to believe in this scientific day and age, we are surrounded by poop and poop-wielding fiends and foods. There is chicken poop on egg shells and in cookie dough; cow poop in ground beef and on lettuce, broccoli and alfalfa sprouts; and sometimes, there is even human poop in our hamburgers, salads or water. My job, when I’m not in meetings, is to find and destroy that poop before it is eaten or drunk by our citizens, and for sure before it reaches me.

Superman had Lex Luthor and General Zod. I, too, have enemies. Some of my enemies dump their sewage directly into our streams and rivers. Some build their septic tanks with inferior materials, or site them too close to wells or springs. Some forget to wash their hands after pooping, or don’t believe they need to take the time to wash them thoroughly. Little do they realize that they are the most likely victims of their own crimes.

Like Superman, I, too, have special powers (granted by the Colorado Legislature, the Jefferson County Board of Commissioners and the Jefferson County Board of Health). I can require builders and homeowners to use approved materials when building and repairing onsite wastewater (septic) treatment systems (OWTS). I can require well-drillers and landowners to keep their wells and their septic systems far away from each other, and I can require that these systems be inspected as to their installation and operational status before being transferred to a new homeowner. And I have a legion of inspectors (two) on my team who make sure these requirements are being followed.

I also have an army of restaurant inspectors (six) working with me who make sure that the almost 2,000 food establishment owners in Jefferson County are keeping their employees under surveillance to guarantee that they are washing their hands with hot soapy water before handling food and after using the rest room; that they are keeping raw meat, poultry, seafood and their juices away from ready-to-eat foods; and that they are heating and freezing potential poop-carrying foods by cooking them at the proper temperatures and refrigerating foods promptly at adequately low temperatures.

But my greatest weapon is education.

As you can see from the size of my army of inspectors, there is no way that I can guarantee that all septic systems are sited and built correctly, or that all food establishments are on guard every minute of every day watching out for the poop-carrying employee who forget to wash his or her hands. So we spend a great deal of time educating builders, well-drillers, homeowners, school children, food establishment managers and food handlers about the dangers of poop, the devious ways it sneaks onto our hands and into our guts, and the steps that must be taken to defeat it before it spreads. We also teach about and recommend immunizations, like the hepatitis A vaccine, so that the poop that might sneak through our defenses is less dangerous to us.

However, just like Superman, my special powers are not limitless. Poop is my kryptonite. I can’t get into every kitchen and rest room in the county to make sure our recommendations are being followed and that poop is being destroyed before it gets loose. I can’t make the general public or food-handlers get immunized against hepatitis A. I can’t inspect the food that is coming into the county to make sure it has been properly grown and cleaned. And I can’t make you wash your hands.
The life of a super-hero can be very lonely and discouraging (I’ll bet), and every time I think about the challenges and obstacles that are out there fighting back against our efforts to keep the citizens of and visitors to Jefferson County from getting sick I find myself using the worst swear word known to public health professionals –   “Poop!”

Tuesday, February 22, 2011

Life as a Meerkat - By Mark B. Johnson, MD, MPH

When I was in college I had the good fortune of living in Tanzania, East Africa, for a year. While there, I was occasionally asked to “guide” visitors through some of the world-famous national parks and game reserves in that area, including Serengeti, Lake Manyara, Amboseli (actually in Kenya) and the Ngorongoro Crater. Having the opportunity to observe the many varieties and species of animals in their natural habitat was an experience I will always treasure!
Serengeti National Park is famous for its vast plains covered with herds of migrating grassland antelopes, including wildebeests (gnus), hartebeests and various gazelle species. Several times while observing these animals we saw lions attack and kill one or two of the young or straggling members of the herds. What fascinated me at the time was how other antelope would watch curiously from a fairly close distance or nonchalantly graze near the kill site while the lions finished off their recently deceased colleagues. They seemed to sense that in this game of chance they were now safe.
I was reminded of this later when I lived in Los Angeles. The daily commute to work on the L.A. freeway system was also a community game of chance. We would all drive as fast as we could, sensing that sooner or later someone would get into a crash and we’d all have to stop and probably be late to our appointments. Then we’d curiously crawl empathetically around the crash site and speed off again on our important business, thankful, for the moment that we were safe.
With a highly probable impending disaster, no individual antelope or Angelino ever seemed to feel that they were going to be the next victim. There was no need to change behavior. After all, what are the odds of getting killed when there are thousands of other wildebeests around or 10 million other crazy drivers on the freeway?
It seems that we’ve built risk denial into many of our cultural rituals and even base public policy on it. For example, we know that there are individuals among us who cannot tolerate the use of alcohol, but we bet that it won’t be us or one of our family members, and therefore we joke about how much college students drink, glorify the use and abuse of alcohol on television and in the movies, and set policies around its sale and distribution that we know won’t really keep it away from the kids. Similar arguments could be made for such things as cigarettes, handguns, marijuana use, unprotected sexual activity and the use of bicycle or motorcycle helmets. We curiously, and perhaps empathetically, watch as the young or the stragglers are destroyed, but quickly speed off again on our important business as soon as we can.
But there are animals on the African savannah that live differently, meerkats. Everybody loves meerkats. They are cute, cuddly-looking and very friendly, sociable animals. They’ve starred in at least two of their own movies (Meerkat Madness (2001) and The Meerkats (2008)), and have had their own television series on the Animal Planet network (Meerkat Manor and Meerkat Manor: the Next Generation (2005 – 2008)). Timon, one of the heroes in Walt Disney’s The Lion King movies, is a meerkat.
One of the most distinctive characteristics of meerkats, however, is their custom of assigning sentinels for their colonies. While the other meerkats are busy playing, exploring, hunting and gathering around the colony’s den, one or more of the adult meerkats stand at attention and scour the landscape for danger. When something unknown or threatening appears, they loudly signal the others to seek the safety of the colony’s shelter.
On June 15, 2009, in a speech at the annual meeting of the American Medical Association, President Barack Obama appealed to the physicians of this nation to join him in safeguarding the community by acting as medical sentinels. Part of his speech was directed at those of us in preventive medicine and public health: “Building a health care system that promotes prevention rather than just managing diseases will require all of us to do our parts. It will take doctors telling us what risk factors we should avoid and what preventive measures we should pursue…. Our federal government also has to step up its efforts to advance the cause of healthy living. Five of the costliest illnesses and conditions – cancer, cardiovascular disease, diabetes, lung disease, and strokes – can be prevented, and yet only a fraction of every health care dollar goes to prevention or public health. That’s starting to change with an investment we’re making in prevention and wellness programs that can help us avoid diseases that harm our health and the health of our economy.”

As I read the transcript of this speech, my mind went back to the meerkat sentinels on the Serengeti plains. They instinctively worked to prevent the injury and death of the members of their community. It’s funny, though – I don’t recall ever hearing anyone refer to those watchful lookouts as “do-gooders” or advocates of “nanny government.”

Wednesday, November 3, 2010

The Promise and Potential of Automatic Public Health
by Dr. Mark B. Johnson, M.D., M.P.H.

One of the lessons I learned in an Injury Control course I took in graduate school was that the fewer intentional steps an individual has to take to protect him- or herself from a potentially harmful situation, the greater the likelihood that an injury will be prevented. It’s a principle that has applications in many arenas of prevention. For example, the fewer steps that one has to consciously take to make sure their water is potable, the less cases of cholera there will be. I like to call this concept “automatic public health.”

Automatic prevention is a term that is used in computer science, but it has not been frequently used to describe public health activities. I am not talking about habitual activities that one might learn through repeated practice, like always fastening your safety belt in a car without even thinking about it. I’m talking about unobserved, behind-the-scenes public health activities that protect you without your conscious involvement, and potentially without your awareness or knowledge.

Access to safe or potable water in most developed countries is one example of automatic public health. In the United States, public water supplies that are unsafe to drink are so rare that they have to clearly identify the fact to ensure that people don’t drink the water. Americans “automatically” assume that water coming from public faucets is safe to drink. They do not have to filter, boil, or chemically treat the water before they consume it. A great deal of unnoticed work has gone into providing this potable water to the public, but no individual consumer has to do anything to ensure that it is safe. This is automatic public health at work.

Another example of automatic public health is the addition of folic acid to cereals in the United States. There is good scientific evidence that if a woman has enough folic acid in her body before and during pregnancy, it can help prevent major birth defects of the baby’s brain and spine. Various surveys of American women of childbearing age have shown that over 80% know about folic acid and its effects and almost 90% would take folic acid supplements if their health care provider recommended it, yet only 40% of them take folic acid supplements and only 37% of the health care providers do, in fact, recommend the supplementation. The most common reasons given for not taking folic acid supplements were that they forgot, they didn’t think they needed it or they thought they were getting enough from their regular diet. Only 12% of the women took folic acid supplements before they knew they were pregnant, but many of these types of birth defects occur, and therefore must be prevented, before a woman knows she is pregnant.

In January of 1998, automatic public health was put in place. It was mandated by the U. S. federal government that cereals be fortified with folic acid. One serving of many commercial breakfast cereals now provides 100% of the recommended daily value of folic acid. During the first year of this program over 1,000 major birth defects were prevented, saving an estimated $560,000,000 (in 2003 dollars) in direct costs for the care of these infants. The women did not have to remember to take an additional pill and they did not have to wait to have their health care provider recommend the addition of folic acid to their diet; they just continued eating the diet to which they were accustomed. This, too, is automatic public health at work.

One of the areas where automatic public health has been the most successful is in the reduction of motor-vehicle crash fatalities. Numerous alterations and modifications have been made, both in vehicles themselves and in the roads and roadways on which they travel. Dashboards which used to have many sharp and rigid items protruding toward the passengers have given way to soft, molded contours with flat buttons and dials. Steering wheels have been modified to collapse and move away from drivers during impacts. Engines, too, are directed down and under the car instead of moving straight into the passenger compartment. Windshields, which were originally made of ordinary window glass that could shatter and lead to serious injuries, are now laminated with an inner layer of cellulose to hold the glass together even when it fractures. Brake lights have been added in a raised position more likely to catch the attention of those behind the vehicle. Car frames are now made with stronger, yet lighter components.

In 1989, U.S. federal law mandated automatic restraint systems with either airbags or automatic seat belts. Since that time, advanced generations of airbags have been devised, and many new cars have several airbags that protect from multiple angles. The National Highway Traffic Safety Administration (NHTSA) estimates that between 1988 and 2008, airbags, while possibly causing 175 fatalities, saved more than 6,377 lives and prevented countless injuries.

In addition to the many modifications that have been made to vehicles, modern roads and roadways have been improved. The slopes and slants of roads have been altered to help hold vehicles on the road. Guardrails crumple when hit or are the ends extend into the ground so they do not slice into cars and their occupants as many used to do. Signs and light poles are lighter and now break away when struck instead of impaling occupants or causing rapid-deceleration injuries.

All of these automatic public health alterations and adaptations have had a significant impact on motor-vehicle safety. Between 1994 and 2008 fatality rates per 100 million vehicle miles traveled in passenger cars decreased by 38%. At the same time, motorcycle fatality rates per 100 million vehicle miles traveled, which did not benefit to the same degree from the automatic public health measures taken, increased by 62%.

Automatic public health activities have the advantage of repeatedly producing positive health and safety consequences for individuals and populations who do not have to consciously and intentionally take single or multiple steps to produce the beneficial outcomes. I believe more public health research should be devoted to identifying automatic public health activities that have the potential of improving safety and saving lives without unduly increasing costs or limiting personal freedoms. Health education and behavior change, while recording numerous historical successes and having honored roles in public health’s armamentarium are severely limited when working with unmotivated, preoccupied or overstressed individuals and populations. Informed automatic public health has the potential of circumventing the common deterrents and disincentives for healthful activities, not by manipulation or exploitation, but by aligning incentives and making healthy choices and activities the paths of least resistance.