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.


  1. How about people getting paid a living wage as to where they can afford health insurance. These are all great analogies, yet where is the one about people who attempt to live a healthy lifestyle yet cant afford basic medical coverage? I understand that the medical professionals cant reach everyone yet why do the insurance companies and the corporations have so much say in our daily lives

    1. rj55,

      You raise some great points and have some good questions! There is a growing movement in medicine and public health to do something about the social determinants of health - those things that lead to the conditions that cause diseases. This includes things like poverty, illiteracy, unemployment, and gender and racial bias. Until we as a society make some progress in these areas, even those individuals who try their best to live healthy lives will continue to have limitations. As far as the insurance companies' and corporations' power in our daily lives, I guess they got that way because we as a society let them. With national health care reform, there is some movement to try to bring basic medical coverage to more of the population, but it's a very controversial issue and we'll just have to wait and see whether it improves access to coverage or not! Thanks for your comments!

      Mark B. Johnson, MD, MPH