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!

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: http://www.denverpost.com/opinion/ci_20335024/guest-commentary-time-money-and-medical-marijuana

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.