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.

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!”

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.”