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!

Results

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.

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.

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.”

Building Health Care a Foundation

Health depends more on what you eat and drink, where you live, whether or not you have a job, how often you wash your hands, whether or not you smoke, how far you got in school, and where the factory next door dumps its waste than it does on high tech surgical procedures or the newest pharmaceutical drugs.

This is where public health fits in. Public health is the foundation of health care. As the Institute of Medicine has said, “The mission of public health is to fulfill society’s interest in assuring conditions in which people can be healthy.”

So how do the “conditions in which people can be healthy” relate to health care reform?

Let me give an example.

Let’s say two children are born on the same day, but in different communities. One is born to a mother who has carefully watched her diet throughout pregnancy and has abstained from alcohol and smoking. She lives in a village with pristine water and unpolluted air. The sewage and garbage in her village are transported far from town, where they are carefully processed and recycled. As she grows, her mother carefully teaches her about health and personal hygiene, and makes sure there is always plenty of nutritious food, soap and toothpaste in the house.

The second child is born a bit premature and is small for his age, due to his mother’s inadequate diet and heavy smoking throughout her pregnancy. He grows slowly because of his frequent coughs and bouts of gastrointestinal disease, and because he shares his limited nutrition with the hookworms he has acquired from running barefoot in the village. The water he drinks is questionable, and the air in his home is polluted from the coal-powered stove on which his mother cooks the meager fare which she is able to find in the marketplace. Outside, the stench is almost palpable from the garbage on the streets and the cracked and leaking sewage pipes. His mother knows little about hygiene, and is too busy with her other babies to teach him what she does know.

This exaggerated picture does have a message: It makes a big difference how much effort and the level of resources your community puts into assuring healthy conditions for you and your family. In fact, Dr. Herman Biggs, the Commissioner of Health for New York City in the late 1800s claimed, “Public health is purchasable. Within natural limitations a community can determine its own death rate.”

Now, if these two families came to buy health insurance from you, which would you prefer to insure? Before either child has even entered the “health care system,” you already know which one is going to have the highest health care costs. One has grown up in a community with a rock solid foundation of public health, and the other is attempting to survive in a community that is falling apart.

The choice is ours. “Within natural limitations, (we) can determine (our) own death rate.”

Treating STD's . . . A community Concern

I met your daughter’s boyfriend last night. Seems to have a good head on his shoulders. He says he wants to get into college on a football scholarship and plans on becoming an engineer. Nice kid. Good family. Bright future.

I felt bad I couldn’t do more for him, but you know how it is. With all the budget cuts lately, we really can’t afford to just give away medications in our sexually transmitted disease (STD) clinics. I’m sure he’ll come up with the funds somehow.

Seems funny now how things used to be. We used to get state and federal funds to treat kids like this. It had something to do with the old-fashioned concept that communicable diseases somehow impact the whole community. In fact, we were forbidden by the state legislature to charge for these services if the person couldn’t pay. How naïve we all were!

What a waste of money, trying to control things like syphilis, gonorrhea, tuberculosis, hepatitis and AIDS. Of course, we didn’t have things like HDTV plasma screen televisions to spend our tax rebates on in those days. I guess we could afford to be a bit more community minded back then.

But I wouldn’t worry too much if I were you. Like I said, your daughter’s boyfriend seems like a really nice kid. And I’m sure that “Just say, ‘No!’” lecture you gave her really sank in. It would be a real stretch to imagine she might be in that group of women (74%) who say they had sex before they turned 19. Besides, I’m sure he’ll come up with the money for the medications somewhere.