Sex, Drugs, and Public Health

A beautiful Spring day in the City of Eternal Spring. Flowers, palms, fruiting trees among the several niches and fountains of the hotel grounds. We are recovering from a long day of travel : left Ollantaytambo at 7 A.M., 6 hour layover in La Paz, plane delay, arrive Cochabamba 9:30 P.M.

“Sleep it is a (wonderous) thing, beloved from pole to pole .” Coleridge was right there. It was good. But this Cochabamba morning is clear and bright and steeped in the gentility of sixteenth centiry Spain. Spiced with the smiles and kindness of the Quechua Indians who seem only a little removed in time from their ancestors, the builders of Macchu Picchu.

My thoughts on that archeological site remain untyped (difficult wifi ecounters) but still rage within my head. I will put them, and all future notes on my Blog, so as not to clog the e mail of those of you who are not interested. For the others, go to my website “greaterstory.com” and click on the blog button.

Tomorrow work at the clinic begins. But today – – – –

   With the help of a Power Point expert, I have two presentations : one on basic Epidemiology and the other on the Social Determinants of Health. These topics were requested by the Bolivian doctor in charge. The audience will be Community Health Workers. I feel reassured that this organization understands that providing clinical care, while important, will not permanently change the community s health for the better.
 
         It will be a few days more before we can see how well the talks fit the CHW s and, more broadly, the clinic organization in Cochabamba.
 
         Meanwhile, refreshing the experience of South America involves more than what the eyes can appreciate. There are flavors which, once they explode on the tongue, evoke nostalgia :
 
         the cherimoya made its encore as chunks blended within a slice of meringue, glistening like pale gold jewels in a snowbank. This high Andean fruit always releases its flavor like a blend of perfumes, as if it were a flower garden, not a green husked DNA repository ;
 
         Dulce de Leche shows up in many forms, but the most poetic was a dessert called “Whispers of Lima” ;
 
         grapes and coffee beans. The former not just fermented, but also distilled, bottled, and offered as a consort to lemon juice as the unavoidable Pisco Sour.  The latter threw me, unceremoniously, off the wagon. I traded in my coffee addiction for a tea habit four years ago, but I am enslaved again to the thick black, highly concentrated but shockingly not bitter “essence” of coffee. Smoother than espresso and madly in love with hot milk, it consummates the union every morning with me the shameless enabler.

Guest editorial by World – famous  psychiatrist to physicians,  Dr. Pannikatakus

I hear from physicians what, to no one else, they tell. Their secrets. Their fantasies. Their failures. Their sick little ideas.

Case # 42

Into my consultation room she comes, this doctor. All riled up and fidgeting.

“I don’t understand people,” she fumes, pacing back and forth on my new oriental rug.

“Lie down,” I say. “On the couch. Tell me about it. Tell me your greater story.”

“How can people be so stupid choosing a doctor?” She rants. “They certainly don’t decide the way we physicians decide.”

“You are thinking, perhaps, of a specific ‘people’?” my incisive skill directs her.

“My own sister,” she blurts. “She has some menstrual pain – don’t we all? – and she called me for advice.”

“Good,” I say to encourage. “Good. Go on.”

“So I told her to go to an Ob-Gyn doctor. I gave her three names. All good physicians whom I know. They are well trained and scientific. They would pursue testing in a logical sequence and find her diagnosis. I’ve watched them do it for others before.

“But. Does she go to one of them? No. Some girlfriend of hers tells her about this – – – this – – – surgeon. I know him. He just LOVES to cut. Cut, cut, cut. Cut and stitch. Then bill the insurance. Bill, bill, bill.”

“Yes,” I interrupt gently. “Yes. But tell me,” I say, “about your sister.”

“So she said to me: ‘he’s a nice guy. Everyone likes him.’ ”

Here I see that my patient has spittle flying from her lips.

“ It’s true he’s a nice guy,’ I told my sister, swallowing my vomit, ‘but that has nothing to do with medical skill.’ ”

“ Then my sister said: ‘my girlfriend went to him. And you know what he did?’ ”

To myself I think:  I can guess, It all, I have heard. But I don’t say anything; I just let her tell me. That is how I am trained.

“So my sister told me that he operated on her girlfriend, and that, after surgery, he sent her the most beautiful bouquet of roses.

“ ‘Roses!’ my sister said, all starry-eyed.  ‘For a patient! How many doctors do that? What a good doctor,’ she said to me. ‘What a nice guy.’ ”

“I tried to tell her: No, I said. Sending roses is not a medical skill. It’s a marketing ploy. You need a good doctor, not a good schmoozer.”

“The right thing, you said,” I reassure her. “So what makes you so upset?”

“She went to him anyway. He opened her up. No work-up. No tests. Just – – – zip – – – slice – – – mess around inside – – – stitch.”

“ Did he send flowers?” I ask before I can shut myself up.

“Oh, yeah. And he gave her his elbow to help her walk down the hall, instead of having the nurses do it. And you know what she said? ‘What a good doctor,’ she said. Like she never heard a word I told her.”

“Is she better?”

“Of course not! Once the pain of surgery disappeared, she found the menstrual pain still there. Right where she left it.”

“Unhappy,” she must be.

“Oh, no. She told me she wasn’t going to mention it to him. You know why? ‘I don’t want to disappoint him, he did such a good job’ she said. ‘Such a good doctor.’ So now she’s asking if there’s a cure for menstrual cramps.”

Here, my patient is up and pacing on my new rug again.

“If I need a physician, I want competence. Knowledge of the scientific process. A diagnosis before treatment. Don’t you?”

“Me?” I ask “You ask me?”

“Yes. You. If you needed a physician, you wouldn’t choose by personality, would you?”

“Of course not,” I say. “A scientist, I am.”

“These Quacks are a Public Health menace,” she mumbles.

Her anger, I can sense it cooling like lava into the ocean. “So what did you tell her?”

“I gave her a bottle of Black Cohosh. I figured, what the hell. She believes in this kind of stuff, and, unlike the surgeon, at least it won’t hurt her. But I feel like such a Sell-out.”

“But you did no harm,” I reassure her. “Time’s up. Come back next week. Several sessions, you will need.”

As the whole world watches the U.S. deteriorate into “the New Medievalism,” it sees, in addition to the decay in politics, the economy, racism, and religion, a shocking disintegration of our educational system.

What’s this got to do with Public Health?

Let me tell you about Nancy.

She understands the value of a college degree. She’s seen what happens when, like her parents, you don’t have one. And she’s smart enuf to read the future from the present in terms of the prospects for jobs and starting salary. She’s a hard worker: she spends 85% of her time attending classes, working in labs, and studying.

The other 15% she dedicates to selling her body for money.

She hooks up with what are euphemistically called “Tuition Sugar Daddies” on any of several websites offering “mutually beneficial arrangements.” Payday comes promptly. She pays down her college debts, and returns to the library.

This is not some isolated phenomenon. One such website alone reports having nearly 180,000 college girls enrolled, with their numbers growing rapidly over the past year. Studies conducted as surveys report an increased percentage of college girls or recent graduates who state they are willing to (or already have) engage in sex for money within the “Sugar Daddy – Sugar Baby” context.

Interviews reveal that the cost of education and the need to take out loans is a major force driving this phenomenon.

The Public Health implications go beyond concerns about Sexually Transmitted Diseases and AIDS. There is a potential for violence – a potential which must, of course, be dismissed or belittled to go forward. To quote one recent grad paying off her loans, “barring rape and death, what’s the worst thing that could happen to me?”

And that leads to another Public Health concern: the need to see yourself differently in the “Sugar Baby” role from the “student” or “recent graduate” role. There’s a psychological stress created by this episodic schizophrenia which can well have adverse effects on one’s mental health.

But the more global Public Health concern about Prosta-tuition is what it portends for the future of our society. If some people must go to such anti-social extremes to afford an education, there are surely many more who simply can’t afford education at all. As Public Health physicians, we see our entire community as our “patient.” And the health of a society is definitely related to its educational level. Less educated cohorts of community have lower income, higher infant mortality rates, higher rates of chronic disease, and shorter life expectancy.

A society that doesn’t value the education of its young adults enuf to make it available to everyone whose brains can use it, but only to those whose parents are sufficiently wealthy to pay for it or to those desperate enuf to make a compromise as extreme as Prosta-tuition to pay for it, is dooming its future.

It’s our Priorities, Stupid.