One of the best little health books ever published

Few books stay with me for long. I read them and give them away. One has stayed on my bookshelf, now for 26 years. That book is Dr. Stephen Bezruchka’s The Pocket Doctor. First published in 1982 by the Mountaineers, this pocket-size reference, now being published at a bit more than 100 pages, is exactly what its title implies. It is a guide to help a traveler cope with illnesses many people in the developing world face daily. You can buy it online from many vendors, like Powell’s Books.

The Pocket Doctor Cover
Cover of the second edition, 1988 version of Dr. Stephen Bezruchka’s The Pocket Doctor (personal copy).

I credit this book for saving my bacon and mental health on several best-forgotten nights. It helped me cope with medical problems that are normal for hundreds of millions of residents globally, and for me something I did not experience back in the comfort of the United States. But I am not the only writer and traveler who praises Bezruchka and his book.

Why many trust Bezruchka’s work

Bezruchka is a Canadian-born former emergency-room doctor trained at some of the nation’s best universities (Standford, Harvard, Johns Hopkins). He has both an MD and MPH. He has worked with medical specialists in the developing world, notably Nepal for 10 years. He also has written a great guide called Trekking in Nepal, which I used back in 1989. Today he is a lecturer on global health at the University of Washington School of Public Health (UW SPH) and a nationally recognized advocate for health care reform to improve public health outcomes and to eliminate health and income inequality.

I have taken this book with me now to three continents: Asia, Africa, and South America. I just cannot say goodbye to it, even when my developing-nation jaunts seem fewer and fewer.

The advice it provides has helped me to self-diagnose all manners of common gastrointestinal disturbances, such as food poisoning (nasty and scary in a crappy place), dysentery, and common diarrhea. I also used it to help me obtain the necessary medicine for what I still believe was malaria, which I had in Kigali, Rwanda in 1997.

With this book in my hand, I felt I could handle the predicaments that afflict visitors from developed countries to less-developed areas. In my 1988 published version, 13 pages are devoted to common drugs and medicines that address typical maladies, such as the  antibiotic ciprofloxacin, to tackle infections, with information laid out in a table on a drug’s use, likely place of need (city, remote, “third world”), form, and dosage.

Basic health care advice can be fun with good writing

Bezruchka’s writing is straightforward and direct. In his chapter on drugs, he begins his recommendation with a simple message: “Remember that drugs, though valuable, are not a cure all.” He provides advice on assembling a medical kit, working with doctors at home and abroad, and dealing with major sources of health problems—namely, food and water.

Bezruchka also highlights a major global health issue that is more severe than microbial agents, trauma from vehicle accidents. “Trauma, especially that caused by motor vehicle accidents results in the majority of disability acquired in developed countries,” writes Bezruchka. “This is even more true in third world countries. Trauma causes more disabilities to travelers in foreign countries than all the exotic diseases put together.” That observation remains true to this day, as shown in global health data.

Photo courtesy of the University of Washingston School of Public Health faculty photo.
Faculty photo of Dr. Stephen Bezruchka, courtesy of the University of Washingston School of Public Health web site.

But there is much more. Rabies? Check. Animal attacks? Covered. Ticks and leeches, fever, rashes? All addressed. The two-page section, in my old and battered version, on dealing with stress in less-developed nations is a classic summary of what many first-world travellers experience.

“If the culture shock of a third-world setting with its attendant poverty and hopelessness have you in despair, take steps to improve your psyche,” writes Bezruchka. “Seek out help, another traveler, or a religious organization or individuals.”

Bezruchka even has sections on death and how to cope with returning from travels with an illness. I definitely experienced lingering issues when I came back and took this advice to heart.

Meeting Bezruchka later in life

When I first met Bezruchka in person during my studies at the UW SPH, I mentioned how much I enjoyed his book and used it frequently in Nepal. I even mentioned how enterprising Nepalis had published black-market copies of his book they were peddling on the streets in Kathmandu. As I recall, he considered that a compliment to the value of his work.

Sometimes small and perfectly executed creations are ones that have the most impact. In Bezruchka’s case, there is far too much to choose from to say what is best—from published papers to advocacy to mentorship of future health leaders. I will submit this still fine tome as work that stands the test of time and proves that small is often better.

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Cheap energy poses a threat to Americans’ health

One of the most talked-about initiatives taking place in public health, with funding supports from the Centers for Disease Prevention and Control (CDC), is policy, system, and environmental change to address the rise of chronic disease in the United States, the country’s leading cause of death. According to the CDC, chronic diseases are responsible for seven out of 10 deaths of all Americans annually, and one half of all Americans have at least one chronic illness. Worse, three-quarter of the $2.5 trillion (yes trillion) dollars spent annually on health care in the United States goes to battling chronic diseases. The CDC’s grant funding is being disbursed to health departments to undertake a range of interventions. But none of these interventions is going after what some say is one of major sources for the rise of obesity and chronic disease—the cheap price of energy in the United States.

According to Ian Roberts of the London School of Hygiene and Tropical Medicine, the overall obesity rate is highest in the United States among all other nations because the price of gasoline is very low. “So where gasoline is really cheap, we over-consume it, it’s bad for the environment and actually because we should be using food energy for human movement – if we use gasoline for human movement, then we store the food energy and you know where we store it.” And there are other costs associated with being a fat nation, says Roberts. “So there’s obviously an increased demand on food supplies, but also there is an increased demand on everything. You know, bigger people need more energy to move them. Airplanes take more energy to get off the ground. It takes more of the shares that, you know, of the Earth’s resources to actually support all that extra weight.”

In the United States, the U.S. Energy Information Agency estimates we use 317 million BTUs per person a year. In this country, nearly half of all of our energy comes from petroleum and natural gas, and the country ranks seventh globally in terms of per capita energy use, trailing Canada and some smaller nations like Luxembourg and Trinidad and Tobago. However, the United States is  No. 2 (19% of global demand) in terms of global consumption of energy after China (20.3% of global demand), which just took the No. 1 slot.

Feeder pipelines gather crude oil produced at Prudhoe Bay, which is eventually shipped to the lower 48 for consumption on the West Coast.

A significant negative outcome can be seen in the widening waistlines of Americans. Charles Courtemanche of the Department of Economics at the University of North Carolina at Greensboro published a study in 2009  (A Silver Lining? The Connection Between Gasoline Prices and Obesity) that found increases in gas prices were associated with an uptick in walking or bicycling and public transportation use (and more people walking to bus and subway stops) and a drop in the how often people eat at restaurants, all impacting weight. Courtemanche estimates that:

– A $1 rise in the price of gasoline would reduce overweight and obesity by 7% and 10% in the U.S. The reduction in obesity would save approximately 11,000 lives and $11 billion per year, savings that would offset 10% of the increased expenditures on gasoline.

– An 8% of the recent rise in obesity from 1979 to 2004 can be attributed to the decline in real gasoline prices during the period.

According to Dr. Brian Schwartz, professor at the Johns Hopkins Bloomberg School of Public Health’s Department of Environmental Health Sciences and co-director of the School’s Program on Global Sustainability and Health, cheap energy also is responsible for creating our built environment, which is exacerbating our poor health trends. Schwartz argues that since World War II, the United States and other developed countries “have invested in large tracts of low density, non-compact, single use developments, which are highly reliant on the automobile and often lack public transit options.  This type of housing and transportation system is totally reliant on cheap and plentiful oil.”

The built environment of U.S. suburbs has been shaped by the relatively cheap price of petroleum paid by U.S. consumers at the pump.

Schwartz argues the average foodstuff in the United States requires about 10 units of fossil fuel-based energy input for each unit of food energy derived from the food, and that ratio jumps to 100 to 1 for many meats. Less energy would lead to declines in food calories too, as many kinds of food would become too expensive to produce and too expensive for consumers. What’s more, Schwartz suggest that this unsustainable suburban lifestyle would change dramatically after peak oil, that future and historic moment when global production of both oil and natural gas reaches its historic peak and begins to decline, setting off chain reactions impacting every facet of our life to what we eat, how we work, how goods and people move about, and how nations respond on a massive scale. (Go here for a summary of peak oil and its health impacts, as explained by Schwartz.)

Schwartz also notes that our entire health care delivery system, on top of our suburban-sprawl development pattern, food production systems, and supply chains, also is tied to unsustainably cheap energy in the form of cheap fossil fuel. “Large energy-inefficient health care facilities are staffed by health care workers living in distant suburbs who require large quantities of paper, plastic, and electronics to do their work. Systems for provision of care will need to be completely redesigned to adapt to the new reality of more expensive energy.”

Portland, Ore., that oh-so progressive Northwest city that has become a beacon of contemporary planning that tries to vaguely resemble what they do in Netherlands or Denmark, for instance, already has assembled a Peak Oil Task Force, back in 2006. The group prepared a report and drafted a resolution, passed by the City Council in 2007. That resolution sets out an ambitious goal to “reduce oil and natural gas use in Portland by 50 percent in 25 years and take related actions to implement recommendations of the Peak Oil Task Force.” It may be no surprise Portland was recently ranked the No. 1 biking community in the United States.

What continues to baffle me is how unengaged or willfully silent the United States’ professional public health system is to the connection between cheap energy and health, notably obesity. I just did a keyword search today (Sept. 3, 2012) on the word “obesity” for the upcoming American Public Health Association (APHA) Annual Meeting and Exposition to be held in San Francisco in October 2012. There were 797 hits for the word–many for papers being presented on the topic. When I typed in the word “oil” I yielded 33 hits, some on the Deep Horizon oil spill and its impacts and others on shale gas development, such as a paper being presented by Dr. Roxana Witter of the University of Colorado called “Comprehending health implications of natural gas development through public health research.” But I saw no papers on any linkage between the so-called “obesygenic environment” and energy prices tagged under the word “oil” in the searchable database of presentations and papers. I did a search for the word “energy” and got 82 hits, but most related to topics like high-energy drinks, not on oil, gas, or energy policy issues impacting human health.

Seattle like other cities is entirely dependent on relatively cheap petroleum, and as a consequence suffers from some of the worst traffic congestion of any metro area in the country, as well as a sprawl development in the city and throughout surrounding King County.

I dream of the day when public health professionals will organize their advocacy less around what kids eat at school and talk more about what our state and national lawmakers are doing to create meaningful tax policy that prices energy–making it more expensive while using revenues to promote renewable energy sources–to create larger downstream impacts. To completely cede this issue to supporters of cheap energy and the status quo and to deny that there are serious public health implications by doing so is to turn one’s back on best available evidence and the duties those in the field have to promote healthy outcomes for the U.S. population.  I did try to raise this issue in one of my classes at the University of Washington School of Public Health, and was met with unusual silence. I hope one day perhaps UW faculty in the economics department, school of business, and schools of public health and public affairs get together one day to pursue research examing negative health impacts of national energy policy.

A tale of two farmers-food markets and what it means

I love fresh food markets. I had a fruit, vegetable, and fish market near me growing up, the old Market in the Loop, in University City, Mo. To this day I remain a loyal supporter of local food and local businesses that sell fresh fruit and vegetables. Today, these markets are very much at the center of the national health discussion on nutrition, healthy food, obesity, and politics. So I decided to examine this issue using two examples in Seattle–one where I shop and the other where I mostly people watch and occasionally will buy some food. (Please go below for my photo essay of both venues.)

For  the last decade, the public health community increasingly has been focussing on how to increase fruit and vegetable consumption by Americans, improve Americans’ nutritional intake, and address the complex systems that are making this country the fattest on earth. Research has shown that Americans still do not consume the recommended amounts of fruits and vegetables, and government research is showing that lower-income consumers eat fewer fruits and vegetables than higher-income consumers do.

According to research by public health experts, communities that lack full-service grocery stores and neighborhood food markets have less access to fresh fruits and vegetables. Since 2009, the CDC, in its list of strategies to reduce obesity, has called for making healthier food choices available in “public service areas.” Specifically, the CDC says local governments can make healthier foods accessible through policy choices and offering vouchers that can be redeemed for healthy food choices. This is happening nationally at farmers markets, where technology to read food stamps, or EBT, cards (known today as Supplemental Nutrition Assistance Program, or SNAP), is being made available to merchants so they can serve lower-income consumers.

The Food Research Action Center (FRAC) has called for increasing participation in SNAP; improving those benefit levels so lower-income persons can afford adequate diets, including healthier foods; promoting fruit and vegetable purchases with SNAP benefits, which is taking place; and boosting the access to healthy and affordable foods in “underserved communities.” To that end, the CDC is making available more than $100 million (chump change, really, when you compare that to funding made available to corporate farms through the U.S. Farm Bill) to promote policy, systems, and environmental change through Community Transformation Grants (CTG).  This is designed to “to reduce chronic diseases such as heart disease, cancer, stroke, and diabetes” — all major health issues that are also bankrupting our health care system and treasury.

A 2010 White House report on childhood obesity notes that in the last three decades, prices for fruits and vegetables rose twice as fast as the price of carbonated drinks, and a bump in the cost of fruits and vegetables relative to less healthy foods can reduce consumers’ desire to buy fruits and veggies, leading to unhealthy Americans. Pricing is of course a key issue impacting purchasing decision of lower-income consumers, among other factors. U.S. Department of Agriculture (USDA) research found that a 10% discount in the price of fruits and vegetables would increase the amount purchased by 6-7%.

So, yes, price matters a lot, along with access. Where I live (Seattle), the Farmers Market Alliance claims “the vast majority” of the fruits, vegetables, herbs, and berries are the same price or less expensive at farmers markets, especially with organics, than at conventional grocery stores (QFC, Fred Meyer, Safeway, etc.). The organization further claims that the quality and variety of its produce exceeds the quality sold at the chain grocery stores. The farmers market movement is truly national in scope, and a network of nonprofits like the Philadelphia based Food Trust is partnering with local farmers to promote farmers markets in underserved areas.

The Atlantic in May 2011 published an article noting that farmers markets were less expensive than supermarkets and provided better food. The article challenges the criticism that farmers markets catered to mostly wealthy white snobs who drive Subarus and Prius’s, and it argues that no formal research supports “this widely accepted contention, and the few studies that have been conducted call its veracity into question.” Of course the movement to support “local food production” and farmers markets has both national and local critics, including conservative bloggers, who call it a trendy cause. Some have blasted the use of electronic EBT card readers as a wasteful expense ($1,200 to purchase, $50 to lease).

The closest market to my home, about one mile away, called the Ballard Farmers Market, most definitely is more expensive than grocery stores and independently owned produce and grocery stores where I also shop in Seattle. Its clientele, based on my many trips there, is decidedly and stereotypically upscale, white or Asian (I’d say 90% white, 5% Asian, 5% other), and professional. I haven’t conducted a poll to actually verify this, but this corner of Seattle is not that diverse, and it is close to a neighborhood where homes fetch $600,000 and where condominiums are sprouting on many major intersections. No, I can’t afford to buy anything there, with the exception of a good bargain, like beets today ($3 a bushel of three). I have bought a few apples and heads of lettuce and other veggies in the past, but not much else — not salmon, not herbs, nothing. For my part, I grow some of my own food, pick some (like berries or tree fruit that abounds in Seattle), and wish I caught salmon like I did in Alaska.

I don’t begrudge the vendors there for selling produce at a higher price point, which shuts out low-income persons like me. (I may have a few university degrees, but I am by all measures very low-income now.) As one food blogger and jam-making blogger from San Francisco notes: “People selling at the markets have priced their products according to a wide range of criteria. First, many of the farmers who sell at markets are smaller operations than those who sell to grocery stores. Maybe they have 10 acres of land compared to 60 or 100 or 200 acres and rely almost exclusively on markets for income.”

I try to support my favorite produce store in Seattle, called McPherson’s Fruit and Produce, in Seattle’s Beacon Hill neighborhood. First, their selection is usually excellent–fresh but not organic food in season. I find their produce is fresher than most grocery stores. Their vegetables and fruits are always cheaper than any grocery store I visit, including stores with hefty supply chain advantages like Costco. They cater to a full spectrum of clients, and that clientele is more low-income and more ethnically diverse than what is found in Ballard. (Beacon Hill is much more diverse ethnically.) I’m as likely to see Hispanic, African American, immigrant, and Asian-American shoppers as I am those who look like me (white). However, McPherson’s is located about seven miles by car from my home, while the Ballard Farmer’s Market is a mile away, making it impossible for me to bike to Beacon Hill, and there are some serious hill and traffic issues. So I drive there, but usually combining outings and errands with a stop. I have been shopping at McPherson’s for years, during my previous and current stays in Seattle. I do not know if their model can be replicated in other cities–unique private owners, a great location on well-travelled road, proximity to distributors, an ability to attract shoppers with and without cars.

Perhaps instead of throwing all of our support into the farmers market craze, more can be done to help smaller businesses and producers. This would require the proverbial “upstream intervention.” For instance, our government tells people to eat five servings of fruits and vegetables a day, but is not providing the supports through federal legislation to make that possible. The White House Task Force on Childhood Obesity notes that by 2020, the country needs to boost the availability of fruits and vegetables by 70%, or 450 pounds per person a year (that’s an enormous pile of food by the way). It is not doing that now because of our dated, bloated Farm Bill.

Such upstream actions, to grow the intake of healthy food consumption, in a policy sense, have the biggest bang for the buck, compared to downstream actions. Many wise and smart persons who follow food and nutrition issues have long said that the pork-laden, decades-old Farm Bill needs to be overhauled to create true change. New York Times food blogger Mark Bittman notes “agricultural subsidies have helped bring us high-fructose corn syrup, factory farming, fast food, a two-soda-a-day habit and its accompanying obesity, the near-demise of family farms, monoculture and a host of other ills.” The farm bill, up for renewal in 2012, offers an agriculture subsidy worth $30 billion, $5 billion of which is direct payments to farmers. Conservative groups like the Heritage Foundation even blast this.

Bittman suggests that a revised Farm Bill–which I believe no one involved in policy-making believes can occur in the current political climate–should support farmers who at the moment now grow unsubsidized fruits, vegetables, and beans, while giving incentives to “monoculture commodity farmers to convert some of their operations to these more desirable foods.” This is food that would make us healthier compared to factory raised meat fed on subsidized grain, which is what our current system promotes. Bittman also calls for incentives to help medium-sized farms, those big enough to supply local supermarkets but small enough to care what and how they grow, compete better with corporate agribusiness.

Personally, I would love to see both farmers markets and McPherson’s in most neighborhoods in most cities. Right now, I’m going to stick with shopping primarily at McPherson’s, despite the inconvenience. And I’ll keep growing a garden where ever I live, too.

A trip to Indian country and the Omak Stampede

So what is “Indian country”?

Drummers gather to perform at the Indian encampment at Omak’s Stampede, in August 2012.

A now-deceased doctor friend of mine who dedicated his life to serving the Native community in the Indian Health Service used the expression a lot describing where he worked in New Mexico and Alaska. It is a legal term, codified in treaty rights, federal regulations, and court decisions. Indian country can be a physical place, associated with customs and cultures of the continent’s first peoples. It is also a state of mind. You literally know you are in Indian country when you go there. There are place names and of course the people. I grew up in St. Louis, Mo., which sits on the mighty Mississippi River (Ojibwe for “great river”), and I felt connected to Indian country there because of the great muddy and the phenomenal Cahokia Mounds just east of the city in Illinois. I knew I was living on historic Indian land even as a kid.

The largest Native mound in the United States is located at the historic Cahokia Mounds, just east of St. Louis.

I have lived the last 16 years of my life in what I definitely consider to be Indian Country, Alaska and Washington State. Alaska felt much more like Indian country to me. Anchorage, my home for six years, is very much a Native city in terms of population (about 16 percent). I rarely feel that connection in modern, congested, urban Seattle.  But I recently took a four-day trip to the hot, upper plateau of central Washington, from the Methow Valley to Omak, and indeed felt I had landed four-square in Indian country again.

According to a section of federal legislation pertaining to Native Americans, “Indian country” refers to three specific criteria:

-All land within the limits of any Indian reservation under the jurisdiction of the United States government, notwithstanding the issuance of any patent, and including rights-of-way running through the reservation;

-All dependent Indian communities within the borders of the United States whether within the original or subsequently acquired territory thereof, and whether within or without the limits of a State; and

-All Indian allotments, the Indian titles to which have not been extinguished, including rights-of-way running through the same.

Indian country also implies U.S. federal recognition of tribal bands as sovereign on their lands and capable of enjoying rights that are government to government. As one source notes, recognized tribes “possess absolute sovereignty [that] are completely independent of any other political power,” but also which is shared with other jurisdictions (local, state, and federal).

In Washington state, federal definitions of “Indian country” apply to state law, in addition to provisions acknowledging tribes non-taxable status in some commerce, such as the sale of tobacco products to tribal members on their reservation. In Seattle, there is still a band, the sparsely populated Duwamish, who have lost their sovereign status  and failed to win legal recognition in the city’s limits, on some of the choicest real-estate on the West Coast. Another nearby tribe, the Snoqualmie, regained their status in 1999 and promptly built a casino and became an economic and political player.

The decades-long fight over treaty-protected fishing and subsistence rights by the tribes culminated in the historic 1974 ruling in the landmark U.S. v. Washington case (the Boldt Decision) that unequivocally affirmed 19 federally-recognized tribes’ fishing rights to salmon and steelhead runs in western Washington. That decision gave the tribes rights to half of the salmon, steelhead, and shellfish harvests in the Puget Sound. It was a major game changer, and its impacts are still felt today–particularly legal squabbles if the decision should still be applied to land-use decisions impacting salmon habitat.

Yet, even as I gaze out on the beautiful Puget Sound, I am hard-pressed to think that I am on historic Indian lands, that I live in Indian country, where there are 29 federally-recognized tribes, in all corners of the state (see tribes and locations here).  But this is very much Indian country in a historic and cultural sense.

In fact, more than half of the state was outright taken by military force, illegal land seizures, and treaties (which also provided fishing and resource rights to tribal members) from the 1850s to the 1890s. Many stories of the exploitation of Native tribes come to mind, notably the hanging of Yakima warrrior Qualchan (also called Qualchew) by the reportedly violent Col. George Wright, in his campaign that defeated five tribes in Washington in the eastern half of what is now is the state. 

On Sept. 25, 1858, Qualchan had surrendered with a white flag and was hung within 15 minutes. That was followed with the hanging of six Palouse warriors the next day. Such incidents typified the period of conquest in my home state. Exploitation of tribal rights followed the signing of treaties. The Colville Tribes, for instance, had their lands stolen without their consent, setting off decades of legal battles that continued to the 1930s and ended in historic settlements returning hundreds of thousands of stolen acres of land.  Salmon and steelhead runs in the state were decimated by commercial fishing interests that harmed tribal groups in the upper and lower Columbia River basin. The runs were further extinguished by the dams built on the Columbia River. Only with the Boldt Decision in 1974 did the tide turn, but with numbers that no where near compared to the great runs of 100 years earlier.

Again, all of this is very academic and abstract to me and most Western Washington residents. Only when I traveled to the “World Famous Omak Stampede” rodeo and suicide race, with Native riders who charge down a 200 foot hill on horseback every second weekend of August, did I again realize I was truly in Indian country. Omak, in north central Washington, lies partially in the 1.4 million-acre Colville Reservation, in sparsely populated Okanogan and Ferry counties. The Confederated Tribes of the Colville Reservation number less than 10,000. I found the area to be amazingly beautiful. It’s hot in the summer, and bitterly cold in the winter. During my visit to Omak for the Stampede, the mercury hit 100 F.

Outside of agriculture (on non-tribal lands), there is little industry in this part of the state, but there is gold mining, forestry, and a limited personal use salmon fishery for tribal members.  Forestry is the mainstay for generating tribal revenues. Gaming is also a big moneymaker at the tribes’ three casinos. If you can believe it, the casinos are attracting acts like blues legend Buddy Guy and rock has-beens like Foreigner and Joe Walsh in the next few weeks. I think it’s a bit sad that even stalwart Canadians are driving south from British Columbia to spend their loonies at the tribal gaming tables, but come they do.

Despite the flow of revenues, health issues remain a problem, as they do throughout Indian country. A June 9, 2012, story republished in the New York Daily News about Tribal Councilman Andy Joseph, Jr., profiles his efforts to address Native health funding issues. The story notes his tribal members and others nationally “are dying of cancer, diabetes, suicide and alcoholism. They are dying of many diseases at higher rates than the rest of the population. And instead of those rates getting better, they’re getting worse.” Joseph is the tribes’ representative to the Northwest Portland Area Health Board, which serves 41 tribes in Washington, Oregon, and Idaho, and is that group’s delegate to the National Indian Health Board, which speaks for all 566 federally-recognized tribes in the country. The story notes that, nationally, tribal members die an average of five years earlier than the rest of the U.S. population and are six times more likely to die of tuberculosis or alcoholism, three times more likely to die of diabetes, and also twice as likely to be killed in an accident. What’s more, they are also twice as likely to die from homicide or suicide. Pretty grim data indeed.

According to Joseph, the major health issues associated with diet and nutrition have occurred as a result of conquest and cultural assimilation: “‘Joseph holds up a jar of canned salmon sitting on his desk. ‘Our people crave this,’ he said. ‘It was taken away from us when they put Grand Coulee Dam in.’ He reaches for a string of dried camas root. ‘It’s what our bodies were raised with for thousands of years. Now, we have Safeway and Albertsons and Walmart.'”

In Omak, I got a taste of Native pride during the Omak Stampede Parade, which mainly featured local businesses, rodeo princesses, groups like firefighters, Republican office holders or candidates, and less than half a dozen Indian floats. (I saw no Latino groups in the parade, despite their large presence picking fruit and in agriculture–they “officially” number about 15 percent of Omak’s residents.)

A Native float at the Omak Stampede parade.
Some of the many teepees at the Native encampment at the Stampede.

The Stampede features a tribal encampment with teepees and a performance area where tribal members perform traditional dances and song in gorgeous costumes.  It reminded me a lot of Alaska, particularly the many gatherings I saw there, including the largest conference called the Alaska Federation of Natives Annual Convention. Yup, I was definitely in Indian country.

My only real, true regret was that I missed the Suicide Race, which features some of the state’s finest Native horseman who charge down the steep hill and swim across the Okanogan River on their way to the finish inside the Omak Stampede stadium. You can watch it on YouTube, and note some times, yes, horses have died in this race.

Portland: hip, healthy, homogeneous, and house of the homeless

I just visited Portland, Ore., twice now in the last nine days. Though I moved away in 1987, I have returned countless times. I still love it, as I have since I first visited the Rose City back in April 1983. I went to college in Portland from 1983 to 1987, and I have always felt comfortable studying, living, and working there. I fondly remember my outdoor summer job painting homes during the day and being able to commute nearly everywhere by my bike to my work locations.

I was enamored by the quirky stores like Corno’s on MLK Boulevard, which closed sadly in 1995 (RIP Corno’s we loved you!), and by the many urban gardens I saw in southeast Portland around the campus of Reed College. I also liked that I could bike throughout the city and feel relatively safe that bike commuting was accepted and more secure than in other cities because of the budding efforts by city planners to make that city bike friendly. Portland’s famous mayor from 1985-92, Bud Clark, a former Reed College dropout and tavern owner, made biking cool to a national audience by biking to his job in downtown nearly every day (way to go, Bud!). Mayor Bud made a big impression on me when we overlapped in Portland.

Portland is well-loved by its fans. Some call it one of the healthiest cities because of its many trails in the hills above the city, in Forest Park, an Olmstead Brothers designed gem from 1903 that today encompasses more than 5,100 acres and miles of multi-use trails and many critters.

Portland also defied a national trend by preventing a major highway construction project planned for Highway 26 from plowing through the downtown (the Mt. Hood Freeway). Instead, famed Gov. Tom McCall diverted highway funds ($23 million) in 1974 to build the now famous public transit system that laid the groundwork for the visionary light rail line known as MAX. Portland still has its freeways and gridlock, but it did go its one way. A highway was torn up in downtown and turned into a riverfront park. In essence, Portland has been making policy changes for many years that promoted an alternative vision to the sprawl development that has fueled this country’s destructive and costly obesity epidemic and proclivity to chronic diseases.

Portland is not perfect, however. By becoming trendy with progressives and attractive for lifestyle refugees, it is becoming more expensive and perhaps less diverse in some measurable ways.

First, on the plus side, many have praised the benefits to the “new urbanism” in Portland, for which the city is becoming increasingly famous. I’m not entirely convinced the high-end makeover of parts of Portland, such as the Pearl District, where the once famous Henry Weinhard’s brewery was converted to pricey condos and office/retail, is a good thing. Portland also has lots of farmers markets, parks, green spaces, and policy measures promoting healthy lifestyles and food choices. The Centers for Disease Control and Prevention touts this as “healthy community design.”

On top of design features, such as denser developments that are pedestrian friendly and built to promote interactivity, the city is now ranked No. 1 as the most bike-friendly, knocking rival and bike-loving powerhouse Minneapolis-St. Paul back down to the No. 2 slot, according to Bicycling Magazine. “After being named runner-up in our last round of best bike city rankings in 2010, Portland reclaims the top spot. The only large city to earn Platinum status from the League of American Bicyclists is a paragon of bike-friendliness, with 180 miles of bike lanes and 79 miles of off-street bike paths. Always quick to embrace cyclist-friendly innovations, Portland was the first city in the United States to implement bike boxes at intersections and elementary-school bike commuting trains. Among the city’s many bike shops is newcomer Go By Bike, which is located under the aerial tram and offers valet parking, rentals, and repairs.”

Of course there’s a downside. The Oregonian newspaper in 2011 analyzed 2010 census data and found the “whitest city” in the country– that would be, yes, Portland–became even less diverse in the last decade, while surrounding areas have grown more diverse. This is also a national trend in other major cities, where exurbs and suburbs are becoming more diverse ethnically.

The April 30, 2011, article in the Oregonian (In Portland’s heart, 2010 Census shows diversity dwindling), noted: “Of 354 census tracts in Multnomah, Washington and Clackamas counties, 40 became whiter from 2000 to 2010, according to The Oregonian’s analysis of the 2010 Census. … The city core didn’t become whiter simply because lots of white residents moved in, the data show. Nearly 10,000 people of color, mostly African Americans, also moved out.” Census data show that of the city’s 584,000 residents, 76% are white, compared to Oregon’s whopping 86% figure. Latinos are the next largest racial/ethnic group at 9.4%, followed by Asian Americans (7.1%), and African Americans (6/3%). And not everyone is living well, riding overpriced road bikes, and sipping microbrews. About one in six residents lives below the poverty line. The unemployment is slightly higher than the nation’s, though on average four in 10 residents has a college degree. One person who works in public health I talked to about job prospects in Portland told me, many PhDs were pouring beers and waiting tables while looking for professional work on the side; don’t come here without a job.

The most glaring example of the problems I saw during my two visits was the crush of humanity that was waiting at the entrance to the Multnomah County Library as it opened its door on a sunny July 3 morning. I counted about 60 persons, the majority of whom were clearly homeless or indigent. There are about 1,700 people living on Portland’s streets. Many persons I saw that morning were carrying all of their possessions in backpacks or large plastic bags. Many had not had a shower in some time. The library provided both a restroom to use and Internet access and simply a shelter. It basically resembled libraries in Seattle that serve as de facto homeless shelters during business hours.

I decided not to photograph the clear signs of economic distress I saw on the streets or at the library’s gates and focused on snapshots of the downtown features that make the city fun and livable – its downtown streetcar, the MAX light rail, beautiful open spaces, yummy food carts, a downtown farmer’s markets, bike infrastructure that made me salivate, and a vibe that keeps my teenager’s crush alive and throbbing.

On becoming a public health zombie

Mark Twain, my favorite writer, in Life on the Mississippi, wrote of the transformation that occurred when he,  the majestic pilot of the paddleboat, no longer saw the magic and wonderment in the beautiful world outside the pilot’s cabin:

The Mark Twain riverboat in Twain’s hometown of Hannibal, Mo.

But as I have said, a day came when I began to cease from noting the glories and the charms which the moon and the sun and the twilight wrought upon the river’s face; another day came when I ceased altogether to note them … . No, the romance and the beauty were all gone from the river. All the value any feature of it had for me now was the amount of usefulness it could furnish toward compassing the safe piloting of a steamboat. Since those days, I have pitied doctors from my heart. What does the lovely flush in a beauty’s cheek mean to a doctor but a ‘break’ that ripples above some deadly disease. Are not all her visible charms sown thick with what are to him the signs and symbols of hidden decay? Does he ever see her beauty at all, or doesn’t he simply view her professionally, and comment upon her unwholesome condition all to himself? And doesn’t he sometimes wonder whether he has gained most or lost most by learning his trade?

And it is with these words, etched in my head, that I began to realize that I had become a zombie. To be precise, I had become a fully credentialed (MPH) public health zombie.

When I attend big festival type events, I no longer experience pure fun and enjoy the carnival atmosphere in a pure form. I look at how healthy or, rather, how unhealthy the food sold is. Is it loaded with transfat and sodium? Is it industrially raised meat with potential risks of carrying e-coli?

Fairgoers at the 2009 Alaska State Fair in Palmer, Ak., load up on deep fried everything.

Instead of people watching for pleasure, I will study the crowd through a public health lens. And are those attending a celebration, like Seattle’s annual Fremont Fair, smoking and drinking excessively? (And they were at the Fremont Fair in June this year – I guessed nearly one in five attendees smoked, and I counted at least four outdoor beer gardens, with people imbibing booze as early as noon on a summer day.)

Did people drive to this event, or did they use a healthy form of active transportation like biking, walking, or perhaps a bus?

Bikes aplenty were found at the Fremont Fair on June 16, 2012, in Seattle.

And what about that “electric” cigarette stand run by “Vapor Pro”– a definite concern of public health officials trying to battle the peddlers of nicotine to young and old people alike.

Electric smokes were being sold at the Fremont Fair on June 16, 2012 — should they be allowed?

I also recently visited a middle school in Snohomish County, and was looking at the school entirely as an environment where public health interventions were or were not working. Were kids walking and biking to school? No, they had to bus. The school was located off a busy highway, and there were no sidewalks anywhere near the school. I could go on and on and on. The visit actually was driving me nuts because of all the built environment issues I was seeing that was preventing the kids from being more active than they could be.

For its part, the CDC has, to my delight, decided to poke fun at its earnest seriousness protecting the public’s health by launching a “zombie preparedness” campaign to prepare for a “zombie apocalypse.” The was a surprisingly successful tongue-in-cheek awareness campaign on how to prepare for disasters. It received a lot of coverage. Was this a sudden dash of entrepreneurial social media savvy by the organization dedicated to protecting the health of the nation that tens of millions of Americans know little or next to nothing about?

As much as I hate seeing people eat incredibly unhealthy food, and smoke cigarettes in any form, and get drunk on beers in the midday sun, and drive their cars everywhere, I wish I could now just turn off my own “public health zombie.”  Now I often ponder if I have succumbed to Twain’s curse of the riverboat pilot, contemplating what I have gained against what I have lost by learning this trade.  The good news is, I have my next Halloween costume already planned: a zombie public health inspector.

I would eat salmon every day if I could afford it

To celebrate the completion of my public health studies at the University of Washington School of Public Health, I celebrated on June 2, the way I always do at the end of long journeys or the start of new chapters—I had a salmon barbecue with good friends. This time I added Alaskan ling cod to the menu.

Copper River sockeye and Alaska ling cod — oh yeah, very very good!

I love salmon. The fish I bought, Copper River sockeye, was very fresh, and the ling cod was amazingly delicious (have to eat more of this). In the past, I have always marked major milestones of my life with salmon. This includes moving, changing my name, celebrations with friends, and other good reasons to cheer. My last night in Alaska, in August 2010, also involved salmon. Times I have left Seattle for journeys abroad have included salmon. In many ways I am following historic traditions of the tribes of coastal British Columbia and their potlatch celebrations.

Salmon has long held a special place in the traditions of West Coast Native peoples, from the Salish all the way up to the Alaska among nearly all Native groups in the Great Land (what Alaskans call their home state). Salmon provided food to support both the health and culture of many tribal bands.

Dipnet caught Kenai River sockeye, July 2010.

Rich in vitamins A and D and omega-3 fatty acids, which reduce the risk of heart disease and stroke, wild salmon is extremely healthy food. Its intake has traditionally been much higher among many Natives because of their subsistence lifestyle. In Alaska, the Yup’ik people, of the Yukon-Kuskokwin region (including the Yukon River), often eat 20 times more fish oil than other people, and they appear to be protected from ill health effects of junk food and obesity with such a diet. However, epidemiologists still assess risk with salmon intake because of potential mercury contamination.

In Alaska, epidemiologists recommend people eat fish at least twice a week, and they say wild Alaska salmon of any species can be eaten in unlimited amounts by women and children, but other species should be eaten less, because of mercury and other toxic contaminants that could be found in fish.

As a former Alaskan, I was spoiled by an abundance of fresh fish.

Alaskan residents are still allowed to dipnet and catch fish as subsistence users in the Kenai River and other areas depending on the runs. During my years there, I would dipnet on the Kenai River for sockeye.

Dipnetting on the Kenai River, 2008.
Rudy Owens and fresh caught Kenai River sockeye, 2010.

The fish I caught would last me through the spring. Here in Seattle, I spent $18 a pound for Copper River salmon. As a just graduated MPH student, that is beyond my budget. My classmate and I once joked when a nutrition professor asked if students ate fish twice a week. Maybe the professor forgot to check what the tuition price was as the University of Washington. Lentils and rice still keep me going. I forever dream of salmon now.