Stephen F. Gambescia: Public health practitioner, heal thyself

Former Surgeon General C. Everett Koop, MD (1916-2013), branded tobacco smoking as Public Health Enemy #1 in several reports during the early to mid-1980s.

By his 1986 report, he “estimated that smoking was responsible for well over 800,000 deaths annually in the United States, representing approximately fifteen percent of all mortality.” Dr. Koop intensified the “tobacco wars” for health advocates by bravely calling out the source of Americans’ fatal addiction: the manufacturers and marketers of tobacco products.

While national, state, and local health groups fought to protect Americans from the myriad hazards associated with tobacco use, offering the best health education and cessation programming available, they for many years did little to confront the tobacco companies who were pushing people into the drink of destruction.

Medical sociologist Irving Zola (1935–1994) challenged traditional public health practices to look upstream and discover the root causes of health deficits, rather than merely addressing proximate causes. Public health practitioners predominantly focused on educational efforts to impart the dangers of smoking, hoping to deter people from starting the habit and emphasize the benefits of quitting. While these efforts were necessary, useful, and admirable, they failed to deter the tobacco titans, as these downstream strategies did little to prevent the steady influx of new smokers — most of whom were under the age of 20.

Using a water stream analogy, it is heroic to jump into the water to save people from drowning by pulling them to shore and performing necessary life-saving measures. However, the new public health era calls for advocates to identify those who are pushing individuals into the water in the first place. They should work upstream to stop those who are leading individuals into self-destructive behaviors.

Addressing upstream causes in the tobacco wars became a popular and ultimately successful approach for public health advocates. Aggressively calling out any entity involved in the production, manufacturing, promotion, and sale of tobacco products has ranked among the top achievements in public health history. Tobacco control strategies progressed through three cycles.

The first cycle focused on imparting information about the dangers of smoking and the benefits of quitting. The second cycle branded smoking as socially unacceptable, while the third and most effective cycle branded the tobacco companies as having engaged in unethical and morally questionable behavior for knowingly producing and aggressively marketing an addictive and dangerous consumer product for decades.

Key areas in safeguarding public health include prevention, protection, mitigation, treatment, and restoration. Prevention and protection represent upstream approaches to public health work, whereas mitigation, treatment, and restoration are considered downstream approaches in public health and healthcare. Illness industries that promote addictive substances, such as alcohol, tobacco, and drugs, do not fear downstream efforts. Although they may lose customers who quit or die, these industries know that new customers are easily attracted and that most maintain long-standing loyalty.

While tobacco use has not been eliminated in America, significant progress has been made in reducing youth onset and in decreasing the percentage of U.S. adults who smoke, consequently lowering the number of deaths attributed to tobacco use each year.

In October 2017, during his first term in office, President Donald Trump declared the opioid crisis a national emergency. However, his federal agencies primarily focused on downstream approaches, allocating funds to states and localities for educational programs about the dangers of drugs and opioid abuse treatment.

Recently, during the first year of his second term, President Trump directed federal agencies to work upstream to confront drug cartels responsible for bringing dangerous drugs and ingredients—such as fentanyl — into the U.S. This included using military resources to attack and eliminate drug-laden boats heading to the U.S. from Latin American countries. Trump has articulated that part of his rationale for imposing tariffs is to dissuade countries from aiding in drug manufacturing, transporting, and importing into our country. Additionally, he has prioritized the arrest and deportation of individuals involved in drug and human trafficking, who have entered our country illegally.

Furthermore, Trump has instructed the FBI to rigorously investigate and dismantle drug networks, as evidenced by a major raid in a well-known open-air drug market in the Kensington neighborhood of Philadelphia. All three of these approaches favor upstream strategies and have the potential to be effective in the “war on drugs.”

Ironically, these bold yet promising methods to address the supply side of drug importation are facing backlash. The critics — often labeled “never Trumpers,” Trump-haters, and representatives of the mainstream media — are expressing objections to these upstream efforts. Surprisingly, even public health advocates, who teach and preach about using upstream solutions against illness industries, have been notably silent in their support of such measures.

Public health advocates have called for bold and controversial efforts in combating drug use — such as needle exchanges and safe injection sites, under the rubric of “harm reduction.” They have been vocal against Big Pharma for aggressively marketing pills to consumers. State attorneys general and governors have invested significant time and resources in suing Big Pharma over the opioid crisis, with successful outcomes resulting in funding for their downstream programs that not only help individuals struggling with addiction but also provided money to government agencies and nonprofits that have the risk of being unaccounted for.

The peculiar pushback against the current administration’s upstream approaches to improve the health of some Americans seems to reflect a desire to engage in the battle against drugs without committing to the strategies necessary to win the war. This inconsistency raises concerns about public health leaders’ ability to rise above political agendas and embrace the bold approaches needed against an indefatigable network of drug runners who have no regard for American lives.

Stephen F. Gambescia is professor of health services administration at Drexel University.