It is not the drug addicts fault that he or she needs to get a fix to just feel normal. Nor is it the fault of a young man that he has gonorrhea. And then what about that guy who gets shot in the belly over a drug deal gone bad. In an ideal world we are all responsible for our choices; but is this always true? This question is what brings out the obvious complexities in life and the choices that we all have to make sometimes. I have learned by experience to replace judgement with sympathy when dealing with people afflicted with various ailments. I was lucky though in that the compassion did come before I really got an understanding of why compassion was really the reasonable option.
I still remember one patient who said; “Dr. Sowah, the first time I used crack cocaine was with my cousin when I was 12 years old”. At age twelve the only vice that I had was sharing a cigar with my big brother. Well, so how can I blame my patient whose introduction was to crack whilst mine was to cigars. Yes, I still smoke a cigar now and then but do not consider myself a smoker. My patient however at the time of our conversation had both cocaine and opiate metabolites in his urine even though he was on Methadone. The complexities of life unfortunately can sometimes be simplified to an accident of birth. I was born in a small private hospital in Accra, Ghana, my patient was born in West Baltimore and had a cousin who both used and sold drugs. In a fair word it must be considered an achievement that this gentleman was alive with HIV and still using heroin and cocaine at age 40, he really never had a chance.
Now, how does this relate to gonorrhea or chlamydia? On that I would quote one classmate of mine who during a class on risk factors of cervical cancer said this; “Sowee, i no be the mileage on the car wey ibi the problem, sometimes the mileage be low but one bad road makes all the difference.” This classmate was making the point that number of sexual partners is not always the best marker of STI risk but the types of environment and the nature of the sexual history of the individuals involved. I have sometimes asked myself this question; having sexual intercourse could lead to contracting a STI as well as make a man or woman a father and mother. I have seen many pregnant women and men and women with sexually transmitted infections. The fact that these two groups of people, those who are creating life in the womb and those who are carrying infectious micro-organisms in their sex organs are viewed differently is really a fundamental problem. These two groups engaged in unprotected sexual intercourse and had totally different outcomes. Our society then goes on to treat them in totally different ways. We congratulate the pregnant woman and the father to be and look with judgement at the man or women with the disease. The stigma and the shame associated with STI risk may be one of factor that is driving these problems in this country.
Today in the United States new diagnosis of sexually transmitted infections continues to increase. Our rates are completely of the charts when compared to the EU. My classmates story on the mileage question comes back to mind again, because without his perspective one may think that Americans are having lots of sex. Anyway, I am not saying Americans are not having sex but I dont believe we are doing better that the Europeans on that.
There reality of the Opioid Epidemic and the rise in STIs may be an indictment on the environment that we have created in the US. A current CDC reports suggests a 22% increase in Chlamydia, 67% increase in Gonorrhea and 76% increase in Syphilis rates since 2013. A less than adequate healthcare system which fails to cover all individuals leaves gaps which allows disease to fester. Another major problem which I alluded to earlier is how we perceive individuals with certain diseases. Stigma associated with disease states have been shown to drive individuals with such diseases underground. I still remember a patient of mine that I treated for syphilis three times and refused to get an HIV test. She just did not want to know because HIV was so stigmatized in her society she would rather not know if she has it.
The drivers of most of some of the diseases that afflict our societies today are complex and intertwine in ways that are usually difficult to grasp. This is why nowadays I am looking less at the disease and more at the communities and societies that they occur in. Surely our Europeans friends are not having less sex than we Americans nor are our Southern US gentlemen and ladies more active in the bedroom and wherever else they choose to enjoy themselves than the rest of America. Community-level and structural changes provide good results and we should address them more aggressively.
By Dr. Leonard Sowah, an internal medicine physician in Baltimore, Maryland
