Dr. Joshua Sharfstein
Although newly appointed city Health Commissioner Dr. Joshua Sharfstein has only been on the job since Dec. 12, it hasn’t taken him long to cause a stir. The 36-year-old Harvard-educated pediatrician and Montgomery County native burned the midnight oil to prepare for the Jan. 1 implementation of Medicare Part D, the massive federal program designed to defray the costs of prescription medications for senior citizens. Under Sharfstein’s guidance, the city Health Department set up a 24-hour referral center, a web site to answer questions for the roughly 28,000 city residents affected by the plan, and a $50,000 reserve fund to buy drugs for low-income residents not covered by the plan. Sharfstein calls the effort an example of his approach to public health: matching available resources to an identifiable problem. And as a former aide to U.S. Rep. Henry Waxman (D-Calif.), Sharfstein has experience at the crossroads of public policy and individual health care, working on issues from needle exchange to environmental hazards in housing—a good primer for Baltimore’s repertoire of public-health challenges. As Sharfstein settles into the big shoes left behind by his predecessor, Dr. Peter Beilenson, who resigned from the post last June to run for Congress, he sat down to talk about the politics, priorities, and perks of being Baltimore’s new health commissioner
City Paper: How did you get involved in the politics of health care, rather than just the straightforward practice of medicine?
Joshua Sharfstein: I read that the American Medical Association was very upset about a policy of the first George Bush that prohibited abortion counseling in federally funded clinics. When I was college, I spent time working on political campaigns, and the AMA always seemed to support the candidates I was fighting against, and realized that generally they gave more money to people that oppose their ambitions. I researched it through the Federal Election Commission to see where the AMA was allocating money and learned that when they gave money they didn’t care about the person’s public health position.
I wrote a series of articles about the AMA and how they spend their money, to make people aware of this, though initially I wrote it as an op-ed piece and publications basically rejected it. But my dad said I should write it up for the medical profession, which I did. Subsequently it was published, and I got a letter from the head of the AMA saying that I was both naive and misguided. That was 1992, and ever since then I’ve been involved in both medicine and policy.
CP: So was being a health commissioner part of the long-term plan?
JS: I wasn’t really sure I wanted to do a job like this until I started talking to people in Baltimore. After I submitted my résumé, I called a lot of people and asked what needs to be done in Baltimore. And after talking to everyone and discussing the challenges, I was totally excited, and I threw myself into the process
CP: Peter Beilenson was health commissioner for 13 years, a long tenure. What is his legacy and how will your approach compare with his?
JS: Peter Beilenson’s main legacy is that people look to the Health Department for innovation and progress. In other cities, they say, “Oh no, here comes the Health Department.” But in Baltimore, that’s not the case, and that’s how Beilenson made a difference. I think ultimately the job of the health commissioner is to push the envelope.
Take, for example, new drugs like buprenorphine [an alternative treatment for opiate addiction which is less addictive than methadone, the most widely used substitute treatment]. It has the potential to quadruple our maintenance program resources for opiate addiction—it’s an awesome tool that gets people into primary care. In terms of being innovative, we’re looking at new ways to use it effectively, including some models in Europe. For example, in France people get started on buprenorphine in the public-health system and then get referred to primary care. Rather than going from the street to a private physician, the program gets them ready to be referred. I think that’s the goal for us, to use new tools like Buprenorphine as innovatively as possible.
CP: Obviously addiction treatment is a huge issue in Baltimore. What do think of harm reduction philosophies—addressing, say, the problems that come with drug addiction rather than the addiction itself—as an approach to treatment?
JS: I would dodge that question, because what people mean by harm reduction usually depends on who is defining it. I sat through hearings in Congress where people distort harm reduction to mean giving marijuana to kindergartners. But I try not to use a specific philosophy—I analyze a policy on its merits. Don’t start with an ideological bias. Decide whether the approach is going to make a difference or not.
The key question in public health is “compared to what?” Compared to what? Is our goal with needle exchange to give out a lot needles? No. But compared to people getting HIV from intravenous drug use, it’s a worthy program. If you show up with a huge ideological bias in advance, you don’t get to the “compared to what” question, and you can’t use that approach and be successful.
When I worked on the needle-exchange issue for Congressman Waxman, I would meet with groups who were morally opposed to the needle-exchange program. I would say, “Look, if you want to find the program morally wrong, that’s your prerogative, but you have to look yourself in the mirror and say people are going to die.”
CP: But sometimes morality seems to trump science, at least in the current political environment?
JS:ûI worked on this issue for Congressman Waxman, We had a web site, www.politicsandscience.org, which included an overview of the Bush administration policies toward science, and [it] has specific examples of where [Republican] ideology has effected health policy. It shows how they’ve distorted web sites—misrepresented information about condoms, for example. When you have money going to programs with no basis of evidence—basically just an extension of ideology—that’s not good for public health. That’s why there has been an enormous outcry from the public-health community, and the scientific community, because of Bush administration policies
CP: What about lead poisoning? While the politicians debate the threshold of harm to the child, science says that there is no safe level. What’s your take?
JS: There are two issues. One is scientific, and there is no evidence for a threshold, meaning there are probably adverse effects from lead poisoning at any level. There’s also a separate public-health question, which is where you put your resources, what you’re trying to accomplish through a public-health program,
With lead poisoning, we need to shift to a prevention model. Historically, the approach has been you wait for the child to get poisoned and then you clean up the environment, thus you’re using kids as human biological indicators for lead in the house. And, as a pediatrician, I don’t like that. I think, logistically, we should be working to prevent the problem. For example, if we could identity problem ZIP codes and identify where new babies are being born; we could clean up the house beforehand. This would shift the mind-set toward prevention, which is what we need to do.
CP: How do you strike a balance between being a physician and dealing with the politics? What’s the balance between policy and practice?
JS: I think there are some people who work on the policy of what type of program works best, and there are some that are purely political. What really drives me is the intersection between the two. Personally, I get a little bored if I’m just dealing with policy, or I get turned off if the discussion is too political. Trying to spot the opening, the opportunity to really pull something off that would make a difference, and then hitting the seam, bringing people together and getting it to work is what I think is important.
The intersection is where you look for opportunities, you see where resources are coming together, and then see how you can make a difference. One example is the Medicare Part D program. There was the problem of transitioning 28,000 senior citizens to a new federal program and all the confusion that surrounded the process. We identified the problem, coordinated with the appropriate agencies, and came up with a solution.
CP: Any unexpected perks from being health commissioner?
JS: I was in a restaurant and noticed a health inspector was there as well. I asked him if the place was OK and he told me under his breath that at this establishment he only ordered coffee. So I followed his advice.
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