County health officer faced tough decisions with honest approach

by: TRIBUNE PHOTO: CHRIS ONSTOTT - Family physician turned public health officer Gary Oxman is used to weighing risk in his job and on the road, where he occasionally rides a motorcycle.Motorcyclists are 26 times more likely to die in a crash than car drivers. So straddling a 650 cc BSA is about the last place you might expect to see the man charged with watching out for the health of everybody in Multnomah, Washington and Clackamas counties.

“People make decisions about risk all the time,” says Dr. Gary Oxman, the tri-county public health officer.

Oxman should know. The 60-year-old physician is retiring this week after 28 years on the job.

Oxman was a family physician when he joined Multnomah County in 1984. He became the county’s health officer three years later. In 2006, he was named the tri-county health officer for the Portland area.

Multnomah County commissioners declared Jan. 17 Gary Oxman Day, recognizing that Oxman may have done more to save lives and improve the health of Portland-area people than just about anybody.

Few outside public health circles know Oxman, but those who run medical clinics for the uninsured, or heroin needle exchanges, or vaccination programs hail Oxman as a public official — forget the motorcycle for a moment — who leads by example.

“He’s been accused of being overly ethical,” says Paul Lewis, the tri-county deputy health officer. “In the heat of the moment, people don’t like his considering too many viewpoints.”

Lewis recalls a time in 2000, when West Nile virus had started weaving its path from the East Coast toward the west. It had been years since mosquitoes had transmitted something as deadly as a brain disease, according to Lewis.

Oxman’s job as public health officer was to coordinate preparations among local agencies and medical providers to battle the virus. Lewis says there were two local camps: vector control officials who wanted to widely spray pesticides in the places mosquitoes might breed, and environmentalists who said no health risk was worth the harm the pesticides might cause.

Oxman convened a series of meetings with all sides. “You could draw a line down the middle of the room with the two groups,” Lewis says.

That was at the beginning. By the end, according to Lewis, Oxman had conveyed to everybody in the room that they needed to listen to each other, and he did it, according to Lewis, by modeling active listening himself.

Everyone agreed to a plan nobody was completely happy with, Lewis says. Pesticides would only be used if the worst scenario occurred locally, with people starting to get seriously ill from West Nile.

“He forced this dialogue to happen with people who ordinarily wouldn’t recognize each other because they lived on different planets,” Lewis says.

Declining overdose deaths

Clinical physicians can count the lives they’ve saved: so many cancers spotted that otherwise would have gone undetected, or successful surgeries performed. Oxman worked as a general practice physician in Portland for five years before opting for a career in public health in 1984. Yet he has no doubt that his greatest impact has been in his second act.

In the late 1990s, a street heroin epidemic overtook Portland. The number of heroin overdose deaths rose to more than 100 per year. Oxman guided the Multnomah County Health Department in trying to at least lower that death rate. But he knew that making top down decisions probably wouldn’t be effective.

There were objections when county staff began forming focus groups of heroin addicts — the only people who could tell them what might work.

“We took a very businesslike approach to this,” Oxman says. “The addicts said matchbooks.”

Specifically, the addicts said that all junkies needed matches to help melt down their heroin, and almost all of them used free matchbooks. So Multnomah County began distributing free bright red matchbooks at places frequented by heroin users. The matchbooks included instructions for avoiding overdoses: never use alone and avoid mixing heroin with alcohol or other drugs. They also gave warning signs of overdose and exhorted users to call 9-1-1: “If you can’t stay ... still dial 9-1-1, ditch and dash.”

Heroin overdose deaths immediately declined about 30 percent.

“It was later pointed out to me that the work my colleagues and I had done probably had saved a few hundred lives over several years,” Oxman says.

Oxman figures that most people probably think the public health office exists for the poor and disadvantaged, and a large part of the budget does support county medical clinics for the uninsured. But Oxman’s office also oversees restaurant health inspections and Portland-area contingency plans for epidemics.

Oxman prefers to operate by building consensus. But that isn’t always possible. In 1999, Multnomah County passed an ordinance making it illegal for people to smoke in workplaces. Not everybody was happy with that decision, Oxman acknowledges.

“We told people what they had to do, and we enforced that,” he says, citing the health danger of second-hand smoke as a primary reason.

On the other hand, two years ago, when fear of a bird flu epidemic raised alarms across the country, the county convened endless meetings with health care providers and hospitals and ended up choosing to not make flu shots mandatory for health care workers, which some thought irresponsible.

But when a measles outbreak hit in 2011, the county decided that all health care workers in its clinics had to get vaccinated if they wanted to keep their jobs. Oxman says there was more evidence that measles gets spread through doctors and nurses than bird flu.

Answers emerge

Two years ago, Oxman made what may be his most controversial public health decision. Overdose deaths had begun to rise again, but a different pattern was emerging. Young people were increasingly becoming addicted to drugs by using prescription painkillers they either stole from home medicine cabinets or purchased on the black market.

Once hooked, many of those addicts turned to heroin, which on the street was much cheaper than painkillers. County health staff wanted to end the cycle of addiction. They decided to set guidelines that would make it difficult for doctors at county medical clinics to prescribe painkillers.

Oxman knew there would be an unintended but unavoidable consequence when painkiller addicts were shut off from their drug of choice. More would turn to heroin, and some of them would overdose. Short term, more addicts would die as a result of the new policy. Long term, the hope was — and continues to be — that fewer addicts would be created.

In media interviews, Oxman didn’t shy away from questions about whether his new policy would likely result in an increase in heroin overdose deaths. He says honesty with the public is inextricably tied to the scientific honesty that needs to be brought to difficult decisions.

“We need to have integrity, telling ourselves the truth about what’s going on,” Oxman says. “When people in public health or any aspect of government try to put too much of a spin on things, you can’t do the work that way.”

That honesty extends to admitting mistakes. Oxman recalls a report of a restaurant worker who tested positive for hepatitis at the same time a community-wide outbreak of the disease took place in the 1980s. He had to decide whether to publicly release the name of the restaurant, so people who had eaten there could get shots to protect themselves.

County workers interviewed staff at the restaurant and came away assured that the outbreak wasn’t due to poor hygiene among the cooks and waiters. They didn’t issue the warning. Later, Oxman learned that the restaurant hadn’t been completely honest — the worker with hepatitis had a habit of not washing his hands after using the bathroom. Oxman also learned that a number of people who had eaten there contracted hepatitis.

Oxman was willing to make changes to the system after some people contracted hepatitis at that restaurant who might not have become ill if the warning had been issued.

“I didn’t take as conservative or protective approach to the public as I could have,” he says.

The county changed its procedures for investigating future outbreaks after that incident, and the state changed its guidelines on timing for public warnings.

Bruce Goldberg, Oregon Health Authority director, says Oxman’s willingness to tackle prescription painkiller addiction head-on has put Multnomah County three or four years ahead of many metro areas in the country.

Oxman’s gift, he says, is getting other people to do their best work. “When Gary walks into a room, (later) you remember what the room did,” he says. “That’s the beauty of Gary Oxman.”

Goldberg, who plays in a rhythm and blues band called Homebrew with Oxman, says the same extends to Oxman’s musicianship. Oxman, not surprisingly, plays bass, where he is more interested in helping the band find its rhythm than in taking solos.

“Everybody plays music a whole lot better when they play with Gary,” Goldberg says.

A new public health officer, Justin Denny, has taken Oxman’s place. Deputy Health Officer Lewis says that in recent weeks public health staff in all three counties has started to deal with not having their longtime leader around. They’re doing it, he says, by channeling Oxman and remembering to become more open, and less isolated.

“When we get backed into a corner and nobody’s agreeing and everyone is mad, we just say, ‘What would Gary do?’ ” Lewis says. “And the answer is always similar. Let’s go talk to these people. Let’s hear what’s going on and see if the answer emerges.”

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