Matt Howie, M.D.: From Family Medicine to Public Health

Matt Howie, M.D.

The nearest traffic light? An hour away. The closest large town? Two hours. It was here, in northern Arizona, that the warm terracotta-colored earth against the deep-azure sky welcomed the doctor, his wife, and their young children. They were thousands of miles away from the world they knew. The idealistic physician, Dr. Matt Howie, had finished his Family Medicine training at the York Hospital, and he wanted to make a difference. 

It was after gentle encouragement from his teaching attendings and a brief clinical experience on a Zuni Reservation during his third year of residency training, that he decided to commit to doctoring at an isolated Indian post. His wife, the daughter of a Methodist minister, was game.

The staff at the new Hopi Health Care Center took care of the people of the Native American Hopi and Navajo tribes. (The two groups have different lifestyles and different ways of providing for their families and they have had an ongoing testy land dispute since 1882 when arbitrary lines were drawn by the federal government.) 

“It was a fantastic time for me,” said Matt, as the ten or so recently-trained family doctors like him were forced by their remote location to become “mini-specialists.” 

They did mostly outpatient work, but also manned the emergency room, managed five inpatient beds, and staffed the few labor rooms (where the native women gave birth quickly). The doctors soon learned their limitations, and complex difficult cases were rushed by air to Flagstaff.

Hopi Health Care Center in Polacca, Arizona 
(photo: Indian Health Service)

As I listened to Dr. Howie tell his story I was struck by his enthusiasm. This experience, I sensed, was clearly a different way to do medicine than he was used to here in York, Pennsylvania. 

“It was a fantastic way to practice,” he gushed.

But medicine wasn’t his first career choice as he finished high school in rural southern Maryland. While he thought “it might be cool” to be a doctor, maybe this was his father’s idea, not his own. So he went to Emory for a business degree. The school work there was easy, but not fulfilling, and his soul wasn’t in it. His grades were mediocre; he wasn’t thriving.

Life changed when he took part in a program with the Methodist Wesley Fellowship Group in Atlanta. As he spent time in soup kitchens and homeless shelters he found that he enjoyed these activities much more than his college studies. And during one spring break, he helped build a house in Appalachia. He told me that he was nourished by “the experience of serving others.”

Appalachian (Kentucky) family: William and Vivian Comett 
and their 12 children (photo: William Gedney)

Since a career in business was out, and since he was “always a science and math geek” anyway, the decision to switch to medicine in his third year at Emory came easily. His parents (both educators) were supportive. 

So he returned to Maryland and transferred to UMBC for his premed studies. He was “very focused” on getting into medical school, but it wasn’t all book work; he made time for other things.

He volunteered in the OR at the University of Maryland Hospital. He also worked at a church camp in the summer (where he told me he met his future wife). 

Matt was accepted to the University of Maryland School of Medicine in 1993. The study of medicine was demanding, of course, but even so, the idea of service to others remained in his sights and was repeatedly reinforced by his experiences. 

After medical school, he took Route 83 North and did a Family Medicine residency at the York Hospital. He was strongly influenced by several members of the teaching staff including Dr. Andre Lijoi, Dr. Andy Delp and, especially, the calm, self-effacing, and always incisive, Dr. Richard Sloan (whom Matt recalled with great respect).   

While in Baltimore (where 24% live in poverty), and again in York City (where the poverty rate is nearly 36%), Dr. Howie frequently witnessed inequities in healthcare, inequities that were grounded in economics and longstanding fragile social circumstances. He was optimistic (during the Clinton presidency) when there was the hope of “a unified system” so that “you didn’t have to worry about who is insured,” he said. He was disappointed when the idea of access to healthcare as a basic human right was put aside (again).

Dilapidated row homes in Baltimore (photo: Scott Beyer)

So it was, that after three years in York, he and his family packed their things and headed to the Southwest, to a place where he felt his services were most needed, where he could make a difference.

The next three years on the secluded Indian lands were formative. Practicing medicine in such a desperately underserved area gave Dr. Howie a sense of inner calm that he feels he might not have otherwise enjoyed. With that peacefulness, he could “sleep better at night.”

Though Matt and his wife were content in Arizona they decided to leave in 2003 when it was time for their children to start school; they knew that education is critical and home-schooling was ruled out. They looked around as a team and chose to return to York. 

Back in Pennsylvania, Matt worked closely with (and “followed”) Dr. Christopher Echterling at the Community Health Center.  He enjoyed being part of the busy inner-city “safety-net” practice for twelve years. When Chris left for another position in 2012 Matt took over as medical director.  

Dr. David Hawk

Things were going along just fine for Dr. Howie until one day when he received a letter from Dr. David Hawk of the York City Bureau of Health. Matt said he was asked to join a group hoping to “partner” public health and clinical medicine in several “joint initiatives.” An attempt, he said, to avoid the dilemma of the two disciplines operating in their own “silos.” (A nice rural Pennsylvania metaphor.)

Dr. Howie was delighted by the prospect of building a better health system at the local level.  He had toyed with the possibility of going into the public health arena for a while, and this opportunity resonated with that unformed idea. 

Time passed, and as Dr. Hawk was planning to retire from his position (he left in 2015) he approached Dr. Howie to see if he was interested in taking his own job with the Bureau of Health. Matt considered it, discussed it with his wife, and said yes. But by then, funding for the half-time position was no longer in the tight city budget.  Dr. Howie waited patiently, and he was grateful when WellSpan Health offered to help financially.

In this capacity with the city (one of the few municipal programs in the state), he has helped formulate a number of public health endeavors. Among these is the multidisciplinary “Healthy Moms-Healthy Babies” program where nurses visit mother and baby regularly for two years. This program remains important for impoverished city residents and for the health and well-being of the next generation.

Matt also helped develop an expanded downtown clinic that provides screening and exams for sexually-transmitted diseases. He said that syphilis, including congenital syphilis, is being diagnosed with increased frequency (along with newer STDs like HIV and hepatitis C). I was shocked; I thought that the “older” diseases were no longer problems.  

He told me that the reappearance of syphilis points to a “dysfunctional system.” He said that we still have a significant population (in the city) “that is disenfranchised.” And he noted, sadly, that “bad things” are more common in this group of people who do not receive routine medical care and have other stubborn life obstacles.

The rising rate of syphilis in Oregon 2013-2018 (Oregon.gov)

One of the “bad things” is a high rate of substance abuse. This may involve nicotine, alcohol, cocaine, methamphetamine, benzodiazepines, marijuana, heroin, or prescription opiates.  

Addiction to potentially harmful substances is, of course, a long-standing and serious worldwide public health problem.  For example, in the U.S. in 2017 there were over 488,000 deaths due to smoking, about 88,000 deaths as a result of alcohol use (and 21 million DUIs), and approximately 47,600 fatal opioid overdoses (15,000 with heroin).

Opiate use and misuse are now in sharp focus, but not everyone who takes an opioid is equally liable to develop an addiction. For example, it has been estimated that about 25% of those who use prescription opiates like oxycodone or hydrocodone for pain misuse them and that 10% of that group becomes addicted. 

Risk factors for addiction include genetic, epigenetic, and even transgenerational epigenetic factors (accounting for 40-50% of the risk), younger age at first use, the type of substance used, peer pressure, mental illness, homelessness, incarceration, lack of attachment, and poverty. 

Specific adverse childhood experiences (ACE), including emotional, physical, or sexual abuse, and living with household members who are substance abusers, mentally ill or suicidal, or ever imprisoned, are especially potent predictors of later substance abuse.   

ACE score and injection drug use (from Kaiser)

The use, misuse, and addiction to opiates have increased dramatically since the mid-1990s (for complicated reasons too controversial to go into) and I asked Matt if he could tell me about the local public health response to this.

But before discussing his ideas, it is helpful to go over a few things about addiction, and why it is so difficult to treat. (My husband helped me here and I read through Judith Grisel’s recent and enlightening book, Never Enough.)

Addiction, as a disease of the brain, involves three interconnected neural systems. 

So, here goes (bear with me). 

First, certain areas of the basal ganglia (deep-seated in the brain) are responsible for producing the pleasurable or rewarding aspects of a substance (e.g., food or water) or activity (e.g., sex or social interaction) that is important for individual and species survival. 

Next, is the extended amygdala, including the nucleus accumbens, and connected to the hypothalamus. This limbic, primitive, “fight or flight” (fear/anxiety) emotion system generates quick, unthinking responses to potential danger signals (e.g., a predator) by matching these signals against memories of past experiences. 

And there is the prefrontal cortex. This newest component of the evolved human brain is intimately connected to the older deep nuclei. It is the executive, or conscious decision-making structure, and needs a bit of time to evaluate what is happening, and to determine its significance. It can be engaged to exert control or override the emotional brain. It can help us decide whether to stop or to go, whether to avoid or to approach. To decide: is it a snake or just a rope? But the prefrontal cortex is not fully wired up and connected until we are in our 20s (later for men than for women).  

The basal ganglia, the extended amygdala, and the prefrontal cortex.

The three connected systems of addiction (NCBI: NIH)

What is it about the pain/pleasure/assessment and survival system that results in addiction? What is it that leads us (according to the American Society of Addiction Medicine) to use substances or to engage in behaviors that become compulsive, and continue despite harmful consequences? 


The reward system relies on dopamine and opiate signaling. The natural opiates, endorphins, mediate the pleasurable (the “positive” or survival-related) effects of a substance or activity. Dopamine reinforces the behavior. All addicting substances result in an increase in dopamine activity in the nucleus accumbens.  

Now the tricky part. Because the nervous system (like all life) needs stability (equilibrium, not too much and not too little) it adapts to change to re-establish balance. 

In her just-published book, neuroscience researcher (and recovering addict) Dr. Judith Grisel used the “opponent-process theory” to explain what happens in the addicted brain. 

To restore harmony, the rewarding, or the “a” effect, of an addictive substance, also leads to an opposite, or so-called “b” effect. 

With repeated use of a drug, the brain learns what to do to return to balance, to compensate, and the “b” effect becomes stronger and longer-lasting. This results in tolerance, (i.e, the need to take larger amounts of the drug for the desired effect), as well as the "negative" unpleasant withdrawal symptoms. 

Schematic of the initial, later "a" and "b" and 
summated (black line) effects of a drug (after Grisel) 

Eventually (and this I find most discouraging), the opposing process, without the presence of the drug, is triggered by cues associated with prior drug use, leading to craving. A vicious cycle develops.    

And yet there’s an even sadder part. The changes that occur in the brain wiring, including learning how to respond to the initially-rewarding but now no longer pleasure-producing substances, can be long-lasting. This type of enduring damage is most likely in the still-developing adolescent brain and may, tragically, lead to dangerous relapses after years or even decades of sobriety. 

Okay, now that we understand the problem a little better, let's get back to Dr. Howie.

While addiction is now seen more clearly as a chronic relapsing brain disease, we still don’t know the ideal way to manage it. There is no simple answer in a disease as complex as this, and Dr. Howie stressed the importance of an individualized approach (as in most chronic ailments). 

He feels that medicine-assisted programs such as those using methadone or Suboxone are a start, but that comprehensive treatment is essential, especially since many individuals have serious mental health problems and social stresses.  

And as he lamented that it is very difficult to get people into treatment he said that this is a start where his public health skills can be used. 

Dr. Howie told me that 28% of people who died of a drug overdose in York in 2018 were in “some sort of parole or probation program.” As were nearly half of the individuals who overdosed and didn’t die. This is an easily-identified vulnerable population that receives inadequate care.

So Matt is working with a group whose “intent is to marry up the correctional system, and the judicial system at large, with the treatment for mental health and substance abuse.” These entities now do their thing in nearly-complete isolation, with almost no sharing of information, and certainly not in real-time, when it can be of most benefit.

Dr. Howie said that when an individual commits a low-level crime related to their substance abuse or to their mental illness, putting them in jail “does not help either one of those conditions at all.” Instead, for the right person, diverting them (even before booking) from the criminal/judicial system directly into mental health and substance abuse treatment is a much better and more humane option. 

With that goal, the group is planning to organize a physical “wellness and diversion center” (perhaps in a space at the prison). If the individuals cooperate, their charges disappear. He said that a program of this type in Seattle showed that fewer people return to prison, and that lives are saved. He is looking forward to getting this program off the ground.

“Public health has drawn me into areas I never thought I would have gone, but that’s where the pain is,” said Dr. Matt Howie, as we neared the end of the early afternoon interview. 

At this time he works 60% for the city, 30% for the county, and 10% for WellSpan. He sees himself as a generalist, dealing with a range of issues including birth outcomes, STDs, prostitution for drugs, the opiate crisis, food insecurity in the city, human trafficking, unwanted pregnancy, gun violence, and others.  

While the opioid situation currently commands his attention he noted that there is a common thread, as these public health issues all center around poverty.  “This is where our society is being strained,” he said. 

Overdose death rates in 2014 (note the high rate in Appalachia) (from NYT 2016)

And where there is emotional pain and where there is stress there will be attempts to soothe this, to escape from pain. Attempts that lead to unwanted and harmful reliance on addictive substances. Substances that no longer satisfy. 

As Judith Grisel remarked toward the end of her frank personal account of addiction and addiction research from the point of view of a concerned neuroscientist:

Among the most astounding findings in recent neuroscience is the context-dependent nature of all neural activity. Even as our thoughts, feelings, and behaviors are products of neurochemical brain activity, what gives rise to this activity is mostly not in our brains. Rather, our brains express the evolutionary, social, and cultural context we occupy. It follows that the answer to the addiction crisis is not solely in the brain, but must include the context. 

Drug addiction, thus viewed, is an enduring societal issue intimately connected with who we are, with what happens to us, and how our brains adapt. A comprehensive public health approach is needed to treat, and, more importantly, to prevent, this affliction.

Dr. Matt Howie is prepared to help.


"Let us put our minds together and see what kind of life we can make for our children."
                                                                                                                     Chief Sitting Bull

P.S. Then Covid-19 came along, and the critical public health response...

Reference/Suggested Reading:

Grisel, Judith. Never Enough: The Neuroscience and Experience of Addiction. New York: Doubleday, 2019, (p.214). 

York Reservoir Park 2/22/20 (photo: SC)

Anita Cherry (2/26/20)

P.S. "The number of yearly overdose fatalities surpassed 100,000 for the first time ever in 2021. Halfway through 2022, the ate appears to be rising even further." (NYT July 5, 2022)