From Gross to Gorgeous, the Evolution of London

Modern London, a sprawling city of over 9 million inhabitants, is the epicenter and shining jewel of the British Isles. As we walk down the bustling streets, one becomes acutely aware of their surroundings. Entering a park, we step aside for the joggers and are ever mindful of the bicyclist as they wiz around the curb. Children play and a yogi enjoys his practice. The city is alive, healthy, and happy. Down the cobblestone streets, we march noticing the inherent lack of refuse and debris.  Pristine white buildings greet us, a testament to the architecture of the early and mid-19th century. What these walls could tell us, what history they hold.

What I have described to you is merely the first five minutes of our walking tour of London. Though busy it is a beautiful and clean city, however, its history is far from pristine. As we will learn from our tour guide, this great city has undergone many trials and tribulations to emerge as the triumph that we have described today. This history provides us a window into the past (and present) of this sprawling metropolis and hopefully gives us a vision of its future.

Our first guide, Charlie Forman sets the scene for us. It is the 1850s and London is a dark and dirty place.  Having tripled its population over the last 50 years, it is a city that is most literally busting at the seams. The buildings on this block are painted grey to hide the smog and smut that stain their walls. Refuse and waste fill the streets and in the height of summer, the stench of human excrement is overwhelming. Thousands die yearly from disease, smog, and occupational hazards. Episodic cholera outbreaks paralyze the city and the medical theorist of the era struggled to make sense of it all.  Then, this now refined city was on the brink of self-destruction.  As our second tour guide of the day, Dr. Barry Walsh, Public Health England retiree and medical microbiologist, would go on to say, “The city was drowning in a sea of its own feces.”  So what happened? How did this cesspool of grime become the city we see today?

The 1850s were really a turning point for London and the health of its dwellers. On August 31st, 1854, with one discarded dirty diaper, an epidemic is unleashed. Within days, 100’s will have died, and when all is said and done, over 600 will have lost their lives to the ravages of Cholera. However, out of this tragedy, a cornerstone of public health is born. John Snow a physician and soon-to-be founder of epidemiology bursts onto the scene determined to discover the cause of this ailment and spare future victims. Through vigorous data collection and epidemiological mapping, he is able to isolate the source of the ongoing infection, the Broad Street pump. Within its clear and crisp waters lay in wait a deadly bacterium, Vibrio cholerae.  Removing the pump’s handle and stopping the epidemic in its tracks, John Snow revolutionized public health practice that day, although it would take many decades before his true brilliance was realized. Dying somewhat unrecognized four years later, Dr. Snow would never see the significance and wide-reaching impact of his groundbreaking work.  (For more information on John Snow and the Cholera outbreak of 1854 read Ghost Map by Steven Johnson.  We did!)

A mere four years after John Snow removes the pump handle another crisis will hit the city. Cue the summer of 1858, also known as the “big stink”. Thousands of pounds of raw sewage flow into the Thames daily. Baking in the sun, a smell of epic proportions reaches the noses of London’s elite as Parliament is shut down due to the overwhelming stench. A city in uproar, change has to happen. Enter a bright young engineer Sir Joseph Bazalgette.  Designing a complex network of undergrown sewers (and with much support from Parliament), for the first time in London’s history waste is successfully transported away from the Thames and the drinking water of the London populous. While imperfect, this system dramatically reduced water-borne illness and death and paved the way for many future public health initiatives to come.

Fast forward 170 years or so and we are back on the modern streets of London. It is now 2022 and Queen Elizabeth II is soon to celebrate her platinum jubilee, the first of its kind in British history.  Universal healthcare is in place and London occupants now have access to clean water, parks, and all manner of recreational activities. The streets are now much safer and smog is a memory of the past. So where do we go from here?

Public health as a profession is very much a retrospective and prospective art. Often the sins of the past are doomed to be repeated if they are not acknowledged and recognized. Where infections and daily hazards once killed, chronic diseases such as heart disease, diabetes, and cancer have arisen to take their place. Public health still has an important role to play in the prevention and management of this new era of illness.  Just as in the mid-19th century, we now must show ingenuity and curiosity if we are to prevail.  Just as John Snow and Sir Joseph Bazalgette sought to improve the population’s health so must we as public health providers and students through utilizing all the tools of the past and creating innovations for the future. History shows us that the work of public health is never done, it is just beginning.


We learned so much today on our first walking tour of London! After, we headed to South Bank for a boat tour on the River Thames and a spin around the London Eye.  Both of these experiences gave us the opportunity to think more about 1850’s London and what it must have been like for people living at that time. Stay tuned for the next UAB SOPH blog post where we will be heading to Bloomsbury to explore the British Museum.  Also, if you are not already, make sure you are following us on the SOPH’s Instagram where we are taking over and posting throughout our travels.

Peace, Love, & Go Blazers
Jane Vines, Jonathan Baker, Jamia Haynes & Cassidy Stoddart


Day 1: London, United Kingdom

We have arrived in London!  After a long flight across the pond, we boarded a coach with Dr. Aaron Hunter.  Dr. Hunter is an evolutionary palaeoecologist at Cambridge University focusing on the “history of science.” You can find out more about Dr. Hunter on his website at AFossilHunter.com

Meeting Dr. Hunter at London-Heathrow Airport

Dr. Hunter took us on a tour of central London giving us a great orientation to the city and its history.  We were able to see and visit important cultural sites including the Palace of Westminster (Houses of Parliament) and Big Ben, Westminster Abby, Buckingham Palace, St. James Park, Hyde Park, Kensington Palace, etc.  We learned about London’s extensive royal parks and greenways and discussed how important these are to those living in the city.  We even drove over the Waterloo Bridge, where Georgi Markov, a Bulgarian dissident writer, was assassinated in 1978 after being stabbed in the leg with an umbrella containing the lethal poison ricin.

Driving around London, we noticed many road and sidewalk improvements underway in preparation for the Queen’s Platinum Jubilee early next month (Similar to what we have seen in Birmingham ahead of the World Games.)  These improvements will enhance walkability and safety, as well as improve overall neighborhood conditions in Central London.  Several students during the tour commented on how “clean” and free of rubbish the streets and sidewalks of London appear.  Dr. Hunter explained that British and neighborhood communities in general pride themselves in keeping common areas clean.  “It is part of the culture,” explained Dr. Hunter. 

Once we were settled into our hotel, our home base for the next few days, we were off to the Cote Kensington, a nearby restaurant for a welcome dinner.  After an excellent meal, we returned to our hotel for a much-needed rest, and to prepare for the next day!

Lisa McCormick and Meena Nabavi

Exploring Population Health: United Kingdom

After three years of planning (and many delays due to the COVID-19 pandemic), I am happy to announce that 14 University of Alabama at Birmingham (UAB) graduate and undergraduate students are setting off to explore population health in the United Kingdom.  This blog will document our travels, activities, the people we will meet, and the things we will learn along the way.

As part of this experience, students will be traveling to both London, England and Aberystwyth, Wales.  While in country, we are planning to meet with university, government, and community partners and organizations to learn more about the structure and delivery of public health and healthcare services in England and Wales.  We will walk the streets of SOHO in London with public health experts and imagine what it must have been like to live in the city during Victorian times, before the implementation of sanitation and environmental health services.  Finally, we will learn, firsthand, about priority public health issues affecting communities in the UK, how these issues are being addressed, and strategies being implemented to advance health equity.  The sum of this experience will illustrate the interdisciplinary nature of public health practice and the need to add attention to the social determinants of health – the conditions in the social, physical, cultural, and economic environment in which people are born, live, work, and age.

Leading this trip is Lisa McCormick, DrPH, and Meena Nabavi, MPH.  Dr. McCormick is the associate dean for public health practice and professor in the Department of Environmental Health Sciences and Mrs. Meena Nabavi is a program manager in the Office of Public Health Practice in the UAB School of Public Health. 

Getting Ready

Before the students departed for the UK, they had an opportunity to meet with several public health practitioners and representatives from community-based organizations in Birmingham (AL) to learn about local public health issues and the programs and initiatives that are working to address them. These pre-travel presentations will allow students to compare issues and programs in the United States to those we will be learning about in the United Kingdom.

Monday, May 9th

First, the students met with Dr. Meredith Gartin, associate professor in the department of Health Policy and Organization at the UAB SOPH. First, Dr. Gartin talked to students about culture and how culture can influence health behaviors and outcomes. She started by defining culture and discussed different dimensions of culture. When examining culture in a population, Jane Vines, an MPH Population Health student said “there is so much under the surface that you do not understand until you immerse yourself in the culture… that’s why immersive experiences like this course are so important.” Grace Albright, a Ph.D. student shared “What stuck out to me was how social norms are so ingrained into our culture that we don’t always think about them or even recognize them. Because culture is “learned” and “shared”, many of our “typical” health behaviors and customs are largely defined by those around us.”

Dr. Meredith Gartin, UAB SOPH

Dr. Gartin then discussed her work with the Alabama Interfaith Refugee Partnership (ALIRP). We learned about common refugee populations and about those who come to Alabama seeking asylum. Dr. Gartin highlighted the difficulties, challenges, and barriers that asylum seekers and refugees have securing legal status and basic human services, including preventative healthcare.

Tuesday, May 10th

Carrie Leland, MPA, executive director of Pathways, met with the students and introduced systematic barriers for people experiencing homelessness in Alabama. She provided several definitions of the term “homelessness” and discussed chronic homelessness and the services available in the community based on the Housing and Urban Development (HUD) definition. She also described Pathway’s programs, including their new emergency Childcare Center, which opened to mothers and children who are experiencing homelessness. After her discussion, Melissa Beck, an MPH Population Health student shared, “I was so impressed that Pathways had created childcare services for children, filling an important gap in the Birmingham community.”

Ms. Carrie Leland, Pathways

 Ritika Samant, a Fast Track MPH student in Health Behavior noted after both Dr. Gartin and Ms. Leland’s presentations that “there is a trend in where public health interventions take place, especially in regards to the most vulnerable populations, which makes me wonder if there are more upstream approaches which can be implemented to address the social determinants of health.”

Dr. Amy Chatham, assistant dean for undergraduate education and assistant professor in the department of Environmental Health Sciences, discussed her rural health work in the Black Belt of Alabama, which focuses on sanitation, environmental activism, and health disparities. She described the lack of sewage treatment infrastructure in Lowndes, Wilcox, Perry, and Dallas counties (AL). People in these counties are still experiencing economic repercussions of the Black Belt’s history, and as such, there is not a tax base to support establishing basic environmental services that are important to keeping a community healthy. Dr. Chatham shared that people who live in rural Alabama have deep roots and ties to the region. Jonathan Baker, a public health undergraduate student said, “the people who live in these communities don’t want to leave their home, they have generational wealth in these properties.”

There needs to be more activism and action in these communities so that these problems will be addressed. Jane Vines summed it up best, “These are their homes, their history, and their heritage.. people in these communities shouldn’t have to leave to live.”

Dr. Amy Chatham, UAB SOPH

Later in the afternoon, students visited the new location of UAB’s 1917 Clinic at Dewberry and met with Kachina Kudroff, the prevention programs manager. Ms. Kudroff provided an overview of HIV in the United States, focusing specifically on the Southeast. Ms. Kudroff Kachina shared basic information on HIV transmission and prevention, discussed current treatment options and the importance of viral suppression, and challenges and barriers to accessing treatment for those living with HIV. Several students shared that they were impressed with the multidisciplinary approach to patient-centered care at the 1917 Clinic and how multiple services are co-located in the same building.  Maya Van Houten, an undergraduate public health student observed, “The 1917 Clinic is a one-stop-shop, where people can access needed services in one visit at one location in one day.”

The exterior of the 1917 Clinic at Dewberry


Next, we visited with Karen Musgrove, Ph.D., CEO, and Josh Bruce, MPH, Director of Research of Birmingham AIDS Outreach or BAO. The mission of BAO is to enhance the quality of life for people living with HIV / AIDS, at-risk, affected individuals, and the LGBTQ community through outreach, age-appropriate prevention education, and supportive services.   BAO is able to accomplish this mission through several programs including the Magic City Wellness Center (which provides wellness and medical for the LGBTQ community), the Magic City Acceptance Academy (which facilitates a community in which all learners are empowered to embrace education in an LGBTQ-affirming learning environment), the Magic City Research Institute (improving the health of and service delivery to people with HIV, the LGBTQ community, and other underserved populations through collaboration, research, and evaluation), the Magic City Acceptance Center (provides a safe, supportive, and affirming space for LGBTQ young adults and their allies providing weekly supportive and social services to the LGBTQ community), and the Magic City Legal Center (provides legal advocacy for LGBTQ communities and community members impacted by HIV).

Students talking with BAO Staff at the Magic City Acceptance Center

The students will leave Birmingham on May 12th and return on May 24th and will be blogging most every day!  Make sure you bookmark the blog and follow our adventures!

– Lisa McCormick and Meena Nabavi

Historical Pandemic and Outbreak Presentations

Students were assigned a historical pandemic and were tasked with creating a video presentation highlighting aspects of the event, including a description and historical context of the event, impact on populations (including morbidity/mortality), response, and lessons learned.

1918 Influenza Pandemic

1957/1958 H2N2 Influenza Pandemic

1968 H3N2 Influenza Pandemic

2009 H1N1 Influenza Pandemic

2014-2016 Ebola Outbreak in West Africa

2015-2016 Zika Outbreak

Blaze Explores Population Health in Panama

How exciting to have been invited by Dr. Lisa McCormick to accompany her PUH 496/696 Exploring Population Health course to Panama! Travelling with a group of UAB students to Panama has really been thrilling. Before we left Birmingham, the students spent a few days preparing themselves to get the most out of this experience by learning about public health programs in Birmingham, Alabama and the historical connections between Alabama and Panama. During that time, I have been doing my own research so that I will be prepared. Did you know that the population of Panama is 4.1 million and the population of Alabama is 4.9 million? And, Panama City with a population of 1.8 million is the largest city in the country much like Birmingham is the largest city in Alabama with a population of 1.15 million. I wonder what other things we will find in Panama that are similar to Alabama.

I have been practicing my Spanish to prepare myself.

 Wait, I think I see Panama!

Our first day in the country and already we are on the go. We went to the Ciudad de Saber. That is the ‘City of Knowledge’ in English. Our first stop was at the Interpretive Center. There we learned about the history of the relationship between United States and Panama. Being on what used to be a military installation that is now being used to facilitate collaborations between non-governmental organizations, schools, universities, and tech companies is so encouraging. There is a feeling of openness and partnership as all of the resident-organizations have committed to engaging the Latin American communities to improve the health and well being in the region.

It reminds me a bit of the Innovation Depot in Birmingham, which has become the epicenter for technology, startups and entrepreneurs.  It has truly become the hub of economic development in Central Alabama.

Then after a great lunch, we went to the University of South Florida Health office to hear Dr. Arlene Calvo speak about historical aspects of health research and the public health system in Panama. I felt very pleased to hear about how Dr. William Gorgas from Mobile, Alabama was responsible for reducing the transmission of yellow fever and malaria in 1904 by creating the necessary infrastructure. His efforts facilitated the completion of the Panama Canal.

Did you know that the Gorgas Course in Tropical Medicine was launched as a collaborative partnership between the UAB School of Medicine and the Universidad Peruana Cayetano Heredia with the purpose of filling an educational gap for the international medical community seeking an intensive experience in tropical medicine with a focus in clinical activities and substantial exposure to real patients. After more than two decades of uninterrupted activity, the Gorgas Courses have trained more than 800 participants.  Currently, the Gorgas Courses in Clinical Tropical Medicine are held at the Alexander von Humboldt Tropical Medicine Institute in Lima, Peru. The diverse geography of Peru provides participants with an unparalleled opportunity of a first-hand exposure to the unique wide spectrum of tropical diseases that concentrate in this facility including: anthrax, cholera, leptospirosis, leprosy, HTLV-1, HIV, viral hepatitis, yellow fever, rabies, malaria, leishmaniasis, Chagas’ disease, strongyloidiasis, and histoplasmosis.

On the first Friday of our trip, we visited the Las Mañanitas Health Clinic. Las mañanitas is the traditional birthday song sung in Latin American countries. Las Mañanitas Health Clinic is funded by the Panamanian Ministry of Health and host a multitude of preventative services. It serves a community of over 60,000 residents!  The staff here is committed to providing services to any and all who need their care at no or very minimal costs.

It is also interesting to note, that much like the environmentalists that let us shadow them in their house-to house visits in Las Mañanitas who are preparing to battle mosquitos and subsequently the diseases that they spread during the rainy season, the City of Birmingham Mosquito Spraying began spraying Birmingham neighborhoods on Monday, May 6.  This coincides with the summer increase in mosquitos that need to be controlled to reduce the risks of diseases such as Zika and West Nile Virus in our communities. The Birmingham technicians treat each neighborhood weekly on the scheduled day of the week, weather permitting. However, unlike what we saw in Panama, residents in Birmingham can request an exemption and have their address listed as a “no spray” address.

Next we visited the non-profit, Nutre Hogar.  It was located not far from the Panama Canal and is a home for indigenous children suffering from malnutrition. Cada Dia Mejor means “every day better” in English. This Panamanian non-profit is committed to treating the nutritional needs of children a day at a time at their facility. It was interesting to see young children temporarily residing in a medical unit/home for nutritional therapy.  In Alabama, we have programs like the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) that provides federal grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk.

When touring Casco Antiguo, the colonial town of Panama City, we viewed a number of beautiful churches. Much like in Alabama, religion plays a significant role on culture in Panama. This was a good time for us to reflect on how religion impacts the public’s health through policy and educational accessibility.

During our time in Panama, we spent a lot of time on buses getting to all of the educational places that we needed to go. I have noticed billboards along almost every roadway that feature famous international figures in a public health campaign to encourage seat belt use and adherence to the speed limits. But feeling like there were so many near misses while riding in the buses and watching pedestrians cross four lanes of traffic on the highway, I was curious about mortality rate associated with traffic accidents. I just had to check. What I found is that according to the latest WHO data published in 2017, Road Traffic Accidents Deaths in Panama reached 420 or 2.44% of total deaths. In Alabama in 2017, according to the Alabama Department of Transportation, there were 857 fatal crashes leading to 948 fatalities. Public health education and promotion regarding traffic safety are necessary everywhere. Wait a second while I put on my seatbelt.

While we were in Chitre’ we participated in three service learning activities, two at elementary schools and one at a senior center. The elements that make service learning effective are providing what the community asks for using course content to enhance experiential learning for mutual benefit, being flexible and adaptable, and reflecting on the experience by answering: what was done?, why did it matter?, and now what will be different? The UAB students offered health education to Panamanian schoolchildren and a group of seniors based on the requests of schools in Chitre’ to reinforce important public health concepts. Before arriving in Panama, the UAB students worked to prepare appropriate lessons, however, once arriving in each location, they had to adapt the plan to work in the situation. This was amazing to watch. Our students used their soft skills to be able to effectively change the initial plans to appropriately fit each situation. Debriefs following each service learning experience, daily reflections and this blog are the many opportunities that were used to reflect on the personal learning.

The service learning days were perhaps my favorites because I watched cultural and language barriers fall while the UAB students sang, laughed, and played games with the school children and danced and danced with the women.

Much like the state of Alabama, Panama has a large urban area at the center of its boundaries. Birmingham and Panama City both sit squarely at the center geographically. Santo Tomas Hospital and UAB Hospital both provide the best medical available in their regions. Yet, both have large rural areas that are remote from accessing this due to distance or lack of available transportation. The public health systems provide preventative care through the Ministry of Health regional clinics in Panama and the county public health departments in the United States. There are smaller hospitals that provide services to these rural communities, but in an extreme health event patients need to be brought to Panama City and UAB hospitals.

This urban vs. rural access to care was very evident when we spoke with Dr. Anna Arrouz. She spoke about how HIV-positive patients in Panama often need to come to Santo Tomas or the Social Security hospital in Panama City to receive testing, access anti-retroviral therapy, or receive hospital care if they are undiagnosed and contract a life-threatening co-infection and must be hospitalized with AIDS. I am reminded of the revolutionary work of Dr. Michael Saag at UAB back in the 1980s when he and his UAB co-investigators traced the source of HIV, helped develop revolutionary treatments, and brought hope to patients from Alabama and the world. Dr. Arrouz with her limited resources is bringing hope to HIV patients in Panama. Her commitment to both the prevention and treatment of HIV is making a difference.

When we went to the Biomuseo, the biodiversity museum, I was struck by the natural marvels that compose all of Panama’s ecosystems and I was thrilled by their commitment to preserving that diversity.

Likewise, maps published in 2017 by biodiversitymapping.org and based on maps developed by Clinton Jenkins at the Instituto de Pesqusas Ecologicas published at proceedings of the National Academy of Sciences have revealed that Alabama is one of the most biodiverse states in the areas of aquatic species and trees. Many environmental nonprofits (the RiverKeepers and Nature Conservancy) in Alabama have realized the importance of that distinction and work diligently to preserve that diversity.

On the day that we went to see the Embera’, one of the many indigenous groups in Panama, I thought of the indigenous groups from our home state.

Did you know the name “Alabama” is a Muskogeannative American word? It meant “campsite” or “clearing,” and became used as a name for one of the major tribes in the area, the Alabama (or Alabamee) Indians. The original inhabitants of the area that is now Alabama included the following tribes: Alabama, Biloxi, Cherokee, Chickasaw, Choctaw, Koasati, Mobile, and Muskogee Creek.

Now it is time to say good-bye to Panama. It was an amazing trip full of meaningful connections, deep experiences, cultural exchange, and service learning. I learned so much about population health, health equity, and social determinants of health during the last 11 days. Travelling and working with Dr. Lisa McCormick, Dr. Ela Austin, Meena Nabavi, and the thirteen public health students was both interesting and fun. I am a bit tired, but I am going to use the time on the flights back to Birmingham to reflect on all that we have experienced and learned.

I hope to return to Panama with other UAB students. I can see how so many of them will benefit from the experience of learning in a country that has one of the fastest growing economies in the world, a public health system committed to the wellbeing of its citizens, and innovative efforts around environmental sustainability.

And between you and me, I certainly hope that I will be invited to join the Population Health course again next year. I hear that they are going to England!

A Deep Dive into the World of Indigenous People in Panama

Panama Viejo

Our group visited Panama Viejo on Friday.  The Panamanian people are a people who are exceptionally proud of their rich history and Panama Viejo is a living exhibit of this history. A direct translation of Panama Viejo is “old Panama” a fitting name for the oldest structures in the country of Panama. Founded on August 15, 1519 by Pedro Arias de Avila, a Spanish conquistador, the original Spanish settlement of Panama served as a convenient home base for gold excavations across the Americas. This area served as a Spanish stronghold for more than 150 years until 1671 when the English, led by Sir Henry Morgan, attacked Panama Viejo leaving the city to deteriorate into the ruins that remain today. Over the years the area surrounding Panama Viejo declined economically and the houses in the vicinity of the ruins are those of the poverty rampant across Panama. It was not until 1997 when UNESCO declared Panama Viejo a world heritage site that restorative and tourism initiatives began in the old ruins.

During our group’s visit, the large majority of our time was spent in the cutting-edge museum at the foot of the ancient ruins. The museum is a chic two-story building with a multitude of brightly colored rooms walking visitors through the history of Panama Viejo. On the walls are informative plaques, like the one displayed in the photograph, describing the history of the old city. The exhibitions start all the way back with the Spanish conquest and as one walks from room to room the exhibits contain more recent history. Several of the rooms had interactive components including a replica of the city in the 1500s and a room mimicking a Spanish colonial household.

Once one finishes the route through the museum and enters the courtyard, the view of the ruins of Panama Viejo stick out alongside the skyscrapers of present day Panama City. Several old buildings and walls remain, and the area is open for adventure. One particularly tall tower, pictured below, still stands 70 meters tall and after an arduous climb up several flights of stairs offers a beautiful view of the ruins and surrounding cities. After scaling the tower, our group of students was able to spend time observing the walls and structures sleft standing in the courtyard and once the searing sun reappeared after a brief shower our group quickly reloaded the buses.

Panama Viejo Ruins

Indigenous Communities of Panama

Tusipono Emberá – Where the River Takes Life

The Tusipono Embera are just a small part of the Embera people with about 30,0000 still living in the Darien Gap and 50,000 living in the Choco region of Columbia. Whether the Embera migrated to Panama or not is still unknown, however, they have been there for centuries. The Panamanian government has seven Embera Comarca’s, which are like reservations for the tribes. Panama did not recognize the Embera people until 1975 when they gave them rights to education and health. Currently, they have access to health care, vaccines, and schools but they often may have to travel great distances to access it. The Embera tribe that we visited near Panama City lives in an area that is now a national parks meaning the Embera cannot use the land or trees for their traditional living habits. Therefore, the Embera cannot farm, use trees for building materials or clothing, or hunt on the grounds. However, through tourism many Embera, such as the Tusipono, make their living. Tourism allows the tribes to have money for staple needs and be able to keep their traditions alive. Though tourism has become a part of their life, one begins to wonder how increased tourism will adversely affect the tribes. Yes, the people can achieve a healthier life and maintain cultural traditions, but at what cost? One hopes as Panama grows, it does not lose its culture for the sake of money.

At 9:00 AM, we departed Panama City to meet the Tusipono Emberá Tribe located in the Chagres National Park along the Alajuela Lake, which feeds the Panama Canal from the Chagres River. On our way to our destination, we stopped for fruit, water, and ice. During this stop a few of us went with our tour guide to the fruit stands where we were able to try fruit that we don’t normally encounter – fruits like lychee and pig spine. Back on the bus, as we headed to Chagres National Park, we learned more about the educational system in Panama and the differences between public and private schools as well as what the government has done to incentivize parents keeping their children in school. In many communities, public school operate on two shifts, in the morning and afternoon, in order to accommodate all of the pupils, but in private schools students attend full days. However, lower-income families do not have access to a private school education and receive a stipend for each child enrolled in public school if they perform to ‘standard.’ While on the road, we drove through some rural areas that do not have piped water or sewer systems.  People who live here have tanks that fprovide potable water to their homes.  Water is trucked in and pumped into these tanks, which is ironic since the nearby Chagres River is the main water source for Panama City. 

We arrived at the Chagres River at 10:30AM and boarded canoes that took us down the Chagres towards the Tusipono Emberá village located about 15 minutes away from the loading dock. We hobbled into two canoes and were led by two indigenous men, one steering and pushing the canoe from the front and one steering and pushing the canoe from the back. Because rainy season had just begun, the waters were low. Because of this, some of us got in the water to help push the canoe. But we were still able to enjoy the beautiful water and surrounding area and two baby alligators that were sunning on the banks of the river. We arrived and climbed up a hill to be welcomed by several women of the tribe shaking our hands and a few men and boys playing instruments to greet us as we walked to the main center and then into a man-made palm structure where we were welcomed by the “Noco” or chief of the community.

The Noco told us more about his community of about 75 people made up of about 22 families, the majority of which had come from the Emberá community come in the Darien. He shared with us that its name, Tusipono, is derived from a tree with a very striking flower that stands out among the tropical rain forests that surround the mouth of the river. Then he taught us a few words of the Emberá language like friends and thank you or “bia bua”. Then we saw the fine crafts that the Emberá are known for and were told more about tagua seeds and the art carved from those as well as the cocobolos wood crafts, and fibers used for making baskets. We watched one the girls weaving a basket and passed around things like turmeric and mud that are used to dye the fibers for the baskets, bowls, and vases. From this, the Noco answered some of our questions like what they do if someone is sick and where do the children go to school. He told us that they use herbal medicine, but if the problem is drastic, they will use more westernized medicine. He also informed us that women birth their babies in their homes unless there is a complication. We also learned that the children attend the nearby school with members of the community that we passed through on our way to the river. We then got to experience more of their culture as we ate freshly fried tilapia and yucca from heliconia leaves that they had folded into cones for us.

Once we finished eating, we were allowed to roam the grounds. We saw the homes of the families as we walked to the Butterfly Room where we viewed seven species of butterflies in a garden containing the plants and flowers of the region. We viewed the life cycle from the cocoon stage, to the pupa, and then a fully grown butterfly. After this we were led to the main gathering point where we were treated to traditional Emberá dance and music. The Emberá use inspiration from their environment to imitate the behavior of animals and relationship with others to create different dances and music. Here we saw two traditional dances: The Dance of the Monkey and the Dance of the Two Sisters. We also heard music known as the Music of the Rumba of Panama and were then pulled from the audience to participate in some of the dancing as well. Afterwards, several of us received temporary tattoos from the community as well as opportunity to purchase handcrafted goods created by the different families. Before we left, we were greeted by Princesa, an orphaned Spider Monkey, that was adopted by the Noco as he had found her in the forest hurt by a Harpy Eagle. Many of us were able to hold her and feed her the bottle of human breast milk that they were giving to her. We then returned to the canoes to head to the Alajuela Visitor’s Center to read more about the artwork that we had seen, the materials used, and wildlife and flora in the Chagres National Park, as well as viewing a map to see where we had traveled.

From canoeing to bus rides, we arrived back in Panama City to prepare for our return to Birmingham. It was hard to believe that our time in Panama was finished for now.

Group 4 – Panama Special Viral Unit

Tim McWilliams

Wilnadia Murrell

Leahgrace Simons

Nadia with Princesa

The Reality of Panama: Santo Tomas Hospital and The Biodiversity Museum of Panama

Santo Tomas Hospital (HST)

This hospital is the largest public hospital in Panama. This hospital is what the Panamanian Ministry of Health refers to as a level-three hospital and provides the highest level of care through the Ministry of Health. Santo Tomas was officially founded on September 22, 1702. It was mentioned for the first time in writing on April 11, 1703, when Juan de Argüeyes, the Bishop of Panama City, wrote a letter to King Phillip V of Spain begging him to change the name to reflect a hospital and not just a hospice facility for treating women. Later in 1819, construction of a new facility began. After the new hospital was built, they began treating men at the facility. Starting in September 1924, new buildings were built where the hospital currently stands on Balboa Avenue in Panama City.

Several former wards of the hospital later became independent facilities. For example, the pediatric ward became Hospital del Niño (Children’s Hospital) and the oncology ward became the Instituto Oncologico Nacional (National Oncologic Institute, located at the former Gorgas Hospital). Currently the hospital serves patients 15 years and older, and includes a maternity ward, an emergency department, outpatient clinics, internal medicine, general surgery, an infectious disease ward, and more. Some of the medical specialties available are cardiology, endocrinology, general surgery, internal medicine, neurology, obstetrics and gynecology, orthopedic surgery, psychiatry, and radiology. Santo Tomas is the only location for these specialties for people without private or social security insurance. Keep in mind that this includes 40-60% of Panama’s population that depend on the Ministry of Health’s clinics and hospitals as their only access to healthcare.

Today, Santo Tomas has 632 beds, and is the largest teaching hospital in Panama. It serves as an integral part of Panama’s public healthcare system and is the only access to healthcare for the poorest residents of Panama.

Outside of the main entrance of Santo Tomas

HIV in Panama

While at Santo Tomas Hospital, we received a tour of the adult infectious disease ward and then the HIV/AIDS clinic from Dr. Ana Belen Arauz, an infectious disease doctor. Hearing her speak about treating infectious diseases, specifically HIV/AIDS, amongst adults at the largest hospital in the country, was encouraging and discouraging at the same time. It was so profound to hear from a physician who was educated in the United States but has chosen to return to Panama to work in the field of HIV/AIDS. Yet her work seems daunting with 60 AIDS patients currently admitted to the hospital (10-14 die monthly), and hearing her speak so candidly about infectious diseases and their control made us feel like we were getting to see behind the curtain. So much of what we have heard about clinical medicine in Panama has focused solely on prevention, however, we learned that no one is being tested for gonorrhea or chlamydia, and treatment of these and other sexually transmitted diseases is based solely on symptoms.

Dr. Arauz spoke to us at length about HIV/AIDS rates and the associated opportunistic co-infections they see in Panama, including TB, histoplasmosis, toxoplasmosis, and meningitis. Often times people are not diagnosed with HIV/AIDS until the signs and symptoms of these opportunistic infections drive them to seek medical care. She shared that currently 4,000 HIV-positive patients are being seen at the clinic at Santa Tomas, and estimates that another 5,000 are being seen at the Social Security Hospital. Dr. Arauz estimates that there are currently 30,000+ HIV-positive individuals in Panama, this is an increase from previously reported estimates of approximately 16,000 in 2017 and 18,000 in 2018.

Dr. Arauz also discussed Panama’s efforts to reach the 90-90-90 targets, 90% of HIV cases diagnosed, 90% of those diagnosed receiving treatment, and 90% of those on treatment achieving viral suppression. That is the goal, but Dr. Arauz explained that the reality in Panama is currently closer to 70-60-60. She believes that there are a number of reasons that are preventing Panama from reaching the 90-90-90 targets, including: 1) Stigma associated with high risk lifestyles which leads to low testing rates in that population, 2) Diagnosis is difficult because blood tests must be administered in a clinic by a lab technician and many people find it difficult to travel to a clinic , 3) Many HIV diagnoses come late, after signs and symptoms of opportunistic infections are occurring, 4) Funding for HIV testing, treatment, and care services is low, and is expected to decrease when PEPFAR funds are reduced, 5) It takes a month or longer to get an individual who tests HIV positive linked into care, 6) Viral loads are only checked every six months and the currently available ART has a 12-14% resistance rate, 7) There is only one social worker for all of Santo Tomas, and 8) Sex education is not allowed in schools and there are high rates of HIV diagnoses among 15-18 year olds.

In wrapping up, Dr. McCormick asked Dr. Arauz, “How do you keep a positive attitude?” This was a great question considering the challenges that she faces on daily basis. Dr. Arauz answered, “After being here eight years, I have noticed change, although it is not fast.” Santo Tomas Hospital is fortunate to have someone like her on their team.

Dr. Ana Arauz presenting to the class

The Biodiversity of Panama

The exterior of the Biomuseo

This afternoon we visited the Biomuseo, a museum that celebrates the biodiversity of Panama. The museum was designed by world-renowned architect Frank Gehry and was designed to tell the story of how the isthmus of Panama rose from the sea, uniting two continents, separating a vast ocean in two, and changing the planet’s biodiversity forever. The museum houses ten different exhibits which explore different aspects of biodiversity in Panama and how it affects life in Latin America.

One of the exhibits highlighted how human beings are an integral part of nature, and how human activity has impacted nature in Panama over the last 15,000 years- the estimated date when the first settlers arrived to the isthmus. It was easy to see how environment and health are so interrelated as we moved through these exhibits.

From the Living Web Exhibit, demonstrating how To demonstrate how living things need and compete with each other in complex and often invisible ways

Chitré Volume 3 and Back to Panama City

UAB Students at the entrance of Hospital Cecilio Castillero

Hospital Cecilio Castillero

On our last morning in Chitré, we had the opportunity to visit Hospital Cecilio Castillero, a Ministry of Health system hospital that provides services for people living in the Herrera, Los Santos, and Veraguas provinces. The services at this hospital are one step above what we observed at the clinics that provide preventative services and include a major focus on maternal and child health. They also provide outpatient services, including pediatric dentistry, breast, and cervical cancer screening, general surgery, internal medicine, and pediatrics.

A poster about HIV transmission in the hospital

This hospital has 135 beds and averages 85 births per month. The maternity ward contains three beds for labor, two for preparation and delivery, four for newborns, and two for women with complications. Once a mother gives birth, she is moved to an OB/GYN ward for post-delivery monitoring. Before mothers are discharged, they are given any necessary vaccinations. There are several services that are similar between the United States and Panama, including providing HIV testing to expectant mothers. However, in Panama, any costs related to maternal health, labor and delivery, and child healthcare through age five are covered for everyone through the Ministry of Health by law.

Nurses from the maternity ward explain to the class about their delivery process

While this facility is convenient for those that live near Chitré, it can be difficult to access for those that live further away. As a level two hospital, it does not have the resources to provide specialty care such as cardiology, nephrology, or oncology. Patients needing these services are referred to larger level 3 hospitals, such as Santo Tomas in Panama City. It is evident that this hospital is attempting to maximize the resources they have to provide a wide array of services. There is an effort to control nosocomial infections in the hospital, as we were introduced to their infection control nurse, but the facility has so many limitations that the task must be daunting.

This facility, like most we’ve visited in Panama, was not accessible for those with physical limitations and had poor signage with directions for navigation written in sharpie on the walls. There were several private clinics surrounding Hospital Cecilio Castilerro, but those clinics only accept patients who can afford private insurance. This creates an inequity in the community around access to health services.  

We want to thank the staff at Hospital Cecilio Castilerro, as well as everyone we met in Chitré. We are taking the lessons we learned here as we head back to Panama City to continue our exploration.

Culture: Tinajas Restaurant

Our first evening back in Panama City we had the opportunity to attend a dinner show at the Tinajas restaurant. Tinajas hosts a space for visitors to experience Panamanian food and cultural dances.  The exterior of the restaurant reminded us of an older Spanish-style house, while the area that we were ushered to was designed to look like a back patio with lines of tables in front of a stage. Tinajas’ food selection consisted of traditional Panamanian fair such as tres leches cake and fried plantains. While we ate dinner, we enjoyed listening to Panamanian folk music, which was performed by a band that included an accordion, guitars, wooden drums, and a la guachara, which is an wooden instrument played by running a stick across the carved notches. Then we were introduced to several genres of Panamanian folkloric dances that dated back to as early as the 17th century. One of the dances, El Tamborito, meaning small drums, is the national song and dance of Panama. A few other dances they performed were Cumbia Suelta, Cumbia Amanoja, and Punto Panameno. There were frequent costume changes so that the dancer’s attire matched the period and dance. At one point, the female dancers wore hand-embroidered pollera with decorated beaded headpieces while the men wore formal montunos along with traditional leather sandals.

The cultural component of our day helped provide context to the things in society Panamanians hold dear, which is important for understanding motivations to perform certain behaviors or think in certain ways. For instance, because dancing is such a central part of Panamanian culture, it could be a more welcomed form of exercise than running in areas that don’t have sidewalks or even surfaces. This was evident in our visit in Chitré earlier in the week when working with seniors on the importance of exercise. Most of the ladies that we met indicated they enjoyed dancing and would participate often as a form of exercise. Now we’ve seen evidence of how culture can influence health.  

Dancers perform in traditional Panamanian attire

Adventures in Chitré: Volume 2

Educating the Community: A Key to Preventative Health

Today we were not mere observers in public health, we engaged the community via service learning activities working with two different populations in Chitré, Panama. During our first stop we worked with aging adults to discuss the importance of physical activity and demonstrated several low impact exercises. Our second stop was at an elementary school in an at-risk area right outside of Chitré.  Here we worked with Kindergarten and 1st grade students to teach the importance of and techniques for hand washing and dental hygiene and with 4th graders to discuss vector borne diseases and vector control. We completed the day by traveling with fourth year nursing students from the University of Panama to learn about their community assessment of the neighborhood where the elementary school children reside which gave context to the student’s daily lives.

Dancing for Health

Our first stop was at a community center operated by the University of Panama and the CSS (the Social Security Fund in Panama). The center offers a variety of services to retired individuals including classes on language, dancing, handcrafts, and exercises. The center also offers jobs and skills training through its University of Trabajo including the creation of handcrafts, house ornaments, and sewing. The courses empower the people, primarily women, by teaching them a trade.

For our project, we worked with a group of retired women between the ages of 65 and 80 discussing the importance of remaining physically active. We provided an introduction to the benefits of physical activity including improving quality of life and reducing chronic illnesses. We engaged in conversation by asking the ladies whether they were physically active and what activities they enjoyed, most of which replied they enjoyed dancing. From there, we taught a few seated exercises and provided the ladies a handout of the exercises to practice on their own. After our seated instruction, we taught a few popular ‘line’ dances that we enjoy in the United States (i.e., the Cha-Cha Slide, the Electric Slide, and the Macareña.) The ladies, in turn, promised to teach us a few Panamanian dances, but only if we danced with them, which of course, we did. At the end of our energetic service-learning activity, we parted friends and appreciated the enriching cultural exchange.

The Eneida M. Castillero School

Yesterday, we spent time at the Hipolito Perez Tello School, a top-ranked elementary school in the country. Today, we visited with students at the Eneida M. Castillero School, which serves a low-income population and has limited resources. This school is more representative of what you would see in other rural areas of the country. As students studying public health, it is vital to understand disparities, and the area that this school serves stands out in stark contrast to what we saw yesterday.

Our service learning began by meeting with fourth year nursing students from the University of Panama. The nursing students have been working in this community to complete a community needs assessment of the neighborhood and have been working to treat the elementary school students in the area with iron supplements due to a nutrient deficiency, as well as to provide needed vaccinations. After learning a little about the community and the children in the school from the nursing students, we split into four groups, two groups taught oral hygiene and the importance of handwashing to Kindergartners and 1st graders while the other groups taught vector control to 4th graders.

As we walked into the Kindergarten class, we were greeted by the children singing a welcome song. We introduced ourselves to the class and explained that we would like to discuss why and how they wash their hands and brush their teeth. The lesson for hand washing included teaching the children the English words for hands, wash, water, and soap. We asked the children to demonstrate how to wash their hands and asked children to recall the English words they learned. A little boy in the front of the class was eager to participate and set the tone for the class by answering questions. The young boy was ecstatic to win a little Blaze mascot for answering the question correctly and immediately opened the package to play with his new toy. For brushing your teeth, we taught the English words for teeth, toothpaste, and brush, which we asked for the children to recall and they did quite well. Then it was our turn to play a song for the students. We played a song about how to brush your teeth in Spanish and acted out brushing our teeth. The Kindergartners enthusiastically joined in on the second round and were excited to receive their goody bag that included a dental hygiene activity book and dental care supplies. We spent about 30 minutes with the students and ended our time by taking a group picture.

Walking into the 4th  grade class, all of the students, and the teacher, gave us their full attention and were actively engaged throughout the entire experience. We started with a question-and-answer session to gauge prior knowledge about the topic of vectors and vector control, with our wonderful translator/USF representative Rolando Trejos. The children did not recognize the word vector when asked, but they had substantial knowledge about mosquitoes, fumigation, and how to protect themselves from vector borne illnesses. After our Q&A, we moved on to our activity which consisted of using a flipchart to identify where mosquitoes breed. The students were very excited to participate in the activity and were awarded prizes for correct answers. The first child to answer a question correctly, immediately put on his prize, a UAB t-shirt. The children were great at recalling and demonstrating that they understood the lesson. At the end of the lesson, we asked if there were any questions and a little boy energetically raised his hand and reminded us to not fumigate at night! The class told us to not forget them and waved goodbye as we departed on the bus.

The Community

After we left the school, we visited the community and were able to observe the social determinants of health and health inequities that directly impact the children we just met. The majority of the people who live in this community are low-income families who struggle to make ends meet. It is a common practice for parents to take their children out of school so they can keep the government allocated stipend for public school tuition. Due to the extreme poverty, parents are faced with the harsh reality of deciding whether they want their child to eat or attend school. Shortly into the community observation, we approached a landfill that was located in the center of the community. As we drove into the entrance of the landfill, we immediately noticed malnourished livestock feeding off of garbage and the sparse polluted grass. The nursing students explained to us that this is where all of the trash from the district of Herrera is dumped. They further explained that community members sometimes fight over trash when they are desperate for food or resources to sell for an income. This is clearly a social determinant of health as poverty and the polluted environment are impacting the health of the community.

Next, we traveled to a nearby port on a polluted river where men were weighing, sorting, and gutting the local catch. The local guide explained to us that it was a common practice for families to rely on subsistence fishing from the river. This concerned us since we know that eating fish from an unclean water source for an extended period of time can result in serious adverse health effects such as liver damage, gastrointestinal distress, and cancer. We know this first-hand because of the negative health outcomes associated with subsistence fishing on the Warrior River in Alabama. As we concluded our tour, we realized how many representations of social determinants of health we had seen. The quality of the water, access to food, housing, education, and ability to have a steady income, all contribute to the communities overall health and the ability of current and future generations to reach their full potential.

Our goal today was to create a culture of prevention. We were able to teach older adults the importance of exercise while at the same time demonstrating fun physical activities. Elementary -aged children were taught to recall their knowledge of handwashing, dental hygiene, and vector control while teaching new knowledge to emphasize the importance of these preventative health practices. The entire healthcare system in Panama is centered around prevention rather than reaction and establishing healthy practices is vital to effectively prevent negative health outcomes, such as vector borne diseases and chronic illnesses associated with dental health, physical activity levels, and handwashing to promote health for all.

Team 1 –

Nekayla Anderson (Public Health Undergrad)

Sloan Oliver (Public Health Undergrad)

Jennifer Schusterman (HCOP Graduate Student)