“La Salud para Todos”: Health for Everyone

Las Mañanitas Health Center

Today’s visit focused on Las Mañanitas Health Center, a clinic with 58 employees including administration, servicing over 60,000 people within the district of Mañanitas that lies just outside Panama City. (The national health system is divided into 26 districts, each with its own health center.) Las Mañanitas Health Center was established in 1989 and will soon be replaced by a new 2-story facility to meet the needs of the growing population in the area. Within this community, most of the people do not work enough hours to be able to contribute and participate in Panama’s social security program or pay for private insurance, so this public health clinic is the primary outlet for this population to access health services. Appointments must be made, so there are often lines starting at 5:00 AM when the clinic opens to secure a spot on the roster. To provide additional context, when the clinic was established, there were approximately 25,000 people living in Mañanitas, but the area’s population has grown rapidly without any planned infrastructure or public services. Currently at the health center, there are two pediatricians, who often each see 16-18 patients a day and a general practitioner who may see up to 28 patients a day.

As Las Mañanitas Health Center is a Ministry of Health health center, services are provided at no charge or a low cost to patients of all nationalities. This can be challenging when establishing specific health programs or initiatives due to varied cultural norms– an example given was in regard to littering in the street. However, providing preventative health care to all is vital since Panama is a hub for travel and trade there are a myriad of infectious diseases that come through the country. There are simply insufficient financial and human resources to aggressively fight pandemics in Panama.

Care is available to all age groups. Prevention starts early and children ages 0-5 are always seen free of charge and provided with vaccines, dental, and nutritional services beginning when the child is 8 days old. Vaccination is obligatory for families, and should a parent not comply, punitive action may be taken by the state. Teens are offered programs both within the clinic and within the school setting regarding consultation and education with behavioral health such as drug use or sex practices. Panama’s population is also aging and with that comes a need to address the quality of life of the population. It is not uncommon for grandparents to take care of grandchildren and delay seeking care for their own health issues. The clinic offers weekly classes or seminars on a given topic to help educate the elders within the community about the issues they may face, as well as provide a safe space to engage with each other, participate in handicrafts, etc.

Vector Control

 Panama has a long history with vector control going back to the elimination of yellow fever and the control of malaria during the Panama Canal construction, and Las Mañanitas vector control unit is carrying on this tradition. Las Mañanitas’ comprehensive public health unit includes vector control, sanitation, epidemiology, and food safety. Today, we met with vector control specialists who told us more about the work they do and took us into the community to observe their surveillance and assessment methods. Much of what the vector control unit does involves checking homes for mosquito breeding grounds, identifying standing water and eliminating these breeding grounds.

A potential mosquito breeding ground

The disease they are currently working to prevent is Dengue Fever. If a person goes into the health clinic with symptoms of Dengue Fever, then the vector control unit visits that person’s home the next day and fumigates everything within a 500-meter radius. Within that radius, breeding grounds are identified and the radius is expanded to 500 meters around where each breeding ground is located. This strategy is very effective and is one of the reasons why Panama has lower rates of Dengue fever than its neighboring countries. The area also has other mosquito transmitted diseases such as Malaria, Zika, and Chikungunya, but these cases only occur sporadically. Additionally, while Yellow Fever is eliminated in Panama, neighboring countries do have cases of Yellow Fever, so vector control units must stay vigilant.

Las Mañanitas

One of the barriers for the vector control unit is the history and demographics of Las Mañanitas. Las Mañanitas population grew very rapidly due to migration from rural areas and other countries to this district near Panama City for jobs. However, there was no initial planning of the streets, homes, infrastructure, or public services, so there are issues with water delivery and sewage systems that aid in the creation of mosquito breeding grounds. Additionally, the residents brought with them many varied cultural beliefs and practices that are not always conducive to vector control. The vector control team works to educate residents about how to prevent mosquito breeding grounds from forming by properly storing water and eliminating standing water. The vector control workers inspect between 20 to 40 homes each day resulting in one of three outcomes: the house is clear, the owner makes a promise to remedy whatever problems the worker identifies, or  the resident is given a fine for continuing to create an environment that facilitates mosquito breeding.

After the vector control told the group about what they do, we split into two groups and they took us out on a few house inspections. Nothing about what they do is particularly glamorous as they go door-to-door and search through yard and porch areas for mosquito breeding grounds with little equipment, not even gloves. One of the houses visited was home to a large, multigenerational family that allowed a group of eight strangers and one vector control worker to traipse through their yard. There was a small cup of water left on the ground by a child providing water for the chickens, but it had to be dumped as it was untreated standing water unlike the nearby bucket of water that had been treated against mosquitos. The matriarch of the family spoke about how difficult it was to maintain their home and follow all of the guidelines with so many living there, many of whom were young children. Towards the end of the visit, one area of concern was identified behind a pile of bricks, under some vegetation, and close to the trash that awaited burning; it was an old sheet of metal containing standing water. As the vector control worker carefully looked through the water he found larvae. Luckily for the residents, it was only fly larvae, which are essentially harmless. Nonetheless, the sheet of water was dumped out onto the ground and a potentially dangerous situation was averted.

Fly larvae found at a house inspection

NutreHogar

NutreHogar has been serving the communities of Panama for over 30 years in an effort to improve malnutrition in rural areas. This organization acts as a nutrition recovery center for children under the age of five. One way the organization has begun to address nutritional needs in rural areas is by surveying indigenous families living in extreme poverty, and finding ways to use existing resources within the community to bridge nutritional gaps. NutreHogar has done this is by teaching gardening and harvesting of native fruits and vegetables to sustain a family’s nutritional needs. This guidance NutreHogar gives to indigenous families is immensely valuable and life altering.

If a child is referred by a clinician to NutreHogar, a parent must give the organization permission to house and care for the child until the child achieves full nutritional health. The downside of this is that it often takes a parents up to six hours to travel from their rural communities to Panama City. This may make initial treatment and parental visits a major obstacle to the child receiving care.

Typically, a clinician identifies an infant with moderate malnutrition and immediately refers her to the center. NutreHogar then assesses the environment of the infant to determine the cause of malnutrition. During this process, the infant is seen by a pediatrician to diagnose other conditions such as respiratory problems or diseases. Then, the infant is evaluated for deficiencies that could possibly affect his or her motor skills. The care team then develops a plan to improve all conditions. Some infants have shown signs of improvement in as quickly as a couple of days, while others remain in the care of NutreHogar for up to 8 months. The child returns home once they reach specific nutrition and health standards and when the family has shown improvement for a better quality of life.

In 2012, NutreHogar reported 68.5% of indigenous children under age five suffered from chronic malnutrition. The center sought context for people suffering from extreme poverty and how they could help improve the communities with their services. The center’s research indicated that indigenous people received limited education about family nutrition. Often little or no income was earned by these families due to the lack of employment opportunities, and thus presented a barrier in sustainably feeding a family. So, NutreHogar began to hold workshops and provide resources for subsistence farming and the nutritional needs of children. Today, these indigenous communities have shown signs of improvement through this program, and in some cases, have created a source of income for their families by selling the surplus of crops.

NutreHogar is trying to improve the quality life of children suffering malnutrition throughout Panama. Their efforts have been effective, but there is still much work to do in the communities they serve. Readers, if you would like to donate to NutreHogar programs or seek more information regarding their services, please visit: http://www.nutrehogar.org/donaciones/.

Team 2: The Harpy Eagles

Katherine Greene (MPH Health Behavior Student)

Jaida Lane (Public Health Undergrad)

Katherine White (Public Health Undergrad)

Laying the foundation at the City of Knowledge: How history has shaped public health in Panama

Centro de Interpretación

Ms. Oriana Sanjur greeted us on the masonry steps that led us into the beautifully refurbished Centro de Interpretación at the City of Knowledge (Ciudad de Saber).

The City of Knowledge is located on a former US military base, Fort Clayton, which served as the Southern Command Network headquarters of US Army South.

The History: Ms. Sanjur introduced us to the history of the City of Knowledge and provided a short tour of the museum that honors the history of the site. The former US commander’s home, which houses the center, exemplifies Mission and Art Deco architecture and houses original wicker furniture, a dining suite, and other historical artifacts. The historical artifacts weave the story of Panama, specifically the history of the canal, the US military presence in the country, the political leadership under Omar Torrijos and Manuel Noriega, and the 1977 Carter-Torrijos treaty that would eventually transfer control of the canal back to Panama.

City of Knowledge Today: After discussing the history, Ms. Sanjur talked about the City of Knowledge’s current mission, vision, and goals. Their mission is to encourage innovative social and economic change through programs that support entrepreneurship, education, public health, child protection, cultural development, human rights, and environmental protection. The City of Knowledge contains over 200 buildings which currently house a multitude of non-governmental, non-profit organizations, including the regional offices of the United Nations. Other buildings house private organizations and academic institutions’ satellites including Florida State University and the University of South Florida. The City of Knowledge has an extensive network of collaborators and their efforts are promoting health equity by removing barriers associated with social determinants of health. They have taken existing infrastructure and transformed it into an extensive innovation hub that will work to improve health throughout Central and South America for generations to come.

University of South Florida

Team 1 Members: Nekayla, Jennifer, and Sloan

History: Later in the day we visited Dr. Arlene Calvo in the University of South Florida Health building located near the front entrance of the City of Knowledge. Dr. Arlene Calvo is a native of Panama who received her MPH and PhD at the University of South Florida. After completing her degrees, she returned to Panama to focus her career on improving health outcomes in her home country. Dr. Calvo’s presentation provided an overview of the history of Panama, the Panama Canal, and US involvement in Panama.  She talked about how the history of Panama is shaping some of the issues that Panamanians face today.    

The history of the Panama Canal construction was extremely interesting from a public health perspective. We learned that after the French completed the Suez Canal in Egypt they were economically motivated to construct a second canal to connect the Atlantic to the Pacific Ocean. They believed that this would provide a safer and faster route to transport goods and people, eliminating the need to go around Cape Horn.  Panama was chosen because of its strategic location and its unique geography given that it is a very narrow landmass and had an abundance of rivers that could be connected to form a canal. Because the Suez Canal was a success, the French believed the technology from that construction would be compatible with construction in Panama, but they were mistaken. Juxtaposed to the geography of Egypt’s arid and fertile land, Panama was wet and marshy, it was impossible for the French to dredge the canal using the same technologies used in Egypt. Another challenge faced was disease, most significantly yellow fever and malaria. Workers died from these diseases at exponential rates. These two factors caused the French project to go bankrupt.

Dr. Calvo shares a depiction of the streets in Panama before Dr. Gorgas arrived

Following the failed attempt to build the canal by France, Panama joined forces with the United States after declaring independence from Columbia in 1903.  In return, Panama gave the United States control over the canal to attempt to complete what the French had started. Again, workers began dying of yellow fever and malaria. So, in 1904, after eradicating malaria and yellow fever in Cuba, Dr. William C. Gorgas, an Alabama native, was sent to Panama to attempt the same.  Dr. Gorgas asked that they halt construction on the canal for one year to allow him time to establish systems and infrastructure to control the spread of yellow fever and malaria, both of which had been recently identified as vector-borne diseases spread by mosquitos.  Dr. Gorgas brought a team of doctors, nurses, and engineers that had worked with him in Cuba and within that one year, they had eliminated cases of yellow fever in the canal zone and controlled malaria. His interventions were instrumental in the construction of the canal and important to this region, perhaps most importantly, he created Panama’s first piped water system and Latin America’s first water treatment plant. These improvements to infrastructure led to significant improvements in health, and marked the beginning of Panama’s current public health programs and institutions. 

Public Health Programs: Next, Dr. Calvo presented the structure of Panamanian healthcare and public health systems.  She discussed current public health concerns in the country as well as provided an overview of some of her current research initiatives. The programs she mentioned range from addressing teen pregnancy, providing HIV testing and treatment services, and Panama’s vaccine programs.  Of note is that Panama, along with El Salvador, are the only two Latin American countries that require the influenza vaccine for all pregnant women. Dr. Calvo spoke about one research project that investigated any possible adverse effects associated with the influenza vaccine in a cohort of 3,500 women. This study was underway during the outbreak of the Zika virus in 2015/2016 and because it was the only ongoing study with a cohort of pregnant women worldwide, study participants were also assessed for Zika. This research provided important insight into the impact of Zika on infants.

Then, Dr. Calvo briefly discussed the causes of mortality and morbidity in Panama. During her discussion we realized that the United States and Panama have similar causes of death including cardiovascular disease, breast and cervical cancers in women, and prostate cancer in men.

We also discussed differences between public health programs in the United States and Panama. Panama has lower smoking rates because they have more aggressive laws which prevent people from smoking in public places and ban the advertising of tobacco products including e-cigarettes. In addition, their anti-tobacco campaigns recruit local artist to design and create graphic murals in popular places around Panama City which depict the dangers of smoking.  Many countries could follow Panama’s lead in efforts to reduce the use of tobacco products and thereby reduce tobacco dependency.   

A no-smoking sign seen on the City of Knowledge Campus

Dr. Calvo shared a collaborative health education program that she worked to develop in coordination with the indigenous communities in Panama.  They found that while interviewing men from these communities that many openly admitted to spousal abuse. When initially conducting focus groups with tribe members they would specifically ask men if they hit their wife and what they would use to hit their wife.  One man, in response to the question, went outside and found a limb and brought it in to show them.  So, they took a photo of the limb and are using this image to begin the discussion about domestic violence in health education sessions with indigenous men. This is one example of why it is important to understand cultural values and norms within a community to work to change attitudes and behaviors to improve the public’s health.

In working with indigenous communities, Dr. Calvo also learned that the method of delivery of the health education content is important.  Community members requested that the content of their educational program be available and appropriate as technology (computers, projectors, etc) is unavailable in most of their communities.  The community expressed that the educational materials needed to be portable, weather resistant (because it often rains in Panama), and comprehensive.  So Dr. Calvo’s team produced a laminated flip chart that addressed a multitude of issues from sexual health and domestic violence to chronic disease prevention and nutrition.  These materials can be used in any community at any time.  This is an example of providing accessible content to address the needs of the community.

Team 1 –

Nekayla Anderson (Public Health Undergrad)

Sloan Oliver (Public Health Undergrad)

Jennifer Schusterman (HCOP/Maternal and Child Health Graduate Student)

Welcome to our Blog!

Thirteen students are traveling from Birmingham to Panama City, Panama for an opportunity to learn about both historical and contemporary public health issues, their effects on population health, and how public health systems are working to solve the health issues affecting communities in Panama today.  The trip is led by Lisa McCormick, DrPH, Associate Dean for Public Health Practice and Associate Professor of environmental health science in the School of Public Health and Ms. Meena Nabavi, MPH, program manager for the Office of Public Health Practice. 

This course will be based from Panama’s “City of Knowledge.” Students will tour historically and culturally significant sites and visit urban and rural communities and community-based organizations that are working to provide public health services. In addition, students will attend featured presentations around both contemporary and historical public health issues in Panama, as well as visit public health and healthcare agencies to learn about their structure, programs, service delivery models, and approaches to addressing issues of public health. 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 – in order to advance health equity.

Students will have the opportunity to shadow a local environmentalist and participate in community vector prevention activities, as well as work with students from the University of Panama to conduct a community health assessment in the city of Chitré, Panama. While in Chitré, students will also visit the Hipolito Perez Tello School and will work with kindergartners and 4th graders to educate them on the importance of personal hygiene and vector control.

There will also be meetings with public health leaders in Panama to discuss the spike in HIV infections in the country, as well as discussions around women’s health, refugee health, and environmental and economic impacts of the Panama Canal.

Getting Ready

Before the students departed for Panama, they had an opportunity to meet with several public health practitioners in Birmingham to learn about local public health initiatives.  This will allow them to compare issues and programs in the United States and Panama.

First, the students met with Kachina Kudroff, the Prevention Program Manager for the 1917 HIV Outpatient Clinic for an overview about HIV in the United States, specifically Birmingham and Alabama. Kachina shared challenges and barriers to accessing treatment, as well as talked about the 90-90-90 goal which aims to diagnose 90% of all HIV-positive persons, provide antiretroviral therapy (ART) for 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020.

Following the visit one of our explorers, Tim McWilliams, MD/MPH student, shared: “The 1917 Clinic really struck home with me and reinforced to me just how unique the HIV treatment process has to be. The entire experience at the 1917 Clinic was incredibly eye opening and showed me that even in the heart of UAB there is still so much left to improve on in HIV treatment, a daunting realization and an interesting framework to consider when visiting HIV treatment facilities in Panama.”

Students also had the opportunity to meet with Jonathon Stanton, the Director of Environmental Health at the Jefferson County Department of Health to learn about what a public health environmentalist does in the US public health system, including food safety, water, and pollution prevention and monitoring.

Madison Turner, a junior majoring in Biology said,  “I had no idea that most of what goes into the storm drains goes straight to our waterways or that plastic bags are clogging drains, which leads to bacteria blooms. This can introduce infectious agents, like cholera, into water systems.  He really got me thinking about how public health crises can be prevented by addressing environmental issues.”

Finally, the students met with Tim Pennycuff, Associate Professor and University Archivist at UAB to learn about UAB’s and Alabama’s connection to Panama. Mr. Pennycuff shared images and stories about Dr. William C. Gorgas, a physician from Alabama, who is best known for his work in Panama in quailing the yellow fever and malaria epidemic during the construction of the Panama Canal.

Katie Greene, MPH Health Behavior student, shared “I thought it incredibly fascinating to see how the role of Alabama physicians and other personnel from the American South helped create a safer, healthier environment for Panama. When I look at what I know of Panama today– especially Panama City– I have to think their economic success would not have been possible without laying some public health infrastructure first and lessening the impact of yellow fever and malaria. I also never appreciated until I began to travel, how seeing other societies can help provide a better lens on our life in America, and this is evident by the work the men who worked on disease eradication in Panama did back in the US when they returned home. As a student, this is so encouraging, that my practice and observations in one place might inevitably come in handy in another place and time later in life.”

Before departure, student groups presented to the class on the following topics: History of Panama, Culture of Panama, Panama’s Health System, and Health Status Indicators of Panamanians. These presentations allowed students to achieve a basic knowledge and understanding of Panama’s challenges, successes, and areas for improvement before they arrive.

The students will leave Birmingham on May 15th and return on May 26th and will be blogging every day!  Make sure you bookmark the blog and follow the adventures daily!

– Lisa McCormick and Meena Nabavi

We are Smarter Together: The Guinea Worm Eradication Program

The Carter Center was founded by the 39th president of the United States, Jimmy Carter. The Center advocates for the different faces of human rights. Programs are focused on health, politics, and peace. The Center collaborates with numerous organizations, like the CDC and WHO, to implement programs in countries willing to better the lives of their citizens. At the Center we met with Lauren Kent-Delaney, who is the educational director. She introduced the overview of the center and the many educational opportunities for college students like ourselves.

One important program of the Carter Center is the Guinea Worm eradication program. We met with Dr. James Zingeser, senior project advisor for the Guinea Worm eradication program, and he taught us about the successes and further challenges for the program. The program has been very successful in eradicating guinea worm in humans; however, the program is now facing a new challenge after the discovery that frogs may be a paratenic host, and may be passing the larvae to many animals such as dogs and baboons, which may be perpetuating the guinea worm. 

With this being our final stop on our road trip, we were able to see many of the underlying themes of the Guinea Worm Eradication Program connect with what we have learned throughout the past 2 weeks. In order to be as successful as they are, the program had to gain the trust of each community they visited. They did this by working with community members and by giving them tools to prevent and contain the spread of the disease. Dr. Zingeser mentions how adequate communication is vital to keep the trust among the community and how it is hard to gain the trust, but easy to lose it. During our visit to the Veterinary School at Auburn, we learned about One Health, which can be applied to the guinea worm program and how relevant it is to understand our connection to our environment and everything in it.

Dr. Zingeser says that we are smarter together. This quote highlights how it is essential to bring all the various fields together in order to achieve health equity, to overcome social determinants of health, and to work in harmony towards the needs of population health.

Emergency Care: Protecting Population Health by Servicing All

Grady Memorial Hospital, founded in 1890, continues to have a significant presence in the city of Atlanta. Those born in the city often refer to themselves as “Grady babies”, an endearing term that comes with a certain sense of pride. This respect stems from the rich history of Grady Memorial and Atlanta as a whole. The hospital is the Southeast’s largest Level 1 trauma center and they are committed to providing quality care for the residents and underserved people of metro Atlanta and Georgia.

Grady Memorial doesn’t turn anyone away. They provide healthcare for all of their patients, including those who cannot pay or don’t have health insurance. Dr. Arthur Yancey, Medical Director for Grady’s EMS Emergency Communications Center, told us about Grady Memorial’s six neighborhood clinics and their Mobile Integrated Healthcare Unit (MIHU). Clinic services focus on treating patients the moment they come in contact with them, and the MIHU focuses on working with high risk patients to reduce the costs associated with hospital readmissions.

On Homelessness

Homelessness is so much more than the stigma that surrounds it. Many believe that the homeless are those who roam the streets; however, this is a biased notion. Not having a roof over one’s head does not equal homelessness — an unstable home does. Atlanta’s increasing homeless population stems from the city having the highest level of income inequality in the U.S., giving way to their inclusive free healthcare system.

According to Emergency Medicine Physician and Medical Anthropologist Dr. Bisan Salhi, it is easier to bring someone from the brink of death than to get them the housing and food security assistance they need in the community. Our social welfare systems and healthcare systems are designed in such a way that our emergency lifesaving treatments are often more available than basic social services.  Resources hard to coordinate for patients include transportation, healthy food, and housing. However, there are many social determinants that keep vulnerable populations from reaching the best possible health outcomes. Dr. Salhi defined social determinants simply as, “the easier and better your life is, the better your health outcome is.” Therefore, if you live in an area with more availability to resources, your health outcomes will be better than those who are restricted.

(link to Georgia Poison Center jingle)

Georgia Poison Center

The Georgia Poison Center is a free and valuable resource for Georgia’s communities. It is part of a national network of poison control centers around the country. These centers are invaluable resources during toxicological emergencies and can be an early warning and surveillance system for contamination events or disease outbreaks.  Poison control centers are an economic investment as every dollar invested in them saves $20 in healthcare costs. The Georgia Poison Center is funded by both state and federal sources and works closely with the Georgia Department of Public Health.  They are a busy center as they receive up to 100,000 calls per year.  Given the medical cost savings and the number of individuals that are assisted, it was noted that each state would benefit from a poison control center.

Dr. Ziad Kazzi, an emergency medicine physician and medical toxicologist at Grady, met with us and made reference to several interesting points about the more commonly ingested products including e-cigarettes and vaping fluids, laundry detergent pod ingestion, and even asphyxia from the inhalation of helium from balloons. Another emerging issue is stemming from the legalization of marijuana and the dangerous effects it has had on children that accidentally consume edible products with THC.  This shows the importance of poison control centers and the need to preserve them to protect the future.

Team 3 — Alyse, Danielle, Deanna

Team 4 — Angela, Auriel, Jennifer

Past, Present, and Future Public Health Leaders at the CDC

Everyone is familiar with the CDC, a looming government institution even featured in pop culture shows such as The Walking Dead. But unless you work there very few people get to experience the magnificence first hand. It was very interesting to see all of the advancements in science throughout the iterations of the organization itself. From focusing on malaria and venereal diseases to now administering surveys and programs concerning exercise to name a few. After touring the CDC museum, which details not only public health advancements of the last 100 years or so and features recent extensive outbreak work battling Ebola, we met with UAB School of Public Health alumni. Meeting with Ivy Singletary, MPH , Margaret Paek, MPH, and Dr. Leigh Willis was an illuminating experience for many of us who wondered exactly how the CDC and all of its many interlocking pieces truly fit together. One of the things that really stuck out to us was the diversity in not only the work that they do but the sheer amount of opportunities awarded by the CDC. Just like any organization there is always some resistance when trying to get new projects up off the ground, but according to our alumni the best traits for public health students to cultivate are to be flexible and resilient.

Despite resistance, one alumnus, Leigh Willis, PhD, was able to create and enable a whole new method of outreach in order to share good health practices with the public. The method he pioneered at the CDC was Motion comics. https://npin.cdc.gov/KABIChronicles/index.html Not only is the program available to the public, but discussion guides come with each video to allow for interactive learning between participants and facilitators. Perhaps one of the keys to success is doing your research and presenting your supervisors with a product, rather than just an idea. Both Ivy and Margaret suggested to us that this was a key to having projects and programs picked up and funded. If you put in the work, and show that you have the initiative, you are more likely to get suggestions on how to improve. The experiences of these alumni gave us a realistic view of working at the CDC and increased motivation to serve in the field of public health.

One Health: We All Need Each Other

Every time you go to the grocery store, a restaurant, or school cafeteria, you can trust that you are eating safe food thanks to the dedicated staff at the state diagnostic laboratories. These scientists are responsible for disease surveillance, testing, and regulation of livestock, poultry, wildlife, and even honey bees. Dr. Frazier and his staff test and monitor domestic and wild animals for emerging and foreign diseases as well as diseases that can be passed from animals to humans: zoonotic diseases. The Alabama State Diagnostic Laboratory collaborates with the Alabama Department of Public Health on the surveillance of zoonotic disease. Human health and animal health interface on a daily basis as people interact with family pets, farmers interact with livestock, and feral animals cross human paths in urban, suburban, and rural areas. To assure that humans are healthy, the animals that share our environment must be healthy and visa versa. The term “One Health” encompasses the collaboration, cooperation, and communication between veterinary scientists and public health professionals to maintain a strong and thriving environment.

Our Wednesday began outside the Alabama Animal Diagnostic Laboratory were we had a  spontaneous conversation with Dr. Tony Frazier, the state veterinarian with the Department of Agriculture and Industries. Cloaked within his humorous banter were some powerful truths: “A country that has lots of food has a lot of problems. A country that has no food has but one problem. Agriculture touches everyone’s life. Food and food safety is important for everyone” As public health students, we don’t often think about how agriculture intersects with our work. We weren’t sure what we’d learn and what we’d see inside the lab. We were in for quite a surprise!

In the pictures below you can see us suited up in personal protective equipment before we entered the part of the diagnostic lab that houses the “Digester”, a large piece of equipment used to safely dispose of animal tissue and bone after its been necropsied and tested. This disposal procedure prevents the spread of harmful zoonotic diseases.

But it wasn’t all fun and dress-up games for the UAB Trailblazers. Dr. Frazier opened our eyes to the various avenues in which human health depends on animal health and visa versa. Did you know that Alabama has an enormous industry? We didn’t! And since the southeast is prone to hurricanes and tornadoes, the state has emergency preparedness protocols in place to assist when farmers suffer loss in the case of a natural disaster, or should a deadly disease be introduced to a chicken house. We learned from Dr. Heather Waltz, Director of Animal Diagnostic Lab, that part of the lab’s role is to monitor livestock populations at several points before they go to be “processed” and eventually sold in supermarkets. The lab runs thousands of tests on behalf of producers and consumers. Dr. Kelly Steury, DVM, MPH, Diagnostician and a recent alum of the SOPH spoke about emerging zoonotic diseases, including bovine  sponginess encephalitic (mad cow disease), and the convergence of animal and human health.  

As students of public health we keep finding we also must be students of history. Dr. Stephanie Ostrowski, Associate Professor of Public Health at the Auburn University’s College of Veterinary Medicine, detailed what could be considered the worst epidemic in history, although it’s not well documented: the Rinderpest plague of the late 19th century. The virus is structurally similar to measles, but can’t be transferred from animals to humans. In 1884, cattle imports introduced rinderpest, a virus known as the cattle plague, into Ethiopian herds of cattle and oxen. One hundred percent of cattle exposed to rinderpest contract the disease and more than 99% of infected cattle die of the disease. This epizootic event in Ethiopia annihilated livestock leading to the Great Ethiopian Famine of 1888-1892. Around 30% of Ethiopia’s population starved or died from other consequences of rinderpest. It spread from Ethiopia to other parts of the African continent, destroying livelihoods and causing economic disenfranchisement along the way. This likely made it much easier for colonists to continue to invade and oppress African people. During the 20th century, rinderpest was eradicated throughout the world by vaccinating cattle herds. However, much can be learned from the events and impacts of the rinderpest disaster of the 19th century. Most of us were unaware that this had even taken place. This historical tragedy highlights the connection between human health and animals, even when the disease itself can’t be transferred from animal to human.

Our day transitioned into a tour of the Auburn University College of Veterinary Medicine’s (AVM) state of the art facility that focuses on the prevention of many diseases and conducts comparative medicine research. While at the AVM, Dr. Jim Wright, Professor at AVM, discussed how vital controlling rabies is for population health because infection in humans almost always results in death. We learned that the Alabama Department of Public Health is at the fore front for monitoring cases of human rabies and track the animal source. Animal sources are not just limited to wildlife, as companion animals can be infected with rabies as well. AVM’s collaboration with other research teams (including UAB!) develop innovative projects that focus on some of the most prevalent diseases. Their collaborations embody the mission of One Health, by demonstrating that animal health is vital to improving the livelihood of populations.

Dr. Wright left us with a memorable approach to public health that will help us indicate when something needs attention: “Embrace the enthusiasm of looking at something weird.”

Teams 1 & 2

Road to an ethical high ground: The Tuskegee Experiment

“History, despite its wrenching pain cannot be unlived; but if faced courageously, needs not be lived again” –  Maya Angelou

Among the green pastures and businesses in Tuskegee lies a strong historical foundation. Tuskegee is a community deep rooted with faith, resilience, and forgiveness. It was these things that pulled them through the 40-year syphilis study that started out as a treatment program with good intentions, with funding from philanthropist Julius Rosenwald, and morphed into a unethical experiment that not only harmed the participants and their families, but also violated the trust of the community.

Trust is the foundation in which public health is set upon. This was known by the researchers and scientists involved in the United States Public Health Service’s Tuskegee Study of Untreated Syphilis in the Negro Male. They needed a connection to their target community; therefore, Nurse Rivers was the perfect bridge to that audience. Nurse Rivers was an African American women deeply rooted in the Tuskegee community as she had served as the communities public health nurse. They trusted and respected her fully; therefore, she was key to recruiting those with “bad blood” into the study.

On Health Equity

How do researchers help ensure the safety and rights of research participants? Through informed consent, which is when research participants understand the potential benefits and risks involved in the study. Dr. Stephen Sodeke, a bioethicist and professor of allied health sciences at Tuskegee University’s National Center for Bioethics in Research and Healthcare, defined bioethics as “identifying and addressing ethical, social, religious, and legal issues that arise in medicine, research, public health, and environmental science.” However, for the African American men of the Syphilis Study there were no such laws in place that discussed consent. Dr. Jontyle Robinson, the curator of the Tuskegee University’s Legacy Museum, introduced the case of Henrietta Lacks during our visit to the museum. Ms. Lacks nor her family, had any idea that cells had been taken from her body or used in research. “HeLa cells” derived from Ms. Lacks, have been used in countless research studies and even used to help create the polio vaccine.  This does not negate the fact that the doctors should have gotten her permission before extracting her cells.

On Population Health

Felicia Chandler and her family took the time to discuss with us their memories of the Shiloh-Rosenwald School and how their community was targeted during the Syphilis Study.  The motto of the school was”good, better,best, never let it rest, never stop until the good is better and the better is best”. Through Mrs. Chandler and the others that talked with us, this motto shows us a glimpse into the educational values instilled in the community.  They are a close-knit, resilient community strong in faith and even stronger in facing adversity. Looking back, they feel that the U.S. Public Health Service unfairly deemed the people of their community as ignorant, poor and uneducated; and as such were made to feel unvalued and less than human.  The people of this community worked hard, educated their children when African Americans could not attend public school, were land owners, with many of their residents continued on to do great things for this country.  The Tuskegee Syphilis Study has had a lasting negative impact on the community as well as a general and deserved mistrust of the government and outside medical professionals. This study left residual trauma that is still felt today and perpetuates health inequities. 

Our Final Thoughts

Considering all that we have learned today, a major theme to recognize is that each one of us is a “piece” of a jigsaw puzzle. Whether you are an educator, policy maker, or medical professional, together we are like a puzzle. We must figure out how to connect, raise awareness, and give vulnerable populations a voice. We need to carry all the lessons that we have learned, and apply them as we progress in our future professions and combat the adversities we are still witnessing today.

Bringing Healthcare Home with the Escambia County Health Department

During this visit, we learned about the Alabama Department of Health’s (ADPH) Southwestern Health District.  This district includes the following counties: Baldwin, Choctaw, Clarke, Conecuh, Dallas, Escambia, Marengo, Monroe, Washington, and Wilcox (see the image below for a graphic representation). It may seem odd to you that Mobile county is not included in this district, as it is so geographically close. However, both Mobile and Jefferson counties operate somewhat independent health departments and as such, have become their own districts.

The Southwestern District is largely rural with median household incomes per county ranging from ~51K (Baldwin) to ~24K (Wilcox). The percentage of folks who live in poverty ranges from 11.7% (Baldwin) to 35.4% (Dallas).  Baldwin has a higher socio-economic status than the other counties due to its lower half being a great destination for tourists and people who want to live by the beach. Dallas and Wilcox Counties are primarily African-American (70%). Naturally, we wondered how the Southwestern District Administrator addressed the diversity between counties with regard to income, poverty, race, and other social determinants of health.

Luckily, we had the opportunity to sit down with the District Administrator, Chad Kent, the Assistant District Administrator, Suzanne Terrell, and the Director of Field Services for ADPH, Ricky Elliott. We met them at the Escambia County Health Department and learned about the many programs and services offered at each of the local health departments, like the one we were in, throughout the District. These programs included, but were not limited to family planning, sexual health screening (STI and HIV testing), lead screening, home health programs, cancer detection programs, and diabetes education. Some counties even offered additional maternity services and included peer breast-feeding educators. We were also surprised and grateful to hear that in one county, the social worker actually brought birth control to a client who had no transportation. While this was likely an unlikely occurrence, the compassion of the local health department staff for their communities and their willingness to go above and beyond the call of duty does not go unrecognized. 

The commitment of the staff of the Escambia County Health Department and the Southwest District to their residents is impressive, especially with their dedication to make healthcare accessible to all that live here. While we were discussing this with them they shared with us a story of an elderly couple who would have had to drive over three hours one way to see a nephrologist at UAB.  The trip was difficult for the couple; navigating Birmingham’s traffic and parking was a source of great stress.  Through ADPH’s Telehealth Program, this couple and others can now “meet” their doctor at their local public health department.  Doctors can communicate with patients via a video call during routine follow-ups.  Some conditions can even be diagnosed and treatments recommended via this technology. This program is breaking down transportation as a barrier to accessing the care their residents need in order to live healthy and active lives.

While Telehealth is certainly a technological achievement, the District leadership was also very excited about two new changes coming to the District (and the state). First, a new electronic health record (EHR) system will be implemented later this year. An EHR system will allow for greater continuity of care within the ADPH system, as well as increase the ability to communicate with other providers. Second, Women, Infants and Children (WIC) is going somewhat digital as well. Traditionally, WIC clients have received vouchers that they can turn in for certain goods at their local retailers. Soon, WIC clients will receive a WIC card that will be loaded with a certain amount of money to purchase WIC items. This eWIC program enables clients more flexibility in the WIC items they can receive, saves time, and reduces any voucher and low income related stigma. Additionally, data from purchases will be used to inform other WIC services moving forward. Overall, technological advances have really increased the ability of ADPH to learn from their communities and adapt to better meet their needs.

Team 2 – Tessa, Kachina, and Dekennon

Rising through History to Overcome Barriers

The UAB Public Health Trailblazers headed to Atmore, AL after a restful but educational weekend. Our class includes students with heritage from most continents, and even some with Indigenous American heritage, but none who grew up in a tribal cultural setting. We were all outsiders as we entered the Poarch Creek Band of Indians.  We were there to visit the new tribal health department and health center and to meet with Sandra Day, the Director of Community Health.

Since our readers, like all of the student Trailblazers, probably would benefit from a brief background of this tribe’s history:

It is well established that the European settlement of North America led to various forms of systemic oppression, relocation, and genocide to the indigenous people that were here. In 1830, the Indian Removal Act forcibly relocated southeastern tribes to federally owned land west of the Mississippi River. The Poarch Band of Creek Indians circumvented this relocation and continued to reside in south Alabama, mainly in Escambia County.   They became a federally recognized Tribe in 1985. Although the acceptance of tribes across the United States has improved, the negative impacts of long term oppression still resound within tribal communities. As much as we’d like to think of this discrimination as ancient history, we must face the harsh realities of what happened not so long ago so that we can work towards genuine equity.

Native Americans experience higher rates of chronic liver and respiratory diseases, assault and homicide, self-harm and suicide, and alcohol and drug abuse when compared to white communities. The Poarch Band of Creek Indians Tribal Health Department is working to decrease these health disparities through access to services, health education, and several specific grant programs.

One such grant is the Good Health and Wellness project sponsored by the United South & Eastern Tribes (USET) and the Centers for Disease Control and Prevention (CDC). Mrs. Wynell Bell, the grant manager, detailed some of the programs they have implemented to address diabetes, obesity, and hypertension – the top three health indicators affecting their tribe. Incentives encourage the use of a monthly farmers market on the reservation. Wellness Wednesday is an event for the whole community, young, old, and in between, to survey individuals’ health and engage elders in physical activity. “They value their youth, and they value their elders,” Day told us. This event brings both together in a fun interactive event to pursue better health. As a reward for participating, vouchers for the farmer’s market (another result of this grant) are handed out to attendees.

Despite the efforts of the Poarch Creek Health Department, the tribe faces numerous barriers to improving their health. After a history of discrimination, distrust for nontribal members resonates throughout. To this day, the reservation remains a food desert. After elevated disease rates lower life expectancies, tribal members accept fatalistic perspectives toward health. The history of the Poarch Band of Creek Indians has shaped their health outcomes, but the devoted employees at the tribal health department remain optimistic. Programs that rely on grant funding are hard to sustain once the funding dries up. According to Bell, “this does not deter them from providing evidence-based programs and services that will work to improve health outcomes over time”.

It was very apparent from our visit that this community is completely family-oriented. We could feel it. And as we departed, we were left asking ourselves how can we reach out to help a community with a history of distrust of outsiders? How can we encourage young tribal members to seek training in medicine and public health and return to the reservation in order to improve health in their community? These and many other questions weren’t answered in a day. We won’t find a one-size-fits-all solution. Nor can we work in isolation; it will take a collaborative approach from many people from different sectors to provide comprehensive solutions. For the Poarch Band of Creek Indians, improved health outcomes can be achieved by programs that involve the whole family and partner with other organizations to seek common goals. With every stop, we gain a deeper understanding of how essential collaboration, trust, and community-focus are for achieving greater health equity.

Team 1 – C– Catherine, Claire, & Courtney