Author: mnabavi

University of Panama Regional Center

To begin the day our group loaded the bus at 7:45 AM and made our way to the University of Panama Regional Center in Chitré. The University of Panama is the largest university system in the country with the main campus located in Panama City and 10 regional campuses throughout the country. Today we visited the regional campus of Centro Regional Universitario de Azuero based in Chitré. This campus offers a variety of majors and technical certificates in fields such as human resources, nursing, business, social work, engineering, and architecture to 3500 students.

Stepping off of our bus the street view of the university was fairly subdued. The entrance to the campus resembled a bus stop with white brick divider walls surrounded by an iron fence. After passing through the gate and walking down a few steps the University of Panama campus opened up into all of its hidden beauty. All of the academic buildings are surrounded by green spaces and the modest white bricks are embellished with inspirational quotes and murals. Pictured above is the building, which houses the office of the regional campus president, the site of our meeting for the morning. Leonardo E. Collado Trejos is the president of the regional campus in Chitré and was the main speaker during our meeting. Mr. Trejos is an incredibly welcoming man who exuded a genuine excitement to speak with us during our brief visit. During the meeting, Mr. Trejos described the history of the university and the opportunities and degrees offered. During the meeting we had the opportunity to meet with a handful of nursing/community health students and various professors. We learned that these students and professors have been conducting health assessments in communities outside of Chitré, and we will be joining them tomorrow as we visit these areas. After leaving Centro Regional Universitario de Azuero, our next stop for the day was the Ministry of Health Herrera Health Clinic in Chitré.  

Herrera Health Clinic

Today we learned just how complex the Panamanian healthcare system is. Panama is divided into 13 provinces. Chitré is located in the province of Herrera, which is a relatively well-off province compared to the rest of the country. The Ministry of Health Herrera Health Clinic provides preventative care to the poorest citizens in the province. Most of the patients seen at this clinic include those that do not earn enough income to participate in the country’s social security health system or cannot afford the private system. Similar to the other Ministry of Health Clinic that we had visited, the Herrera clinic has a relatively modest exterior with the Ministry of Health insignia plastered above the entrance. Once inside the doors of the clinic the first thing that catches the eye is a huge mural of a woman breastfeeding her child directly above the reception desk.

The walls in the clinic are filled with intricately designed bulletin boards informing the public about heart health, fall avoidance, and services offered by the clinic. After a brief wait in the crowded lobby, our group toured the clinic with the chief nurse. She explained to us that all medical services are free or provided for a cost of one dollar. Of the free services a large majority are related to maternal and child health with all vaccinations, yearly check-ups, and prenatal care offered for free. Other services provided by the clinic, like routine dental visits, may require a small fee. During our tour the nurse described  the general flow of the clinic as a patient may experience it. The clinic, similar to other Ministry of Health clinics, opens at 5:00 AM where it is common for long lines to be waiting at the door. Contrary to the US system, patrons can scan their “cédulad”, a Panamanian ID card, and enter their cell phone number to be called into the clinic closer to the time they will be seen. For more specialized services like dentistry or an appointment with the mental health provider, patients can book appointments in advance to avoid long lines and be guaranteed to be seen on a particular day.

This appointment system is crucial due to the incredibly low staffing in the clinic. On a typical day there are seven doctors, three dentists (one of which is a pediatric dentist), and a number of nurses and nursing assistants working in the clinic. We were told on an average day they have about 21 people working in the clinic.  Each doctor sees about 25 patients a day, while nurses and nursing assistants, depending on their expertise, may see anywhere between 20-30 patients each day. The chief nurse estimated that they may see upwards of 400 patients each day in the clinic. She also shared that they are expecting a crowd of 1000 patients this next Thursday and Friday for a community clinic preventative program. They will have the same 21 healthcare workers staffing the day. The good thing is that these healthcare workers all seemed to love what they do and every nurse we met seemed vivacious and happy to speak with us. However, there was a common message throughout the day of the difficulty of having such a limited number of staff working in the clinic. During our time at the clinic it was easy to see that these healthcare providers were doing everything they could to care for the community but the number of people they can help with such a small workforce is limited.

Herrera Immunization Program – “En Panamá, no perdemos la oportunidad de vacunar (In Panama, we don’t miss an opportunity to vaccinate).” 

After leaving the Herrera Health Clinic, we visited with the nurses who run the province’s immunization program at the Ministry of Health.  Just like the immunization programs in the rest of the country, vaccination rates in the Herrera province are high, with some vaccination rates as high as 100%.  The nurses explained that Panama has one of the best immunized populations in the world. In the Herrera Province, with a population of around 118,000, in 2018, 89% of the population was vaccinated for influenza. We were also told that 100% of all healthcare personnel in the country are up-to-date on all of their immunizations. As a comparison, in the United States during the 2017-2018 season, influenza vaccination coverage among healthcare professionals was only 78.4% as reported by the CDC.

The most surprising part of the presentation was that Panamanian immunization nurses travel to places where clinics are inaccessible and where community members lack transportation. They said they need to visit these people because receiving free vaccinations is a right for all, nationals and non-nationals. The nurses explained that if a child becomes sick with or dies from a preventable disease, the parent could face hefty fines or even jail time. There are laws in Panama that ensure a child’s right concerning access to vaccinations. If a parent refuses to vaccinate their child, their parental rights may be removed. Since 1997, Panamanian children have received comprehensive vaccines to guarantee their right to health, and this trend continues into adulthood. In Panama, the following vaccinations are available for the following age groups:

• Children 0-1 year old receive 5 shots: Hepatitis B, BCG, Conjugated pneumococcus, a 6-1 for DPT, Hib+Hepatitis B, Polio), the flu shot, and the rotavirus shot.
• Children 1-4 years old receive 7 shots: Pneumococcal conjugate, Triple Viral MMR, Hepatitis A, Varicella, Yellow Fever, Pneumococcal polysaccharide, Polio, inactivated polio, Tetravalente (DPT-Hib), DPT, and Influenza.
• Children 5-19 years old receive 9 shots: Poliol, inactivated polio, Hepatitis B, MMR, Conjugated pneumococcus, Pneumococcal polysaccharide, influenza, Tdap, papiloma virus. However, the HPV shots needs parental consent since it is administered in schools.
• Women 15-49 or of child-bearing age receive 3 shots: Tdap Adulto, MR, Influenza, Tdap.
• In addition to this, the general population receives 2 additional shots: Tdap for adults and varicella.

As a comparison, in the United States, the CDC recommends that vaccines are for those who meet age requirement, lack documentation of vaccination, or lack evidence of past infection. In Alabama, verification of vaccinations occurs at enrollment in daycares, some K-12 schools, and higher education institutions. Additionally, Alabama has medical and religious exemptions from vaccinations, which are not allowed in highly conservative Panama.

Providing Health Education at the Hipolito Perez Tello School:

As part of our time in Panama, our class was requested to visit the Hipolito Perez Tello School to provide health education sessions to kindergartners and 4^th graders. Specifically, we were asked to cover personal hygiene topics with the younger students and to talk about vector control and vector borne diseases with the older students. Another reason for our visit was to give students of Hipolito Perez Tello the opportunity to interact with native English speakers so that they could practice the language. 

Hipolito Perez Tello School serves roughly 900 children from an upper/middle class neighborhood in Chitré. As we entered the school grounds we were led through a beautiful courtyard, with a covered outdoor play area where children were playing ball. We were all a little nervous as this was the first time that many of us had interacted with a group of elementary age students. But our fears were quickly laid to rest when we were greeted by curious faces and vibrant hellos once we entered the classrooms.

In the weeks leading up to our arrival at Hipolito Perez Tello, we had prepared sessions for each grade and had been fortunate enough to secure donations to bring with us from the Alabama Department of Public Health, the Montgomery County (AL) Health Department, UAB’s School of Public Health, and UAB’s New Student Programs.  We brought a variety of items to give the students including toothbrushes, toothpaste, floss, and dental hygiene activity books for the kindergartners, and backpacks stuffed with vector control activity books, colored pencils, and stickers.

Our group chose to work with one of the Kindergartner classes. When we entered the classroom, we were warmly greeted by the teacher and 20 or so students.  Classroom walls were adorned with student artwork and, interestingly enough, reminded each of us of our time in elementary school.  One of the UAB students in our group is fluent in Spanish, so we immediately began teaching the children the words for hands, washing, soap, water, teeth, toothbrush, paste, etc. in English.  Miming washing our hands and brushing our teeth, the kids mimicked our movements and repeated words in English with such confidence that we almost forgot that English was not their first language.  One young lady was so outspoken and smart, she had her fellow classmates quickly engaging with us. It is safe to say we learned a lot about communicating and interacting with children.  Because of this experience, I think my group will be more confident as we begin to work in the community.  In fact, before we left the school the children began sharing other personal hygiene tips with us including the importance of washing our face, eating well, and drinking plenty of milk.  It was the best information received from the cutest experts ever.

Down the hall my fellow Blazers were teaching 4th graders about vectors (specifically mosquitos) and how to protect yourself from them.  The kids in these classes were more than ready to answer the questions and enjoyed playing the game Mosquito Vector si o no?.  Students competed for prizes as they answered questions posed to them about the topic.

What did we learn?  These kids knew a lot more about these topics than we expected.  We were surprised that they were able to communicate with us about the health topics in even more detail than we had anticipated.  After our visit we learned that this particular school is consistently a top ranking public school in Panama.  They have a respected and devoted principal and teachers who are doing their best to improve their students’ educational outcomes. We left the school energized and hopeful that the information we shared will be useful to the kids as they learn and grow.

Team 4: Panamá Special Viral Unit

Tim McWilliams (MD/MPH Student)

LeahGrace Simons (Graduate EPI Student)

Wilnadia Murrell (Public Health Undergrad)

The Panama Canal

The Past: “An aquatic elevator,” as our tour guide Gabriel described it, is the perfect name for the 80 kilometers long canal. Considered one of the largest waterworks in the world, the Panama Canal has been serving Panama, along with about 160 other countries since its formal opening on August 15, 1914. However, we learned that building the Panama Canal was no easy task. The idea to connect the Atlantic and Pacific Oceans began in the early 16th century when the Spaniards arrived to the isthmus in search of gold. It was not until 1880 that efforts to build the canal through Panama began with the French, but the initiative was halted because of financial problems and tropical diseases that affected the Canal Zone. Dr. William Gorgas, an Alabama native, was recruited and put in charge of abating the transmission of tropical diseases  during the United States’ construction of the Panama Canal. Dr. Gorgas is credited with eliminating Yellow Fever and Malaria during this time, which allowed the Panama Canal to be built and opened. Since 1969, the canal has brought neutrality to Panama. Our tour guide explained how important it is that the country abolish its official military. This decision was made to protect the canal and the people of Panama in case of any conflict, as this way, the canal can continue to operate regardless of affiliation with world powers. The United States controlled the canal until Panama gained full operation through the Panama Canal Authority (ACP) on December 31, 1999.

The Present: The Panama Canal continues to be at the center of global trade. Since 1963, the canal has been operating 24 hours a day. With this constant operation, 6% of the world’s merchandise passes through the canal. The most recent expansion of the canal added a new lane that can accommodate cargo ships that hold over 13,000 containers. These type of ships carry about 27% of the world’s cargo. Through this expansion, the Panama Canal is seeing more ships than ever utilizing the canal to travel between oceans. In order for ships to utilize the canal they must make a reservation six months in advance; otherwise, the cost goes up significantly. The fee varies depending on the size and weight of vessel. A small catamaran may pay as little as $500, while larger container ships may be charged upwards of $500,000. As an alternative, for those who show up without making a reservation, they can try to make the highest bid to pass through. This helps the Panamanian economy by providing additional funds to the government via the canal. Through the Panama Canal, Panama houses some of the largest ports in the world, with the Colon Free Trade Zone (CFZ) having the second largest free port in the world. Through these venues, the canal adds a huge boost to the economy, not only by financial revenue, but also by providing jobs and bringing resources to the country.

Casco Viejo

Casco Viejo of Panama City was built during the colonial period. It was designated as a UNESCO World Heritage site in 1997. Casco Viejo, which means ‘old compound’ in Spanish, was constructed along the coastline of the Pacific Ocean in 1673 following attacks by Welsh pirates who destroyed the Panama Antiguo, the original city, which is five miles away from this site. The Spanish king commissioned this new site to better protect the city against future attacks. From its inception, the newly constructed Casco Viejo was full of travelers, adventurers, and workers from other countries. The cultural atmosphere was influenced first by the Spanish; then later an amalgamation of French, North American, and Caribbean customs and traditions entered the mix.  During the first part of the 20^th century when the Panama Canal was under construction yellow fever killed thousands of workers who came here to build the canal. Many hygiene improvements were made by Dr. Gorgas and his team to Casco Viejo including eliminating standing water and building infrastructure to handle sewage and water treatment. The main streets were paved and open air ditches were eliminated making streets more suitable for heavy traffic. A water system was established bringing water into homes and businesses eliminating leaking and uncovered water tanks. Also, there was house-to-house fumigation, oil was sprayed on the surface of all uncovered water to eliminate mosquito breeding, and windows and doors were screened to protect citizens from disease-carrying mosquitoes. Our tour guide Gabriel brought us to the outside of an old church in Casco Viejo. He explained that if not for the presence of this very stable arch, which was built in the 1600s, shown in the photo above, the Panama Canal could have ended up being built in Nicaragua, The flat stone arch demonstrated that Panama did not have earthquakes that could destabilize structures, nor did the country have active volcanoes; both of which are common threats to Nicaragua. This made Panama the ideal location for the massively engineered canal. 

Today there is a ‘Renaissance,’ what we would call gentrification, taking place in Casco Viejo. After decades of deterioration of buildings in this area, along with the deterioration of its infrastructure when squatters started inhabiting the structures, Panamanian and foreign investors are now pouring money into beautifying this colonial section of the city. Since 2014, infrastructure has been updated, including the water system. Roads and streets have been repaired using historically accurate materials from the early 20^th century. All of this is being done in efforts to draw tourists to the area so that the local landmarks and history can be preserved and shared.

Through both of these visits we were able to explore Panama’s past and see how history has shaped the current state of the country. The Panamanians have honored the past in order to build their future. In reflecting on everything we’ve learned thus far, it is clear the Panama Canal is the economic driving force in Panama.  And the work done by Dr. Gorgas and his team in the early 20th Century is still shaping Panama’s public health landscape today.

Team 3: PanaBamians

Lakeitha Seroyer (MPH Health Behavior Student)

Sally Engler (Global Health Certificate Graduate Student)

Madison Turner (Biology Undergrad)

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.

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.

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.

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)

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

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.

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.   

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)

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