Blaze Explores Population Health in Panama

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

I have been practicing my Spanish to prepare myself.

 Wait, I think I see Panama!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Deep Dive into the World of Indigenous People in Panama

Panama Viejo

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

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

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

Panama Viejo Ruins

Indigenous Communities of Panama

Tusipono Emberá – Where the River Takes Life

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

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

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

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

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

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

Group 4 – Panama Special Viral Unit

Tim McWilliams

Wilnadia Murrell

Leahgrace Simons

Nadia with Princesa

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

Santo Tomas Hospital (HST)

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

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

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

Outside of the main entrance of Santo Tomas

HIV in Panama

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

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

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

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

Dr. Ana Arauz presenting to the class

The Biodiversity of Panama

The exterior of the Biomuseo

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

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

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

Chitré Volume 3 and Back to Panama City

UAB Students at the entrance of Hospital Cecilio Castillero

Hospital Cecilio Castillero

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

A poster about HIV transmission in the hospital

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

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

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

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

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

Culture: Tinajas Restaurant

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

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

Dancers perform in traditional Panamanian attire

Adventures in Chitré: Volume 2

Educating the Community: A Key to Preventative Health

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

Dancing for Health

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

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

The Eneida M. Castillero School

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

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

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

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

The Community

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

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

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

Team 1 –

Nekayla Anderson (Public Health Undergrad)

Sloan Oliver (Public Health Undergrad)

Jennifer Schusterman (HCOP Graduate Student)

Adventures in Chitré: Volume 1

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.

Blazers with Mr. Leonardo E. Collado Trejos , President of the Regional University of Panama Campus in Chitré

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.

Two nurses from the Herrera Immunization Program

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 4th 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)

A Taste of Panama: The Panama Canal and Casco Viejo

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.

Group picture at the Panama Canal

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.

Team 3 at the Panama Canal

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 20th 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 20th 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.

The Cathedral Basilica Santa María la Antigua located in the Old Quarter of the Panamanian capital that the Pope visited earlier this year.

Team 3: PanaBamians

Lakeitha Seroyer (MPH Health Behavior Student)

Sally Engler (Global Health Certificate Graduate Student)

Madison Turner (Biology Undergrad)

“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 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:

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