Uncovering London’s Public Health Past

At the beginning of our first full day in London Dr. McCormick divided us into 3 teams.  Each team had to navigate London’s public transportation system and meet her at the Royal College of Physicians. This was our first unguided adventure using public transportation and the London Underground (a.k.a. the Tube) for most of us. Each team plotted their own route, and we are happy to report that everyone successfully made it to our destination on time. Once at the Royal College of Physicians we met up with Charlie Forman, our guide for the day. Charlie walked us through major historical public health issues faced over the decades and described public health innovations that have occurred in response to these challenges.

The Royal College of Physicians is located across the street from Regent’s Park.  Charlie did a great job of connecting the need for green spaces with improvements in physical and mental health and overall well-being of Londoners over time.  Some parks and green spaces, such as Regent’s Park, were initially intended for only elite groups of people. The park became publicly available to all in 1835.  Today, it is very evident that parks and spaces across London are well used. While at Regent’s Park, we were surrounded by joggers, walkers, cyclist, and families coming to spend time promenading around the park. Charlie also showed us a picture from the mid-1800’s that showed how vital these parks were to those in the “working class”.  Victoria Park was used extensively by Londoners, who yet had running water in their homes, for bathing in the lake.  Even today, these parks are an integral part of the community and provide a space for increased physical activity as well as an escape from the bustle of the city.  During our walk, we passed multiple green spaces, big and small, that were all being extensively used.

Inside Regent’s Park
They are closing the streets of London so that families can bike!

Charlie also discussed the correlation of tobacco use and lung cancer, and the shift of the medical community to advocacy.  Some members of the Royal College of Physicians did not think it was their role to tell people not to smoke or to advocate against the tobacco industry.  In 1962, guided by their president, Robert Platt, the Royal College of Physicians published a report titled “Smoking and Health” which was a landmark report connecting smoking with lung cancer.  This marked a new time for the Royal College of Physicians as now they began to understand their role in matters relating to public health.   

Next, Charlie pointed out that the mid-1800’s was a pivotal time for London.  The population had increased rapidly from 1 to 3 million, everyone was using coal to heat their homes and cook, gas lanterns were being used to light the streets, and there was no functionally sound sewage infrastructure in place. London was not a good place to live or work during this time. The stink was sometimes so bad that it was hard to breath and the air quality was sometimes so poor that people would get lost in their own neighborhood.  By pointing out the chimney’s on the top of homes that have been in use since the late 1700’s, you can just image what air quality was like when they were all burning coal! Environmental conditions became so egregious that people were commonly suffering from respiratory illnesses, leading to numerous fatalities.

Charlie Forman

Walking further we learned of Lord Joseph Lister.  Lord Lister was instrumental in pioneering antiseptic surgery.  He did research in bacteriology and infection in wounds, which revolutionized modern surgical practices and lead to a reduction in post-op infections.

Statue of Joseph Lister, the father of modern surgery and famously known for finding ways to prevent infections after surgery.

As public health students, we were able to learn many things ranging from public health policy, housing, diet and physical activity, addiction, women in public health, and much more. Being able to see these momentous sites and learn the history behind each one really opened our eyes to how much the world and everything around us affects health. Some fun facts from the day tour were:

  • London has a Congestion Charge and ULEZ (ultra-low emission zone) charge for London citizens who drive motor vehicles in the congestion/ultra-low emission zone.  This zone is the largest congestion/ultra-low emissions zone in the world and works to reduce noise and air pollution while investing in London’s transportation system.  If you drive your personal motor vehicle any time between Monday through Friday from 7:00am-6:00pm and weekends from 12:00pm-6:00pm, you are charged ~19 USD per day that you use your vehicle. If your vehicle is over 15 years old, you are not allowed to drive in the ULEZ. This policy has lowered gas emissions throughout the city and restored cleaner air; however, this could cause inequity between those who can afford
    to pay the fee and own a newer car and those who cannot.

  • As you know, London is famous for its double decker buses.  Back in the 1950’s, on each bus there was a driver and a bus conductor who was responsible for collecting tickets after people boarded the bus.  A link between sitting and illness was found in a study of these bus drivers and conductors.  A bus driver would sit for over 90% of their shift, while bus conductors stood and climb ~600 stairs per day up and down to collect tickets.  Bus drivers were found to be twice as likely to have heart attacks as their peer conductors. This was the first study to established a correlation between physical activity and quality of health.

  • Charlie took us to Piccadilly Circus to discuss sewage in London in the mid-1800’s, specifically, the “Great Stink” of 1858.  At one time raw sewage flowed just beneath the street until it ended up in the River Thames. The Great Stink occurred over the summer months of 1858, when the English Parliament could not conduct business because the sewage stink coming from the river was so bad that people were passing out in the streets.  Because of this, and the fact that the Palace of Westminster which houses the Houses of Parliament is on the River Thames, Parliament funded the design and creation of London’s current sewage system. However, Charlie noted that when the system was built, there were ~3 million people living in London, and it was designed for 6 million.  However, today there are 9 million currently living in London and there is much work being done to expand their sewage treatment capacity.
A Stink Pipe

Next, we walked through the narrow streets of SOHO. SOHO in the mid-1800’s was a working class neighborhood. Charlie really helped paint the picture of what it was like to live in the crowded conditions of SOHO with no sewage system and bad air quality.  Poorer people could not afford low sulfur coal to heat their homes so the air quality was often worse in these crowded neighborhoods. 

And finally, we ended our tour at the John Snow Pub!  We were all so excited to get here.  John Snow, an English physician, is know as the founding father of modern epidemiology.  Dr. Snow hypothesized that cholera was being spread via water not miasma (the belief of the time that all infectious agents were spread by bad air). His work in mapping cases lead him to the Broad Street pump – ground zero for the outbreak – and where the John Snow Pub is located.  And whether this action alone was responsible for ending the outbreak or not, he is famously known for removing the handle from the Broad Street pump to prevent others from drinking the contaminated water.  After taking pictures at the pump, we went inside the pub to sign our names in the John Snow Society’s visitor book; which all public health professionals want to do!  Then we sat upstairs in the pub and discussed Ghost Map: The Story of London’s Most Terrifying Epidemic – and How it Changed Science, Cities and the Modern World, the book by Steven Johnson.  During this discussion we drew parallels with contemporary times, particularly the COVID-19 pandemic. Overall, it was a very enriching, exciting, and memorable experience for all of us.

Cheers from the Broad Street Pump!

After we left the pub, we headed to the River Thames for a boat cruise. This boat ride was full of historical facts about the River Thames and its surroundings. It allowed us to contrast Steven Johnson’s description of the river 170 years ago to today.  London did a remarkable job of cleaning up the river. Just 60 years ago the river was biologically dead.  Today it is known as one of the cleanest rivers running through an urban center.  The boat tour operator shared that earlier in the day they had spotted dolphins, seals, and beavers in the river!   

After the boat ride, we rode the London Eye. The London Eye is Europe’s tallest cantilevered observation wheel at over 430 feet tall, which enabled us to witness some of the best views of London.  We had a great day and what a great start to our trip.

Areva, Grace and Tayyaba

London is our cup of tea!

Greetings from London, England! After a whirlwind journey spanning over 30 hours, marked by weather delays and missed connections, we all touched down at London Heathrow Airport on Friday morning (except for our fellow student, Akshar, who didn’t make it until Friday afternoon due to severe storms and tornadoes in the Dallas, TX area). Despite the trials of traveling, we were all excited to see each other and start our trip exploring population health.

Dr. Aaron Hunter, Faculty at Cambridge University and our tour guide for the day

After arriving at our hotel, we had a moment to freshen up before we headed out with Dr. Aaron Hunter for our guided tour through the streets of London. We learned about historical figures in public health and their contribution to the field.  We walked through the University College of London (UCL) campus and discovered that it was the first higher educational institution in the city of London and the first in England that admitted students regardless of their religious affiliation (and one of the first to admit women.)  We visited several areas of London including Westminster, SOHO, Bloomsbury, St. Giles, Covent Garden, and Trafalgar Square.  He even showed us the alley that inspired J.K. Rowling’s Diagon Alley in the Harry Potter series.  This tour gave us the historical bearings of the city so that we may better understand the importance of public health in London over the centuries. Dr. Hunter was engaging, funny, and brilliantly British. He kept us all moving and awake as we grappled with jet lag.

As we were walking through the streets of London, we saw many monuments and placards memorializing the public health and medical contributions of women. Dr. Hunter made a point to stop at many of these along the way. He also pointed out that in 2019 the London School of Hygiene and Tropical Medicine, where we will be visiting later in our trip, added the names of three women health innovators (Marie Curie, Florence Nightingale, and Alice Augusta Ball) to the façade of its Kappel Street building in Bloomsbury.  We were so impressed by this as so often it can feel like women’s contributions are overlooked or pushed aside to favor and center men in history. Dr. Hunter’s commentary was greatly appreciated by all. The London School of Hygiene and Tropical Medicine has always been at the forefront of public health and healthcare innovation, so it was nice to see them moving towards equality in where they place their admiration.

We all came to the consensus that the architecture of London and its myriad of famous historical sites is the most breathtaking aspect of the city. Truly just walking the various cobblestone streets adorned with copious amounts of intricate sculptures and structures was all inspiring.  London’s architecture is a rich tapestry of historical and modern styles. We were privileged to view iconic landmarks such as the Elizabeth Tower (which we commonly call Big Ben, but Big Ben refers to the bell that is inside of Elizabeth Tower), Westminster Abbey, and the various other royal locations. Being surrounded by these iconic landmarks was like stepping into another world! The astonishment was only furthered once our Dr. Hunter navigated us through the complex histories associated with site. Even taking time to tell us of his own familial histories gave us insight to see just how important these buildings and establishments are to the people of England!

After our tour we headed to Marquis Cornwall, a local eatery in the heart of Bloomsbury, for a celebratory dinner of local cuisine.  London has lots of different kinds of food from all over the world that is very different from what we’re used to in the U.S., especially Alabama. For example, fish and chips are a famous British dish with crispy fish and fries, usually eaten with malted vinegar. Many of us selected this as our first meal in London. 

In spite of all the delays and difficulties we had in getting to London, experiencing the most famous parts of this great city was amazing. From the architecture to the food to the tour, everything was very interesting and hearing about these famous locations from such a knowledgeable guide helped in our understanding the city and diverse culture. It gave us a glimpse of the history of the city where public health had its beginnings.

Sidebar – From Akshar’s Point-of-View: While everyone was touring the city of London, I was stuck on a 10-hour flight that had been delayed and canceled multiple times in Dallas due to severe weather. Luckily, on the plane I was able to finish an assignment on Ghost Map that was due on Saturday when we planned to discuss it at the John Snow Pub. Ghost Map is a book by Steven Johnson that chronicles the cholera outbreak of 1854 in the SOHO area of London and John Snow’s contribution. My flight finally landed at the London Heathrow airport and I used the Tube to get to the hotel to meet everyone. So all in all, this experience was a lesson in patience, and really solidified the famous British saying – Keep Calm and Carry On

Akshar, Alicia, Becca, Chandler, Colleen, Nneka, and Shannon

Crossing the Pond: Our UK adventure begins!

In just a few days, a group of 16 University of Alabama at Birmingham (UAB) graduate and undergraduate students and faculty will journey to the United Kingdom to explore public health and healthcare systems in both England and Scotland. We will visit the historic cities of London, Edinburgh, and Glasgow, where students will take a deep dive into population health and global healthcare perspectives. We will be blogging daily, sharing our adventures, insights from our travels, encounters with public health professionals and policy makers, and the invaluable lessons we will learn along the way. So please make sure you check our blog for new post daily beginning May 12, 2024.

As part of this experience, students will have the opportunity to learn about the history of public health, beginning with sanitation and the control of infectious diseases.  While walking the streets of London, students will learn about John Snow, an English physician known as the founder of modern epidemiology and early germ theory, and his response to the cholera outbreak of 1854. We will learn, firsthand, about priority public health issues affecting communities in the UK, how these issues are being addressed, and strategies being implemented to advance health equity.  While in London, we will meet with faculty from the London School of Hygiene and Tropical Medicine to learn how the UK’s public health and healthcare systems are structured.  We will meet with representatives from the Terrence Higgins Trust, UK’s leading HIV and sexual health charity, to learn about the services they provide and their goal to end new HIV cases by 2030.  In Edinburgh, we are scheduled to meet with a member of the Scottish Cabinet, the main decision-making body of the Scottish Government, Mr. Neil Gray.  Mr. Gray is the Cabinet Secretary for NHS Recovery, Health and Social Care. Two ministers support the work of the Cabinet Secretary, the Minister of Public Health and Women’s Health and the Minister of Social Care, Mental Wellbeing and Sport.  From Mr. Gray’s staff we will learn about the policies Scotland hopes to prioritize and implement to improve its citizens’ health outcomes. Also, while in Edinburgh, we will meet with representatives from Four Square, a community-based organization that provides support and services to those experiencing homelessness or who are at risk of becoming homeless. And finally, in Glasgow, we will meet representatives from NHS National Services Scotland or NSS.  The NSS provides a broad range of both clinical and non-clinical services in Scotland, and we will learn about their response to infectious disease outbreaks, such as COVID-19, and about their efforts to stop the spread of bloodborne pathogens, such as HIV. 

We hope that this experience will showcase the interdisciplinary nature of public health practice and will emphasize the critical importance of addressing the social determinants of health.  Moreover, we endeavor to shed light on the ubiquitous impact of health inequities on global health outcomes, recognizing that disparities exist across various social strata in all nations.

Before we travel!

Prior to our departure for the UK, students convened with various healthcare and public health practitioners and representatives from community-based organizations in Birmingham (AL). These sessions provided insight into global health, local public health concerns, as well as the programs and initiatives aimed at tackling them. The purpose of these meetings is to facilitate a comparative analysis between public health issues and initiatives in the United States and those to be encountered during our time in the United Kingdom.

On Monday, May 6th, Camryn Durham, Assistant Director of the Sparkman Center for Global Health, conducted a seminar introducing students to global health, its history, interprofessional global health core competencies, and the 17 Sustainable Development Goals. She also discussed issues around building equity by addressing historical and contemporary injustices, overcoming economic and social obstacles to health and health care, and eliminating preventable health disparities.  This presentation set the stage for us as we begin our journey!

Sparkman Center for Global Health, Camryn Durham

On Tuesday, May 7th, we made a stop at the UAB’s 1917 Clinic. Here, we had the pleasure of meeting Kachina Kudroff, the manager of prevention programs, who is both an alum from the School of Public Health and this very course! Ms. Kudroff provided us with a comprehensive overview of HIV in the United States, with a special emphasis on Alabama. She shared invaluable insights into HIV transmission and prevention, discussed the latest treatment options, underscored the importance of viral suppression, and illuminated the challenges faced by individuals seeking HIV treatment. The purpose of this stop was to equip students with a comprehensive grasp of HIV in Alabama prior to exploring challenges in the UK, with the goal of enabling them to effectively compare and contrast the two contexts.

Kachina Kudroff, UAB 1917 Clinic

To underscore the clinic’s multidisciplinary approach to patient-centered care, Kachina put together a panel discussion for the students. The panel comprised experts from various fields, including prevention/outreach (Kachina herself), providers (Raven Peggins, CRNP), nurses (Marsha Hawkins, RN), social workers (Rashundra Hopkins, MSW), research (Heather Logan, DNP), and community representation (Tony Billups). Despite the absence of pre-prepared questions, the students eagerly dived into the 1.5-hour session, covering topics ranging from vaccine research to medication costs and the enduring stigma surrounding HIV. It was a deeply engaging conversation that showcased the collaborative spirit and dedication of those working at the UAB 1917 Clinic.

Panel discussion at 1917 Clinic

After our visit to the 1917 Clinic, we walked just two blocks away to meet with two remarkable individuals from Birmingham AIDS Outreach (BAO): Kris Hutchins, LICSW, MSW, PIP, Director of Client Services, and Joshua Glenn, B-FED Coordinator. BAO is committed to enhancing the well-being of those affected by HIV/AIDS, individuals at risk, and members of the LGBTQ community. Their mission is realized through extensive outreach initiatives, age-appropriate prevention education, and the provision of supportive services.

Visiting with Kris and Josh at BAO’s Magic City Acceptance Center

During our conversation, Kris and Josh elaborated on the array of services offered by BAO and how they effectively address the needs of individuals living with HIV in the Birmingham area. One significant aspect we discussed was the challenge of food insecurity. In response, BAO established the “B-FED” program, aimed at improving the health outcomes of HIV patients.

Before the inception of B-FED, BAO faced limitations in the types and quantities of food and nutritional supplements they could provide to clients. However, with the launch of this program, their outreach has expanded significantly. Initially serving around 200 clients per month, by 2024, BAO is now reaching approximately 1400 clients monthly. Josh led us on a tour of their facility, showing us that clients now have access to high-quality restaurant-grade vegetables, fruits, meats, dairy, and grains.

Josh discussing B-FED and showing us the BAO food bank

In addition, an education department was established to provide information on nutrition, food safety, meal preparation, and health education to clients. For those with medical requirements, BAO facilitates meal delivery offering healthy pre-made microwaveable meals tailored to individual health needs.

On the final day before we traveled, students conducted presentations to introduce the culture, politics, demographics, history, and public health indicators and concerns in England and Scotland.  These presentations provided everyone with a baseline to draw upon as we visit with multiple stakeholders, policy makers, and organizations in the UK.

Students and faculty will leave Birmingham on May 9th.  We will be blogging most every day, so make sure you bookmark the blog and follow our adventures!

– Lisa McCormick and Meena Nabavi