Thank you for following along with our blog. It’s hard to believe we’re at the end—time has flown by! We’ve had the privilege of meeting so many wonderful public health professionals in London, Edinburgh, and Glasgow.

We’ve delved into the history of public health, explored how culture influences health, and gained a better understanding of how we can impact health not only in Alabama but around the world. This journey has highlighted both the similarities and differences among the people and places we’ve visited, reminding us just how small the world is and how much we all have in common.

Hats off to our students who stayed engaged, asked insightful questions, and participated in our Instagram stories despite a busy travel schedule. We hope that each student has learned valuable lessons from this experience that they’ll carry throughout their careers. Instead of us recapping the trip, we’re going to let the students share their most impactful visits from the course.

Lisa and Meena

We all started the day off early by taking a train from Edinburgh to Glasgow. Glasgow is Scotland’s largest city with a population of approximately 1.6 million people. People in Glasgow speak with a very distinct Scottish brogue, so we really had to pay attention. Once at the train station in Glasgow, we had a quick walk to a bus stop to make our way to the Queen Elizabeth University Hospital. Here we met with several members of NHS Scotland where they provided an overview of Scotland’s public health challenges, prevention and treatment programs for HIV, harm reduction programs for intravenous drug users, a brief overview of the health care system in Scotland, and general care/advocacy priorities throughout Scotland. 

Currently one of Scotland’s greatest health challenges is drug addiction; where approximately 60,000 Scottish citizens face drug related issues. Many involve heroin and cocaine which cause major issues for those taking these drugs intravenously. The majority of HIV cases are caused by sexual contact, but there’s also a portion related to sharing needles. In order to combat this issue, Scotland implemented needle exchange programs and safe consumption rooms so those who partake in drugs have lower risks of facing secondary issues. For instance, many people take these drugs in hidden places which tend to be unsanitary and also tend to reuse needles, thus causing greater risk of injecting unwanted disease and bacteria. These programs are meant to lower these risks and enforce safer practices of drug consumption in order to continue living with less complications for these individuals. Although this intervention is something that has been very controversial in the U.S., Scotland has prioritized this initiative as it helps people who use drugs to live longer and supports the creation of a healthier community. 

Our time here with NHS Scotland showed us that one of the hot topics of public health everywhere is the issue of harm reduction. Both in Scotland and in the U.S., politics and healthcare often clash. While policymakers and public health workers agree on the fact that drug use in communities is a problem, the way these two groups deal with that problem differs. For many public health workers, the goal may not be to completely stop drug use, especially because reaching that goal in the near future is unlikely. Rather, the goal is instead to reduce the negative impacts of existing drug use as much as possible and prevent the issue from increasing. On the political end, laws against drug use may stop drug use in certain contexts but in others create some prominent barriers preventing people from seeking care or at least support.Our job as community advocates is to work toward solutions that work for as many people as possible. Even if we don’t morally agree with certain interventions, we still have a responsibility to make health attainable for that person no matter how much time and resources it takes. Will it be simple or easy? No, as we learned from NHS Scotland. But we can keep trying, and we can keep learning – on both sides. 

We also learned of HIV testing, treatment and care programs in Scotland. Just like in the U.S., there are many challenges still faced. But, unlike the U.S., Scotland is well on the way to meeting its 95/95/95 goals by 2030. 

We all walked away feeling this was one of the best visits in Scotland and wished we could have met with these public health professionals earlier in our trip. There are many takeaways and lessons learned that could be used to improve public health programs in the U.S. With more time, we could have learned so much more about how programs are designed and implemented in Scotland and what might work in the U.S.

After lunch, we went on a walking tour through the West End of Glasgow, including the famous Ashton Lane, before heading to the University of Glasgow. The campus was absolutely beautiful, culturally rich and historically significant. Some significant sites we came across included the James McCune Smith Learning Hub, named after the first African American to earn a medical degree. We also visited the prior residence of Sir William Thomson, Baron Kelvin, famous physicist, who introduced the absolute temperature scale, now known as the Kelvin scale in his honor. We also walked past the Sir James Black building, named after the Nobel Laureate himself. We also learned that Albert Einstein visited the university in 1933 to receive an honorary doctorate and gave a lecture about his theory of relativity. These were just some of the highlights from the University of Glasgow campus. It was blooming with beautiful spring flowers and greenery everywhere, serving as a great backdrop for our pictures. 

Here are some of the sights from the walking tour!

A statue of William Thomson, better known as Lord Kelvin. One of his most fundamental scientific contributions was creating the system of absolute temperature, though he was responsible for many more contributions.

Beautiful medieval-style architecture from the Victorian Era done at the historic University of Glasgow. Very Harry Potter-esque!

We ended our walking tour at the Botanical Gardens, after which we took the bus to Café Anti Pasti for our farewell dinner. Although we were sad to leave, we were able to enjoy one last group dinner before we departed. Some of the highlights included playing a game of trivia that revolved around what we had learned on our trip, UAB prizes, and lots of laughs with friends.

This day was a day of museum. We were given information to get into the Surgeons’ Hall Museum at the Royal College of Surgeons of Edinburgh and the National Museum of Scotland and were allowed to go through them at our own pace. Some of us also visited the National Galleries of Scotland. This was fun, as there were a lot of interesting things in the museums that we would have missed on a tighter deadline. First stop was the Surgeons’ Hall Museum.

The Surgeons’ Hall Museum was made of three parts: pathology, dentistry, and technology in medicine. There were many pieces of medical history in the museum that helped to shed light on how medicine has grown as a profession. Things like washing your hands before performing a surgery were not common practice and actually learning these things and putting them into practice was a major step forward for medicine and public health. These advances in medicine helped increase life expectancy. We thought that the technology in health exhibit exemplified this. There were a number of exhibits that showcased how robots and other technologies are now being used in surgical theater. These technologies have led to shorter recovery times and better outcomes. These technologies cannot operate on their own, they still needs skilled surgeons. Surgeons must practice these techniques and hone their skill set over many hours.

In the 1800s, cadavers were the only way for medical students to learn anatomy and physiology. At this time, if you were a criminal that was executed by the Scottish Government, your body would have been donated for medical science. However, since Edinburgh was the hub of medicine and anatomy, there were many medical students training in the city with few cadavers available.  This led to an underground trade of bodies that were sold to medical theaters, in order to be used as teaching aids.

As we discussed in the previous blog, this led to the rise of “body snatching” and to more nefarious cases, such as Burke and Hare, who murdered at least 16 people to sell their bodies to Dr. Robert Knox for dissection. Their methods, involving intoxication and suffocation, highlighted the era’s disregard for the poor and the desperate lengths people went to escape poverty. Public outrage over the murders reflected a sense of morality amidst hardship. This dark chapter underscored the need for ethical sourcing of cadavers and stricter regulations in medical research. The visit was more than a scare; it was a sobering lesson on the importance of ethical practices and health equity, instilling in us a responsibility to advocate for these principles as future public health professionals.

Next, we visited the National Museum of Scotland. This museum was full of different exhibits, mainly focused on science and culture. There was an amazing nature and animals exhibit that spanned three floors and talked about topics from evolution to climate change. There were also cultural exhibits with items from Egypt, Eastern Asia, Scotland, and more. These exhibits were interesting, as they showed what the culture and communities of these areas at certain times in history were like. Dolly the Sheep was also featured in this museum!

Dolly was the first successful cloning of the living mammal. She represents a huge leap in science and medical technology and possibly one of the next steps in the health sector. Cloning would present some interesting public health challenges, both ethically as well as medically. The National Museum of Scotland was also highly interactive, which kept us all interested and engaged.

We visited the National Galleries of Scotland on our own today as well. This is a free art museum that is separated into two buildings: one in a beautiful Victorian style building and the other a more modern one. It is home to one of the greatest art collections in the world and they have a variety of art from modern and contemporary. In these galleries, you can dive into dramatic landscapes, encounter iconic images, and be wowed by the very best of Scottish art from 1800 to 1945. We also marveled at spectacular views over Edinburgh and discovered other works of pioneering Scottish artists such as William McTaggart, Anne Redpath, Phoebe Anna Traquair, Charles Rennie Mackintosh and the Glasgow Boys. They even have portraits of people who shaped Scotland over time, artists like Ramsey and Raeburn. There is also art by Botticelli, Monet, Van Gogh and much more.

As we walked through the halls of these museums, we couldn’t help but think about how culture and health are so intertwined. The implications of access to free museums can change how people see themselves. It can increase our sense of wellbeing and belonging and help us feel proud of where we come from. It can inspire, challenge, and even stimulate us. As we have seen from our studies, human health and culture play an integral part in the social determinants of health. It is important to understand culture so that we can implement interventions that are culturally appropriate and acceptable to the populations that we serve.  

From the growth of medical technology and pathology to the availability of free public spaces, Edinburgh’s museums show both the past of public health, the present of today’s public education, and the future of health in Scotland. Knowing the history of a community and how we have gotten to where we are today allows us to further our learning and proceed into the future better prepared and more culturally competent.

Today was the day we would discover the Castle of Edinburgh and delve into the history of Burke and Hare. First stop: The Castle of Edinburgh. On our way, we noticed a royal vehicle and caravan outside of the University of Edinburgh, so we stopped and asked who was here. We were told a member of the Royal Family would be out shortly! We waited and were able to see and meet Prince Edward, Duke of Edinburgh. This was a real highlight of Dr. McCormick and Meena’s trip!  

Afterwards, we headed up the Royal Mile towards the Castle, where the paths take you through time. The castle is home to many historical figures including Mary Queen of Scots, who gave birth here to future King James VI of Scotland and the 1st of England and Ireland.

Edinburgh Castle is perched atop the rocky cliffs of Castle Rock and stands as a formidable symbol of Scotland’s historical legacy. Its origins date back to the Iron Age, making it one of the oldest fortified places in Europe. The area around Edinburgh Castle started as Din Eidyn, a busy Roman settlement. After the Goddidin King of the Edinburgh invaded the land that is now known as England in AD 638, the castle became known as Edinburgh.  The town grew from the castle, with the first houses built in what’s now known as Lawnmarket and then down the rock’s slope, forming a single street, later referred to as the Royal Mile. This street got its name because royalty often traveled the route to the castle. Over the centuries, the castle has witnessed countless sieges, royal ceremonies, and pivotal moments in Scottish history. Its role varied over history from a royal residence to a military stronghold to now storing the Scottish crown jewels and being a major tourist attraction. This iconic fortress, with its storied walls and strategic location, offers a fascinating glimpse into Scotland ‘s history.

After our morning at the Castle some of us went to find the classic scone with clotted cream. We enjoyed this for the first time at the British Museum, and were excited to try it again in Scotland.

On the way to lunch, some of the students ran across CREW; a clinic whose main goal is to reduce drug and sexual health related harms and stigma. They also advocate for improving mental and physical health without judgment. CREW’s values are acceptance, genuineness, empathy, justice, and accountability. This organization enhances public awareness of sexual disease and stigmas through experts that built their reputation in the community of Edinburgh. They also influence policies to improve the community of Scotland. CREW serves as a place of inclusion in the community and helps facilitate social justice while challenging modern stigmas. They mainly focus on young people to help reduce drug related deaths. To combat these deaths, CREW offers free drug tests to ensure that the drug is safe to consume. They also fight the war against drug related deaths by providing naloxone for anyone in need. Congruently, CREW provides other preventive and protective products such as PREP and PEP. CREW also offers free condoms, period products, STI testing, and HIV testing.

Our next stop of the day gave us an in-depth illustration of the realities of living in Edinburgh in the 1800s. This experience delved into the history of surgery and allowed us to learn how the medical students of the time mastered human anatomy. For this, they needed human cadavers which were hard to come by in 1828. This cadaver shortage created a grave robbing economy which led to new rules on how anatomical specimens could be acquired. This led to body snatching, or what was referred to as “resurrectionist”, where body would be dug up from their grave and sold to people teaching/studying anatomy. In fact, we noticed that in Greyfriars Kirk, there were many graves that still had cages over them to deter body snatchers. Two of the most infamous for providing bodies to Dr. Robert Knox, head of the anatomy school in Edinburgh, was William Burke and William Hare. In the year 1828, over the course of seven months, this dynamic duo murdered 16 individuals and received payment from Dr. Knox for each body. This first was a person who was in debt to these men and died in their inn. To recoup their missing funds, they brought the body to Dr. Know where they received 8 pounds in return. Through this experience they decided to continue procuring bodies through suffocation which allowed for perfectly presentable cadavers. These men were caught in October of 1828 and Hare was granted amnesty by turning Burke in. In 1832, the Anatomy Act was enacted in response to public revulsion at the illegal trade in corpses. This highlights the importance of ethical integrity when advancing public health and medical knowledge and illustrates the consequences when those boundaries are crossed.

A group of us students woke up early today so that we could hike up to Arthur’s Seat.  Arthur’s Seat is the highest point above Edinburgh and has breathtaking panoramic views of the whole city. This mountain peak is just east of the city center and rises to a height of 822 feet. It was a beautiful morning, and everyone thought the hike was absolutely worth it. You could see all of Edinburgh from just one spot. You could even see the Firth of that we could hike up to Arthur’s Seat.  Arthur’s Seat is the highest point above Edinburgh and has breathtaking panoramic views of the whole city. This mountain peak is just east of the city center and rises to a height of 822 feet. It was a beautiful morning, and everyone thought the hike was absolutely worth it. You could see all of Edinburgh from just one spot. You could even see the Firth of Forth which connects to the North Sea! From the top, the people looked like ants and you could clearly see Edinburgh Castle. Arthur’s Seat is famous because it is said that King Arthur would watch over his kingdom from this point each day.

     Later, we met back up at the hotel to begin our service day with the community-based organization, Four Square Edinburgh. Four Square is a charity with the mission of improving the lives of people who are experiencing homelessness in the city of Edinburgh. Housing is a growing issue in Scotland. Yesterday, when we met with members of the Scottish government, they had discussed a recently declared “cost-of-living” crisis in the country that is further exacerbating housing insecurity. Four Square serves over a 1,000 individuals per year through their various programs to provide housing and life skills and job training to people who are thought by most to be on the outskirts of society. This only addresses a fraction of the need in Edinburgh as for some of their services there can be a two-year waiting list.  Once we arrived at Four Square, we met with Rebekka Ford, Four Square’s Community and Event Coordinator.  Rebekka stressed that homelessness is a significant burden on the population and is a complex cycle to break. We loved how Four Square focuses on teaching residents skills that will allow them to live independently and eventually break the cycle of homelessness. Through empowering women, education, and creating a community, many women who are victims of domestic abuse can regain their lives. We often forget about some social determinants of health, and homelessness is usually one. In the future, we will be sure to remember this population when working in public health.

Another vital part of the Four Square organization is their charity shop, one of the main funding sources for their different programs. During our visit we did various tasks to help at the shop including gardening, cleaning furniture, and reorganizing inventory. The shop provides high quality pre-loved furniture.  And whether you buy or donate furniture, you are supporting people who are experiencing homelessness as well as helping the environment by keeping items out of the landfill.

Before and after photos from one reorganization effort we undertook in the shop!

Similar to Scotland, the United States also has a major homelessness issue. Based on data from the U.S. Department of Housing and Urban Development (HUD) which is summarized in the “State of Homelessness: 2023 Edition”, around 18 out every 10,000 people in the U.S. are currently dealing with homelessness (National Alliance to End Homelessness [NAEH], 2023). Since 2017, homelessness has increased by about six percent (6%) overall, with specific racial/ethnic groups, such as Pacific Islanders, African Americans, and Native Americans, experiencing greater numbers of homelessness (NAEH, 2023). Another subgroup disproportionately impacted by homelessness is men, who are the gender at most risk (NAEH, 2023). Unfortunately, though there is a clear need for shelter, support, and other resources that can help mitigate the effects of this public health problem, 40% of people who are homeless still live unsheltered (NAEH, 2023).

Though homelessness in the U.S. is and likely will continue to be a rising public health concern, many organizations exist whose goal is to assist people who are homeless with support, tools, and resources that they can use to get back on their feet. An example (which is just one of many throughout the country) is the Firehouse Shelter in Birmingham, which is run by Firehouse Ministries and was founded in 1983 (Firehouse Ministries, n.d.). Right now, this agency helps more men who are chronically homeless than any other organization in the state of Alabama, helping around 5,000 individuals per year (Firehouse Ministries, n.d.). Much like Four Square, this charity not only provides shelter, but also provides employment support, life skill development, and literacy training (Firehouse Ministries, n.d.).

Seeing this work in both the U.S. and Scotland really drives home the idea that public health should be holistic in nature. To give people who are experiencing homelessness a chance to thrive and to promote health equity, our approach should include multiple factors, especially the social determinants of health (education, housing, transportation, etc.). But the biggest, most important lesson is that we are dealing with people – people who, though they do not have a home, still have hopes, dreams, and goals, just like we do. Our service experience today only solidified our resolve to keep this lesson in our minds even after we return to the U.S.

References

Firehouse Ministries. (n.d.). The Firehouse shelter. https://firehouseshelter.com/#:~:text=The%20Firehouse%20Shelter,-Firehouse%20Ministries%20serves&text=Founded%20in%201983%2C%20we%20operate,in%20Birmingham%20and%20surrounding%20areas. National Alliance to End Homelessness (2023). State of homelessness: 2023 edition [Data set]. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness/

Today, we had an early start with a foggy Edinburgh morning. After breakfast, we took the tram to travel to the Port of Leith, which is on the coast of Edinburgh. The tram reminded us of the New Orleans streetcar, but more modern and a smoother ride, running through the city connecting Edinburgh airport to the city center. After getting off the tram and a short walk, we reached Victoria Quay, one of the Scottish Government buildings.

After going through security, we met with three representatives who work for directorates concerned with population health within the Scottish government.   Each shared great insights about the Scottish public health and healthcare systems and policy they are working to implement to improve health outcomes across Scotland.  Kai Stuart, Senior Policy Officer, gave us an overview of Scotland’s population priorities, the government’s prevention agenda, and the population health framework they are currently working to develop.  The framework is focused on four primary preventative drivers of health and well-being, including social and economic factors, healthy places and communities, health promotion, and equitable access. It was interesting for us to make comparisons between NHS Scotland and NHS England from our time in London.

Caitlin Frickleton, Senior Policy Officer for the Place and Well-being Program, shared the care and well-being portfolio of the country with us, in line with the government’s missions of equality, opportunity, and community. We learned that Scotland is prioritizing prevention as part of a wider healthcare strategy and is using the Health in All Policies approach. David Thompson, Head of Innovation Adoption, shared the use of technology and AI in healthcare. Some programs which have been piloted and currently taking place include the Dermatology Referral Program, Type 2-Diabetes Remission program, Pharmacogenetics program, and the lung cancer screening program. All of this information prompted us to ask many questions, which led to a great discussion about these programs and priorities of the Scottish Government as well as comparisons with those in England and Alabama. So much so, that we ran over our scheduled time and had to rush back to the hotel to get ready for our next tour. There was so much to learn, we could have stayed here all day!  Thank you to Kai, Caitlin, and David for a very rewarding morning!

After a quick change of outfits and shoes, we made our way to the Mary Kings Close! Not to mistake Mary King with Mary Queen of Scots, Mary King was declared a Burgess (a member of parliament for a borough) by her late husband, which means she could own a borough and have voting rights in the town. This was incredibly uncommon for her time, the 17th century, but she was granted these rights and built a borough that was suspected to support independent women of the time and was 80% occupied by women.

 Closes are very narrow streets which date back all the way to medieval Edinburgh, where residents would reside within these narrow paths deep that extended off the Royal Mile. This was highly convenient considering they were close to many of the royal buildings, markets, other residents, etc., but this caused tremendous problems. Since the residents were all packed together in these narrow paths, they were constantly near one another and had increased chances of spreading diseases and various illnesses. For instance, during Mary Kings’ time, they were faced with the bubonic plague, also known as the Black Death! This was caused by Yersinia pestis, a bacterium spread by fleas from the rats that ran rampantly throughout the city. Once infected, individuals will experience symptoms such as fever, headache, weakness, painful and swollen lymph nodes, and develop buboes in the neck, underarm or groin area. The window between onset of symptoms and death was approximately 48 hours (about 2 days) and only about 5% survived the illness.  The tips of fingers, toes and nose would turn black with gangrene, hence the term “Black Death”.

The plague epidemic throughout Edinburgh, Scotland was due to the crowded and unsanitary living conditions. There was not a sewage system during the 1600 and 1700’s, so residents would place their waste into buckets, then every morning and night the waste would be dumped out their windows or tossed down the steep incline that would drain into Nor Loch. This was usually the job of the youngest child in the household.  This practice would attract the rats which carried the fleas that spread the deadly plague. To put this into perspective, for every resident in Edinburgh there were approximately three rats (1:3 ratio of people to rats) within the city. So, we could imagine how fast this plague was spreading! Unfortunately, there were also not many physicians able to treat all these people, except one man…the plague doctor! The plague doctor would wear a leather and waxed fabric suit head to toe (the historic PPE) and would visit patient homes to try to treat them.  Treatment included lancing the buboes to release the infection. Then the doctor would cauterize the area. Some people died of septicemia due to infection being introduced to the blood stream, others dies of shock due to the cauterization.  So the options for treatment were very limited.  And all of this chaos was happening within these steep, narrow closes that we visited today and really stresses the importance of good environmental health and sanitation practices.  

After this we went on a walking tour of Old City Edinburgh and the Royal Mile, where we briefly discussed the theft of the Stone of Destiny in 1296. The Royal Mile is a stretch of streets running from Edinburgh Castle to the Palace of Holyroodhouse. It is called the Royal Mile because it is a 1.12 mile stretch between the two royal sites. On this tour we saw a few of the local closes as well as St. Giles Cathedral. St Giles is known as the Mother Church of Presbyterianism. We were able to view the Edinburgh High Court, where extremely important governmental decisions are made. We finished this tour by rounding the outside of the National Museum of Scotland where we finished our discussion on the Stone of Destiny. It turns out that the stone was returned to Scotland in the 1990s by some college students. Soon after its discovery, the Scottish government sent the stone back to England before its final return in the 2000s. This stone was used in the coronation of King Charles III in 2023.

We are so excited about the activities that we will be engaging in for the rest of the trip! Follow along for more from UAB School of Public Health!

On Wednesday, we departed London on our way to Edinburgh, Scotland. Our journey began at King’s Cross Station, where we had the opportunity to visit the 9 ¾ Platform, a must see for any Harry Potter fan!

We boarded the train on our four-hour journey to Edinburgh.  Some of us slept, some of us caught up on work, and some of us enjoyed the beautiful scenery though England and Scotland.

Once we arrived in Edinburgh, we made our way to our hotel on Princes Street. We were immediately in awe of the beautiful architecture we saw just on our brief walk from the train station.

After a quick refresh, we made our way to Calton Hill, which boasts a collection of some of Edinburgh’s most important monuments and offers fantastic panoramic views of the city.

Afterwards, we were able to enjoy a group meal at Howies, where some of us dined on a traditional Scottish cuisine of Haggis, Neeps & Tatties! For dessert, we celebrated one our student’s birthdays!

When we came out of the restaurant, we were greeted with an eerie scene of fog and mist while we walked back to the hotel. We are looking forward to our time in Scotland!

Lisa and Meena

Today was an early morning as we met up with our faculty members and classmates. After breakfast, we loaded up on a coach which took us to the Terrence Higgins Trust, the leading HIV and Sexual Health charity in Europe. We got there early so we enjoyed some snacks (fresh strawberries!) and waited for our program to begin. At around 9:30 am we went into a conference room where we were introduced to Cornelis, Barrie, and a very inspirational guest speaker and advocate named Pank Sethi.

Pank spoke about his personal story and the trials he endured as an inmate in the English prison system in 2018. Pank educated us on the disparities in treatment of HIV in the prison system and the stigma that contributes to the lack of access to care.  He told us about how his status was revealed to people in prison without his permission and how his dignity was striped by the sharing of this private information. Pank explained how the first step of addressing HIV stigma is education.  And he began educating others while still in prison. Pank was ignored and bullied and even threatened with bodily harm because he was assigned kitchen duty and was involved in food prep. Misinformation about HIV was being spread among inmates and guards, including that the HIV virus can be spread via food. They offered to move him to another prison because the threats grew, but Pank decided he would sit down with a group of inmates and explain HIV and how it is spread. This led to him being accepted by his fellow inmates. 

Pank fells like he is lucky in that he is comfortable and confident in his own skin and with his sexuality, but others in his position are not.  Pank also is a very articulate and educated person which gave him the ability to communicate effectively with others. Pank shared that his time in prison dealing with these issues was the pivotal moment where he decided he would spend the rest of his life advocating for people with HIV; especially those in the prison system. His friend Stephen, a man in prison with HIV, committed suicide three days before he was to be released because he could no longer handle the bullying from his fellow inmates. Pank fells that Stephen could no longer see past his situation when he reached his breaking point and ended his life. Stephen’s official cause of death was reported as suicide due to depression. However, Pank made sure that Stephen’s parents knew the real reason Stephen took his own life and Pank again dedicated his life’s work to telling Stephen’s story and fighting for people who cannot fight for themselves. 

Pank also let us know that he was denied his HIV antiretroviral medication for sometimes weeks at a time.  Nurses didn’t understand why doses should not be missed and, when he complained, guards thought it was about him wanting to get “high”. But Pank explained that when he was diagnosed, doctors explained to him quite clearly that he should never miss a dose.  And when you have to repeatedly miss doses because the prison system is not making it available, you are super stressed and know that you can form a resistance to that particular medication.  So viral loads are not regular monitored and you may or may not get your needed viral suppressant medications. 

While treatment is an important priority to address the HIV epidemic, prevention is equally important as we learn at the UAB 1917 Clinic during our pre-travel visit.  We know that condoms are extremely effective in preventing STI’s.  We were shocked to find out that UK prison systems do not allow condoms in their prisons as it counter to their rule of “no relationships”.  However, sex happens and health departments are providing condoms, but are fined for bringing them into the prisons. PrEP is another tool for HIV prevention, but currently on one in 117 prisons in the UK are piloted the use of PrEP. Without these simple preventative measures, HIV is being spread in the prison system. 

Opt-out HIV testing is available in prisons, but most opt-out because they don’t understand exactly what they are being tested for and why.  More than two thirds of people living in prisons in the UK have a lower reading level than an 11-year-old, which means that they cannot understand the consent forms and opt-out of all testing. About 7% of the prison population is living with HIV, but others may not know their status. 

As an HIV and Sexual Health specialist, Pank encouraged us to use our voices to help bring justice to those in the prison system who have wrongly been treated because of knowing their status. Mr. Sethi’s biggest message was: “You need to get used to being at least a little uncomfortable all of the time”. He believes that in order to truly make changes and work towards ending the stigma around HIV, we, as public health professionals, need to be okay with hearing the hard stories and speaking up for people who feel like they cannot. Building a relationship with the people you work with, or better yet, working within your own community, is necessary to make people feel like you are on their team. Without building that trust, no progress will be made. 

After Pank’s presentation, we heard from two of employees of the Terrance Higgins Trust, Cornelis and Barrie.  They provided an overview of HIV in England, challenges with testing, treatment options, and care, and common preventative measures being used. We found out that 40.3% of those living with HIV in the UK are gay and bisexual males. Another 30.2% are black people of African heritage, 2.9% are black people of Caribbean heritage, and 0.21% are people who identify as trans and gender diverse. However, they feel much work is left to do as some communities are not being reached for awareness and testing. The community that is the hardest to reach in the UK is black and African women. There is a need for cultural competency when educating African women particularly, as this population may have experience other forms of discrimination and trauma including unequal power relationships, gender-based violence, social isolation, and limited access to schooling. These things increase the HIV vulnerability of these women and girls. Cultural practices such as female genital mutilation and other harsh rituals make the issue even more complex.   

Barrie spent a good bit of time explain how HIV treatment is accessed in the UK. For the general UK population, the goal for HIV is 90/90/90: 90% tested, 90% treated, and 90% with an undetectable viral load. Fortunately, the NHS makes it easy for more people to be tested and treated. Prevention is easier as well, with generic PrEP being no cost to patients within the NHS; even private PrEP is quite affordable (~19 pounds a month). This is a stark contrast to the $2,000 per month required for Truvada in the states. 

In both the U.S. and the UK, many obstacles remain before we can conquer HIV. These barriers, including fear, stigma, and prejudice, are deeply embedded in our culture and society. However, thanks to dedicated healthcare professionals and community-based organizations, education, and individuals willing to share their experiences, we are making progress every day. This gives us ample reason to be hopeful.

Once we finished, we then loaded back up on the coach and headed to our next location,The Tower of London. The Tower of London has a long history and has been many things over the years, a royal palace, a prison, an armory, a zoo, and much more. It was originally built by William the Conqueror in 1078 and expanded in 1399. As we walked the cobbled pathways, as public health students, we couldn’t help imagine the medieval health challenges that were seen here throughout the centuries.  From the basic hygiene practices in the palace (i.e. urinating in a hole in the wall of the palace) to dealing with disease outbreaks, the Tower provided us a reminder of the evolution of public health over the 900 plus years since this site was occupied by William the Conqueror.   

While at the Tower of London, we visited the White Tower, saw the Ravens, stood near where Anne Boleyn was imprisoned and beheaded, viewed the Crown Jewels, and took pictures with a Yeomen Warders of His Majesties Royal Palace and Fortress The Tower of London (i.e. a beefeater). As we were leaving the gates of the Tower of London, we couldn’t help but notice the striking juxtaposition between the ancient and modern city of London.  This blend of new and old highlights London’s ability to honor it’s rich history while progressively evolving.    

-Alicia, Nneka, and Shannon

By Monday in London, we have figured out the Tube, how to mind the gap, and we can almost always remember to look right for traffic. Some of us are discovering the differences in United Kingdom (UK) and American foods while others are navigating the big city life coming from small town rural Alabama.

Today all of us had the opportunity to visit The London School of Hygiene and Tropical Medicine! The London School of Hygiene and Tropical Medicine (LSHTM) is a research University and postgraduate school in Public and Global Health. LSHTM was founded in 1899 by Patrick Manson, a Scottish physician and founder of tropical medicine. Originally, twenty-six names appeared on the façade of the LSHTM building. These names were all men who contributed to science and public health such as Robert Koch and Louis Pasteur. In 2019, the school added three female names to the building to recognize their contribution in furthering innovations in public health: Marie Sklodowska-Curie, Florence Nightingale, and Alice Augusta Ball. During our tour of the inside of the building, we visited their library that holds the largest collection of public health literature in the United Kingdom and saw the John Snow Pump on loan from the John Snow Society to the LSHTM. 

After our tour of the building, Dr. Hilary Davies-Kershaw gave a lecture on the overview of the healthcare delivery and public health system in the United Kingdom. We learned more about the National Health Service (NHS) and the differences between England, Wales, Scotland and Northern Ireland public health systems. Dr. Davies-Kershaw explained that some specialties such as optometry and dental services are not covered under the NHS, these services are private. Dr. Davies-Kershaw discussed the financial structure and how public health and healthcare is funded through tax payer dollars. She explained that the structure is different for other parts of the UK such as Scotland, Wales, and Northern Ireland. In the United Kingdom, the process of receiving care, specifically specialty care can be prolonged. After discussing the differences between private insurance and the NHS, Dr. Davies-Kershaw discussed how public health in the UK has changed overtime and sentinel laws that they hope will lead to improved health outcomes.

After a quick lunch break, we visited the National Portrait Gallery. Here we saw a myriad of different pieces from various artists spanning the globe. The National Portrait Gallery was established in 1856 and holds the most extensive collection of portraits in the world. The gallery’s collection includes paintings, photographs, and sculptures of notable figures. From the moment you step inside, you’re transported through the centuries, surrounded by captivating artworks that bring the past to life. The gallery highlights the Tudor, Elizabethan, Victorian and Contemporary eras. Our class was most excited to see the various attributes to our current public health strategies and foundations of epidemiology. One example of this was the images we viewed of Margaret Jennings; she played a crucial role in the purification of penicillin. Her work involved developing methods to extract and purify penicillin, which greatly contributed to its mass production and use as an effective antibiotic. Jennings’ contributions were instrumental in saving countless lives and revolutionizing the field of medicine. Another interesting character was Aneurin Bevan. He was a prominent British politician and a key figure in the establishment of the National Health Service (NHS). Putting faces to names humanizes the historical figures we have been learning about on this trip. With a deep understanding of the histories within public health and epidemiology, we now have a strong foundation on which to build and continue to gain more insight in Scotland!

After our afternoon in the museum, we played tourist and experienced London culture. One group used their time to check off many of their remaining bucket list items. We continued to explore different parts of the city by riding double-decker buses, taking the tube, and walking everywhere! Some of us visited Buckingham Palace and even met kind police officers who were willing to snap some photos and even lend their hats! The night ended with dinner and then some of had a friendly competition to see who could navigate public transportation and get back to the hotel the fastest. 

Another group chose to spend their time by going to the Sondheim Theater to enjoy a West End show. Here the group sang, laughed, and cried during Les Miserables. Surprisingly, the premises of Les Miserables related back to some of what we have been discussing in the course: poverty, homelessness, mental health, discrimination (i.e. the social determinants of health). As we dried our tears from the moving performance, we headed back to the hotel but not before popping by a pub for traditional fish and chips! We are so fortunate to be able to take advantage of all London has to offer. These experiences will last a lifetime and are really spurring a desire to explore and learn in other parts of the world.

Happy Mother’s Day (which just so happens to be day three of our trip)! The day got off to a good start with a breakfast of beans on toast. Not our favorite, but it was not as terrible as expected and a good lesson in managing one’s biases.

Our first visit of the day was to the British Museum, which we had been looking forward to visiting since we learned of our course itinerary. Our assignment was to go on a public health “scavenger hunt” of sorts, looking for items in the museum that could be linked in some way to our class themes (social determinants of health and health equity) or general public/population health. Since public health is such an expansive and multidimensional field, which is both influencing and being influenced by diverse factors, this task was not a very difficult one. The existence of the museum as a whole already raises some concerns about ethics which are worthy of discussion. For example, while the British museum does allow large groups of people to view and appreciate artifacts from around the world at no costs and is a major caretaker of millions of items essential for the understanding of world history, this museum also has a negative side. Unfortunately, many items were taken from other countries and kept even until the modern day. Because culture and history are important aspects of human life that are woven into day-to-day existence and therefore contribute to health and well being, we have to wonder if the removal of these items from their home countries has had any effect on culture and sense of identity in the populations of said countries. Has the removal of these items impacted history sharing, pride and esteem, or traditional practices? How have the actions of the British limited or propelled forward innovation and development in countries around the world? These and other questions were pondered as our visit began.

The British Museum is quite extensive, having several floors that contain rooms upon rooms filled with fascinating historical-cultural collections. The first item of interest we saw was the Rosetta Stone, which is a famous artifact known for helping historians crack the code of Egyptian hieroglyphics. Because many of us are fans of Egyptian history and mythology, we explored that section first, then made our way around to the Assyrians, Greeks, Romans, and other ancient cultures. One of the major themes that we saw as significant in these sections is socioeconomic status and how it is closely linked with food security, education, housing, and leisure. The relationship between class and social determinants of health is a concept that transcends time. Another concept relevant to public health that we found interesting about the museum is the portrayal of the human body in art. In several cultures, there was a push to create idealized figures, which eventually changed into a desire to make art that reflected the true human condition: capturing emotion, nuance, and so-called flaws. Around the 4th century BC, Greeks became interested in depicting people with visible physical impairments. While the purpose of this is unknown, it is believed that they may have been made to inspire laughter, which in turn was thought to promote good luck. The Greeks did not have a very thorough understanding of disability as it is known today, and even now, many people are under educated about disabilities. This translates into effects on multiple levels of the sociological model, all the way up to policy. While in London, we have noticed the lack of easy accommodations for mobility impaired individuals in London public transport. To change the norms around disability, accessibility, and accommodation, we need to begin with education. If people are not aware of the need for health equity for more vulnerable populations, then they will not know the specific changes needed for this population to exist comfortably within society.

Here are some other items of interest we found on our scavenger hunt through the museum:

At a half past one, the class met up for high tea at the Great Court Restaurant, which is located on the top floor of the British Museum. We were seated at two long tables, which were set with teapots, teacups, and saucers, as well as little containers of milk and sugar cubes. The teapots were filled with English Breakfast tea, which is a strong, flavorful mix of black teas meant to be consumed with milk and sugar. We also had the customary pairing of sandwiches and sweets with our tea. Some of the treats, such as carrot cake, lemon meringue, and egg salad sandwiches, were familiar. Tasting British scones was especially interesting because the taste was not too dissimilar from that of an American biscuit – they were quite delicious with clotted cream and jam! Many of us in the class were quite excited for this part of the day choosing to dress-to-impress so that we could take nice photos for our first proper tea. Although this experience was a relatively brief one, we were able to immerse ourselves in one of the defining cultural activities of London and the country of England as a whole. Sitting down for tea highlighted the importance of two tenets of culture: socialization and food, which are often intertwined. It also emphasized one of the things that is often absent in our society: the need for us to sit down, rest, and just allow ourselves to “be” for a moment.  Rest, socialization, and mindfulness are all major components of a healthy lifestyle, and though activities such as high tea are not direct public health interventions, we can all take the principles underlying such practices and incorporate them into our personal and collective lifestyles. We students were certainly inspired by the English culture of high tea and some of us will even be incorporating this activity into our routines once we return to the States!

After high tea we walked to the corner of Euston Road and Gordon Street, the site of the Wellcome Collection. This was a small yet fascinating museum dedicated to various artistic representations of health, medicine, and life. The exhibits included historical and contemporary artifacts, artworks, manuscripts, ant literature that addressed topics such as disability, ethics, bias and public perception, pollution, food supply, and infectious disease. The Wellcome Collection does a wonderful job at generating interest and awareness with a seamless blend of art and science. We were inspired by the “Help the Normals” and “Dignity” pieces. Because so many of us deal with mental health concerns, we believe it is essential to change the narrative around mental health. Mental health issues are not moral failures nor the fault of those who have them; rather, they are often medical or contextual in nature and can be addressed with the right treatment. But preconceived ideas about these issues can often create barriers to treatment. Still, if we are willing to start normalizing mental health issues and let people know that they are still valuable as human beings, perhaps we can start breaking down barriers like stigma. These exhibits are great starters for that type of conversation and be used to continue this method of education.