A Crisis of Care

  • December 1st, 2003

Alabama’s Black Belt Faces Health Care and Education Challenges

by Elizabeth M. Smith

Dr. John Higginbotham, Dr. Alfonza Atkinson and Dr. John Stone meet at Tuskegee University to discuss Project EXPORT research.
Dr. John Higginbotham, Dr. Alfonza Atkinson and Dr. John Stone meet at Tuskegee University to discuss Project EXPORT research.

Alabama’s Black Belt is part of a region that is home to both the richest soil and the poorest people in the United States. It is an area where economic stagnation is common and small, dying towns dot the landscape. Insufficient health care and underfunded and understaffed schools are the norm.

Still, the people who live in the Black Belt hold a strong and determined hope for a brighter future. The University of Alabama and Tuskegee University hope to work with them to overcome the formidable obstacles that have come from years of neglect.

Their collaborative effort is a project titled “Reducing Health Disparities in Alabama’s Black Belt.” It is better known as Project EXPORT, short for Excellence in Partnerships for Community Outreach, Research on Health Disparities and Training. The project is being funded with a $7.5 million grant from the National Center on Minority Health and Health Disparities, a division of the National Institutes of Health.

The funds are being used to establish a “Center of Excellence” through facilities on both campuses. Each school has developed six core research areas that will fund new projects and enhance existing ones. During the five years of the project, Tuskegee and UA will expand and focus on infrastructure to decrease health disparities in diabetes, cardiovascular disease, cancer, hypertension, HIV/AIDS and infant mortality.

These activities will involve a broad array of faculty, students, staff and community members at both universities and beyond. Dr. Benjamin F. Payton, president of Tuskegee University, is principal investigator for the project, as is Dr. John C. Higginbotham, director of UA’s Institute for Rural Health Research.

“In everything we do, we’re working with Tuskegee and with communities,” Higginbotham says. “I want to emphasize that we’re not working on folks—we’re working with folks, so that they have a voice have the ability to have input as well as a stake in what happens in their communities as we try to reduce the disparities.”

Higginbotham says one of the things he and Dr. Alfonza Atkinson, dean of the College of Veterinary Medicine, Nursing and Allied Health at Tuskegee University and co-principal investigator of Project EXPORT, are doing is working with the Alabama Department of Public Health to implement a program in the Black Belt to screen for diabetics who have not previously been identified.

“The Alabama Department of Public Health was given that charge by Secretary of Health and Human Services Tommy Thompson, but the department was not given any additional resources to get that done,” Atkinson says. “So, Dr. Higginbotham and I are working to assist the state in identifying these 200,000 cases, which is a big effort.”

At each university, Project EXPORT has six specific core component areas that are complementary to each other and led by faculty on each campus. At UA, Core 1, the Administrative Core, takes care of the day-to-day business of the grant and is headed by Higginbotham.

Core 2, the Shared Resource Core, which facilitates sharing between the two universities, is led by Dr. Grant T. Savage, professor of management and marketing in the Culverhouse College of Commerce and Business Administration, with Dr. Jeri Dunkin, holder of the Martha Saxton Memorial Endowed Presidential Chair in the Capstone College of Nursing, as co-director.

Core 3, the Research Core, works with existing research and new applications for research. It is directed by Dr. James D. Leeper, professor of community and rural medicine in the College of Community Health Sciences, and co-directed by Dr. Rhoda Johnson, associate professor of women’s studies in the College of Arts and Sciences.

Core 4 is the Pilot Project Core and is used to teach new and young investigators in conducting research, as well as funding pilot projects. Co-director Dr. Melissa C. Kuhajda is an assistant professor of community and rural medicine in CCHS and assistant director of research for the Institute for Rural Health Research. Co-director Dr. Sharol Jacobson is associate dean for research and practice and professor in the Capstone College of Nursing.

Core 5, the Training Core, is directed by Dr. John Wheat, professor of community and rural medicine in CCHS. This core helps fund all ongoing training efforts.

Core 6 is the Community Outreach and Information Dissemination Core, which focuses on research and education in children’s insurance and other health topics. It is directed by Dr. Rex E. Culp, professor and research chair in the College of Human Environmental Sciences. Co-director is Tracy Carter, project manager for Covering Alabama Kids and Families in CHES.

Higginbotham says both universities hope their successes in developing the Center of Excellence will lead to greater future funding, so that they can have more impact on health disparities not only in the Black Belt of Alabama but also throughout the state and even across the nation.

Education and Children’s Insurance

Project EXPORT has afforded its community outreach core an opportunity to better understand the barriers that keep families from enrolling their eligible children in public health insurance programs.

“National research suggests that one of the barriers is knowledge, but no one has really sat down and talked to [groups of] predominately African-American families and people who work with them in the Black Belt,” Culp says. “It is likely the barriers they face are quite different than what a white, middle-class [family] is going to encounter just because cultural differences are going to impact the perception of programs.”

For the last few months, Carter’s web of contacts has been getting to know several different communities in the Black Belt by going to health fairs, church and community meetings, and by making themselves available. Culp says it is imperative to get to know communities and their unique needs before pitching health insurance programs.

He says that as a general rule, two-thirds of the uninsured are eligible for existing insurance programs and that at any one time approximately 70,000 children in the state are uninsured.

“The messages you get out in the community need to be continuous,” Culp says. “You can’t do this once or twice a year and think you can accomplish the goal because every day there’s a child somewhere in the state who is losing coverage.

“So what we do is identify what kinds of things work to get children enrolled in these programs,” he says. “EXPORT has given us the opportunity to expand our efforts into the Black Belt. It is designed to train people who are trusted in these communities to go out and reach those who need the information. We’re involved in interviews with agencies and families so that we can understand what they need to make the programs work for them.”

Send Medical Professionals, Quickly

Not only is there a lack of access to health care in the Black Belt, there is a lack of health professionals. The training core of Project EXPORT is focused on expanding UA’s ongoing efforts to produce physicians and allied health professionals who will be leaders for rural Alabama by helping to develop healthy communities. Dr. John Wheat heads CCHS’s three rural scholars programs: Rural Health Scholars, Rural Medical Scholars and the Minority Rural Health Pipeline Program.

“We’re interested in increasing the education and training of students, particularly from the Black Belt, and working with them to become the health and science professionals who are needed to advance that part of Alabama,” Wheat says. “With Project EXPORT we’ve been able to offer much-needed scholarships to Black Belt students so they can be included in our special preparatory programs.”

Wheat’s team is working with two ethicists at the Tuskegee University National Center for Bioethics in Research and Health Care, Dr. Steven Sodeke and Dr. John Stone, who have been making trips to Tuscaloosa to speak to rural medical students about ethics in medicine and research in public health. Wheat says these seminars have been well received and that the two universities have been working to expand their contributions, as well as help to recruit more Black Belt students into UA’s programs.

The center was established in remembrance of the U.S. Public Health Services syphilis study, which began in the 1930s and continued until the 1970s.

The next step for the training core is to produce graduate studies specific to rural community health that will be particularly applicable to the Black Belt and to rural Alabama in general.

“We’ve been using a pre-existing master’s course in the College of Human Environmental Science’s department of Health Education, but with the EXPORT grant we’ve decided it should be a bit more specific,” Wheat says.

That decision has resulted in a rural health certificate proposal. UA students who will enter medical school next year as Rural Medical Scholars are required to participate in the program. During the next two to three years the plan will develop into a master’s degree program.

“We’re looking at ways we can partner with Tuskegee to produce students who are committed to this part of the state and have the education to make an impact,” Wheat says.

More Work is Needed

Both Higginbotham and Atkinson know that Project EXPORT is just the beginning of years of research and work needed to reduce health disparities in Alabama’s Black Belt.

“A lot of these conditions are preventable or treatable, but prevention is the key,” Atkinson says. “You’re not going to see any immediate returns in these areas because it’s going to take years to see a decline in any incidences and prevalences of these conditions.”

Atkinson cites an alarming increase in Type 2 diabetes among minority teenagers. Research shows that much of the increase is due to an unhealthy diet and lack of exercise. He cautions that changes in the level of Type 2 diabetes won’t be seen until educational efforts aimed at adults and teenagers focus on good eating habits and regular exercise.

“This is really the only way that I see it can be done—prevention as opposed to curative medicine,” he continues. “We have no control over access to medical care in the Black Belt, but we do have some control over education and the dissemination of information. I think to a great extent the health disparities can be attributed to a lack of information.”

Higginbotham agrees. “It is only when we work together as individuals, communities, universities and with government that we can eliminate disparities, eliminate disgraces and realize social justice. It’s going to take us all.”

The University of Alabama, part of The University of Alabama System, is the state’s flagship university. UA shapes a better world through its teaching, research and service. With a global reputation for excellence, UA provides an inclusive, forward-thinking environment and nearly 200 degree programs on a beautiful, student-centered campus. A leader in cutting-edge research, UA advances discovery, creative inquiry and knowledge through more than 30 research centers. As the state’s largest higher education institution, UA drives economic growth in Alabama and beyond.